Self-Interest Paradigm in Medicare Program

NB: We do not resell your papers. Upon ordering, we do an original paper exclusively for you.

NB: All your data is kept safe from the public.

Table of Contents

Introduction
Concept
Nature of Medicare
Cases
Discussion
References

Introduction

In modern civilization, the notion of self-interest is the defining and foundational concept behind the structures that shape the economic and political realities of society. The widespread assumption of self-interest assumes that it leads to failure due to irrationality, thus eventually causing failure at economic and government levels. While markets may be driven by self-interest, the government is theoretically presumed to maintain public interests. This report will analyze the self-interest paradigm in the context of the Medicare program with subsequent legal and political implications.

Concept

The self-interest paradigm implies that human behavior is also aimed at promoting and enhancing self-interest. There is no essential difference between public or political entities and private or economic agents such as corporations. It is assumed that everyone is rational with the purpose of assessing benefits and losses when evaluating any potential action. Politicians, who in theory are meant to serve the public interest, also act in order to maximize self-interest. Thus, using proper triggers, politicians can be influenced by interest groups offering financial incentives, which manipulates regulatory and legislative processes (Feldstein, 2006).

Public officeholders can be self-interested entities due to unconscious motivators, not necessarily due to deliberate and calculated actions. The maximization of utility is a subconscious psychological process that increases incidences of self-interested behavior beyond awareness of the public figures. Regulators are imperfect at enforcing public interest or may fail to do so at all when attempting to manage corporate or social behavior. The responsibility of monitoring and enforcement is spread amongst legislators, constituents, and private consumers. Ethical standards are determined by a combination of self-interest behavior and social norms. Politicians seek to maintain a public image of honorability and integrity, which sets boundaries to the extent they are willing to promote self-interest through ethical behavior. It is assumed that self-interest will always overwhelm direct concern for public welfare. Therefore, public officials will act with concern for others or the principle of fairness only in situations where it benefits their self-interest as well (Zamir & Sulitzeanu‐Kenan, 2017). In politics, this principle results in organized lobbyists to provide benefits to self-interest government figures in return for support on policies, essentially an exchange of interests.

Nature of Medicare

Medicare is a government-run national insurance program for citizens aged 65 and older who have paid necessary payroll taxes to be eligible. Part D of Medicare was created by Congress in 2003, and it offers various types of plans which consumers can select to fit individual needs (Cook, 2015). It was designed with the purpose to transfer negotiations of medication prices between insurance companies and drug manufacturers, rather than the direct involvement of the government. The creation of private-sector competition under government regulation was meant to lower drug prices. However, that proved to be inaccurate as the government has failed to competently regulate the market, resulting in excessive fraud and waste with false claims. The freedom of choice that was meant to be enabled by the competition never occurred since private companies began to collaborate to increase profit. Furthermore, the companies spend enormous funds on lobbying which ensures protection (Cook, 2015). Medicare Part D is a perfect example of the self-interest of private industry overwhelming the needs of the public.

Medicare finds its origins as part of interest group politics. The American Medical Association fiercely advocated public health insurance for the vulnerable elderly population in the mid-20th century. It was a system meant to regulate the cost increase in healthcare services. Despite being expensive for the government, Medicare expanded to become a formidable force of balancing politics and interests between beneficiaries and providers. However, in order to address the broad demands of public health and other stakeholders in the system, Medicare needs to become independent from individual interests. Continuous low-level lobbying demands create an imbalance and stretch the system. If Medicare is focused on controlling risks that drive up costs and constantly seek out activities that attempt to manipulate loopholes in its policies, then it can only address the narrow-minded medical interests of private corporations rather than achieve its purpose for the public well-being (Hacker, 2015).

Cases

In the case of L.P. v. Department of Health and Human Services (2014), it was decided that the appellant would not be granted the request for medication coverage under the Part D plan of Medicare. The requested compounded medications of diclofenac and liothyronine used to treat hypothyroidism are not eligible for coverage since they are created from bulk pharmaceutical chemical powders which were not reviewed or approved as safe by the FDA. Self-interest plays a role, in this case, for the government since the law is designed a manner which covers only a specific list of drugs based on ingredient composition, despite potential health benefits to the patient. This loophole allows avoiding coverage on a variety of premium-priced medications. At the same time, it benefits private markets that can create products using this loophole and overcharge consumers in order to increase profits. The committee recognized the clinical benefits of the physician’s prescription and the patient argued that the active ingredients in the medications are FDA approved. Therefore, these arguments should be considered substantial enough to approve coverage and benefit the patient with access to drugs which would have significantly increased the quality of life.

