Healthcare Legal & Professional Fundamentals

Healthcare Industry Overview

• U.S. health-care spending (2019): 3.8\text{ trillion} and rising with aging Baby Boomers.
• Health care is a major, expanding employment sector.

Frontline Role & Professionalism

• Frontline employees (e.g., nurses, MAs) often see patients before physicians.
• Expected to be “above reproach”: professional appearance, communication, efficiency.
• Errors (e.g., dosage miscalculation) can be life-threatening; accuracy is critical.

Payment Systems & Managed Care

• Traditional fee-for-service: provider paid for each service delivered.
• Managed care (HMO, PPO): providers receive fixed payments, shifting cost risk to them.

Licensure vs. Certification

• Licensure = legal requirement (RN, MD, electrician); practicing without it is criminal.
• Certification = voluntary credential (MA, billing/coding, ultrasound); employers may still hire non-certified staff.
• Scope of practice and oversight board established by Medical or Nursing Practice Acts.

Disciplinary Actions by Licensing Boards

• Warning → Suspension (temporary) → Revocation (permanent) of license.
• Boards can impose conditions on reinstatement (e.g., mandatory supervision).

Board Certification (Physicians)

• Additional education + exam; indicates expertise.
• Raises legal standard of care—errors judged against other board-certified peers.

Key Legal Concepts

• Respondeat superior (vicarious liability): employer is liable for employee’s on-the-job actions.
• Ignorance of the law is no defense; professionals presumed to know applicable regulations.
• Standard of care: minimum acceptable practice; violations underpin malpractice.
• Agent: anyone acting on behalf of another (nurse → hospital/physician).

Confidentiality & HIPAA

• Privacy/security rules under HIPAA Title II; breaches are fireable offenses.
• Individuals cannot sue under HIPAA; must claim invasion of privacy instead.

Mandated Reporting & Public Duty

• Must report births, deaths, tuberculosis, elder/child abuse, dog bites, etc.
• Failure to report can trigger penalties.

Liability (Malpractice) Insurance

• Occurrence-based policies: insurer on date of incident defends any future claim.
• Declaration (DEC) page: retain for proof of coverage (company, policy #, dates).
• Insurer pays attorney fees, litigation costs, and judgments/settlements up to policy limits; insured must promptly report claims.

Litigious Environment

• U.S. society is highly litigious; health professionals are frequent targets—insurance and meticulous documentation are essential.

Hierarchy & Scope of Practice Snapshot

• Office staff (clerical) → Medical Assistant (administrative/clinical) → LPN (limited IVs, no initial assessments) → RN (assessments, IVs, supervision) → PA (5–6 yr program, direct MD supervision via phone acceptable) → NP/APN (MSN, some states independent practice).