Question

a) Discuss the four (4) managed health care organizations.

b) Discuss the provisions for EMTALA and ERISA.

c) What are the roles/positions of community and public health nurses? Explain how each of those roles/positions are fulfilled.

d) Differentiate hospice and palliative care. Provide an example of a situation when each are implemented?

Answer 1

a)

Health maintenance organization (HMO),

preferred provider organization (PPO),

point of service (POS), and

exclusive provider organization (EPO)

Controlled health care plans are a cost-effective alternative to conventional health insurance fee-for-service or indemnity plans because they share the financial risks of medical expenses between:

• Member Persons
• Their arrangements for insurance
• Members of the care network that is operated.

Advantages :

• Members of the Integrated Health Care Network benefit from lower premiums and access to health care services promised
• Health network members benefit from providing a steady customer stream
• Plan members have an easier time because they avoid having to file paperwork while dealing with providers in the network, as the members of the network and providers of medical care have payment systems. This is made the simplest by the HMO strategy.

b) EMTALA

The Emergency Medical Care and Labor Act (EMTALA) is a federal statute requiring care and treatment of anybody coming to an emergency room, regardless of their insurance status or willingness to pay, although an unfunded provision has existed since its passage in 1986.

Purpose :

Ensuring public access to emergency services irrespective of the capacity to pay

Provisions:

• To decide if an emergency medical condition occurs, any person who comes and requests must be given a medical screening test. Test and therapy cannot be postponed by inquiring about payment options or insurance coverage. Emergency departments must also post signs reminding patients and visitors of their right to an assessment and treatment for medical screening.
• Care must be given before the emergency medical condition is resolved or stabilised if an emergency medical condition occurs. If the hospital does not have the capacity to handle an emergency medical condition, the patient must be "appropriate" moved to another hospital in accordance with the provisions of EMTALA.
• Hospitals with advanced capacities are obliged to allow transfers from hospitals that lack the capacity to handle medial conditions in unstable emergencies.

ERISA
ERISA will cover employer-offered defined-benefit and defined-contribution programmes. 401(k) plans, pensions, deferred-compensation plans, and profit-sharing plans are common types of employer-sponsored retirement accounts which fall under ERISA.

Purpose :

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal statute that provides basic requirements to provide protection for persons in these arrangements for most mutually established retirement and health plans in the private sector.

Provsions:

• Conduct: The conduct of managed care (i.e., HMOs) and other trustees is regulated by ERISA rules.
• Reporting and Accountability: Comprehensive reporting and federal government accountability are needed.
• Disclosures: Certain disclosures given to plan participants (i.e. a plan overview that explicitly lists the benefits offered, rules for accessing such benefits, drawbacks of the plan, other requirements for obtaining benefits, such as obtaining advance referrals for surgery or doctor visitors
• Procedural Safeguards: ERISA includes the development of a formal policy as to how claims should be filed, as well as a written appeal mechanism for rejected claims. ERISA also demands that claim appeals be handled in a fair and timely manner (although the terminology is quite loose).

c)

• Evaluating demographic groups' health patterns and risk factors, and helping to define targets for tailored interventions.
• Working to establish public strategies and tailored programmes for health promotion and disease prevention with populations or particular demographic groups within the city.
• Participating in the assessment and evaluation of health care resources to ensure that individuals are aware and supported in the use of the programmes and services available.
• Providing critical information to interdisciplinary initiatives that in demographic groups track, predict, and respond to public health issues.
• Providing people and families who are representatives of vulnerable communities and high-risk groups with health education, care management, and primary care.

d)

Comfort is provided for both palliative care and hospice care. But at diagnosis, and at the same time as treatment, palliative care will begin. After treatment of the disease is stopped and when it is clear that the person will not survive the disease, hospice care starts.

Hospice treatment is most commonly provided only when it is predicted that the person will live for 6 months or less.