Healthcare Delivery Exam 3

Healthcare Law, Healthcare Tech, and Financing (Slide )

What is “law” in the slides?

a body of rules for the conduct of individuals and organizations

What are some important aspects of law?

1) Often interpreted differently and may change over time

2) Created so there is at least a minimal standard of action required by individuals/orgs

3) Created by federal, local and state governments4) Enforced through government mechanisms of penalties or sanctions.

What is common law?

When the judiciary system makes decisions on a case based off of previous legal decisions about past cases

What is the minimal standard for action?

Federal law, but state laws may be stricter

What are statutes?

Laws created by legislation

T or F: Both common and statutes are interpreted by administrative agencies by developing rules and regulations that interpret the law

True

What is Civil Law?

Focuses on the wrongful acts agaisnt individuals/orgs based on contractual violations

What is a tort

“A wrong”. A wrongful act, considered under the category of civil law, but may not have a preexisting contractthat causes harm or loss to another person, allowing the injured party to seek legal remedy.

T or F: To prove a civil infraction, you need just as much evidence as a criminal case

False, criminal cases need more

What is criminal law?

Concerned with actions that are illegal based on court decisionsWhat

What is important to remember about criminal law?

1) In order to convict someone of a criminal activity, it has to be proven without reasonable doubt of guilt

What are some examples of criminal law infractions?

Medicaid or Medicare fraud

What is the American Heritage Dictionary’s definition of medical malpractice?

improper or negligent treatment of a patient by a provider, which results in injury, damage, or loss

T or F: Medical malpractice has resulted in over 200,000 deaths per year

False 80-100k

T or F: Patients have sued providers bc they feel they were not given the proper level of care compared to the standard in the industry

True

What is the general requirement for a patient to sue a provider based on standard of care?

The patient must show that the provider acted negligently in rendering care, and that such negligence resulted in an injury

What are the four specific requirements to sue a provider for negligence?

1) Professional Duty owed to the patient

2) Breach of such duty

3) Injury caused by the breach

4) Resulting damages

T or F: Money damages, if awarded, only provide for the economic loss that occured

False, it also accounts for pain/suffering that ocurred as a result

What is the definition of negligence

Unintentional act or omission of an act that would contribute to the positive health of the patient

What is an intentional tort

Assault/battery or invasion of privacy (surgeon performing surgery on a patient without consent)

T or F: As a result of the number of malpractice suits in the US, malpractice insurance premiums have raised

True

What is defensive medicine

Providers order more tests or lab work than necesary to protect themselves from any potential malpractice suits

T or F: There is no cap on the amount someone can claim in malpractice claims

False, there are statutory caps in place to limit the amount

Why did states feel the need to introduce a statutory cap on malpractice claims?

The less an insurance company has paid out in insurance claims, the less they have to raise insurance rates

T or F: Voluntary hospitals are exempt from malpractice suits

False, they used to be but are no longer

T or F: The fact that employers have to take responsibility for their employees wrongdoing has increased malpractice claims

True

The concept of informed consent being expanded has had what effect on malpractice claims?

Increased them

“Standard of care” has become what kind of standard in the US, and what has it done for malpractice claims?

State or national standard, and has increased claims

What did the supreme court state about malpractice claims and income?

They must be included as taxable income to the person who made the claim

What is the most common violation in the healthcare system?

Healthcare fraud (illegal acts for financial gain)

What is the Medicar Fraud Strike Force?

A task force that uses both federal and local law enforcement agencies to combat healthcare fraud

What has the effect of the Medicare Fraud Task force?

They recoup 4$ for every 1$ spent, and combat all kinds of medical abuse

What is the false claims act?

Originally intended to protect the federal government against defense contractors, has now been amended many times with a focus on healthcare (medicare/aid) fraud. Imposes criminal penalties on anyone who tries to present fictitious clais for paymeny to the federal government.

