Anthem Insurance Companies’ Risk Management Essay

Medical malpractice is an issue that affects healthcare establishments and insurance companies from both legal and ethical perspectives. The primary implication of the problem is its impact on the health of individuals and the reputation of the clinic as an accountable care organization (ACO) that provides high-quality services. It is crucial for Anthem to have proper assessment criteria and strategies to manage the financial risks connected to medical malpractice. Anthem Insurance Companies’ Risk Management Essay

Issue Description

The organization in question is an insurer Anthem that has to provide reimbursements to medical establishments for their services. While Anthem does not have to deal with malpractice claims directly, the company suffers from unnecessary payout for visits to medical establishments and drug prescriptions. The insurer does not account for malpractice claims or adverse patient outcomes, for instance, death, but the issue remains to be a risk factor due to indirect reimbursement implications.

The specific malpractice issues that Anthem deals with are connected to the increase in spending per patient by 5% in 2019 despite them using the same number of services per year (“This week in healthcare reform,” 2019).

One aspect of this safety issue is the improper management of chronically ill individuals who often visit the emergency department (ER) despite a possibility of receiving care at home or during a regular visit to a hospital that can be reduced by 30%. Reports indicate that over $8.3 billion is wasted each year due to the improper management of patients (“This week in healthcare reform,” 2019). Anthem has to reimburse providers for services event in cases where the results of their interventions are adverse. Anthem Insurance Companies’ Risk Management Essay

Legal and Ethical Implications

The Patient Protection and Affordable Care Act outline the problem and encourage organizations to develop solutions that would help mitigate the issue and ensure safety (Zigrang, 2017). From an ethical perspective, the personnel of medical centers has a responsibility to help individuals, without causing harm to their health state and by adhering to the choices that patients make. This issue is the basis of work for all medical establishments. The internal context of the problem involves the emotional and professional impact that lawsuits and adverse events can have on physicians, while the external effects include the perception of medical care. Anthem Insurance Companies’ Risk Management Essay

Risk Indicators

Firstly, performance indicators and measurements of risk should be included in the balanced scorecard to ensure proper control of this issue. Black, Wagner, and Zabinski (2017) argue that patient safety indicators (PSI) have a connection to the malpractice claims. According to the study conducted by the authors, healthcare organizations that pay more attention to PSIs are less likely to receive payout requests or legal claims.

Additionally, Rahimi, Kavosi, Shojaei, and Kharazmi (2017) developed a model that consists of 22 indicators, which can help track adverse events and implement strategies that will reduce the number of adverse events claims. Among those, the following can be used to identify the quality of services – discharge with personal satisfaction, hospital infection rate, clinical errors, the rate of patient complaints, and patient satisfaction percentage.

Thus, the risk financing issue can be identified by monitoring the balanced scorecard. Goals regarding a number of errors and complaints can be set, with appropriate strategies for achieving them to manage this issue. The challenges with this approach include bias connected to patient satisfaction rate and self-reporting of errors. However, the former does not affect PSI measures directly, while the latter can be mitigated by explaining the importance of reacting to problems that arise with patients appropriately. Anthem Insurance Companies’ Risk Management Essay

Thus, the personnel of the clinic should be aware of both legal and ethical implications of malpractice and should cooperate with the establishment to improve PSI. Based on the literature, it can be concluded that measures that this medical clinic should take include increased attention to the safety of patients within the establishment.

Recommendations

The primary aim of this memo is to ensure that Anthem and its personnel can adopt strategies for lowering the risk of malpractice cases and the provision of unnecessary services to patients. One option is ensuring that providers have professional liability insurance and work in accordance with the “no blame” policy as an approach to managing the financial risks associated with the problem in question (Zigrang, 2017; Cooper et al., 2017).