The modern healthcare sector faces a significant problem that limits its further evolution and prevents it from performing the central task, which is the provision of care to all people who might need it. This issue is a too high price for the majority of available treatment plans or services that should be offered to patients. The problem has always been topical for the sphere, and that is why the introduction of various insurance schemes was presupposed to introduce an effective and available solution to populations. Unfortunately, today there are still many clients who are not able to acquire the demanded care because of financial limits and problems of this sort. For this reason, there is a critical need for the investigation of the problem to outline the most important aspects and propose potent solutions to improve defective insurance schemes.
Outlining the existing healthcare problem, it is critical to mention several critical aspects. First of all, today, there is a comparatively low level of trust in the healthcare institution because of the existence of multiple plans that confuse consumers and show decreased effectiveness when they are needed (Arboleda-Arango, 2015). It means that the sector faces a significant problem of gradual degradation and loss of trust from patients. It should be considered a significant issue because of the necessity to align meaningful cooperation between health workers and clients with the primary aim to achieve the best possible results. At the same time, the existence of ineffective approaches evidences that there is a particular administrative inefficiency that arises from the poorly organized work of the sector and disregard of the basic demands (Xu, Burgess, Cabral, Soria-Saucedo, & Kazis, 2015). In such a way, the decreased ability to introduce appropriate alterations in the work of the healthcare sector results in the emergence of undesired outcomes and worsening of the situation.
Additionally, the last reforms resulting from the Affordable Care Act (ACA) that was expected to introduce positive change stipulated a serious increase in health care coverage (Bauchner, 2017). Expansion of Medicaid also had provided young adults with an opportunity to acquire the needed care (Bauchner, 2017). However, due to the same policies and regulations, about 25 million citizens remain deprived of health insurance and suffer from the further deterioration of the situation (Bauchner, 2017). The given critical flaws and defects in the approach to management pose a serious threat to the further improvement of the health of the nation, which is one of the primary tasks of the healthcare sector (Campbell, Manns, Soril, & Clement, 2017). In general, in accordance with the majority of investigators and reports, the existing system and regulations regarding the provision of care to patients and insurance schemes remain ineffective because of the lack of flexibility, adoption, and optimization of proposed plans. This healthcare problem is a significant barrier for the whole sector.
Significance of the Problem
The significance of the selected problem is evidenced by several factors. First of all, today, there is a tendency towards the increase in the price of the provided services and care preconditioned by the use of innovative technologies and the complexity of many diseases that emerge (Bauchner, 2017). Under these conditions, healthcare insurance remains one of the basic tools that exist in modern society, with the primary aim to provide citizens with an expensive treatment they might need in the most challenging cases (O’Connor, 2018). However, regardless of the fundamental role of this instrument and regulations associated with its functioning, there are still many issues that limit opportunities to acquire the needed assistance. It means that ACA has to be modified with the primary aim of expanding coverage (Bauchner, 2017). In accordance with the relevant statistics, only 17.2% of all citizens were covered by Medicare (Bauchner, 2017). This number remains inappropriate for modern society.
At the same time, the price of hospitalizations remains high. The majority of provided services, especially in complex or emergency cases, might cost more than $10.000, which is unaffordable for a significant percentage of people (Glied & Jackson, 2018). Considering the fact that about 9%of all Americans do not have healthcare insurance at all, the significance of the problem becomes apparent. At the moment, annual health spending exceeds $3 trillion, which is too high even if compare with other states (Glied & Jackson, 2018). Which is even worse, these funds are distributed ineffectively, and many people remain uncovered by existing health insurance plans. That is why there is a critical need for the reconsideration of the sphere with the primary aim to find appropriate solutions and provide people with the needed care.
Current Practice Related to the Problem
At the moment, the utilized approach to healthcare insurance remains critically ineffective. First of all, it lacks the flexibility to adapt to the diverse needs of people, their current financial status, and their ability to afford particular care. It means that the majority of Americans will still face barriers while trying to become insured and acquire needed assistance (Glied & Jackson, 2018). Additionally, the existing schemes can be described as defective because of their inability to adjust them to the current environment and to the requirements that are relevant at the moment (Gabel, Green, Oran, Stromberg, & Whitmore,2015). The government offers schemes that are not welcomed by people as they prefer to enroll in some private healthcare plans to guarantee the ability to acquire needed care. Out-of-pocket funds to pay for medical bills do not work appropriately and cannot be a substitute for unreliable medical coverage due to the rising cost of healthcare services.