What are thhe three ways a physician can initiate a reltionship with a patient and what do they mean?

Contractual relationship, express contract, implied contract

Contractual right to admission can be considered a contract in what situation?

IF the hospital has contracted to treat certain members of an organization, if gov’t hospitals are required to provide care regardless of ability to pay

Contract to care for a designated population is indicative of what?

An HMO or managed care contract

What is an express contract?

A simple contract, and a mutual agreement of care between doctor and patient (but the physician defines the limits/parameters of care”

What is an implied contract?

Can be implied from a physicians actions, if a physician gives advice regarding treatment

T or F: Physicians must take proper steps to end the patient relationship so they are not accused of patient abandonment

True

When is ending the patient relationship not on the physicans?

If the patient withdraws or if medical care is no longer needed

What is the Hill-Burton Act of 1946

Federal grants were provided to states for hospital construction to ensure there were beds for 4.5 beds oer 1k people

What is the Emergency Medical Treatment and Active Labor Act (EMTALA)?

Requires Medicare-participating entities to provide emergency care for a life-threatening condition if that entity provides dedicated emergency services. Facilities can be fined thousands of dollars for not adhereing to EMTALA

What is CHIP?

Enacted under the Balanced Budget Act of 1997, and funded by federal and state financing (administered BY THE STATES and CMS). Created to provide coverage for low-income children (19-) whose family income exceeds the income level requirements of medicaid

What is BIPA?

Benefits Improvement and Protection Act of 2000, added coverage for preventive and therapeutic services, increased federal funding to state programs

What is the Health Insurance Portability and Accountability Act (HIPAA)?

Passed in 2002 to protect a patient’s personal medical records and other health info maintained by healthcare providers, hospitals, insurance companies and health plans

What is the purpose of an antitrust law?

To protect consumers by ensuring there is a market driven by competition so consumers have a choice for healthcare

What did the Sherman Act of 1980 do?

Prohibited monopolies and targeted price fixing (which prohibited the consumer from paying a fair price) to stablilize the market

What are 5 things the Sherman Act prohibits?

Market division (when 1+ health orgs decide which services will be offered at each), Tying (when healthcare providers only sell a product to a consumer who will buy a second product from them), Boycotts (when healthcare providers have an agreement not to deal with anyone outside their group, which interferes with the consumers right to choose), places restrictions on hospital mergers and aquisitions, and allows individuals to sue for three times the damages plus legal costs.

Hart-Scott-Rodino Antitrust improvement Act of 1976

An amendment to the Clayton act ensured that hospitals and entities that have entered mergers/acquisitions and joint ventures must notify the DOJ and FTC before any final decisions are made

What is informed consent?

Based on the patients right to make an informed decision regarding medical treatment. It is a legal requirement in all states. Providers must discuss the diagnosis, the nature of the proposed treatment, risks and benefits of treatment and possible alternatives, and the risks and benefits of not agreeing to the treatment,

T or F: If a patient provides consent for a procedure or treatment , its considered negligence.

False, if they DO NOT provide consent, it is considered negligence

In a medical emergency where informed consent cannot be given, what happens?

Statutory consent, which presumes a reasonable person would give consent to the lifesaving procedure. Consent may also be implied in non-emergency situations, such as when a patient volunteers for a procedure.

What are the two legal standards to determine what consitutues informed consent?

Reasonable patient standard, which focuses on the patient’s info needs, including risks and benefits that allow the patient to make a decision

Reasonable physican standard which focuses on the standard information that would be given by any physican to a patient contemplating the same procedure or treatmentT

T or F: Most states do not utilize the reasonable patient standard

False, most states do

What is the patient self-determination act of 1990?

Requires hospitals, nursing homes, home health providers, hospices, and managed care orgs that provide services to medicare and medicaid eligible patients to supply information on patients rights to patients upon admission, virutally applies to every healthcare facility

What is the patient bill of rights?

