Which of the following best defines what a provider referral is?

Judson, K., & Harrison, C. (2016). Law and ethics fort health professions. (7th ed.). New York: McGra - Hill.

Law&Et • ICS FOR HEALTH PROFESSIONS

• KAREN JUDSON CARLENE HARRISON

Workinq in Health Care

LEARNING OUTCOMES After studying this chapter, you should be able to:

LO 3. I Define licensure, certification, registration, and accreditation.

LO 3.2 Demonstrate an understanding of how physicians

are licensed, how physicians are regulated, and the purpose of a medical board.

LO 3.3 Discuss the changing configuration of health care management.

LO 3.4 Distinguish among the different types of managed care health plans.

LO 3.5 Discuss the federal legislation that impacts health care plans.

LO 3.6 Discuss the impact of telemedicine and social media on the health care workplace.

51

LO 3.1

Define licensure, certification, registration, and accreditation.

licensure A mandatory credentialing process established by law, usual ly at the state level, that grants the right to practice certain skills and endeavors.

certification A voluntary credentia li ng process whereby applicants who meet specific requirements may receive a certificate.

FROM THE PERSPECTIVE OF . .. • - "'''l . - -rr-'11~ --- ..- .......

MELODY, A CERTIFIED NURSING ASSISTANT (CNA), works in a skilled nursing care facility caring for elderly patients. "I like the hands-on care," she says, "and I love just visiting with my patients. They come from all walks of life, and some of them have traveled all over the world."

The part of her job she dislikes the most, Melody adds, "is the demanding patients, who want everything right now. Demanding rel- atives can also be unreasonable. A daughter will tell me, 'I want you to respond immediately whenever my mother calls for you.' They don't understand, or don't care, that I have several patients to look after."

Once, Melody recalls, several family members were visiting their elderly relative. "I walked in to check my patient, and one of his grand- daughters asked me to get her a soda. There was a vending machine in the visitors' lounge, and I debated telling the woman I'm not a wait- ress, and she could get her own drink. I didn't, though. I got her the drink, but I resented being asked to do it. I'm just a CNA, but I'm not there to wait on patients' relatives."

From Melody's perspective, her job did not include providing refreshments for patients' visitors.

From the demanding visitor's perspective, perhaps Melody's job is to serve all needs of anyone in the patient's room.

Licensure, Certification, Registration, and Accreditation With increased medical specialization have come more exacting profes- sional requirements for health care practitioners. Members of the health care team today are usually licensed, registered, or certified to perform specific duties, depending on job classification and state requirements. Furthermore, programs for educating health care practitioners are often accredited. Accreditation is a process education programs may complete that ensures certain standards have been met. Managed care plans may also earn accreditation or certification for excellence.

Licensure is a mandatory credentialing process established by law, usually at the state level. Licenses to practice are required in every state for all physicians and nurses and for many other health care practitioners as well. Individuals who do not have the required license are prohibited by law from practicing certain health care professions.

Certification is a voluntary credentialing process, usually national in scope, and is most often sponsored by a nongovernmental, private- sector group. Certification by a professional organization, usually through an examination, signifies that an applicant has attained a cer- tain level of knowledge and skill. Since the process is voluntary, lack of certification does not prevent an employee from practicing the profes- sion for which he or she is otherwise qualified. (In the opening sce- nario, Melody has chosen to fulfill requirements to become a certified nursing assistant. In her state she could begin working as a nursing assistant without certification, but at a lower hourly wage.)

52 Part One I The Foundations of Law and Ethics

Registration is an entry in an official registry or record, listing the names of persons in a certain occupation who have satisfied specific requirements. The list is usually made available to health care provid- ers. One way to become registered is simply to add one's name to the list in the registry. Under this method of registration, unregistered per- sons are not prevented from working in a field for which they are oth- erwise qualified.

A second way to become registered in a health occupation is to attain a certain level of education and/ or pay a registration fee. Under this second method, when there are specific requirements for registra- tion, unregistered individuals may be prevented from working in a field for which they are otherwise qualified.

Under no circumstances may persons claim to be licensed, certified, or registered if they are not.

Unlike licensing, certification, and registration as discussed earlier, accreditation does not refer to a qualification process for individu- als practicing health care professions. Instead, it refers to a process for officially authorizing or approving health care practitioner edu- cation programs, health care facilities, and managed care plans. For example, if the school where you are enrolled is accredited by a rec- ognized regional or national accrediting agency, advantages for you include:

• An assurance of high-quality standards at your school, based on the latest research and professional practice.

• An opportunity for you to participate in federal and/or state finan- cial aid programs.

• A better chance that credits earned at your present school will be accepted at another institution if you transfer to another school or want to attend graduate school.

Two examples of accrediting agencies for health care practitio- ner education programs are the Commission on Accreditation of Allied Health Education Programs (CAAHEP), discussed in more detail later in the chapter, and the Accrediting Bureau of Health Education Schools (ABHES). Accreditation is usually voluntary, but accredited programs for various disciplines must maintain certain standards to earn and keep accreditation. Most accredited programs for health care education also include an internship or externship (practical work experience) that lasts for a specified period of time.

The Joint Commission (TJC) accredits health care organizations that meet certain standards including the following:

• General, psychiatric, children's, and rehabilitation hospitals.

• Critical access hospitals.

• Health care networks, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), integrated deliv- ery networks, and managed behavioral health care organizations.

• Home care organizations, including those that provide home health services, personal care and support services, home infu- sion and other pharmacy services, durable medical equipment ser- vices, and hospice services.

registration A credential ing procedure whereby one's name is listed on a reg ister as having paid a fee and/or met certa in criteria within a profession.

accreditation Official authorization or approval for conforming to a specified standard, for healt h care education programs, health care facilities, and managed ca re p lans.

Chapter 3 I W orking in Health Care 53

reciprocity The process by wh ich a professional license obta ined in one state may be accepted as valid in other states by prior ag reement without reexam ination.

• Nursing homes and other long-term care facilities, including sub- acute care programs, dementia special care programs, and long- term care pharmacies.

• Assisted living facilities.

• Behavioral health care organizations.

• Ambulatory care providers, such as outpatient surgery facilities, rehabilitation centers, infusion centers, and group practices, as well as office-based surgery.

• Clinical laboratories, including independent or freestanding labo- ratories, blood transfusion and donor centers, and public health laboratories.

To earn and maintain TJC accreditation, an organization must undergo an on-site survey by a TJC survey team at least every three years. Laboratories must be surveyed every two years.

A recognized accrediting agency for managed care plans is the National Committee for Quality Assurance (NCQA), an independent, nonprofit organization that evaluates and reports on the quality of the nation's managed care organizations. NCQA evaluates managed care programs in three ways:

1. Through on-site reviews of key clinical and administrative processes.

2. Through the Healthcare Effectiveness Data and Information Set (HEDIS)-data used to measure performance in areas such as immunization and mammography screening rates.

3. Through use of member satisfaction surveys.

Participation in NCQA accreditation and certification programs is voluntary. At the NCQA Web site (www.ncqa.org/ReportCards), a person looking for quality medical facilities or health insurance plans can see rankings.

The Commission on Accreditation of Allied Health Education Pro- grams (CAAHEP) accredits more than 2,000 programs in 23 allied health professions throughout the United States and Canada. CAAHEP provides information concerning duties, education requirements, and sources for further information about allied health professions and the location of schools offering the accredited programs.

RECIPROCITY

For those professions that require a state license, such as physician, registered nurse, or licensed practical or vocational nurse, reciprocity may be granted. This means that a state licensing authority will accept a person's valid license from another state as proof of competency without requiring reexamination.

If a state license is required and reciprocity is not granted when moving to another state, then the health care practitioner must apply to the state licensing authority to take required examinations to obtain a valid license to practice in the new state.

54 Part One I The Foundations of Law and Ethics

Check Your Progress

I. Define registration.

2. Define licensure.

3. How does licensure differ from registration or certification?

4. Explain how certification for a health care practitioner differs from accreditation of a health care facility or education program.

