1. CHAPTER 13: ETHICAL ISSUES AND
INTERNATIONAL HEALTH CARE SYSTEMS
• Analyze a current health care concern using the
ethical principles of autonomy, justice,
beneficence, and nonmaleficence
• Explain how nurses can avoid the risk of at least
two types of health care fraud
• Compare the health care financing of one other
country to the U.S. health care system
• Summarize at least three concerns shared by
many countries in the world related to health
care quality, access, and costs
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2. PRINCIPLES OF BIOETHICS
• Autonomy: The right of individuals to make
their own decisions about their care
• Justice: Equal or fair distribution of health
care benefits and risks
• Beneficence: Health providers must do good
and provide the most benefit possible
• Nonmaleficence: Health providers must avoid
or minimize harm
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3. IS FRAUD A PROBLEM? 2011 UPDATE
• Office of the Inspector General: 92% of U.S.
nursing facilities employ at least one person
with a criminal conviction
• CMS estimates FY 2010 improper payments
for Medicare fee-for-service and Medicare
Advantage of almost $48 billion, 9.4% of the
estimated total $509 billion spending
– This does not include the Medicare D drug
program
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4. FINANCIAL FRAUD
• Intentional deception or misrepresentation designed to
obtain something of value held by another
• 1996 Health Insurance Portability & Accountability Act
(HIPAA): health care fraud is knowingly and willingly
executing, or attempting to execute, a scheme to defraud any
health care benefit program or to obtain, by means of false or
fraudulent pretenses, representations, or promises, any of the
money owned by, or under custody or control of, any health
care benefit program
• Includes filing false claims, offering and receiving kickbacks,
and other schemes to divert money from the government
• Medicare and Medicaid are frequent targets of fraud
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5. FINANCIAL ABUSE
• Often difficult to distinguish from fraud
• Methods or practices that are unnecessarily
costly, improper, or at odds with customary
practice
• Exploitation of vulnerable clients such as the
elderly by family, caregivers, or criminals
• Example: neglect of nursing home patients;
phone solicitation offering cash giveaway in
exchange for cash outlay
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6. FRAUDULENT PRACTICES
• Billing for services not rendered
• Misrepresenting the diagnosis to justify
payment (DRG upcoding)
• Soliciting, offering, or receiving inducements
to influence future purchases (kickbacks)
• Billing for separate parts of a single procedure
(unbundling)
• Falsifying documents to justify payment
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7. MORE FRAUDULENT PRACTICES
• Providing services more often than indicated
(over-utilization or “churning”)
• Billing for unnecessary services
• Making single visits while billing for multiple visits
• Exhausting insurance benefits for one family
member then billing for another (looping)
• Falsifying the credentials of a provider to bill at a
higher rate (phantom billing)
• Billing Medicare and a private insurer for the
same treatment or procedure (double billing)
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8. Copyright © Springer Publishing Company, LLC. All Rights Reserved.
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Type of System Pluralistic
National Health
Insurance
National Health
Service
Principal
Features
Some uninsured
citizens and foreign
residents;
government and
non-government
providers; multiple
government and
non-government
funding streams
Universal
coverage;
government and
non-government
providers; often
national and
provincial budgets
Universal
coverage; largely
government
providers; funding
largely
government with
some self-pay
Typical
Problems
Uninsured
populations
Health care
rationing
Health care
rationing
Examples of
Countries
United States Canada, Japan,
many European
nations
Great Britain
Source: Adapted from V.G. Rodwin, in Kovner & Jonas, 1999.

9. U.S. HEALTH CARE PERFORMANCE
Compared to other industrialized countries:
• Proportion of elderly and rate of health care
employment is not the highest—these would
account for higher health care costs
• % GDP for health care expenditures is the
highest
• Per capita health care expenditures are the
highest
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10. DISPARITIES IN GLOBAL HEALTH CARE
FINANCING
“Low- and middle-income countries account
for only 18% of world income and 11% of
global health spending. Yet 84% of the
world’s population live in these countries
and they bear 93% of the world’s disease
burden.”
WHO, The World Health Report 2000, pg. 7
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11. APPROACHES TO HEALTH CARE RATIONING
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Approach
Strict controls limiting the health
care budget
Controls based on specific
priorities
Target Does not target specific diseases or
interventions
Often provides an affordable "basic" or
"essential" package of interventions
Principal
Features
Most common approach; most
frequently used in countries with
national health budgets
Social, political, and cost-effectiveness
criteria used to determine priorities
Typical
Problems
Resources managed according to
politics, often favoring the higher
income citizens at the expense of
the poor
Providers respond to demand for
services outside the approved package;
limitations to cost-effectiveness criteria
Examples of
Countries
Pre-1990 National Health System in the
United Kingdom, some European Union
countries, some developing nations
The Netherlands, New Zealand, Norway,
Sweden, Oregon (U.S.), Mexico,
Bangladesh, Columbia, Zambia
Source: Adapted from WHO, World Health Report 2000.

12. SOME GLOBAL HEALTH CONCERNS
• Shortage of nurses and other health care
professionals
• Aging populations
• Quality of health care services and patient
satisfaction
• Economic downturn
• Medical tourism
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13. HEALTHSPROCKET AUGUST 10, 2012
• Ranking of Selected Countries by % of Patients Rating Their Doctor 9 or 10 (1-10 scale)
• Top Ten Countries with Most Hospital Beds per 10,000 Population
• Top Ten Countries with Most Physicians per 10,000 Population
• Top 25 countries with the world's best healthcare systems
• The US ranks at the bottom of 19 industrialized countries in preventable deaths
• How the Performance of the U.S. Health Care System Compares Internationally
• Six Country Comparison: Hospital Satisfaction Level
• Six Country Comparison: Consumers Rating Their Health System Failing
• Six Country Comparison: Consumers Rating Their Health System Excellent
• Six Country Comparison: Public Health Care Spending % of Total Health Expenditure
• Health Expenditures per Capita - Seven Selected Countries
• Commonwealth Fund Overall Quality Ranking of Seven Nations' Healthcare Systems
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