Hlth 3050 Midterm Robinson ECU

What is health policy?

federal and state policy shape virtually all aspects of the healthcare system, from structure to organization

laws/policies impact our access to healthcare, how medicine is practiced, and how it is paid for

What are the types of health policies?

1. those that define the functions and powers of public health agencies (ex: government support for planned parenthood but money can't be used for abortions)

2. those that aim to directly promote and protect health (ex: smoke-free laws, seat belt laws)

Where is the authority for public health derived?

-Public health is not mandated in the constitution

-Federal powers is derived from interstate commerce

- most public health activities are enacted at state level

what are police powers?

- authority of state and local governments to regulate individuals and private business

- very powerful and wide reaching by permitting specific parties to engage public health activities

Typically speaking, what powers does the federal government have as it relates to health policy?

confers powers on the government that allow it to engage in public health activity that promote health and prevent disease (ex: taxes on cigs and alcohol, allocation of funding by congress, and minimum age drinking laws)

what are the three conceptual frameworks?

1. one based on broad topical domains

2. one based on historical contexts

3. one focused on stakeholders impacted by a particular policy

Conceptual Framework 1

Domain 1: concerned with individuals access to care, quality, and person's finance (ex: dying with dignity act)

Domain 2: why and how government regulates private individuals and corporations (ex: trans-fat ban in NYC)

Domain 3: ethical issues raised in the area of medical practices, intersection of public policy and law and morals (ex: stem cell research)

Conceptual framework 2

- based on social, political, and economic views

- perspectives:

1. professional autonomy

2. social contract

3. free market

Professional Autonomy Perspective

- Grounded in the notion that medical profession should have the authority to regulate themselves

- Dominate from 1880-1960

- Physician's expertise should translate into legal authority

- Policymakers allowed physicians to control a broad spectrum of policies (including payments, licensure, types of patients they would treat, amount of info disclosed to patient, determining negligence)

Social contract perspective

-dominate from 1960-1980

- the belief that complete physician autonomy over delivery and financing of healthcare is dangerous

-public policy and law should enforce a social contract

-sees physicians as just 1 stakeholder

-policies in this era centered on access to healthcare, creating new insurance programs, and pass anti-discrimination laws

Free Market Perspective

-grounded in freedom of marketplace and competition

- started dominance in 1990 and continues today to some extent

- healthcare services operate best in deregulated environment

- commercial competition and empowerment leads to most efficient healthcare system

-contends that social contract model is too much regulation

Conceptual framework 3

-policies are categorized by who is affected by them

- stakeholders: those whose interest are impacted by certain policy choices

- ex: patients, providers, governments, insurance companies, research community, etc have strong interest in various policies

authoritative decision

a decision made by an individual or a group that has the power to implement the decision

Defining Policy

-authoritative decisions made in branches of gov that influence actions and decisions of others

- a course of action pursued by a government

- authoritative decisions and guidelines that direct human behavior toward specific goals

Who makes policy?

- private and public actors or governments at the federal, state, and local levels

- importance of private actors includes insurance companies and private employers

What determines if something is policy?

-public policy problems

- beyond individual concern

-determine whether something is individual or policy affecting the public:

1. Individual: decides to participate in employee health program

2. policy: mandate to participate

Policy and Private sector

- private companies can dictate policy as well

- ex: shortage in flu vaccines (government could incentivize manufacturers through taxes to increase production but ultimately its up to the private manufacturer who determines how many vaccines are made

Policy Sturcturing options

1. authoratative decisions

2. incentives for persuasion

3. inaction can also be a policy

Public policymaking structure

various branches of government and the individuals that make up that branch that play a role in making policy

State-level Policymaking

-many of healthcare decisions come from the state level

- governor is the head of the executive branch at state level

- regarding health policy:

1. provider licensure

2. accreditation

3. some aspects of health insurance

4. most public health concerns

Differences in state-level policymaking vs. federal

- must have a balanced budget

- most states can't borrow money

- states are more likely to cut programs due to budget

Who are the official lawmakers in the U.S.?

Congress

Congressional Power

Levy taxes, collect revenue, pay debts, provide general welfare, regulate interstate commerce**, regulate foreign commerce, declare war, and senates can ratify treaties and confirm public officials