5. Define reciprocity.

Physicians' Education and Licensing THE PHYSICIAN'S EDUCATION

Doctor of Medicine (MD) Degree Before a person can be licensed to practice medicine, he or she must complete a rigorous course of study. Programs leading to the doctor of medicine (MD) degree consist of:

• Graduation with a bachelor's degree from a four-year, premedi- cine course, usually with a concentration in the sciences.

• Graduation from a four-year medical school-in the United States, a school accredited by the Liaison Committee on Medical Educa- tion. Upon graduation from medical school, students are awarded the doctor of medicine (MD) degree.

After earning the MD degree, the prospective physician must then pass the United States Medical Licensing Examination (USMLE), com- monly called "medical boards." Student physicians take Part 1 of the exam after the first year of medical school. They take Part 2 of the exam during the fourth year of medical school, and Part 3 during the first or second year of postgraduate medical training.

The next step in a physician's education is completion of a resi- dency: a period of practical postgraduate training in a hospital. The first year of residency is called an internship.

After completion of the internship and passing the medical boards, the National Board of Medical Examiners (NBME) certifies the physi- cian as an NBME Diplomate.

LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board.

ChafJter 3 I Working in Health Care 55

allopathic Means "different suffering" and refers to the medical philosophy that dictates training physicians to intervene in the disease process, through the use of drugs and surgery.

To specialize, physicians must complete an additional two to six years of residency in the chosen specialty. When the residency is completed, specialists can then apply to the American Board of Medical Specialties (ABMS) to take an exam in their specialty. After passing this exam, phy- sicians are board-certified in their area of specialization. For example, a specialist in oncology becomes a board-certified oncologist, and so on.

Doctor of Osteopathy (DO) Degree All 50 states also license physicians who have obtained a doctor of osteopathy (DO) degree from an accredited medical school, have successfully completed a licensing examination governed by the National Board of Osteopathic Medical Examiners, and have successfully completed the required internship and residency.

MDs and DOs spend 12 years or more training to become physi- cians. Both medical and osteopathic physicians prescribe drugs and practice surgery. The difference between the two is in their approach to medical treatment. Osteopathic doctors are trained to emphasize the musculoskeletal system of the body and the correction of joint and tissue problems. Medical doctors are trained in allo.pathic medicine, which means, literally, "different suffering" and emphasizes interven- tion in the form of drugs and/or surgery to alleviate symptoms.

Osteopathic and medical doctors can practice as generalists or primary care physicians-a designation that includes primary care spe- cialties in family medicine/general practice, general internal medicine, and general pediatrics-or they can specialize in a specific type of medi- cine, such as obstetrics/gynecology, oncology, geriatrics, surgery, ortho- pedics, or a host of other specialties. Medical and osteopathic physicians may also further specialize in subspecialties, such as abnormalities of the hand within orthopedics, or diseases of the gastrointestinal system within internal medicine.

Recent U.S. government statistics show that in the United States, medical students are three times more likely to specialize than to remain generalists or primary care physicians. This has led to a ratio in the United States of 37.4 percent primary care physicians to 62.6 percent specialists. According to the American Medical Student Association (AMSA), reasons for the preference among medical stu- dents to specialize include these:

• Higher financial compensation for specialists (studies have found that a surgeon can earn up to seven times more than a primary care physician, per time spent with the patient).

• Decreased prestige for generalists.

• Medical training most often provided in tertiary care settings- those providing highly specialized services.

• Decreased exposure to generalist role models.

• Lack of attractiveness of general practices in, for example, rural and underserved areas because of relative isolation from technol- ogy and peer support.

A person educated in a foreign medical school who wants to prac- tice in the United States must serve a residency and must take the Clinical Skills Assessment Exam (CSAE) before being licensed. The CSAE evaluates a candidate's ability to use the English language, to take medical histories, and to interact with patients and treat a case.

56 Part One I The Foundations of Law and Ethics

THE PHYSICIAN'S LICENSE AND RESPONSIBILITIES

After physicians have finished their education and obtained licenses to practice medicine, their continued licensure falls under the juris- diction of state medical boards (see Figure 3-1). Each state's medical board has the authority to grant or to revoke a physician's license. The federal government has no medical licensing authority except for the permit issued by the Drug Enforcement Administration (DEA) for any physician who dispenses, prescribes, or administers controlled sub- stances, including narcotics and nonnarcotics (see Chapter 9).

When these conditions are satisfied and a license is granted, the physician who moves out of the licensing state may obtain a license in his or her new state of residence by:

• Reciprocity-the process by which a valid license from out of state is accepted as the basis for issuing a license in a second state if prior agreement to grant reciprocity has been reached between those states.

• Endorsement-the process by which a license may be awarded based on individual credentials judged to meet licensing require- ments in the new state of residence.

FIGURE 3-1 Criteria for State Licensing of Physicians

The following criteria must be met before a physician can be granted a state license to practice medicine. He or she

~ Must have reached the age of majority, generally 21.

~ Must be of good moral character.

• Must have completed required preliminary education, including graduation from an approved medical school.

• Must have completed an approved residency program.

~ Must be a U.S. citizen or have filed a declaration of intent to become a citizen. (Some states have dropped this requirement.)

• Must be a state resident.

~ Must have passed all examinations administered by the state board of medical examiners or the board of registration.

- ·+·--

Chapter 3 I Working in Health Care 57

medical practice acts State laws w ritten for t he express purpose of governing the practice of medicine.

In some situations, physicians do not need a valid license to practice medicine in a specific state. These situations include the following:

• When responding to emergencies.

• While establishing state residency requirements in order to obtain a license.

• When employed by the U.S. armed forces, Public Health Service, Veterans Administration, or other federal facility.

• When engaged solely in research and not treating patients.

Physicians may be licensed in more than one state. Periodic license renewal is necessary; this usually requires simply paying a fee. How- ever, many states require proof of continuing education units for license renewal; the average is 50 hours annually.

License Revocation or Suspension A physician's license can be revoked (canceled) or suspended (temporarily recalled) for convic- tion of a felony, unprofessional conduct, or personal or professional incapacity.

A felony is a crime that is punishable by death or a year or more in prison. Conviction of a felony is grounds for revocation or suspen- sion of the license to practice medicine. Felonies include such crimes as murder, rape, larceny, manslaughter, robbery, arson, burglary, violations of narcotic laws, and tax evasion.

Unprofessional conduct is also cause for revoking or suspending a physician's license. Some states substitute the term gross immorality for unprofessional conduct, but offenses in either category are considered serious breaches of ethics and may also be illegal. Conduct deemed unprofessional includes falsifying records, using unprofessional meth- ods to treat a disease, betrayal of patient confidentiality, fee splitting, and sexual misconduct.

Personal or professional incapacity may be due to senility, injury, illness, chronic alcoholism, drug abuse, or other conditions that impair a physician's ability to practice.

MEDICAL PRACTICE ACTS AND MEDICAL BOARDS

In all 50 states, medical practice acts have been established by statute to govern the practice of medicine. Primary mandates of medical prac- tice acts are to:

1. Define what is meant by "practice of medicine" in each state.

2. Explain requirements and methods for licensure.

3. Provide for the establishment of medical licensing boards.

4. Establish grounds for suspension or revocation of license.

5. Give conditions for license renewal.

Medical practice acts were first passed in colonial times, but were repealed in the 1800s, when citizens decided that the U.S. Constitution gave anyone the right to practice medicine. Quackery became rampant, and for the protection of the public, medical practice acts were reenacted.

Although laws are in place to protect consumers against medical quackery, even today unscrupulous people attempt to circumvent the law by hawking devices, potions, and treatments they say are

58 Part One I The Foundations of Law and Ethics

"guaranteed" to cure any ailment or infirmity. Each state periodically revises its medical practice acts to keep them current with the times. Medical practice acts can be found in each state's code, which consists of laws for that state. Copies of state codes are available in most public libraries, in some university libraries, and on the Internet. (State codes as they apply to health care can be accessed electronically at official state Web sites under "medical practice acts.")