Impact of the Problem
The further increase in the significance of the problem will have a serious negative impact on the whole healthcare sector. At the moment, the level of people’s trust in the sphere remains critically low because of too expensive services and the decreased effectiveness of the proposed insurance plans. It means that the cooperation between a health worker and a patient will be undermined. Moreover, the absence of health insurance coverage undermines the health of the nation as millions of citizens are not enrolled in the existing schemes and might suffer from the critical deterioration of their health, including lethal outcomes. That is why there is a set of negative effects that emerge due to the existence of this problem.
Research and Non-Research Evidence
The majority of existing sources also support the idea that the currently existing approach to healthcare insurance remains critically ineffective. If the given tendency preserves, the ability to acquire appropriate care will be available only to the smallest part of the population or to the elite (O’Connor, 2018). It means that the situation is critical, and there is a need for the introduction of laws pertaining to ACA to alter the existing paradigm and include more individuals and services to guarantee that it will achieve the desired effectiveness levels (O’Connor, 2018). Otherwise, there will still be many flaws in the organization of these schemes and their provision to clients.
Moreover, there is a tendency towards the unfair distribution of insurance coverage. In other words, high-income consumers will be able to spend more time and available resources to make appropriate decisions regarding their insurance plans (Zhao, Mir, Ackermann, Kaphingst, & Politi, 2018). It means that existing schemes work well for those who have enough money to afford the most effective plans, while other people might not have coverage at all. This fact evidences the existence of a significant problem in the sphere that should be solved to attain critical improvement and guarantee that all plans and schemes will work appropriately and improve the health of the nation. In such a way, various sources prove that the proposed solution is desired.
Regarding the investigated problem, the following PICO question can be formulated to ensure the in-depth investigation of the problem:
In existing defective insurance schemes, can the approach presuppose adjusting the insurance models for optimal insurance flexibility compared to the reliance on out-of-pocket funds to cover for medical bills increase medical coverage and precondition better health outcomes?
|What is the problem, and why is it important?|
|Defective insurance schemes they result in the deterioration of the quality of people’s lives and the health of the nation|
|What is the current practice?|
|The reliance on out-of-pocket funds to cover medical bills|
|What is the focus of the problem?|
|How was theproblemidentified? (Check all that apply)|
|Safety/risk management concerns |
+Quality concerns (efficiency, effectiveness, timeliness, equity, patient-centeredness)
+ Unsatisfactory patient, staff, or organizational outcomes
Variations in practice within the setting
|Variations in practice compared with external organizations |
Evidence validation for current practice
|What is the scope of the problem?|
|What are the PICO components?|
|P – (Patient, population, problem): |
Defective insurance schemes
I – (Intervention):
Adjusting the insurance models for optimal insurance flexibility
C – (Comparison with other interventions, if applicable):
The reliance on out-of-pocket funds
O – (Outcomes that include metrics for evaluating results):
Increase medical coverage and precondition better health outcomes
|Initial EBP question:|
|What are the current health insurance problems and coverage?|
|List possible search terms, databases to search, and search strategies:|
|Search terms: healthcare, insurance, coverage, out-of-pocket funds, ACA, Medicare |
Databases: PubMed, NCBI, PMC
Search strategies: look for scholarly resources using search terms in databases.
|What evidence mustbegathered? (Check all that apply)|
|+Literature search |
+Standards (regulatory, professional, community)
|+Patient/family preferences |
Intervention for Recommended Practice Change
In such a way, the proposed intervention presupposes adjusting the insurance models for optimal insurance flexibility. The given approach will help to decrease the overreliance on out-of-pocket funds and provide more opportunities for people to become insured and improve the quality of their lives. The possible intervention might also presuppose more effective policymaking related to the sphere and cooperation at various levels with the primary aim to collect credible pieces of evidence proving the necessity of change.
