Health Insurance Costs Term Paper

Pages: 14 (3597 words)  ·  Bibliography Sources: ≈ 9  ·  File: .docx  ·  Level: College Senior  ·  Topic: Healthcare

As of October 1998, 59,000 people in the United States were on the national waiting list for a life-saving organ transplant. Every day, about 55 people receive such a transplant and with it, a second chance for life. (About 80% of those who receive a donated kidney, for example, are still alive five years later.) Thousands more people, however, die each year waiting, helplessly, for a donor. And every 18 minutes, another name is added to the waiting list (

The question of how to balance the real fiscal concerns of organ donation with the responsibilities of managed care (either within the context of a private health maintenance organization or within a managed public program such as Medicaid) requires a well thought-out management philosophy, one that balances the needs of patients, the skills of health-care providers and the economics of health-care; this is all too often not the case. Both public programs such as Medicare and private HMOs are currently not able to handle as gracefully as many might with the complex medical, logistical, legal and financial requirements of a national organ donation program, as we can see in this assessment of the ways in which a new Medicare program has fared:

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We found, however, that hospitals and OPOs have not taken full advantage of the rule. Despite projections of a 10% increase in organ donors in the rule's first year, the increase was less than 1%. We also found that HCFA lacks data to assess how well the rule is working. We recommended that HCFA revise the Medicare conditions for coverage for OPOs to make them more accountable for implementing the donation rule, by requiring OPOs to provide hospital-specific data on referrals and organ recovery and to make hospital-specific data on donation publicly available (Biomedical Market Newsletter 2000).

The difficulties involved in organ donations - in which there are never enough organs to go around and never enough money to fund operations and follow-up treatment even when there are donations might well be expected nearly to overwhelm a publicly managed health organization. One might think that a private HMO might avoid some of these problems with the efficiency that private companies are in many cases blessed with.

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However, the cost of organ donation has proven to be a significant stumbling block for private HMOs as well. The following perspective is that of a patient advocate. The general response from HMOs has been that while they would of course like to provide in all cases the gold standard of care for their clients, the cost involved makes this prohibitive. Among the complexities that HMOs engender in the transplant process is the fact that HMOs generally will pay for minimum post-operative hospitalization, a fact that alone bumps many patients from the potential rolls for an organ:

The American Association of Kidney Patients] wishes to bring to your attention the numerous complaints we continue to receive from kidney patients enrolled in HMO's. Complaints include difficulties in securing transplant services outside the HMO and the ability to choose dialysis facilities and physicians. In an effort to cut costs in a managed care environment, hospital admittance times have been shortened for transplantation. This can lead to only the healthiest patients receiving transplants because the hospital can guarantee a short patient stay (Warren 1995).

One of the continuing problems faced by those needing organ donations who rely on either HMOs or Medicare for health care is that HMOs especially are inclined to look at short-term over long-term costs of treatment. (The emphasis on short-term costs and short-term benefits is of course an endemic problem within the world of modern business and is in no way restricted to the arena of HMOs). While organ donation is of course an expensive process, in many cases the cost of ongoing care to treat failing organs or failing organ systems can be far greater than the one-time cost of organ transplantation:

Terran Warren Sims, BSN, RN, CNN, immediate past president of the American Nephrology Nurses Association on the cost of dialysis vs. transplantation: "According to one HCFA source, in terms of annualized costs, a dialysis patient dialyzing for one year has TOTAL costs of Medicare of $44,000. In the year he receives a transplant, that patient represents annualized TOTAL costs to Medicare of $88,000. However, in subsequent years as a 'functioning graft' patient, TOTAL costs to Medicare average $7,400 (Warren 1995).

Another systematic problem that enters into the picture for those patients who need organ donations and who are reliant on HMOs is the designation of certain kinds of procedures as elective (and therefore not covered) while other seemingly analogous procedures are covered, as in the case of living vs. cadaveric livers. Because such transplants are less successful, requiring more follow-up care, including a greater likelihood of an additional transplant, the overall costs of the patient's care are substantially higher because of the ways in which HMOs reimburse direct health-care providers.

But because Dunn will use part of her brother's liver if approved for surgery, the entire procedure has become more expensive; her brother's insurance company has denied coverage for the organ donation because it is "elective" (American Health Line 2001).

The problem of balancing the rights of patients to receive life-saving care with the reluctance of HMOs to cover "experimental" treatments will likely only worsen as advances into what must be seen as experimental methods become more and more important to the field of tissue and organ donation, including xenotransplantation, or the use of non-human donors (Dobson 2002).

Philosophy of Health-Care Management: Who Pays for What In many ways when we consider the issue of organ donation (which almost always dramatically increases the quality of life of an individual and often that person's life), what we are asking is: What rights do people have? When the funding comes from a source like Medicare or Medicaid, we are also asking: What can we rightfully demand of our government?

Part of how we answer these questions, and part of how we address the economic demands not only of organ donation but of 21st-century healthcare in general, lies in how we define the role of the doctor in our society as well as the role of hospital and insurer. There is currently a distinct conflict between two different culturally current definitions of the health-care providers' role in our society. On the one hand we have the definition that doctors, nurses and other health-care givers that what they do is a profession. And so, of course, in many ways it is: health-care providers receive lengthy formal education in their fields, have formal codes of ethics, join together in professional organizations to improve the practice of what they do and have all of the other marks of the professional.

However, there is another model that we must consider that is at least equally valid in terms of the actual practice of medicine today, which is that of the doctor or nurse as a businessperson or government of the agent - in both cases rationing medical resources because of economic rather than purely medical or professional concerns. This is the model that most often obtains under HMOs and tends to result not only in higher health costs (as health-care providers have to bill for an increasing number of procedures to make a reasonable amount of money) as well as a lower quality of care for the patients. It also results in a high level of stress for the doctors who are caught in a bind as well.

Physicians also act as gatekeepers, often rationing medical resources for the benefit of providers, insurers, government, or society at large. Primary care physicians in HMOS and other managed care settings play this role when they control the flow of patients to specialists, or deny marginally beneficial services to patients to promote the institutions' interests. Physicians also work for the government, certifying eligibility for disability income and insurance benefits.... In all these legitimate roles physicians are expected to act in ways that do not promote the best interests of their patients. (Rodwin, 1995, p. 245.)

Nurses are in some measure exempted from this dual identity: They are far more closely associated with the professional rather than the business aspects of the medical field. This allows them unique opportunities to help patients through the process of waiting for and (hopefully) recovering from tissue or organ donations. They also serve a key function in helping patients adjust to life after transplantation, including both potential physical risks and psychological complications (Sagedal 2002).

Nurses, as well as other health-care professionals, may be especially helpful in working to educate patients about their medical options and their legal rights with insurers as well as serving as advocates for potential donors. This role of advocate not only for particular patients but for donation and transplantation in general can allow nurses to assume a vital role in the process of saving ever more lives.


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APA Style

Health Insurance Costs.  (2003, June 11).  Retrieved September 22, 2020, from

MLA Format

"Health Insurance Costs."  11 June 2003.  Web.  22 September 2020. <>.

Chicago Style

"Health Insurance Costs."  June 11, 2003.  Accessed September 22, 2020.