|Learning Objective #1: Describe Professional Caregiver Insurance risk and how unsound insurance risk transfers to health care providers limit service availability|
|Learning Objective #2: Discuss the need for health care financing mechanisms that explicitly protect health care providers from insurance risk assumption and assure the integrity of insurance markets|
Design: Risk theoretic analysis of the impact of insurance risk transfers on health care providers and organizations (HCPs), explicating the impact of portfolio transfers from insurers, to HCPs, and describing how PCIR transfers limit resources for marginalized HCPs and consumers using individual presentations showing these impacts.
Population, Sample, Setting, Years: Affected populations include HCPs and consumers in marginalized communities such as urban and exurban areas, vulnerable consumers, disease specific populations, and chronically ill clients.
Concept or Variables Studied Together: PCIR is financial and insurance risk assumed by HCPs in capitation, DRG, HMO, and nursing operations. PCIR limits revenues and obligates HCPs to perform uncertain levels of service, constraining operations, and reducing services to compensate for necessary premium inadequacies. PCIR disadvantages consumers and HCPs by eliminating insurance benefits, destabilizing HCPs financially, moving insurance claims management to bedsides, and decreasing operational efficiencies.
Methods: This symposium uses small sample theory to explicate the impact of PCIR transfers on HCPs, demonstrating higher relative risks of financial ruin in HCPs compared to financially stronger, insurers. Additional presenters apply PCIR insights to assess and reveal consequences of PCIR on HCPs and marginalized consumers.
Findings, Conclusions and Implications: PCIR forces HCPs to manage insurance/financial risks. Insurance risk assumption creates ethical, legal, and financial conflicts incompatible with trusted caregiving, and compromising clients and HCPs. Healthcare financing mechanisms must insulate HCPs from insurance risk assumption, guarantee access to care, and insure the integrity of the insurance market by preventing inappropriate PCIR transfers. Nurses from bedside to advanced practice must understand PCIR transfers, recognizing that while providers profit, most must reduce service capacity and delivery, address needless ethical conflicts, non-existent in traditional insurance aggregation and risk retention.