Each state's medical practice acts also mandate the establishment of medical boards, whose purpose is to protect the health, safety, and wel- fare of health care consumers through proper licensing and regulation of physicians and, in some jurisdictions, other health care practitioners. Board membership is composed of physicians and others who are, in most cases, appointed by the state's governor. Some boards act indepen- dently, exercising all licensing and disciplinary powers, while others are part of larger agencies such as departments of health. Funding for state medical boards comes from licensing and registration fees. Most boards include an executive officer, attorneys, and investigators. Some legal ser- vices may be provided by the state's office of the attorney general.

Through licensing, each state medical board ensures that all health care practitioners who work in areas for which licensing is required have adequate and appropriate education and training and that they follow high standards of professional conduct while caring for patients. Applicants for license must generally:

• Provide proof of education and training.

• Provide details about work history.

• Pass an examination designed to assess their knowledge and their ability to apply that knowledge and other concepts and principles important to ensure safe and effective patient care.

• Reveal information about past medical history (including alcohol and drug abuse), arrests, and convictions.

Each state's medical practice acts also define unprofessional con- duct for medical professionals. Laws vary from state to state, but examples of unprofessional conduct include:

• Physical abuse of a patient.

• Inadequate record keeping.

• Failure to recognize or act on common symptoms.

• The prescription of drugs in excessive amounts or without legiti- mate reason.

• Impaired ability to practice due to addiction or physical or mental illness.

• Failure to meet continuing education requirements.

• The performance of duties beyond the scope of a license.

• Dishonesty

• Conviction of a felony.

• The delegation of the practice of medicine to an unlicensed individual.

Minor disagreements and poor customer service do not fall under the heading of misconduct.

medical boards Bodies established by the authority of each state's medical practice acts for the purpose of protecting the health, safety, and welfare of health care consumers through proper licensing and regulation of physicians and other health care practitioners.

Chapter 3 I Working in Health Care 59

Check Your Progress

6. Define medical practice acts.

7. Where can you find the medical practice acts for your state?

8. What is the primary responsibility of state medical boards?

COURT CASE Physician Disciplined by Board of Medical Examiners

A licensed pharmacist and a state pharmacy board

investigator called a state's Board of Medical Examiners

to express concern about a physician's prescription prac-

tices. The board investigated and found the physician had

deviated from accepted standard of care by:

• Inadequately evaluating patients before prescribing antidepressants and failing to document reasons for prescriptions or following up on patients' use of the prescribed medications.

• Prescribing antibiotics for prolonged periods as treatment for urinary tract infections without determining that the infections had recurred or documenting the recurrence of the infections. The physician had also prescribed sev- eral antibiotics to a patient at once, allowing the patient to choose which antibiotic was the most effective.

• Prescribing narcotic and anxiolytic medications (drugs that relieve anxiety) to patients with nonterminal chronic pain without adequately pursuing and docu- menting use of available alternatives to narcotics and controlled medications.

Based on the above findings, the Board of Medical Exam-

iners placed the physician on probation for two years

and ordered him to take 60 hours of continuing educa-

tion in the treatment of urinary tract infections, medical

treatment of the elderly, management of chronic pain

patients, and record keeping. He was also ordered to

make prescription records available at all times for board

inspection and was directed to stop making telephone

refills for prescriptions of controlled medications.

Miller v. Board of Medical Examiners, 609 N.W.2d 478, 2000 Iowa Sup.

COURT CASE State Board of Nursing Finds Nurse Incompetent A state board of nursing found that a nurse violated

the section of the state code that regulates nurs-

ing by repeatedly failing to conform to the minimum

standards of practice with regard to the proper main-

tenance and documentation of controlled substances.

Since the finding could have led to revocation of the

nurse's license, the nurse filed a petition for judicial

review. The district court affirmed the board's deci-

sion, and the nurse again appealed. The state court of

appeals upheld both the district court and board deci-

sions, clearing the way for temporary or permanent

revocation of the nurse's license, or other penalty. (No

final decision is available, since the opinion has not yet

been published.)

60 Part One I The Foundations of Law and Ethics

Several times while on duty, the nurse failed to

properly document and account for missing controlled

substances. In one instance, she claimed containers of

morphine and other drugs had fallen from her pocket

while she was running down a stairwell. On other occa-

sions, she claimed drug ampules had broken in her

pocket, or she had misplaced syringes filled with con-

trolled substances. Since her stories could not be cor-

roborated, and she did not properly document losses

or destruction of controlled drugs, the state court of

appeals upheld the state board of nursing's finding that

the nurse was incompetent in violating minimum stan-

dards of acceptable nursing practice.

Matthias v. Iowa Board of Nursing, 2-153/01-1019, 2002 Iowa App.

It is important to remember that while a variety of health care prac- titioners often work together as a team to provide medical care to patients, each individual is legally able to perform only those duties dictated by professional and statutory guidelines. Each health care practitioner is responsible for understanding the laws and rules per- taining to his or her job and for knowing requirements concerning renewal of licenses; recertification; and payment of fees for licensure, certification, and registration.

Fraud may, in some states, be considered unprofessional conduct, or it may be separately specified as grounds for revoking a physician's license. A physician is considered guilty of fraud if "intent to deceive" can be shown. Acts generally classified as fraud include:

• Falsifying medical diplomas, applications for licenses, licenses, or other credentials.

• Billing a governmental agency for services not rendered.

• Falsifying medical reports.

• Falsely advertising or misrepresenting to a patient "secret cures" or special powers to cure an ailment.

Check Your Progress

9. In the United States, physicians may be licensed to practice medicine as MDs or as DOs.

Distinguish between the two.

I 0. Name three types of unprofessional conduct for which a physician may lose his or her license.

Fill in the blanks or answer the following questions in the spaces provided.

I I. A physician is licensed by the in which he or she wishes to practice.

12. The federal government's authority regarding medical licensing extends only to

13. Give one example of fraud. _______________ _

14. Name four situations in which physicians do not need a valid license to practice in a specific state.

Chapter 3 I Working in Health Care 61

"'

II LO 3.3 Discuss the changing configuration of health care management.

sole proprietorship A form of medical practice management in which a physician practices alone, assuming all benefits and liabilities for the business.

group practice A medical management system in which three or more licensed physicians share the collective income, expenses, facilities, equipment, records, and personnel for the business.

associate practice A medical management system in which two or more physicians share office space and employees but practice individually.

partnership A form of medical practice management system whereby two or more parties practice together under a written agreement specifying the rights, obligations, and responsibilities of each partner.

professional corporation A body formed and authorized by law to act as a single person.

Revocations and suspensions of license are never automatic. A phy- sician is always entitled to a written description of charges against him or her and a hearing before the appropriate state agency. If a hearing is held, the physician also has the right to counsel, the right to present evidence in his or her defense, the right to confront and question wit- nesses, and any other rights granted by state law. Decisions are usu- ally subject to appeal through the state's court system.

An honest mistake or a single incident of alleged incompetence or negligence is not usually sufficient grounds for license revocation.

Medical Practice Management Systems Physicians have traditionally established medical management sys- tems for the delivery of health care, but such systems have evolved over time, from the sole proprietorships most common before 1960, to various forms of staffing configurations and practice consolidations prevalent in today's health care marketplace. (A sole proprietorship consisted of a physician practicing alone, assuming all responsibility and liability for his services.)

Today' s economic realities-for instance, the advent of managed care organizations, reduced Medicare reimbursements, and higher technology costs-are transforming the practice of modern medi- cine. Now fewer physicians practice alone. In fact, hospitals, private equity firms, and even health insurance companies are acquiring physician practices to the extent that according to a recent survey by Accenture, a global management consulting firm, just 39 percent of doctors nationwide are practicing independently, down from 57 percent in 2000.

Consolidation arrangements may take the form of group practices, where three or more physicians engage full time in providing health care services. They share the collective income of the practice, as well as expenses, facilities, equipment, patient records, and personnel necessary for running the business. Physicians in group practice may be engaged in the same specialty, calling themselves, for example, Urology Associates, or they may provide care in two or three related specialties, such as obstetrics-gynecology and pediatrics. Alterna- tively, they may offer a variety of services, for example, obstetrics- gynecology, pediatrics, family practice, and internal medicine.