Vice President

President of the senate

speaker of the house

presides over the chamber

senate majority leader

speaks on behalf of majority party, schedules floor actions and bills

house majority leader

works with the speaker

house and senate minority leaders

speak on behalf of minority party

house and senate majority/minority whips

track legislation, mobilize members, etc

legislative committees

"workhorses" on Congress

Key decisions are made

Draft legislation is developed

Have a variety of roles

Standing committees: permanent

authoritative jurisdiction

make new agencies

appropriation authority

funding

oversight authority

monitor programs

legislative powers

congress- can override veto, controls spending of money, establishes lower federal court, can impeach and remove federal judges

president- can veto laws sent from congress, executive power

How a bill becomes a law

1. written

2. discussed in committee + voted

3. discussed in House of Reps. and Senate + voted on in both

4. President signs it or vetoes it (which brings back to Congress, needs 2/3 vote to override veto)

budget resolution

deciding how the federal money will be spent by broad categories (ex: defense, agriculture)

conference report

agreement on budget

reconciliation

making changes to law for mandatory spending programs to meet budget goals

continuing resolution

when budget hasn't been decided, gives government authority to keep spending

How a Budget is signed into law

1. The President submits a budget request to Congress

2. House and Senate complete initial resolution and completes concurrent resolution

3. House and senate complete appropriations bills

4. House and senate complete appropriations conference report

5. House and senate vote separately on the final bill

6. president signs budget into law

Appropriations

line item amounts to agencies and programs

Time period of Budget process

- Oct. 1 is first day of fiscal year for fed. government

- if no agreement is reached by then, operate on continuing resolution until budget agreement is reached (voted by congress)

- congress has only approved budgets 4 times before the start of fiscal year

Who is the head of executive branch?

president

Presidental powers

Military:war powers

Diplomatic:treaties and agreements

Executive:Executive orders and pardons/amnesty,

legislative:veto

executive order

direct agencies on how to implement certain laws

Adminstrative agencies

Executive department: Department of health and human services, department of defense, department of state, homeland security

independent agencies: US postal service, US securities and exchange commission

Why are departments and agencies important?

- carry out law

- Medicaid/medicare protection act - 2001??

Federal health bureau

- DHHS, VA, DOD are most important to healthcare policy

DHHS

Office for women and minority health, surgeon general, HIV/AIDS policy, vaccine program office, public health emergency preparedness

VA

-largest healthcare system

- for vets who didn't receive honorable discharge

- no premiums, copay, or enrollment issues (doesn't cover family)

DOD

- tricare program

- provides insurance for retired military

-variety of plans for active and retired members

- patients pay but still less than private health insurance

Local public health agencies

- focus on diseases, environmental health, and children health issues

- services include: immunizations, food inspection/safety, community assessments, epidemiology, TB testing, and screenings

Role of Law

- serves as a tool to govern relationships with each other, the government, and with society

- recognizes and establishes enforceable rights and responsbilities

- creates institutions to enforce them

What is a Law?

a system by which rules are disseminated, enforced, violated, disputed, interpreted, applied, and revised

Sources of law

Constitution, statues, regulations, common law/case law which are all primary laws

Constitutions (Fed vs state)

Federal: ratified 1789, short and general, delineates fundamental rights and obligations of government and individuals, includes bill of rights

State: state bill of rights, cannot take away rights by Cons., additional rights and protection, amended more frequently

Living Constitution

interpretation should be a reflection of current moral, political, and cultural values

moral constitution

infuse interpretation with moral philosophy

originalism

constitutional provisions have a fixed and knowable meaning

strict constitutionalist

limit their interpretation the constitution's actual words

statutes

-laws written by legislative bodies at all levels that command or prohibit something

- tend to be forward thinking and general

-can lead to interpretation issues

-federal statutes overrule state's

Adminstrative power

-specific regulations written to assist with implementation of directives

- involves agencies of the executive branch (medicaid program)

common law

- essay-like opinions written by appellate courts articulating the basis for their decision

- courts interpret and apply law to match values of society

-heavily influenced by legal precedent and stare decisis doctrine

decisis doctrine

says prior case law should not be overturned

Separation of Powers

Constitutional division of powers among the legislative, executive, and judicial branches, with the legislative branch making law, the executive applying and enforcing the law, and the judiciary interpreting the law

Federalism

- allocation of federal and state legal authority

- fed. gov is one of limited powers while statess retain all powers not expressed exclusively to fed gov

- most legal issues regulated at the states (marriage, divorce,etc)

- results in public health regulated under police powers of the state

Role and Structure of federal court

- 3 tiers: trial court and 2 levels of appellate courts for appeals

-federal cases are decided in appellate courts

- can petition to have case heard by supreme court but 4 of the 9 judges have to agree to hear it (only grant about 15 petitions annually)

Public Health relation to legal system:

-federalism (via police powers) is why public health falls to the state's responsibility (ex: immunizations, infectious disease mandates, environmental hazards regulation)

- fed gov can tax and regulate the spending

Role and structure of State court

- 3 tier similar to fed court (trial and 2 appellate courts)

-some have inferior courts (small claim court)

-some have specialty courts (juvenile court)

Judicial Review

-The power of the courts to declare laws unconstitutional

- supposed to be impartial

-Marbury v. Madison

Marbury v. Madison (1803)

- supreme court ruled that it had the power to review acts of congress and determine its consitutionality

- established and justified the power of judicial review

Why is health insurance coverage important?

