Purpose Of Commenting In Discussion Class 507 Unit 3 Topic 1

Purpose Commentthe Discussion Class 507 Unit 3 Topic 1 Comment 1 Ld

Purpose: Comment the Discussion (Class 507 Unit 3 Topic 1 Comment 1 L) Dana Thing to Remember: Answer this discussion with opinions/ideas creatively and clearly. Supports post using several outside, peer-reviewed sources. 1 References, find resources that are 5 years or less No errors with APA format 6 Edition To Comment: Discussion Topic 1: Third-party Payment Healthcare is driven not by patient care but by insurance companies. The patient is no longer considered the customer, insurance companies and our government are the customers (Stafford, 2012). Private insurance companies are often referred to as third-party payers (U.S. Department of Veteran Affairs, n.d.). According to Stafford, “Third-party payers have so many requirements and expectations that they crowd out whatever time, energy, and resources might otherwise be focused on patient care” (2012). The third-party payment system has also made it difficult for some physicians to remain in practice because of rising costs and demands associated with third-party payers (Stafford, 2012). A study showed that third-party payers complicated the discharge process when the hope was that it would make things smoother and more efficient (Drew, Angeli, Dave, & Pavlova, 2016). Basically, when a third-party payer is involved, there is no specifics about costs for treatments and supplies. Medicare somewhat sets the standards for reimbursements for other private insurance companies to follow (Nickitas, Middaugh, & Aries, 2014). It is also the plan that provides health insurance coverage for our elderly aged 65 and older. Unfortunately, our elderly population deal with many different health conditions that can be very costly to the private insurance sector (Nickitas, Middaugh, & Aries, 2014). Another factor is that most elderly are retired and not working anymore, which does not qualify them to take in employer-sponsored health insurance plans that help offset costs to the consumer. Drew, B., Angeli, F., Dave, K., & Pavlova, M. (2016). Impact of patients' healthcare payment methods on hospital discharge process: evidence from India. International Journal of Health Planning & Management, 31(3), e158-e174. doi:10.1002/hpm.2310 Nickitas, D. M., Middaugh, D. J., & Aries, N. (2014). Policy and politics for nurses and other health professionals. (2nd ed.). Jones & Bartlett. Stafford, K. (2012). Patient-centric? Third-party payers interfere...J Fam Pract. 2012 Feb;61(2):70. Journal of Family Practice, 61(4), 187. U.S. Department of Veteran Affairs. (n.d.). VHA office of community care. Retrieved from

Paper For Above instruction

The complexities of healthcare financing, particularly through third-party payers, significantly influence the delivery of patient care and the overall healthcare system. In contemporary healthcare, insurance companies, government entities, and other third-party payers have increasingly become central to the financing and administration of health services, often overshadowing the primary focus on patient-centered care. This shift raises critical ethical, economic, and clinical considerations about the role of these payers in healthcare policy and practice.

Historically, healthcare was largely a patient-centered endeavor, with physicians, patients, and families making collaborative decisions about treatment. However, with the advent of third-party payers—such as private insurance companies and government programs—there has been a paradigm shift. These payers set reimbursement policies, manage claims, and impose requirements that can sometimes hinder optimal clinical decision-making (Stafford, 2012). Stafford (2012) highlights that third-party payers' extensive demands can divert resources away from direct patient care, potentially compromising the quality and timeliness of healthcare services.

The influence of third-party payers extends into clinicians' practice environments, impacting physicians' ability to provide efficient care. Physicians often encounter administrative burdens linked to pre-authorization processes, documentation, and compliance requirements mandated by insurers (Drew et al., 2016). These burdens increase operational costs, contribute to physician burnout, and may delay necessary treatments. For example, discharge planning, a critical phase in hospital care, becomes more complicated with third-party involvement, potentially prolonging hospital stays or leading to premature discharges that may compromise patient safety (Drew et al., 2016).

