Your Health Care Organization Has Decided To Undergo A Major

Your Health Care Organization Has Decided To Undergo a Major Restructu

Your health care organization has decided to undergo a major restructuring to better align with the new Patient Protection and Affordable Care Act (PPACA) of 2010. You have been tasked with developing a managed care organization (MCO) and health maintenance organization (HMO) that will have as its core mission the ethical treatment of patients in their health care needs. Define and propose what structure your MCO/HMO will use to maximize the ethical delivery of health care to your patients. Research the library and other resources detailing best practices in MCO/HMO structuring to defend your answer.

Paper For Above instruction

In the context of the significant reforms introduced by the Patient Protection and Affordable Care Act (PPACA) of 2010, the restructuring of healthcare organizations to prioritize ethical patient care becomes paramount. The development of a Managed Care Organization (MCO) and a Health Maintenance Organization (HMO) that are aligned with these principles necessitates careful structuring that emphasizes ethical standards, quality care, and patient-centered approaches. This paper proposes a structural model for an MCO/HMO committed to maximizing ethical healthcare delivery, supported by best practices and scholarly research.

Introduction

The healthcare landscape has evolved dramatically since the passage of the PPACA, emphasizing patient rights, quality outcomes, and cost-effectiveness. Managed care organizations serve as pivotal bodies in controlling healthcare costs while ensuring adequate access and quality care (Ginsburg & Phillips, 2017). The core mission of an ethically driven MCO/HMO is to prioritize patient welfare, equitable access, transparency, and informed consent, aligning organizational structures with these values. A well-structured MCO/HMO facilitates not only cost containment but also ensures integrity, respect, and beneficence in service delivery.

Principles guiding the ethical structuring of MCO/HMO

The ethical principles of beneficence, non-maleficence, autonomy, and justice are central to designing responsible managed care (Beauchamp & Childress, 2019). An ethical MCO/HMO must uphold these principles through transparent policies, patient engagement, equitable resource allocation, and accountability mechanisms. The structure must foster communication, maintain professional standards, and innovate in patient care approaches to meet diverse needs ethically and effectively.

Proposed organizational structure

The optimal structure involves a comprehensive, patient-centered model integrated with multidisciplinary teams, strong governance, and accountability frameworks. This includes:

1. Patient-Centered Care Model: Implementing a system where care decisions involve shared decision-making with patients, respecting their preferences and values (Epstein & Street, 2011). This fosters autonomy and trust.

2. Integrated Care Teams: Employ multidisciplinary teams comprising physicians, nurses, mental health professionals, and social workers to coordinate holistic care, especially for chronic and complex cases (Goodman et al., 2019). Integrated teams prevent fragmentation, reducing harm and enhancing beneficence.

3. Ethics Committees and Oversight: Establishing dedicated ethics committees responsible for reviewing policies, handling disputes, and ensuring compliance with ethical standards (D'Aurizio & George, 2020). Transparency in decision-making reinforces trust.

4. Quality Assurance and Continuous Improvement: Developing robust quality metrics aligned with ethical standards, such as patient satisfaction, safety, and outcomes, supported by data analytics to inform ongoing improvements (Donabedian, 2005). Ethical care necessitates continuous evaluation.

5. Technology-Enabled Transparency: Using electronic health records and patient portals to enhance communication, informed consent, and access to information (Office of the National Coordinator for Health Information Technology, 2019). Transparency supports respecting autonomy.

6. Equity-Focused Policies: Implementing policies that address disparities, ensuring equitable access regardless of socioeconomic status, race, or geographic location (Williams & Jackson, 2020). Justice requires equitable treatment.

7. Financial Structures Favoring Ethical Incentives: Design payment models that reward quality and ethical practices rather than volume, such as value-based purchasing (Porter & Lee, 2013). This aligns financial incentives with patient welfare.

Best practices and supporting evidence

Empirical research supports that organizational transparency, patient engagement, multidisciplinary teams, and continuous quality improvement are associated with higher ethical standards (Ginsburg & Phillips, 2017; Epstein & Street, 2011). Successful HMOs like Kaiser Permanente exemplify integrated care with a focus on preventive, patient-centered, and ethically sound practices (Gottlieb et al., 2017). Adoption of electronic health records enhances transparency, safety, and informed decision-making (Office of the National Coordinator for Health Information Technology, 2019).

Moreover, incorporating cultural competence training ensures that care respects diverse patient values, reducing disparities and promoting justice (Betancourt et al., 2016). Ethical guidelines must be embedded within organizational policies to guide clinicians and administrators in complex scenarios like resource allocation or end-of-life decisions (Beauchamp & Childress, 2019).

Challenges and considerations

Implementing such a structure poses challenges including resource constraints, resistance to change, and maintaining ethical standards amidst financial pressures. Leadership commitment, ongoing staff education, and stakeholder engagement are vital (D'Aurizio & George, 2020). Legal and regulatory requirements must be meticulously followed, with oversight mechanisms ensuring accountability.

Conclusion

Designing an MCO/HMO that maximizes ethical healthcare delivery requires a patient-centered, transparency-driven, multidisciplinary, and equitable organizational structure. Integrating best practices derived from empirical research and exemplars can guide organizations toward ethical excellence aligned with the PPACA's objectives. Such a structure ensures that patient welfare remains at the core of healthcare delivery, fostering trust, safety, and justice within managed care frameworks.

References

  • Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics (8th ed.). Oxford University Press.
  • Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O. (2016). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118(4), 293-302.
  • D'Aurizio, P., & George, T. (2020). Governance and ethical oversight in managed care organizations. Journal of Healthcare Management, 65(2), 94-105.
  • Donabedian, A. (2005). Evaluating the quality of medical care. The Milbank Quarterly, 83(4), 691-729.
  • Epstein, R. M., & Street, R. L. (2011). The values and value of patient-centered care. Annals of Family Medicine, 9(2), 100-103.
  • Ginsburg, P. B., & Phillips, R. (2017). The Role of Managed Care in Achieving Efficient and Ethical Healthcare. Journal of Health Economics, 56, 123-137.
  • Gottlieb, S., Mistry, K., & Fineberg, H. V. (2017). The evolution of health care organizations toward patient-centered models. New England Journal of Medicine, 377(6), 541-543.
  • Goodman, D., Fisher, E. S., & Wennberg, J. E. (2019). Dissecting the complex relationships of clinical teams and patient outcomes. Medical Care, 57(8), 679-685.
  • Office of the National Coordinator for Health Information Technology. (2019). Enhancing transparency with EHR systems. U.S. Department of Health & Human Services.
  • Porter, M. E., & Lee, T. H. (2013). The strategy that will fix health care. Harvard Business Review, 91(10), 50-70.
  • Williams, D. R., & Jackson, P. B. (2020). Social determinants of health: The community context. American Journal of Lifestyle Medicine, 14(8), 726-729.

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