DISCUSSION BOARD POSTING 1

Health Care Policy

Sheryl Chua Wen Jing

Nova Southeastern University

College of Health Care Sciences

Department of Health Science

Master of Health Science Program

MHS 5003: Current Trends and Cultural Issues in Health Care

Elby Pernsteiner, DHSc, MHSc, R.T. (R) (M).

Discussion Board Posting

January 4, 2018
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Discussion Board Posting

Week 1

What is Health Policy and Who Makes Health Policy in the United States?

The World Health Organization defines health policy as “ decisions, plans,

and actions that are undertaken to achieve specific health care goals within a society”

(World Health Organization, 2018). An explicit health policy “defines a vision for

the future which in turn helps to establish targets and points of reference for the short

and medium term” (World Health Organization, 2018). The purpose of health policy

is to provide a clear outline of priorities and expectations of the roles required of

different groups of people, while educating the public and reinforcing collaboration

between stakeholders (World Health Organization, 2018). At a governmental level,

the implementation of health policy endeavours to “enhance health or facilitate its

pursuit” (Longest, 2010, pp. 16).

Health policy is considered a variation of a public policy (Longest, 2010),

which is comprises “authoritative decisions made in the legislative, executive, or

judicial branches of government that are intended to direct or influence the actions,

behaviors, or decisions of others” (Longest, 2010, pp. 5). Health policies exist in

various forms such as laws, rules and regulations, operational decisions and judicial

decisions (Longest, 2010). Health policies can also be classified into distributive,

redistributive and regulatory categories (Longest, 2010).

These policies are “established at federal, state, and local levels of

government” (Longest, 2010, pp. 6) and are made through the public policymaking

process (Longest, 2010). The pubic policymaking process is a dynamic process in

which interactions from the legislative, executive and judicial branches take place

(Longest, 2010). Health policy decision makers are primarily “legislators, executives
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of government or judges” (Longest, 2010, pp. 5). The legislative branch of the

government is involved in the process of formulating health policy and enacting laws

related to it while the executive branch of government implements the health policy

by implementation of laws (Longest, 2010). Finally, the judicial branch helps to

interpret and review health policy by interpreting constitutional and statutory law

(Longest, 2010).

What is an Accountable Care Organization?

According to the Centers for Medicare and Medicaid Services, “accountable

Care Organizations (ACO) are groups of doctors, hospitals, and other health care

providers, who come together voluntarily to give coordinated high quality care to

their Medicare patients” (Centers for Medicare and Medicaid Services, 2017, para. 1).

This ensures that all patients have access to the appropriate care at the appropriate

time while preventing medical errors and duplication of medical services (Centers for

Medicare and Medicaid Services, 2017, para. 2). The goal of having the ACO is to

“share in the savings it achieves for the Medicare program” (Centers for Medicare and

Medicaid Services, 2017, para. 3) as high-quality healthcare is delivered to patients,

while health care dollars are spent wisely (Centers for Medicare and Medicaid

Services, 2017, para. 3).

Under Medicare, there are various schemes of ACO programs (Centers for

Medicare and Medicaid Services, 2017, para. 4). These include the Medicare Shared

Savings Program, Advance Payment ACO Model and Pioneer ACO Model (Centers

for Medicare and Medicaid Services, 2017, para. 4), all of which are put in place to

ensure high quality and coordinated health care is given to Medicare patients (Centers

for Medicare and Medicaid Services, 2017, para. 4).

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Who are Purchasers, Insurers, Providers and Suppliers?

Health care in the United States involves complex relationships among

consumers, health care providers and those who finance health care (Moses et al.,

2013). These relationships are interdependent (Moses et al., 2013) and are made up of

four major actors (Bodenheimer and Grumbach, 2016, pp. 201). They are the

purchasers, insurers, providers and suppliers (Bodenheimer and Grumbach, 2016, pp.

201). These four actors influence the economy of the United States by influencing the

health care sector (Bodenheimer and Grumbach, 2016, pp. 201). Under the United

States health care system, the purchasers are fund suppliers. They comprise of

“individual health care consumers, businesses that pay for health insurance of their

employers, and the government, which pays for care through public programs such as

Medicare and Medicaid” (Bodenheimer and Grumbach, 2016, pp. 201). Other than

individual single payers, a variety of payers exist in the United States healthcare

system, which include “the federal and state governments and commercial health

insurance companies” (Ridic, Gleason and Ridic, 2012). These third-party payers hold

the responsibility of reimbursing providers of health care, in addition to individual

consumers (Ridic, Gleason and Ridic, 2012). Reimbursement is usually provided on a

fee for service basis (Ridic, Gleason and Ridic, 2012).

Insurers are those who “receive money from the purchasers and reimburse the

providers” (Bodenheimer and Grumbach, 2016, pp. 201). They receive the money

from the purchasers to reimburse providers when the policyholders require medical

care (Bodenheimer and Grumbach, 2016, pp. 201). Currently, there is no single

countrywide system of health insurance in the United States (Ridic, Gleason and

Ridic, 2012). Health insurance is mostly purchased in the private sector or provided to

certain vulnerable groups by the government (Ridic, Gleason and Ridic, 2012).
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Employment-related health insurance makes up a significant portion of insurance held

by policyholders and such health insurance is usually funded internally (Ridic,

Gleason and Ridic, 2012). There are also two major public health insurance schemes,

Medicare and Medicaid, which are available to citizens (Ridic, Gleason and Ridic,

2012). Medicare is a public health insurance program that serves the elderly and

disabled (Ridic, Gleason and Ridic, 2012) while Medicaid provides coverage for

groups of individuals that are disadvantaged economically (Ridic, Gleason and Ridic,

2012).

Providers of health care are made up of a vast array of different professions

and organizations that are responsible for clinical care of a patient (Moses et al.,

2013) As such, the providers in the health care sector are made up of “hospitals,

physicians, nurses, nurse practitioners, physician assistants, pharmacists, social

workers, nursing homes, home care agencies, and pharmacies” (Bodenheimer and

Grumbach, 2016, pp. 201). Lastly, the suppliers are “the pharmaceutical, medical

supply, and computer industries, which manufacture equipment, supplies, and

medications used by providers to treat patients” (Bodenheimer and Grumbach, 2016,

pp. 201).
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References

Bodenheimer, T., & Grumbach, K. (2016). Understanding Health Policy: A Clinical

Approach. New York: McGraw-Hill Medical.

Centers for Medicare and Medicaid Services (2017). Accountable Care Organizations

(ACO). Retrieved January 03, 2018, from

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/

Longest, B. B (2010). Health Policymaking in the United States. Chicago, IL: Health

Administration Press.

Moses, H., Matheson, D. H., Dorsey, E. R., George, B. P., Sadoff, D., & Yoshimura,

S. (2013). The anatomy of health care in the United States. Jama, 310(18),

1947-1964.

Ridic, G., Gleason, S., & Ridic, O. (2012). Comparisons of health care systems in the

United States, Germany and Canada. Materia socio-medica, 24(2), 112.

World Health Organization (2018). Health policy. Retrieved January 03, 2018, from

http://www.who.int/topics/health_policy/en/
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