Question

Describe existing safeguards used to ensure providers provide quality care, due to lack of sufficient financial incentives.

Answer 1

Existing safeguards used to ensure providers provide quality care, due to lack of sufficient financial incentives are

Health Care Expenditures

The interest in quality of care must be viewed in a larger social and economic context. On the one hand are the staggering reality of a federal budget deficit created during the 1980s (now conservatively estimated at over $135 billion), a growing desire to protect the 35 million persons who are uninsured for health care (most of whom are not elderly), and much discontent about numerous other components of the social fabric (housing and the homeless, education and literacy, and the pervasiveness of illegal drugs). On the other hand are the increasing need for care by a growing elderly population and the concomitant pressure to broaden the benefits within the Medicare program, as seen most recently in the debates about the Medicare Catastrophic Coverage Act of 1988 and about expanded coverage for long term care.

Access to Services

Germane to any discussion of health policy are the twin issues of geographic and financial access to services. Persons in need of care are forced on occasion to forgo treatment because they live in areas that are underserved by medical practitioners or otherwise face limited access to health care institutions and technologies; this is particularly evident in rural areas and inner cities. Gaps in coverage, restrictions on the use of needed services, inconsistencies in the application of reimbursement policies, and cost-sharing can all be obstacles to the receipt of appropriate levels of care.

Settings of Care

Changes in the settings of care, such as the shift of some types of surgery to the ambulatory setting and the growth of home care, produce uncertainty about quality and continuity of care. These changes complicate quality assurance efforts because needed data systems may be lacking for these nontraditional settings. Ensuring high quality in the diagnosis and treatment of mental health problems, conditions recognized as important health issues for the elderly, is difficult because they, too, often fall outside the usual practice domains.

Integration of Financing and Delivery of Services

The strong trends toward the integration of financing and delivery of services and the growth of for-profit enterprise in health care have serious implications for quality of care. Prospective payment systems, capitated programs, and many other payment methodologies put providers at financial risk. Price competition among providers and insurers is vigorous, and competition for market share is being pursued through overt marketing to consumers and employees to an unprecedented degree. These developments, it is feared, lead to conflicts within, or erosion of, the traditional physician-patient relationship. Others perceive these trends as obstacles to providing continuity of care; instead of increasing the choices, these developments limit the choices of providers available to consumers.

Medicare's Physician Payment System

Reform of the physician payment system for Medicare has emerged recently as a contentious issue . Expenditures for physician services have grown significantly over the years, increasing the financial burden on both beneficiaries and the taxpayers. In addition, increases in physician charges, the unwillingness of some physicians to accept Medicare assignment, and the impact on beneficiary out-of-pocket expenditures (in terms of copayments and extra billing) raise concern about diminished access to quality care for Medicare beneficiaries who, under the constraints of limited financial resources, avoid seeking services that may not be reimbursed.