Some of the more familiar forms of group practice include:

• Associate Practice. Two or more physicians decide to practice individually but agree to share office space and employees. This arrangement allows a sharing of expenses, but usually not a shar- ing of profits or liability.

• Partnership. Two or more parties practice together under a written agreement specifying the rights, obligations, and responsibilities of each partner. Advantages of partnerships include sharing the workload and expenses, and pooling profits and assets. A major disadvantage is that each partner has equal liability for the acts, conduct, losses, and deficits of the partnership, unless specific pro- visions are made for these contingencies in the initial agreement.

• Professional Corporation. A body formed and authorized by law to act as a single person, although constituted by one or more

62 Part One I The Foundations of Law and Ethics

persons and legally endowed with various rights and duties. State law governs corporations, so requirements for incorporation may vary. The corporation may own, mortgage, or sell property; man- age its own business affairs; and sue or be sued. Physicians who form corporations are shareholders and employees of the organi- zation. There are financial and tax advantages to forming a cor- poration, and fringe benefits to employees may be more generous than with a sole proprietorship or partnership. Forming a corpora- tion also means that the incorporators and owners have limited liability in case lawsuits are filed.

In the past, hospitals were hubs within health care delivery systems serving specific areas. Physicians admitted patients to hub hospitals and were paid a fee for services rendered; hospitals were reimbursed separately for providing the facility, equipment, and personnel for ser- vicing patients. Today, with the growing number of privately-owned ambulatory care centers, diagnostic facilities, surgical centers and spe- cialty hospitals, the health care delivery system offers a complicated variety of services and staffing arrangements. For instance, with the advent of managed care organizations (MCOs), physicians are often salaried employees of hospitals, clinics, or other entities, which in turn are part of for-profit or not-for-profit corporate networks. (One exam- ple of such a not-for-profit arrangement is the Mayo Clinic Health Care and Research System, which employs salaried physicians and other health care practitioners in various locations within the United States.) In fact, large, for-profit health care service corporations, such as Hospital Corporation of America, the largest U.S. hospital chain as of 2014, are increasingly the norm for health care delivery.

Just as methods of health care delivery have morphed from sole physicians in private practice to the corporate model, managed care organizations have entered the health care marketplace as cor- porate entities that link health care financing, administration, and service delivery.

Types of . Managed Care Managed care organizations are corporations that pay for and deliver health care to subscribers for a set fee using a network of physicians and other health care providers. The network coordinates and refers patients to its health care providers and hospitals and monitors the amount and patterns of care delivered. The plans usually limit the ser- vices subscribers may receive under the plans. Managed care plans make agreed-upon payments to providers (hospitals or physicians) for providing health care services to health care subscribers. The pay- ment from a managed care plan to providers may be one of several types, including contracted fee schedules, percentages of billed charges, capitation, and others. (Capitation is a set advance payment made to providers, based on the calculated cost of medical care of a specific population of subscribers.)

Before managed care plans, private health insurance policies were tra- ditionally written as third-party indemnity health insurance. Third party means that the insurance company reimburses health care practitioners for medical care provided to policyholders. Indemnity is coverage of the

LO 3.4 Distinguish among the different types of managed care health plans.

managed care A system in which financing, administration, and delivery of health care are combined to provide medical services to subscribers for a prepaid fee.

Chapter 31 Working in Health Care 63

health maintenance organization (HMO) A hea lt h plan that combines coverage of health care costs and delivery of health care for a specific payment.

insured person against a potential loss of money from medical expenses for an illness or accident. Indemnity health insurance policies are fee- for-service and usually allow enrollees to see any doctor.

In an attempt to confront increasing health care costs- due in part to increasingly large awards in litigation, an aging popula- tion that requires more health care, the expensive technology used in modern-day medicine, and the impact of thl.rd-party payers for medical care-traditional fee-for-service health insurance compa- nies now incorporate elements of managed care into their plans. (The impact of third-party payers is that there is little incentive to keep health care costs down when health care providers and recipients know that a third party- Medicare, Medicaid, other insurance- will pay.) Consequently, virtually all insured Americans have become familiar with such cost-containment/managed care measures as coinsurance, copayment fees, deductibles, formularies, and utilization review.

• Coinsurance refers to the amount of money insurance plan mem- bers must pay out of pocket, after the insurance plan pays its share. For example, a plan may agree to pay 80 percent of the cost for a surgical procedure, and the subscriber must pay the remain- ing 20 percent.

• Copayment fees are flat fees that insurance plan subscribers pay for certain medical services. For example, a subscriber might be required to make a $20 copayment for each visit to a physician office.

• Deductible amounts are specified by the insurance plan for each subscriber. For instance, the deductible for a single subscriber might be $500 a calendar year. In other words, the plan does not begin to pay benefits until the $500 deductible has been satisfied.

• Formularies are a plan's list of approved prescription medications for which it will reimburse subscribers.

• Utilization review is the method used by a health plan to measure the amount and appropriateness of health services used by its members.

HEALTH MAINTENANCE ORGANIZATIONS

Health maintenance organizations (HMOs) are one of several types of managed care organizations providing health care services to sub- scribers within the United States. HMOs and preferred provider orga- nizations (PPOs) are the most common types of managed care plans. Under HMO plans, all health services are delivered and paid for through one organization. The three general types of HMOs are group model HMOs, staff model HMOs, and individual (or independent) practice associations (IPAs).

Group model HMOs contract with independent groups of physi- cians to provide coordinated care for large numbers of HMO patients for a fixed, per-member fee. They often provide medical care for mem- bers of several HMOs. Group model HMOs include prepaid group practices (PGPs). Physicians in PGPs are salaried employees of the HMO, usually practice in facilities provided by the HMO, and share in profits at the end of the year.

64 Part One I T he Foundations of Law and Et hics

Staff model HMOs employ salaried physicians and other allied health professionals who provide care solely for members of one HMO. Subscribers to staff model HMOs can often see their doctors, get laboratory tests and X-rays, have prescriptions filled, and even order eyeglasses or contact lenses all in one location. Staff model HMOs also employ specialists or contract with outside specialists in some cases.

An individual (or independent) practice association (IPA) is an association of physicians, hospitals, and other health care providers that contracts with an HMO to provide medical services to subscrib- ers. Health care practitioners who are members of an IPA may usually still see patients outside the contracting HMO. The providers who contract with an IPA practice in their own offices and receive a per-member payment, or capitation, from participating HMOs to provide a full range of health services for HMO members. These pro- viders often care for members of several HMOs, which gives them a larger patient and income base than staff model HMOs.

PREFERRED PROVIDER ORGANIZATIONS

Preferred provider organizations (PPOs), also called preferred provider associations (PPAs), are managed care plans that contract with a net- work of doctors, hospitals, and other health care providers who provide services for set fees. Subscribers may choose their primary health pro- vider from an approved list and must pay higher out-of-pocket costs for care provided by health care practitioners outside the PPO group.

PHYSICIAN-HOSPITAL ORGANIZATIONS

Physician-hospital organizations (PHOs) are another type of man- aged care plan. PHOs are organizations that include physicians, hos- pitals, surgery centers, nursing homes, laboratories, and other medical service providers that contract with one or more HMOs, insurance plans, or directly with employers to provide health care services.

OTHER VARIATIONS IN MANAGED CARE PLANS

Managed care plans may also include the following identifying features:

•

•

Gatekeeper or primary care plan. The insured must designate a primary care physician (PCP). Also known as a gatekeeper physi- cian, the primary care physician directs all of a patient's medical care and generates any referrals to specialists or other health care practitioners.

Point-of-service (POS) plan. Point-of-service plans allow plan members to seek health care from nonnetwork physicians, but the plan pays the highest benefits for care when given by the PCP or via a referral from the PCP. When care is provided without a referral, but still within the network, the plan pays benefits at a reduced level. Members also have out-of-network benefits, but at greatly reduced payment levels.