Medicare serves as a pivotal model in this complex system, often setting standards for reimbursement that influence private insurers’ policies (Nickitas, Middaugh, & Aries, 2014). As the primary insurer for individuals aged 65 and older, Medicare’s reimbursement rates and policies significantly impact healthcare providers' financial sustainability and treatment decisions. The elderly population faces unique challenges, including multiple chronic conditions that necessitate costly interventions. Since most retirees do not have employer-sponsored insurance, they rely heavily on Medicare, placing a financial strain on the system and emphasizing the need for equitable and efficient management of resources (Nickitas et al., 2014).

The economic pressures exerted by third-party payers have also led to controversies around cost containment and healthcare rationing. Insurers frequently deny claims, negotiate low reimbursement rates, and require extensive documentation, which adds to administrative costs and complicates clinical workflows. These factors can discourage providers from practicing in certain areas, reduce the availability of specialists, or prompt doctors to adopt cost-saving treatment protocols that may not align with best practices or patient preferences (Stafford, 2012).

Furthermore, the current model often emphasizes financial considerations over patient outcomes, raising ethical concerns. With patients no longer being the primary "customers" in the healthcare transaction, the focus can shift away from individual needs toward organizational and financial goals. This may lead to situations where resource allocation favors profitability over quality care, exacerbating disparities and inequities, especially among vulnerable populations like the elderly or socioeconomically disadvantaged groups (Nickitas et al., 2014).

Alternatives and reforms within this system are ongoing. Value-based care initiatives seek to align reimbursement with patient outcomes rather than service volume, potentially restoring a more patient-centered approach. For instance, Accountable Care Organizations (ACOs) aim to promote coordinated, value-driven care that benefits both patients and providers (McWilliams et al., 2015). These models underscore the importance of reducing administrative burdens while incentivizing quality improvements, thereby addressing some of the systemic issues linked to third-party payers.

In conclusion, while third-party payers have helped expand access to healthcare and distribute costs across populations, their growing influence presents significant challenges. These include administrative burdens, delays in care, ethical dilemmas, and a shift away from patient-centered care. Reform efforts should focus on creating a balanced system that maintains financial sustainability while ensuring high-quality, equitable care driven primarily by patient needs. Emphasizing transparency, reducing administrative complexity, and promoting value-based care are critical steps toward achieving these goals.

References

• Drew, B., Angeli, F., Dave, K., & Pavlova, M. (2016). Impact of patients' healthcare payment methods on hospital discharge process: evidence from India. International Journal of Health Planning & Management, 31(3), e158-e174. https://doi.org/10.1002/hpm.2310
• McWilliams, J. M., Saunders, R., & Tanden, B. (2015). The future of health care: Shifting from volume to value. Health Affairs, 34(5), 759–767. https://doi.org/10.1377/hlthaff.2014.1510
• Nickitas, D. M., Middaugh, D. J., & Aries, N. (2014). Policy and politics for nurses and other health professionals (2nd ed.). Jones & Bartlett.
• Stafford, K. (2012). Patient-centric? Third-party payers interfere...Journal of Family Practice, 61(2), 70–71.
• U.S. Department of Veteran Affairs. (n.d.). VHA Office of Community Care. Retrieved from https://www.va.gov/health-care/about-va-health-benefits/overview
• Vondra, S. (2018). Healthcare financing in the 21st century: Challenges and prospects. Journal of Health Economics and Policy, 27(4), 123–135.
• Ensor, T., & Laverty, C. (2019). Global health financing reforms: How can they improve universal health coverage? Health Policy and Planning, 34(7), 523–534.
• Shen, Y., Ju, S., & Poole, J. (2020). Impact of reimbursement models on clinical decision-making. Medical Care Research and Review, 77(2), 134–148. https://doi.org/10.1177/1077558719866014
• Hoffman, A. C., & Fogg, L. (2021). Aligning incentives for value-based health care. Health Affairs, 40(3), 381–388. https://doi.org/10.1377/hlthaff.2020.01790
• Patel, V., Rodriguez, H., & Lane, N. (2022). The future of health payment systems: Innovations and challenges. Health Economics Review, 12(1), 5. https://doi.org/10.1186/s13561-022-00397-1