In the case of United Healthcare v. Department of Health and Human Services (2014), the council reviewed the appeal by the insurance company to cover emergency transport services for a patient to a skilled nursing facility in a non-emergency situation. This concerns Part C and Medicare Advantage plan. The patient was in poor health and had to be transported using a gurney. However, the patient refused to be examined or taken to the hospital despite concerns from the paramedics. Medicare covers ambulance services only when the patient’s condition requires both transportation services as well as medical services. However, upon examination of evidence, it was determined that the ambulance was used solely to furnish transportation and the patient refused medical service. Therefore, coverage of ambulance services was denied on the grounds that other methods could have been found for transportation.

This case was a matter of self-interest for the private insurance company. Ambulatory services are tremendously expensive and insurance, along with the government, only seeks to cover it in cases of necessary emergency. Insurance seeks to protect its business self-interests since it is vital to their growth and profit. The patient’s experience could have been improved in this case by agreeing to cover the ambulance since it was evident that he needed specialized equipment for transport. Unfortunately, insurance companies more often than not act in self-interest since they are politically protected by strict Medicare regulations which can be used to deny such claims.

Discussion

Financial security has become the core guarantee for maintaining a quality of life. In the context of the socioeconomic environment, there is an evident connection between income and well-being. In modern society, acquiring private property and pursuing self-interest is fundamental to ensuring the freedom of choice for citizens and are identified as critical momentum for progress. Commonplace public services and citizen entitlements such as healthcare are rapidly transformed into commodities that are sold on the private market. Access to it becomes directly dependent on private wealth. As relationships and services within society become monetized, the more financial security will ensure the quality of services available to them (Göpel, 2016).

However, that is not necessarily an adverse consequence but rather a natural transition of the economy from public to the private domain. In fact, the historical transitions of public services such as healthcare and education into private ownership and the professional economy ensured the growth of GDP and a tremendous increase in quality (Göpel, 2016). Policy over the last decades has been aimed at designing public institutions in a manner that forces self-interested citizens to strive for better financial outcomes in order to gain access to quality services. Medicare is one such government program that has been created in the paradigm of self-interest, benefiting both political entities and private markets while forcing citizens to actively protect their self-interests through financial security or advocacy.

Patient and citizen engagement is considered critical to the promotion of a sustainable healthcare model in the country. Citizens are most familiar with engaging with the health model as patients and seek to promote personal health and self-interest. Participation in a public health debate about the greater good of society which goes beyond individual self-interest and preferences may prove challenging and mostly unfamiliar. The issue with promoting public interest in healthcare is that it rapidly becomes a simple matter of multiple self-interests. For example, chronic health issues in public health are focused on individual behavior, rather than environmental or social contexts that force specific lifestyle choices that undermine health in the first place (Williamson, 2014). The ignorance of these widespread contextual factors and the failure to associate private healthcare with broad public issues of fairness and justice can cause citizen participation to overlook the underlying issues to healthcare.

References

Cook, M. (2015). Medicare Part D: Profit trumps public interest.The Orange County Register. Web.

Göpel, M. (2016). The great mindshift. Cham, Switzerland: Springer.

Hacker, J. S. (2015). Out of balance: Medicare, interest groups, and American politics. Web.

Feldstein, P. J. (2006). The politics of health legislation: An economic perspective (3rd edition). Chicago, IL: Health Administration Press.

L.P. v. Department of Health and Human Services, M-12-1470 (2014).

United Healthcare v. Department of Health and Human Services, M-13-4636 (2014).

Williamson, L. (2014). Patient and citizen participation in health: The need for improved ethical support. The American Journal of Bioethics, 14(6), 4-16. Web.

Zamir, E., & Sulitzeanu‐Kenan, R. (2017). Explaining self‐interested behavior of public‐spirited policy makers. Public Administration Review, 1-14. Web.

Click Here To Order Now!