• Open access plan. Under open access plans, subscribers may see any in-network health care provider w ithout a referral.

individual (or independent) practice association (IPA) A type of HMO that contracts with groups of physicians who practice in their own offices and rece ive a per- member payment (capitation) from participating HMOs to provide a full range of health services for members.

preferred provider organization (PPO) A network of independent physicians, hospitals, and other health care providers who cont ract w ith an insurance carrier to provide medical care at a discount rate to patients w ho are part of the insurer's plan. Also called preferred provider association (PPA).

physician-hospital organization (PHO) A health care plan in which physicians join with hospitals to provide a medica l care del ivery system and then contract for insurance with a com mercial carrier or an HMO.

primary care physician (PCP) The physician responsible for di recting al l of a patient's medica l care and determining whether the patient should be referred fo r specialty care.

Chapter 3 I Working in Health Care 65

The National Committee for Quality Assurance (NCQA), the accrediting agency mentioned earlier, has introduced a new concept in primary care called the Patient-Centered Medical Home (PCMH). The organization offers accreditation to qualifying primary care practices implementing PCMH, and helps patients find those practices. The goal is to offer patients:

• Long-term partnerships between patients and clinicians, instead of patients being limited to sporadic, hurried visits.

• Physician-led teams that will coordinate care, especially for illness prevention and chronic conditions.

• An organization that will coordinate other clinicians' care and resources within the community, as needed.

• Enhanced access, which will include expanded hours and online communication.

• A share in decision making, ensuring informed choices and improved results.

• Improved quality of care without ever denying care.

An important added benefit, according to NCQA, is that insurers will pay for these services because they save more than they cost.

Managed care plans differ from one another in some respects, but all are designed to cut the cost of health care delivery. The impact of cost-cutting measures on the quality of health care remains a major point of contention. Advocates claim that managed care plans can deliver medical services more efficiently and at much less expense than traditional fee-for-service plans. Critics argue that necessary, quality medical services are often sacrificed for profit margins. The following questions are of special concern to patients enrolled in man- aged care plans:

• Will the most knowledgeable and experienced physician treat my medical conditions and those of my family?

• Is my physician too concerned with saving money?

• Must I fight to get routine procedures from my HMO?

• What if my HMO refuses to pay for a procedure I need?

In addition, physicians and other medical professionals, adminis- trators of managed care plans, government officials, and HMO mem- bers are concerned with issues such as these:

• Do managed health care and competition actually drive down costs?

• Do regulations exist regarding patient rights in managed care plans?

• Do quality ratings for HMOs help consumers?

• Does managed health care provide higher-quality care than fee-for-service medicine?

Managed care is a fixture of modern medicine, but health care con- sumers and practitioners continue to debate its advantages and disad- vantages, and may do so for many years to come.

66 Part One I The Foundations of Law and Ethics

Check Your Progress

15. Discuss two ways medical practice management systems have changed over time.

16. Define managed care.

17. What were two of the original objectives for establishing managed care?

18. Name and list distinguishing characteristics of three types of managed care plans.

19. Briefly define the concept Patient-Centered Medical Home.

Legislation Affecting Health Care Plans PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA)

When Barack Obama was elected President of the United States in 2008, he vowed to initiate comprehensive changes in the American health care system. After months of heated debate, H.R. 3590, the Patient Protection and Affordable Care Act (usually abbreviated ACA) was signed into law on March 23, 2010. Additional changes to the health care system were enacted by the Health Care Education and Reconciliation Act, signed into law on March 30, 2010. The two acts mandated major changes in the American health care system, which included the following (see Table 3-1) at the time they were passed:

Table 3-1 PPACA Provisions Effective in 2010

Issue Effect

LO 3.5 Discuss the federal legislation that impacts health care plans.

Patient Protection and Affordable Care Act (PPACA) A federal law enacted in 2010 to expand health insurance coverage and otherwise regulate the health insurance industry.

Health Care Education and Reconciliation Act (HCERA) Also enacted in 2010, a federa l law that

added to regulations imposed on the insurance indust ry by PPACA.

Temporary high-risk insurance pool

Creates a national pool to provide health coverage for individuals with preexisting conditions who have been uninsured for six months.

Preexisting conditions Prevents insurance companies from denying coverage to children with preexisting medical cond itions.

(continued)

Chapter 3 1 Working in Health Care 67

Table 3-1 (continued)

Issue

Adult children

Coverage limits

Tanning salons

Preventive care

Effect

Insurance companies must cover dependent children up to age 26.

Insurance plans cannot place lifetime limits on coverage and cannot rescind coverage except for fraud.

A 10 percent tax is imposed on indoor tanning services.

Insurance plans must cover preventive services such as vaccinations for children and cancer screening for women.

Medicare recipients

'Tax credit for business

Some Medicare patients receive a $250 rebate to help cover the cost of medications.

Small businesses with 25 or fewer employees can receive tax credits for the 2010 tax year to help pay for offering employees health insurance.

'In 2013, compliance for small businesses was pushed ahead to January 1, 2015.

Changes implemented in 2011 concerned annual fees imposed on pharmaceutical manufacturers, tax changes on health care savings accounts, closing the Medicare "doughnut hole" for seniors who experience a gap in drug coverage, paying bonuses through Medi- care fees to primary care doctors and general surgeons practicing in underserved areas, funding community health centers for low-income people, and requiring insurance companies to pay rebates to enrollees if they spent less than 80-85 percent of premium dollars on health care as opposed to administrative costs.

In 2012 and 2013, the annual fees on drug makers were to increase, limits were placed on contributions to health care savings accounts, the threshold for out-of-pocket medical expenses on income tax forms increased, and the Medicare tax rate increased.

Table 3-2 PPACA Provisions Effective 2014 through 2018

Year

2014

2015-2016

2017-2018

Issue

Health insurance exchanges

Individual mandate

Medicaid expansion

Federal subsidies

Annual insurance company fees

Individual mandate

Annual insurance company fees

Effect

State-run health care exchanges for uninsured individuals and small businesses created.

Everyone must have health insurance or pay a fine. Companies with 50 or more employees will pay a fine if any of their full-time workers qualified for federal subsidies.

Income eligibility increased for those under 65.

Federal subsidies will help lower income people buy insurance.

Annual fees imposed on health insurance companies.

Penalties for not carrying insurance are increased each year.

Annual fees imposed on health insurance companies increase.

Annual fee on drug manufacturing Annual fee on pharmaceutical manufacturers is increased each year.

Annual insurance company fees Annual fees imposed on health insurance companies are increased each year.

Excise tax on high-cost insurance A 40 percent excise tax is imposed on the more expensive health care plans. plans

68 Part One I The Foundations of Law and Ethics

As a provision of the ACA, health care insurers were encouraged to unite with health care providers to form accountable care organiza- tions (ACOs). The accountable care model emphasized preventive care, health care team coordination, electronic health records, treat- ment based on proof, and day or night access. Those ACOs that met quality standards might also reward doctors and hospitals for control- ling costs and improving patient outcomes by allowing them to keep a portion of what they save.

The Affordable Care Act called for establishing ACOs for certain groups of patients, such as those receiving Medicare, the chronically ill, those with high hospital usage, and those with mild health risks such as asthma or high blood pressure. However, at the beginning of 2014, ACOs had been established just for patients on Medicare.

The extent of the effect of the 2010 legislation on health care plans in the United States remains to be seen as provisions are rewritten, post- poned, or otherwise enacted over time.

Earlier legislation that has impacted health care insurers, providers, and consumers in the United States includes the following health care legislation.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was an ambitious attempt by Congress to reform the American health care system. The HIPAAhelps workers keep continuous health insurance coverage for themselves and their dependents when they change jobs, but its many provisions go far beyond this mandate. The primary objectives of the law were to:

1. Improve the efficiency and effectiveness of the health care indus- try by:

• Accelerating billing processes and reducing paperwork.

• Reducing health care billing fraud.

• Facilitating tracking of health information.

• Improving accuracy and reliability of shared data.

• Increasing access to computer networks within health care facilities.

