Healthcare Assignment: Funds Flow, Consumer Challenges, Solutions

This report examines the critical aspects of healthcare finance and consumer experience. It begins by addressing the prevention of abuses and inefficiencies in third-party payments, emphasizing the importance of data mining and technological solutions to detect fraud. The report then defines the flow of funds within healthcare organizations, including private pay and third-party reimbursement, and explores the challenges faced by consumers enrolled in private insurance, such as high premiums and limited coverage. Finally, it outlines methods for empowering consumers, such as online portals, provider directories, and mobile apps, to enhance their decision-making and overall healthcare experience. The report draws on scholarly references to support its analysis and recommendations.

Running head: HEALTHCARE
HEALTHCARE
Name of the Student
Name of University
Author’s note

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Answer: 1
Inappropriate payments by third party payers or insurance organizations occur due to
errors, fraud and abuse. The severity of this problem is vast and thus is an issue of priority in
healthcare system. Abuses deal with practices of the providers that either indirectly or directly
results in the generation of unwanted costs to the payer. Abuse includes any form of practice that
is not related with the main aim of providing the patients with healthcare services that are
medically important, fairly priced and meet the required professional medical standards (Centers
for Medicare and Medicaid Services, 2014). Insufficiencies or healthcare fraud is defined as
intentional deception that is used to enjoy unauthorized benefits. These are criminal offenses
under law but lack global consensus (Joudaki et al., 2015).
In order to prevent fraud and inefficiencies in the third party payments proper mining of
the emerging data is extremely important. The electronic health records and the growing use of
the computerized systems have added on to the new inspiring technology of the using soft copy
based data mining (information technology based approach). This is cost-effective and less time
consuming procedure that helps the third party insurance payers to easily detect the fraudulent
cases and inefficiencies. It also helps in the identification of the smaller subset of claimants for
further scrutiny in abuse or fraud cases (Joudaki et al., 2015).
Answer 2
As the healthcare reform generates incentives for proper alignment with the industry
competitors, organizations across the continuum of healthcare will experience their bottom lines
tied to partnership of success. A critical step of generating any form of partnership dealing with

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different types of healthcare institution is to develop guiding framework for flow of funds with
the partners. Flow of fund is used in reference to remuneration to reflect the overall agreed-upon
sum within any particular transaction. This agreed upon sum exists between different partnership
like community hospital and medical center, incentive payments shared among hospital and
physicians and partnership with community-based non-profit organization and population health
management body (Evans & Stoddart, 2017). The fund flow framework mainly helps to govern
the flow of cash under different arrangements like purchased services agreement, discrete joint
operating agreements, joint investment and cost sharing, shared margins for new services and
virtual joint venture (Evans & Stoddart, 2017).
Cost of healthcare is US is higher in comparison to other countries. In United States, the
healthcare technology is advanced but it is expensive. Here the healthcare costs amounts to $3.3
trillion during the year 2016. With the growth of economy, the total amount of money spent in
healthcare is has also increased. During the year 2016, US spent approximately $9900 per person
for healthcare service and it higher than Switzerland by 25% (Milani & Lavie, 2015). In order to
manage the cost of healthcare in US, proper flow of fund is important. In US healthcare the flow
of funds occurs with the private sector insurance, government funded insurance and individuals’
personal payments. Under government funded insurance, patient protection and affordable care
act (ACC) holds prime importance. Other government insurance programs in the US healthcare
include Medicare and Medicaid. Medicare funds for healthcare requirement of the elderly,
disabled people or people suffering from long-term medical complications. Medicaid funds for
healthcare services availed by people who resides below the poverty level (Milani & Lavie,
2015).

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Answer 3
One of the biggest challenges of the private health insurance is high cost of premiums.
This scenario is extremely relevant for the people who are poor or do not have enrollment under
any form of group coverage. Individual policies under private insurance cost several hundred
dollars per month and the total coverage of the family is even higher. Moreover, few of the
comprehensive policies come with copays and deductibles that insureds are required to satisfy in
order to become eligible for the coverage (Thadani, 2014). The private health insurance policies
also lack coverage for the all type of diseases and other allied healthcare conditions. The
majority of the private health insurance policies do not provide coverage to non-communicable
diseases that common among the older adults like cardiovascular disease and diabetes or
pulmonary disease (if having previous history of smoking).Under the American healthcare
perspective it can be stated with the growing lifespan of the older adults in America, the rate of
occurrence of non-communicable and other lifestyle diseases are also expanding. Moreover, with
growing inflation, there is scarcity of jobs along with high cost of living (mainly imposed after
Brexit). Thus, the private health insurances are mainly imposing financial challenges over the
mass rather than helping them to avail healthcare (Thadani, 2014).
Answer 4
Empowering consumer of the healthcare service users is important to drive consumer
focus service. One of the notable approach for consumers’ empowerment include generating
online portals for the consumers where the patients and their family members can compare and
contrast different schemes along with the required set of premium, total coverage and
considerations (if any). This kind of patients’ portal helps the patient or their family members to
decide the best plan on their own without seeking help form others by paying a personal visit.

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Second initiative that is used includes provider directories. It offers a comprehensive list of
doctors, nurses, clinicians and other allied healthcare professionals like dieticians,
physiotherapists and psychologist. Getting the details of the healthcare professionals like their
qualification, experience and area of expertise helps the consumer to feel empowered and
thereby helping them to come forward and take positive decision in favor of availing health
insurance (Nazi et al., 2016). There are some private insurance organizations are using mobile
apps in order to promote consumers empowerment. These apps enable the consumer to make
self-appointment with the doctors to directly connecting the doctors on call (Househ, Borycki &
Kushniruk, 2014). Steinhubl et al. (2015) are of the opinion that reward programs like free health
assessment for the people who are older adults or people who are below the poverty line also act
as a source of empowerment. Nazi et al. (2016) stated that educating and consumers and keeping
them updated about the current trends in the healthcare system is the main source of consumer
empowerment in the health insurance sectors.

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References
Centers for Medicare and Medicaid Services. (2014). Medicare Learning Network. Access date:
29th July 2019. Retrieved from: http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.Pdf
Evans, R. G., & Stoddart, G. L. (2017). Producing health, consuming health care. In Why are
some people healthy and others not? (pp. 27-64). Routledge.
Househ, M., Borycki, E., & Kushniruk, A. (2014). Empowering patients through social media:
the benefits and challenges. Health informatics journal, 20(1), 50-58.
Joudaki, H., Rashidian, A., Minaei-Bidgoli, B., Mahmoodi, M., Geraili, B., Nasiri, M., & Arab,
M. (2015). Using data mining to detect health care fraud and abuse: a review of
literature. Global journal of health science, 7(1), 194.
Milani, R. V., & Lavie, C. J. (2015). Health care 2020: reengineering health care delivery to
combat chronic disease. The American journal of medicine, 128(4), 337-343.
Nazi, K. M., Hogan, T. P., Woods, S. S., Simon, S. R., & Ralston, J. D. (2016). Consumer health
informatics: engaging and empowering patients and families. In Clinical Informatics
Study Guide (pp. 459-500). Springer, Cham.
Steinhubl, S. R., Muse, E. D., & Topol, E. J. (2015). The emerging field of mobile
health. Science translational medicine, 7(283), 283rv3-283rv3.
Thadani, K. B. (2014). Public Private Partnership in the Health Sector: Boon or Bane. Procedia-
Social and Behavioral Sciences, 157, 307-316.