-Uninsured are less likely to have a primary care physician

-uninsured are less likely to follow treatment recommendations

-uninsured are more likely to forego care

-uninsured are more likely to be hospitalized

IOM 6 areas to improve healthcare quality

Safety - patients and healthcare workers should not be in danger

Efficacy - use evidence-based treatments

Patient-centeredness - Sensitive to the needs, values, and preferences of the patient

Timeliness - provide care in a timely manner

Efficiency - make the best use of resources

Equity - provide essential health benefits to all people

US health care system

System Type: no unified system

Universal Coverage: near universal after ACA

Role of Private Insurance: significant

Financing: private payments and tax revenue

Hospital reimbursement: varies by payor

Physician reimbursement: fee schedule or per person

Canada health care system

System Type: national health insurance

Universal Coverage: yes

Role of Private Insurance: supplemental to medicare

Financing: mostly tax revenue

Hospital reimbursement: global budget

Physician reimbursement: negotiated fees with provinces/territories

Great Britain healthcare system

System Type: national health insurance

Universal Coverage: yes

Role of Private Insurance: minimal

Financing: all federal income tax revenue

Hospital reimbursement: global budget

Physician reimbursement: salary or per person

Germany health care system

System Type: socialized health insurance

Universal Coverage: yes

Role of Private Insurance: minimal

Financing: mandatory employer and employee contributions to national health fund

Hospital reimbursement: diagnostic related group

Physician reimbursement: negotiated fees with fund

Standard of Care

- physicians have no legal responsibility to care for a patient

- if they opt to provide treatment, they are responsible for level of care

-failure to do so results in legal liability

Licensure and Accreditation

- police powers: to ensure residents are protected from healthcare

- you either are granted a license or not

- little monitoring

- most states rely on AMA to have sufficient ethical and practice standards

- licensure laws prevent poor quality of care rather than promoting high quality care: Ex- license is revoked for poor quality of care while taking intoxicants but if you provide substandard care it goes unnoticed

medical errors as a public health concern

-overall, more people die each year from medical errors that from motor vehicle accidents, breast cancer, or AIDS

-44,000 deaths due to hospital related error

-other estimates are as high as 98,000

-approximately 1.5 million adverse medical events that seriously hurt or permanently disable patients

Risk managment programs

monitors risks associated with non-physican personnel and with facilities under the direct control of hospital administrations

peer review process

a secretive evaluation of hospital-based physician practices by physicians themselves

medical error reform

2 objectives:

- to redesign healthcare delivery methods and structures to limit the likelihood of human error

- to prepare in advance for inevitable errors that will occur in deliveries regardless of the precautions taken

strategies for medical reform

-more standardization of medical procedures

- mandatory reporting of medical errors

-increasing and improving technology systems

- establishing national focus on patient safety

Patient safety and quality improvement act

-Mandates reporting system anonymously

-Protects individuals who report

-2005

Hospital liability

-larger focus on hospital based care

-need for response to liability claims

- 2 theories of liability:

>Vicarious

> Corporate

Vicarious liability

-Legal doctrine under which a party can be held liable for the wrongful actions of another party

- institution can be held responsible because physician is acting as an agent for the hospital but are considered independent contractors

-exceptions: actual agency and apparent agency

Corporate liability

-Holds entities accountable for their own "institutional" acts or omissions when their negligence causes or contributes to an injury

-Darling v Charleston Community Memorial Hospital (Case)

Insurer liability

- not susceptible to be sued

- after darling decision, courts held insurance companies liable for the coverage decisions resulted in injury or death

-insurance has to approve treatment before doctor can do it

How did ERISA of 1974 impact liability cases?

-prevents the recovery of monetary damages under state law theories of liability when employer-sponsored benefits are improperly denied

-can only sue to recover actual cost of the benefit lost

supersedes any state law regarding liability cases

ERISA (Employee Retirement Income Security Act of 1974)

prohibits individuals from recovering damages for death and injuries caused by denial of coverage to the extent that the individual receives healthcare coverage through a private employer sponsored plan

-established in 1974 to protect employee pension system from fraud

MMA and DRA

Hospitals who report on specific quality measures get full annual payment while failure to report results in a 2% decrease

ERISA case: Aetna health inc v Davila

-patient received a substitute medication that resulted in complications

- supreme court ruled that ERISA preempts lawsuits for damages against an individual with ERISA-covered plans

TRHCA, MMSEA, MIPPA

physicians who report quality indication gets bonuses

ARRA

provides incentives to utilize electronic medical records

ACA and quality

-quality measurement and development

-public reporting

-value-based purchasing

-made it to where medicaid could identify, measure, and pay for higher quality of care

Locality rule

Hall v Hilburn

the testimony provided on behalf of the patient as to whether a physicians actions met the standard of care could only come for physicians who practiced within the same or similar locality as the physician on trial

What is quality

varies based on stakeholder

Custom Rule

Helling v Carey

the doctor violated the customs of his own profession as determined by others within the profession

ACA requires that:

-HHS select an organization to bring together stakeholders to agree upon quality measures

-used by government health programs and private insurance