2. Help employees keep their health insurance coverage when trans- ferring to another job.

3. Protect confidential medical information that identifies patients from unauthorized disclosure or use.

HIPAA also created the Healthcare Integrity and Protection Data Bank (HIPDB), but a provision of the 2010 Patient Protection and Affordable Care Act merged the HIPDB with the National Practi- tioner Data Bank. HIPDB is a national health care fraud and abuse data collection program for the reporting and disclosure of certain adverse actions taken against health care providers, suppliers, or practitioners. Data from the combined HIPDB and the NPDB are available to federal and state government agencies and to health plans, but are not available to the general public.

Accountable care organization (ACO) A health care payment and delivery model that could reward doctors and hospitals for controlling costs and improving patient outcomes by allowing them to keep a portion of what they save if standards of quality are met.

Health Insurance Portability and Accountability Act (HIPAA) of 1996 A federal statute that helps workers keep continuous health insurance coverage for themselves and their dependents when they change jobs, protects confidential medical information from unauthorized disclosure or use, and helps curb the rising cost of fraud and abuse.

Chapter 3 I Working in Health Care 69

LO 3.6 Discuss the impact of telemedicine and social media on the health care workplace.

telemedicine Remote consultation by patients with physicians or other health professionals via telephone, closed-circuit television, or the Internet.

HEALTH CARE QUALITY IMPROVEMENT ACT

In creating the Health Care Quality Improvement Act (HCQIA) of 1986, Congress found that "the increasing occurrence ofmedical mal- practice and the need to improve the quality of medical care have become nationwide problems that warrant greater efforts than those that can be undertaken by any individual state." Accordingly, the act requires that professional peer review action be taken in some cases. It also limits the damages for professional review and protects from liability those who provide information to professional review bodies.

One of the most important provisions of the HCQIA was the estab- lishment of the National Practitioner Data Bank (NPDB). Use of the NPDB was "intended to improve the quality of medical care nation- wide by encouraging effective professional peer review of physicians and dentists. Information that must be reported to the NPDB includes medical malpractice payments, adverse licensure actions, adverse clinical privilege actions, and adverse professional society member- ship actions. The NPDB is a resource to assist state licensing boards, hospitals, and other health care entities in investigating the qualifica- tions of physicians, dentists, and other health care practitioners.

National Practitioner Data Bank queries are mandatory for physi- cians when they apply for privileges at a hospital, and every two years for physicians already on the medical staff who wish to maintain their privileges. They are voluntary for hospitals conducting professional review, other health care entities with formal peer review programs, state licensing boards at any time, those who wish to self-query, and plaintiffs' attorneys under certain circumstances. The NPDB may not disclose information to a medical malpractice insurer, defense attor- ney, or member of the general public.

Telemedicine Telemedicine refers to remote consultation with physicians or other health care professionals via telephone (both landline and smart- phone), closed-circuit television, fax machine, or the Internet. When telemedicine was first used, it generally involved transmission of X-rays, sonograms, or other medical data between two distant points. In some cases, usually through closed-circuit television, a physician could examine a patient in a distant location, thus allowing patients in rural areas more complete access to medical care. Today, transmitted medical data includes video, audio, and written or computerized patient data. In fact, increasing use of the Internet has made telemedi- cine an important component of the health care system, and one that health care practitioners should be prepared to use.

According to the American Telemedicine Association (ATA), tele- medicine provides the following services:

• Primary care and specialist referral services. Primary care physicians can ask specialists to review a patient's medical history, laboratory and X-ray results, medications, and other data for help in making a diagnosis or in other aspects of the patient's care.

• Remote patient monitoring. Through remote transmission, medical data for homebound patients can be sent to home health agencies or remote diagnostic testing facilities for interpretation. Data can

70 Part One I The Foundations of Law and Ethics

be specific to one condition, such as blood glucose levels, or it can cover a broader area of concern. These services often supplement home health care visits.

• Consumer medical and health information. Through use of the Internet and/or wireless devices, consumers can find specific information about medical conditions, locate support and discussion groups, learn about prescribed medications, and so on. This aspect of tele- medicine includes the use of patient portals for patients with com- patient portal puters or smartphones to schedule appointments with physicians, A secure online Web site that gives

review lab results, ask for medication refills, see educational materi- patie nts 24-hour availability to hea lth

als, and otherwise communicate with health care providers. care p roviders.

• Medical education. Physicians and other health care professionals can enroll in online courses where relevant, attend professional seminars remotely, hear specialists speak, and otherwise partici- pate in continuing education.

I!

Another aspect of telecommunication that the Health Research Institute says is actually" changing the nature of health-related interac- tions" is social media. The term social media includes social network-

II ing sites, such as Facebook, Linkedin, and Twitter, as well as media sharing sites, blogs, microblogs, subject-specific discussion sites, and

II wikis, which are Web sites that allow collaborative editing of content and structure. I '

HRI's 2012 report, "Social Media 'Likes' Healthcare: From Market- ing to Social Business," lists four characteristics of social media net- works that are especially adaptable to health-related interactions:

! 1. User-generated content

2. Community ! 3. Rapid distribution i

4. Open two-way dialogue

Consider the following documented incidents of health-related ! social media use:

• A diabetic patient tweets about her long wait in a hospital emer- gency room. Someone on the hospital staff sees her tweet and responds, even sending a person to talk to her.

• A high school student with a rare cancer posts her diagnosis on her Facebook page and a nurse sees the post and refers the student

I ' to a nearby specialist.

• Diabetic patients with problems controlling blood sugar and energy levels post journals, and even strangers respond with reci- pes and helpful tips about diet and exercise.

I

• A patient with multiple sclerosis posts a YouTube video showing I how a new drug has helped him with movement issues, and 5,000 I

watchers post questions and comments.

• One large insurance company partnered with a social media com- pany to offer Life Game, an online social game to help players with personal wellness goals.

The Health Research Institute survey found that 42% of respondents had used social media to access health-related consumer reviews;

Chapter 3 I Working in Heal th Care 71

c

32% read health experiences others had posted via social media; and 29% had sought information about other patients' experiences with their disease.

Other recent surveys have found an increasing use of mobile medi- cal applications among health care providers and consumers. The most popular mobile medical app function in the survey was drug reference, followed by general medical reference and personal fitness. A smaller percentage of physicians and other medical providers used subscription-based apps for image-based diagnostic support, or for help with clinical and billing systems. According to a 2013 survey by Manhattan Research, a New York health care marketing research com- pany, about 95 million Americans use their mobile phones as health care tools or to find health information.

However beneficial social media can be to health care and health care practitioners, it also has a dark side. Health care workers and students posting on Facebook, Twitter, Pinterest, and other sites-even on their own spare time-must always be aware of confidentiality issues. In one instance, for example, a student serving an externship in allied health posted derogatory comments about a physician for whom she worked. The physician saw the student's remarks, and she was dismissed from her program. Other incidents of unwise use of social media have resulted in job loss, difficulty in obtaining a job, permanently derailing a career, and even legal difficulties.

Clearly, telemedicine is an integral part of today's health care envi- ronment. As such, health care practitioners must be aware of laws reg- ulating the service. Furthermore, confidentiality is a crucial concern as an ever-increasing amount of health care information is stored and transmitted online.

CONSUMER PRECAUTIONS REGARDING TELEMEDICINE

Individuals using the Internet for health care and medical information should evaluate Web sites for reliability. Users should ask questions such as these:

• Who is sponsoring the site? Sites sponsored by or linked with major medical centers and groups, government agencies, and medical professionals or major medical publications are most likely to present reliable information.

• Are several reliable Web sites offering similar information? If so, the information is most likely to be reliable.

• Does the site tout miracle cures or peculiar therapies? Users should discuss any claims made with a trusted health care practitioner before sending for materials or "cures" or otherwise following such advice.

Advances in technology have improved our ability to record, store, transfer, and share medical data electronically. They have also magni- fied privacy, security, and confidentiality concerns that pertain to patient medical records. Privacy issues are discussed at length in Chapter 8.

