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HA4070D – Regulatory Environment in Health Care
Assignment 06: Appealing Decisions
 
Directions
Complete the questions below based on the problem identified. Your written response should be no less than two to three pages in length.
Problem: Mr. H. was a diabetic and had severe ulcers on his feet. He was a member of an HMO, and his primary care physician had prescribed a treatment regimen that was proving ineffective. In response, the primary care physician offered Mr. H. an amputation below the knee that was his only option. Mr. H. went out of plan to a local wound care center that specialized in diabetic wound treatment where he was advised that vein by-pass surgery would likely take care of his problem. The HMO denied such surgery because Mr. H. referred himself to the specialist without permission. The HMO advised Mr. H.’s family that its utilization review department was reviewing the case, but that it would take at least a month to review. Subsequently, the HMO agreed to approve such surgery, but only if done by Mr. H.’s current medical group, which did not have any physician who had ever performed vein by-pass surgery. Mr. H.’s family asked for him to be transferred to a primary care physician at the medical group that staffs the wound care center. The HMO responded that although they sometimes approve such requests, they would not do so in Mr. H.’s case and that they had already granted enough of his requests. They gave as their reason a provision in the plan documents that prevent referrals outside the plan’s network when the network’s physicians have the capability to perform the required procedure.
This problem is adapted from a real case history developed by the Center for Health Care Rights in California.
• What procedural remedies does the patient likely have under private insurance and under Medicare or Medicaid?
• Are they adequate?
Be sure to include the following based on the criteria below:
Student examines legal issues related to healthcare rationing and medical necessity.
Student identifies remedies the patient would have under private insurance and if they are adequate.
Student identifies remedies the patient would have under Medicare and if they are adequate.
Student identifies remedies the patient would have under Medicaid and if they are adequate.

Program/policy evaluation is a valuable tool that can help strengthen the quality of programs/policies and improve outcomes for the populations they serve. Program/policy evaluation answers basic questions about program/policy effectiveness. It involves collecting and analyzing information about program/policy activities, characteristics, and outcomes. This information can be used to ultimately improve program services or policy initiatives.
Nurses can play a very important role assessing program/policy evaluation for the same reasons that they can be so important to program/policy design. Nurses bring expertise and patient advocacy that can add significant insight and impact. In this Assignment, you will practice applying this expertise and insight by selecting an existing healthcare program or policy evaluation and reflecting on the criteria used to measure the effectiveness of the program/policy.
To Prepare:

• Review the Healthcare Program/Policy Evaluation Analysis Template provided in the Resources.
• Select an existing healthcare program or policy evaluation or choose one of interest to you.
• Review community, state, or federal policy evaluation and reflect on the criteria used to measure the effectiveness of the program or policy described.

The Assignment: (2–3 pages)
Based on the program or policy evaluation you selected, complete the Healthcare Program/Policy Evaluation Analysis Template. Be sure to address the following:

• Describe the healthcare program or policy outcomes.
• How was the success of the program or policy measured?
• How many people were reached by the program or policy selected?
• How much of an impact was realized with the program or policy selected?
• At what point in program implementation was the program or policy evaluation conducted?
• What data was used to conduct the program or policy evaluation?
• What specific information on unintended consequences was identified?
• What stakeholders were identified in the evaluation of the program or policy? Who would benefit most from the results and reporting of the program or policy evaluation? Be specific and provide examples.
• Did the program or policy meet the original intent and objectives? Why or why not?
• Would you recommend implementing this program or policy in your place of work? Why or why not?
• Identify at least two ways that you, as a nurse advocate, could become involved in evaluating a program or policy after 1 year of implementation.