Concerning the nature of the investigated problem, the introduction of critical change might presuppose the involvement of the most important stakeholders. First of all, the government, as the main authority regulating the work of the sphere, should be considered. It has all the needed tools to accept the proposed change and create a new framework. Second, patients as the main actors affected by the change should be taken as key stakeholders. Their role in the process is critical and should be given specific attention to attain success. Finally, health facilities and insurers are also important stakeholders that take an active part in the implementation of a new approach and its promotion with the primary aim to improve the current situation.
As for the possible barriers that might emerge while implementing the proposed change, one should, first of all, speak about the financial aspect. The healthcare sector critically depends on money as they are needed to provide needed services. That is why the reconsideration of the existing approach to insurance schemes might face complications because of the lack of financing (Zhao et al., 2018). Another possible barrier is the resistance of actors who are involved in the work of the existing system and might resist change because of the adherence to the old patterns. One more obstacle is the lack of understanding from clients and health workers related to the proposed reconsideration and its impact on the work of the whole sector. That is why there is a critical need for the consideration of all factors that might emerge and the provision of strategies for their resolution.
Strategies for Barriers
The most effective strategies to overcome the barriers mentioned above include the discussion of the problem of defective health schemes at the state’s level. First of all, it will guarantee the involvement of all stakeholders responsible for change and the introduction of positive alterations. Moreover, it will gather potent public support to attain reconsideration of the approach and transformation of the sphere. Another strategy might presuppose special education for clients to generate additional knowledge needed to engage in the change process and guarantee better conditions in terms of the existing approach to health insurance (Zhao et al., 2018). Utilization of these strategies will help to eliminate the majority of mentioned barriers and create the basis for positive change.
Indicator to Measure Outcome
One of the possible indicators to measure outcomes is the evaluation of the number of people who have health insurance that will help them to preserve the high quality of life and enjoy all benefits of the modern healthcare sector. The appearance of the positive dynamics reflected by the constantly increasing number of patients who can afford various care plans will prove the increased effectiveness of the proposed change and multiple opportunities for its further integration with the work of many health facilities to provide people with the demanded treatment. Moreover, the appearance of new, more flexible insurance schedules can also be taken as a credible indicator to measure outcomes and conclude about their effectiveness regarding the investigated problem.
Arboleda-Arango, A. M. (2015). Healthcare plans and consumer perceptions of healthcare institutions. Revista de Salud Pública, 17(1), 12-21.
Bauchner, H. (2017). Health care in the United States: A right or a privilege. Jama, 317(1), 29-29. Web.
Campbell, D. J., Manns, B. J., Soril, L. J., & Clement, F. (2017). Comparison of Canadian public medication insurance plans and the impact on out-of-pocket costs. CMAJ Open, 5(4), E808 – E813.
Gabel, J., Green, M., Oran, R., Stromberg, S., & Whitmore, H. (2015). Consumer cost-sharing in marketplace vs employer health insurance plans. The Commonwealth Fund, 38, 1-11.
Glied, S. A., & Jackson, A. (2018). How would Americans’ out-of-pocket costs change if insurance plans were allowed to exclude coverage for preexisting conditions? Commonwealth Fund, 1-9.
O’Connor, G. E. (2018). The relationships of competition and demographics to the pricing of health insurance premiums in Affordable Care Act– Era health insurance markets. Journal of Public Policy & Marketing, 37(1), 88–105.
Xu, P., Burgess, J., Cabral, H., Soria-Saucedo, R., & Kazis, L. (2015). Relationships between Medicare Advantage contracts characteristics and quality-of-care ratings: An observational analysis of Medicare Advantage star ratings. Annals of Internal Medicine, 162(5), 353-358.
Zhao, J., Mir, N., Ackermann, N., Kaphingst, K. A., & Politi, M. C. (2018). Dissemination of a web-based tool for supporting health insurance plan decisions (show me health plans): Cross-sectional observational study. Journal of medical Internet research, 20(6). Web.