72 Part One I The Foundations of Law and Ethics

Chapter Summary

Learning Outcome

LO 3.1 Define licensure, certification, registration, and accreditation.

LO 3.2 Demonstrate an understanding of how physicians are licensed, how phy- sicians are regulated, and the purpose of a medical board.

LO 3.3 Discuss the changing configura- tion of health care management.

LO 3.4 Distinguish among the different types of managed care health plans.

Summary

How do licensure, certification, registration, and accreditation differ?

Licensure is a mandatory credentialing process established by law, usually at t he state level. Licenses to p ractice are required in every state for all physicians and nurses and for many other health ca re practitioners as well. Individuals who do not have the required license are prohibited by law from practicing certain health care professions.

• Certification is a voluntary credentialing process whereby applicants who meet specific requirements may receive a certificate.

• Registration is an entry in an officia l registry or record, list ing the names of per- sons in a certa in occupation who have satisfied specific requirements.

• Accred itation is the process by which health care practitioner education pro- grams, hea lth care facilities, and managed ca re plans are officially authorized.

How are physicians licensed and regulated?

• Each state's medical practice acts establ ish procedures for licensing physicians, registered nurses, and many other health care practitioners and regu lat ing the practice of medicine within that state .

• A physician 's license can be revoked or suspended for conviction of a felony, unprofessiona l conduct, or personal or professional incapacity.

What are the different types of medical practice management systems?

• A physician practicing alone is a sole proprietor.

• Physicians practicing with one or more partners have a group practice, which may be a pa rtnership or a limited liability corporation, depending upon the lega l agreement the physicians sign.

What is managed care, and how do the major managed care plans differ?

Managed care refers to a system that combines financing, administration, and delivery of health ca re to provide medical services to subscribers fo r a prepaid fee. Major types of managed care plans include:

• Health maintenance organization (HMO): A health plan that combines cover- age of hea lth care costs and delivery of health care fo r a prepaid premium.

• Ind ividua l (or independent) practice association (IPA): A type of HMO that con- t racts with groups of physicians who practice in their own offices and receive a per-member payment from participating HMOs to provide a full range of health services for members.

• Preferred provider organ ization (PPO) : A network of independent physicians, hospitals, and other healt h care providers who contract with an insurance car- rier to provide medical care at a discount rate to patients who are part of the insurer's plan.

• Physicia n-hospital organization (PHO): A health ca re plan in which physicians join with hospitals to provide a medical ca re delivery system and then contra ct fo r insurance with a commercial carrier o r an HMO.

• Accountable care organizations (ACOs): Hea lth ca re payment and delivery models that can reward doctors and hospitals for control ling costs and improv- ing patient outcomes by allowing them to keep a portion of what they save if standards of qua lity are met.

Patient-Centered Medical Homes (PCMH): A primary care concept that uses physician-led teams to coordinate patient ca re.

Primary care and specialist referral services.

• Remote patient monitoring.

• Patient portals-Web sites giving patients 24-hour access to health care providers.

Medical education . Physicians and other health ca re professionals can enroll in online courses where relevant , attend professional sem inars remotely, hear specia lists speak, and otherwise participate in continuing education.

Chapter 3 1 Working in Health Care 73

LO 3.5 Discuss the federal legislation that impacts health care plans.

LO 3.6 Discuss the impact of telemedi- cine and social media on the health care workplace.

Summary

What major federal leg islation has affected hea lth care insurance and payment fra ud in t he United States?

• Patient Protection and Affordable Care Act (PPACA): A federal law enacted in 2010 to expand health insurance coverage and otherwise regulate the health insurance industry. Many provisions of the law are scheduled to take effect in 2014 and 2015.

• Health Care Education and Reconciliation Act (HCERA): Also enacted in 2010, a federal law that added to regulations imposed on the insurance industry by PPACA.

• Health Insurance Portability and Accountability Act (HIPAA) of 1996: A federal statute that helps workers keep continu ous health insurance coverage fo r themselves and their dependents when they change jobs, protects confidential medical information from unauthorized disclosure or use, and helps curb the rising cost of fraud and abuse.

• Health Care Quality Improvement Act (HCOIA) of 1986: A federal statute passed to improve the quality of medical care nationwide.

• Federal False Claims Act : Allows for individua ls to bring civil actions on beha lf of the U.S. government for false claims made to the federal government.

How has telemedicine affected t he delivery of health care?

• Patients can find medical and health information, join discussion groups about certain medical conditions, communicate with others for support, and journal about personal med ical experiences.

What precautions shou ld consumers use regarding telemedicine?

Individuals using the Internet for health care and medical information should evaluate Web sites for reliability. Users should ask such questions as these:

• Who is sponsoring the site? Sites sponsored by or linked with major medical centers and groups, government agencies, and medical professionals or major medical publications are most likely to present reliable information.

• Are several reliable Web sites offering similar information? If so, the informa- tion is most likely to be reliable.

• Does the site tout miracle cures or peculiar therapies? Users should discuss any claims made with a tru sted health care practitioner before sending for materi- als or " cures" or otherwise following such advice.

Ethics Issues working in Health care

Providing competent, effective patient care without doing harm are the cornerstones of ethical medical practice. Health care practitioners want to make ethical choices in performing their duties, but sometimes decisions are difficult.

Ethics ISSUE 1: As one of three receptionists/appointment schedulers in a small medical clinic, pharmaceutical representa- tives often offer you pens, coffee mugs, schedulers, or other products. They request nothing in return, but you usually feel obligated to reciprocate, either by checking to see if a physician can squeeze them in between patients, or otherwise facilitating their visit.

Discussion Questions

1. Is accepting these small "gifts" ethical if nothing is asked in return?

2. Are pharmaceutical industry-sponsored lunches or trips provided for physicians ethical in your opinion?

7 4 Part One I The Foundations of Law and Ethics

3. Is it ethical for physicians to accept free drug samples from a drug company if they plan to give the samples to low-income patients?

4. Is it ethical for all or some health care workers in a facility to use free drug samples for themselves and their families?

Ethics ISSUE 2: A personable celebrity visits a physician in the medical center where you work. The celebrity travels fre- quently, and she has asked for an appointment with short notice. As the person responsible for scheduling appointments, you could easily use a trumped-up excuse to bump a patient at the desired day and time, in order to accommodate the celebrity.

Discussion Questions

1. Would it be ethical for you to cancel a patient's appointment in order to accommodate the celebrity?

2. If the celebrity is a hospital patient, would it be ethical for the hospital administrator to drop in to be sure the celebrity is satisfied with her room and care?

Ethics ISSUE 3: By law, health care practitioners can perform only those duties that are within their scope of practice-that is, those duties for which they are duly licensed, certified, registered, and competent.

Discussion Questions

1. You are a medical assistant in a clinic and a nurse asks for your assistance. She is way behind schedule and she asks you to administer an intravenous drug push to a patient. You want to comply, but is it ethical for you to comply?

2. As a student medical assistant you have learned the correct technique for giving a shot, but you have never perfected the technique. You begin working in a clinic right after graduation and your first assigned duty is to give a flu shot to an elderly patient, and you don't want to do it. Is it ethical for you to do it anyway? Would it be ethical for you to ask someone else to administer the shot?

3. As a new medical assistant, it takes you two attempts to successfully administer a flu shot to a young patient. You don't want to admit to the first failure, so you consider leaving the first unsuccessful attempt out of the medical record. Would this behavior be ethical?

Chapter 3 1 Working in Health Care 75

Chapter 3 Review

Enhance your learning by completing these exercises and more at http://connect.mheducation.com!

Applying Knowledge

LO 3.1

a connect®

Write "L" for licensure, "C" for certification, "R" for registration, and "A" for accreditation in the space pro- vided to indicate which is applicable in the following descriptions.

1. Involves a mandatory credentialing process established by law, usually at the state level.

2. Involves simply paying a fee.

3. Involves a voluntary credentialing process, usually national in scope, most often sponsored by a private-sector group.