States that the patient has the right to all information from their provider regarding any testing, diagnoses, and treatments. Must be provided to the patient in terms they will understand.

What is the Fraud Enforcement and Recovery Act of 2009 (FERA)?

Expanded possible liability for false claims by applying FCS to a broader range of transactions, reducing the proof required ot establish illegal activities and expanded the pool of potential whistleblowers that may bring retaliation claims. The ACA also provided funding to support new initiatives aimed at combating fraud, including more stringent federal sentencing guidelines for it.

What is the Title VII of the Civil Rights Act of 1964?

This landmark act prohibits discrimination based on race, sex, color, religion, and national origin. Sexual harassment issues fall under this act

What are some examples of things that fall under hostile work environment?

Lewd photos on display or suggestive joke telling. Nurses often experience sexual harassment from colleagues, physicians, and patients.

What are some examples of unlawful sex discrimination?

Failing to hire an applicant because she is transgender, firing an employee because he is planning or has made a gender transition, denying an employee equal access to a common restroom corresponding to the employee’s gender identity, harassing an employee because of a gender transition, denying a promotion based on sexuality, providing a lower salary to an employee because of sexual orientation or gender or denying spousal benefits to a gay couple.

What did Title VII allow individuals to do?

Seek damages for back pay. Enabled individuals to receive punitive (damages to punish the defendant) and compensatory damages (financial/psychological harm) and then further extended the damages to include sexual, racial, and disability related discrimination

What is informatics?

The science of computer application to data in different industriesW

What is medical informatics?

The science of computer application that supports clinical and research data in different areas of health care

What are health information systems?

Systems that store, transmit, collect and retrieve research and clinical data

What is the goal of Health Info Tech?

To manage health data that any stakeholder or player in the healthcare industry can utilize. The result is an electronic patient record. Continued increases in healthcare costsand lack of access to quality healthcare resulted the need to develop more efficient delivery has led to HIT

Why is a Chief Info Officer important?

Emphasized how important info systems and tech had become to healthcare orgs, and manages the orgs information systems

What did the IOM report on New Health systems say?

It stressed the importance of improving the info tech infrastructure as well as the importance of an electronic health record (EHR) of the patient’s med history. Additionaly discussed the importance of patient safety by establishing data standard for collecting patient information

What is the HITECH Act?

Enacted to stimulate the adoption of health info tech in the US

What is the Office of the National Coordinator for Health Info Tech (ONC) Responsible for?

Implementing the incentives and penalties program and creating “meaningful use” guidelines for physicians and others that will help them recieve incentive payments and avoid penalties in the future

T or f: Nearly all states are implementing the EHR system.

tRUE

T or F: Most of the hospitals eligible for Medicare and Medicaid EHR Incentive Program haven’t achieved meaningful use

False, they have

What is “meaningful use”?

As defined by CMS, it has established core measures that healthcare providers must meet to determine the EHR system is being adequately used.

EHR vs. EMR?

EMR is an electronic record of health related info on an individual that is accumulated from one health system and is utilized by the health org that is providing patient care

EHR is an accumulation of info from the MANY orgs that have been involved in patient care and can be shared with other sites

What are some of the benefits of EHRs?

Increased comprehensive reporting that uses both clinical and admin data, provides an opportunity to analyze and review patient outcomes (due to standardization of clinical assesments), automate reports can improve patient discharge, improves operational efficiency, online documentation takes less time to write, it provides aggregate data to other departments and its always legible.

What are some of the cons of EHR systems?

½ of Physicians spend their time entering data info in the system, which results in more burnout and less time with patients. Higher implementation costs, no consistent national data standards, staff and professionals have to be trained to use the program, and there has to be uniform adoption of the system by ALL participants

What are Patient Portals?

Enable patients to securely access their patient info at any time, they can view lab results, visit summaries, records of tests, and prescriptions. Patients can also message their providers, request prescription refills and schedule routine appts. They can also make payments

What are some medical applications of AI?

