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Copyright © Springer Publishing Company, LLC. All Rights Reserved.
CHAPTER 13: ETHICAL ISSUES AND INTERNATIONAL HEALTH CARE SYSTEMS• Analyze a current health care concern using the
ethical principles of autonomy, justice, beneficence, and nonmaleficence
• Explain how nurses can avoid the risk of at least two types of health care fraud
• Compare the health care financing of one other country to the U.S. health care system
• Summarize at least three concerns shared by many countries in the world related to health care quality, access, and costs
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PRINCIPLES OF BIOETHICS
• Autonomy: The right of individuals to make their own decisions about their care
• Justice: Equal or fair distribution of health care benefits and risks
• Beneficence: Health providers must do good and provide the most benefit possible
• Nonmaleficence: Health providers must avoid or minimize harm
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IS FRAUD A PROBLEM? 2011 UPDATE• Office of the Inspector General: 92% of U.S.
nursing facilities employ at least one person with a criminal conviction
• CMS estimates FY 2010 improper payments for Medicare fee-for-service and Medicare Advantage of almost $48 billion, 9.4% of the estimated total $509 billion spending– This does not include the Medicare D drug
program
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FINANCIAL FRAUD• Intentional deception or misrepresentation designed to obtain
something of value held by another
• 1996 Health Insurance Portability & Accountability Act (HIPAA): health care fraud is knowingly and willingly executing, or attempting to execute, a scheme to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money owned by, or under custody or control of, any health care benefit program
• Includes filing false claims, offering and receiving kickbacks, and other schemes to divert money from the government
• Medicare and Medicaid are frequent targets of fraud
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FINANCIAL ABUSE• Often difficult to distinguish from fraud• Methods or practices that are unnecessarily
costly, improper, or at odds with customary practice
• Exploitation of vulnerable clients such as the elderly by family, caregivers, or criminals
• Example: neglect of nursing home patients; phone solicitation offering cash giveaway in exchange for cash outlay
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FRAUDULENT PRACTICES
• Billing for services not rendered • Misrepresenting the diagnosis to justify
payment (DRG upcoding)• Soliciting, offering, or receiving inducements
to influence future purchases (kickbacks)• Billing for separate parts of a single procedure
(unbundling) • Falsifying documents to justify payment
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MORE FRAUDULENT PRACTICES• Providing services more often than indicated
(over-utilization or “churning”) • Billing for unnecessary services • Making single visits while billing for multiple visits • Exhausting insurance benefits for one family
member then billing for another (looping) • Falsifying the credentials of a provider to bill at a
higher rate (phantom billing) • Billing Medicare and a private insurer for the
same treatment or procedure (double billing) 7
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Type of System PluralisticNational Health
InsuranceNational Health
Service
Principal Features
Some uninsured citizens and foreign residents; government and non-government providers; multiple government and non-government funding streams
Universal coverage; government and non-government providers; often national and provincial budgets
Universal coverage; largely government providers; funding largely government with some self-pay
Typical Problems
Uninsured populations
Health care rationing
Health care rationing
Examples of Countries
United States Canada, Japan, many European nations
Great Britain
Source: Adapted from V.G. Rodwin, in Kovner & Jonas, 1999.
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U.S. HEALTH CARE PERFORMANCECompared to other industrialized countries:•Proportion of elderly and rate of health care employment is not the highest—these would account for higher health care costs•% GDP for health care expenditures is the highest•Per capita health care expenditures are the highest
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DISPARITIES IN GLOBAL HEALTH CARE FINANCING “Low- and middle-income countries account for only 18% of world income and 11% of global health spending. Yet 84% of the world’s population live in these countries and they bear 93% of the world’s disease burden.”
WHO, The World Health Report 2000, pg. 7
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APPROACHES TO HEALTH CARE RATIONING
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ApproachStrict controls limiting the health
care budgetControls based on specific
priorities Target Does not target specific diseases or
interventionsOften provides an affordable "basic" or "essential" package of interventions
Principal Features
Most common approach; most frequently used in countries with national health budgets
Social, political, and cost-effectiveness criteria used to determine priorities
Typical Problems
Resources managed according to politics, often favoring the higher income citizens at the expense of the poor
Providers respond to demand for services outside the approved package; limitations to cost-effectiveness criteria
Examples of Countries
Pre-1990 National Health System in the United Kingdom, some European Union countries, some developing nations
The Netherlands, New Zealand, Norway, Sweden, Oregon (U.S.), Mexico, Bangladesh, Columbia, Zambia
Source: Adapted from WHO, World Health Report 2000.
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SOME GLOBAL HEALTH CONCERNS• Shortage of nurses and other health care
professionals• Aging populations• Quality of health care services and patient
satisfaction • Economic downturn• Medical tourism
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HEALTHSPROCKET AUGUST 10, 2012• Ranking of Selected Countries by % of Patients Rating Their Doctor 9 or 10 (1-10 scale)
• Top Ten Countries with Most Hospital Beds per 10,000 Population
• Top Ten Countries with Most Physicians per 10,000 Population
• Top 25 countries with the world's best healthcare systems
• The US ranks at the bottom of 19 industrialized countries in preventable deaths
• How the Performance of the U.S. Health Care System Compares Internationally
• Six Country Comparison: Hospital Satisfaction Level
• Six Country Comparison: Consumers Rating Their Health System Failing
• Six Country Comparison: Consumers Rating Their Health System Excellent
• Six Country Comparison: Public Health Care Spending % of Total Health Expenditure
• Health Expenditures per Capita - Seven Selected Countries
• Commonwealth Fund Overall Quality Ranking of Seven Nations' Healthcare Systems
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