Expert systems, which were developed to imitate experts’ knowledge in decision making, and Clinical decision support systems, which are designed to integrate patient info, medical info, and an expert system to generate information that assists with cases.

What are some advantages of Expert Systems

They can be used to alert healthcare providers of a change in patient condition and can have a lab test or intervention performed. Can also assist with diagnosis using the system database. In addition, can expose weaknesses in a treatment plan or check for drug interactions and allergies. Can interpret imaging tests to falg any abnormalities.

What are some legal or ethical issues with EHRs?

The sharing of patient info electronically with other providers, does it violate HIPAA about privacy and confidentiality? Does the patient consent to the sharing of information every time their info is shared with other providers?

What is CDSS (Computerized Physician Order Entry)?

Enables a patient’s provider to enter a prescription order or order for a lab or diagnostic test into a computer system. Can be entered from a device, it enables the provider to order a test/prescription/procedure, connected to a decision support system and alerts providers to any problems with their orders, and can be integrated into the overall computer system of an org.

What is e-prescribing?

An electronic prescription focuses on improving patient safety, seeks to address problems that can arise in meds ordering and admin because of drugs with similar names, dosages, and labeling.

T or F: OVer 90% of pharmacies accept e-prescriptions

True

What did MIPPA do?

PRovided incentives to encourage physicians to e-prescribe

T or F: Medicare penalized physicians who do not e-prescribe by reducing their reimbursement for all subsequent years

True

What do Pharmacy Benefit Managers (PBMs) do?

They are companies that administer drug benefits for employers and insurance companies, they contract with managed care orgs, self insured employers, Medicaid and MEdicare managed care plans, federal health insurance programs and local govt orgs.

T or F: Most patients with drug coverage do not recieve benefits through a PBM

False, they do

What is spread pricing?

When PBMs are reimbursed at a higher rate for generic drugs than what they paid for from pharmacies

What are drug-drug interactions?

used by software programs to alert pharmacists and clinicians about possible drug interactions. Alerts can notify the provider about interactions, and strategies regarding them

What are HIEs (Health info exchanges)

Developed as a single source platform to collect, store, and share data that was be used by providers to make informed decisions. They are the foundation of data driven patient care because they provide the ability of interoperability among patient systems to integrate data

What are RHIOs

a group of orgs funded by the federal govt, within a geographic area that shares health data electronically, typically from EHR and EMR systems.

What is blockchain tech?

A system for recording and storing transaction records which are distributed across all participants who are sending the data. The TrustYourSupplierIt enabled suppliers to easily connect healthcare industry to much needed supplies

What is IBM Watson

A computer built with AI tools. Prodives health analytics consulting for health organizaitons. Focuses on genomic adn oncology, improving medical imaging, life sciences, value based and patient centered care

What was the inherent flaw with IBM Watson?

Hypothetical data was used instead of actual cancer data for their cancer diagnostic tools.

E health vs telehealth

Telehealth: broad term, encompasses the use of IT to deliver education, research and clinical care

E-health: the use of the internet by individuals and healthcare professionals to access education, research, products and services

What is telemedicine

the use of IT to enable healthcare providers to communicate with rural care providers regarding patient care or to communicate directly with patients regarding treatment (ex: telephone consultation)

What is the Council for Affordable Quality Health Care?

A nonprofit of alliances and health plans and trade associations that discusses efficiency initiatives to exchange patient info

What is the CORE commitee?

Borrows from the banking industry’s standards for one of the largest electronic payment systems in the world, used for data exchane of EHRs to comply with HIPAA and other standards

What are Enterprise data warehouses?

Designed to provide information that helps orgs in strategic decision making. Requires integration of many computer systems across an org

Who hs the best EDW’s in the nation?

The Veteran’s Affairs Org

What is RFID?

Radio frequency identification chips transmit data to recievers, and has a unique signal indicating where it is (can be used to identify who scans it and when)