4. Required of all physicians, dentists, and nurses in every state.

5. Consists simply of an entry in an official record.

6. A process that implies that health care facilities or HMOs have met certain standards.

7. Which of the following is mandatory for certain health professionals to practice in their field?

a. Endorsement

b . Reciprocity

c. Licensure

d . Certification

8. Licensure to practice medicine is done by

a. Each individual state

b. The federal government

c. Local and state governmen!s together

d. The federal government and the local government

9. Which of the following statements best defines accreditation?

a. It is a process that allows hospitals to license qualified employees.

b. It is a process for licensing clinical laboratories.

c. It is a process for officially authorizing health care education programs, facilities, and managed care plans.

d. It is another way to become licensed as a health care practitioner.

10. Which of the following best defines the osteopathic approach to medicine?

a. Emphasizes allopathic medicine

b. Emphasizes the use of drugs over surgery

c. Emphasizes surgery as the ultimate cure

d . Emphasizes the musculoskeletal system of the body and the correction of joint and tissue problems

76 Part One I The Foundations of Law and Ethics

11. Allopathic medicine means, literally,

a. "Different suffering"

b. "All encompassing"

c. "Ever enduring"

d. "Different approach"

LO 3.2

12. Which of the following is an example of a tertiary care setting?

a. A Catholic hospital

b. An endoscopic center

c. A children's hospital

d. A free clinic for the homeless

13. Which of the following is an explanation for the increasing number of medical specialists?

a. More women entering medicine

b. More scholarships available for medical students

c. Loss of prestige for generalists

d . Forgiveness of college loans for specialists

14. A physician fails to meet continuing education requirements. He or she is guilty of

a. Laziness

b. Deception

c. Unprofessional conduct

d. Fraud

15. Which of the following is not a purpose of medical practice acts?

a. To define what is meant by "practice of medicine" in each state

b . To be sure physicians are adequately compensated for their services

c. To explain requirements and methods for licensure

d. To establish grounds for suspension or revocation of license

16. Each state's medical practice acts also provide for the establishment of

a. Health care teams

b. Hospital ethics committees

c. Medical boards

d. HMOs

17. Laws vary from state to state, but unprofessional conduct for medical professionals usually includes

a. Physical abuse of a patient

b. Inadequate record keeping

c. Failure to meet continuing education requirements

d. All of these

Chapter 3 I Working in Health Care 77

-------------- ----- ----

18. Physicians' actions generally classified as fraud include

a. Falsifying medical diplomas and other credentials

b. Falsifying medical reports

c. Promising a patient "secret cures" or other special ways to cure an ailment

d. All of these

19. The sole authority granted to the federal government in the licensing of physicians is

a. License to practice a specialty

b. The permit issued by the Drug Enforcement Administration for controlled substances

c. Revocation of a physician's license for fraud

d. An endorsement when a physician moves to a different state

LO 3.3

20. Physicians today practice primarily

a. At the hospital

b. In sole proprietorships

c. In group practices

d. In large corporations

21. When two or more physicians practice together, with a written agreement specifying the rights, obligations, and responsibilities of each partner, what is the arrangement called?

a. A partnership

b. A group practice

c. A professional corporation

d. A sole proprietorship

22. What is an advantage to forming a professional corporation to practice medicine?

a. Physicians need just one license for the group.

b. Fees can be higher.

c. The incorporators and owners have limited liability in lawsuits.

d. None of these.

LO 3.4

23. Which of the following best defines a managed care health plan?

a. Preferred provider organization

b. A corporation that pays for and delivers care to subscribers

c. A sole proprietorship

d. A group practice

24. What is a copayment?

a. A percentage of the fee for services provided

b. A set amount that each patient pays for each office visit

c. The portion of the fee the physician must write off

d. The portion of the fee that the insurance company pays

78 Part One I The Foundations of Law and Ethics

25. Under this type of plan, insured patients must designate a primary care physician (PCP).

a. Point-of-service plan

b. Gatekeeper or primary care plan

c. Independent practice plan

d. Health maintenance plan

26. When physicians, hospitals, and other health care providers contract with one or more HMOs or directly with employers to provide care, what is it called?

a. A physician-hospital organization

b. A preferred provider plan

c. A health maintenance organization

d. A fee-for-service plan

27. Under this type of plan, a patient may see providers outside the plan, but the patient pays a higher portion of the fees.

a. Health maintenance plan

b. Independent practitioner plan

c. Preferred provider plan

d. Primary care plan

LO 3.5

28. The National Practitioner Data Bank

a. Is accessible to everyone

b. Is accessible to other providers on a routine basis

c. Is accessible only to hospitals and health care plans

d . Is accessible only to the government agencies monitoring health care

29. Which federal law mandated that insurers carry children of an insured family through age 26 and prohibited refusing to insure clients with preexisting conditions?

a. HIPAA

b. Health Care Quality Improvement Act

c. Patient Protection and Affordable Care Act

d. HMO

30. What recent federal law provides for the establishment of state-run insurance exchanges?

a. Federal False Claims Act

b. Health Insurance Portability and Accountability Act

c. Patient Protection and Affordable Care Act

d. Health Care Quality Improvement Act

31. Which of the following is not a stated goal of the Health Insurance Portability and Accountability Act?

a. Ensure that every person has health insurance

b. Improve the efficiency and effectiveness of the health care industry

c. Help employees keep health insurance coverage when they transfer to another job

d. Protect confidential medical information

Chapter 3 I Working in Health Care 79

LO 3.6

32. Which of the following statements best defines telemedicine?

a. It is medicine that is practiced via telephone, closed-circuit television, fax machine, or Internet.

b. It is medicine practiced only over the telephone.

c. It is television programs that discuss medicine and health care.

d. None of these.

33. Patient portal refers to

a. A special patient's entry to a medical facility

b. A place for consultaton via e-mail from physician to patient

c. Increasing use of the Internet for consumer health information

d. A patient procedure

Case Studies

LO 3.1

Use your critical thinking skills to answer the questions that follow each case study.

Physician assistants (PAs) are employed in physician offices throughout the United States. Although the PA provides direct patient care, he or she is under the supervision of a licensed physician. Duties include taking patients' medical histories, performing physical examinations, ordering diagnostic and therapeutic procedures, providing follow-up care, and teaching and counseling patients. In most states, PAs may write prescriptions. The PA may be the only health care practitioner a patient sees during his or her visit to the phy- sician office. Therefore, patients often refer to a PA as "the doctor." Ned, a PA for five years, says the patients he sees often address him as "doctor."

Similarly, Marie, a long-time employee of a physician in private practice, is often called "the doctor's nurse." Although Marie has never had the training necessary to become a certified medical assistant or a reg- istered nurse, she sometimes refers to herself as the "office nurse."

34. What legal and ethical considerations are evident in these situations?

35. Should Ned and Marie allow patients to call them "doctor" or "nurse," respectively? Why or why not?

Note: A health care practitioner is held to the standard of care practiced by a reasonably competent person of the same profession. A physician assistant using the title "doctor" and a medical assistant using the title "nurse" may be held to the standard of care of a physician and a nurse, respectively, and may be accused of practicing without the appropriate license.

LO 3.2

A source of potential problems for health care practitioners is advertising. Buying print ads, creating radio spots, or sponsoring Web sites are commonplace activities for today's health care practitioners, which may subject them to a different type of lawsuit.

Part One I The Foundations of Law and Ethics

For example, two New Jersey patients sued their physician over the Web site ads she ran for LASIK eye surgery. The patients claimed the doctor made false or misleading statements in her ads, leading them to believe she would provide all of their treatment. Instead, the patients said a physician who was not fully licensed provided their follow-up care. (This practice is generally medically acceptable.) The two patients sued the physician under their state's Consumer Fraud Act, an area of law from which physicians have tra- ditionally been exempt. A trial court allowed the suit to proceed, but the state supreme court reversed that decision, preventing the patients from suing the physician for advertising fraud.

36. In your opinion, should health care practitioners be protected from consumer fraud suits over advertising? Explain your answer.

37. As a health care practitioner, would you advertise your services? Why or why not?

Internet Activities LO 3.4 and LO 3.7

Complete the activities and answer the questions that follow.

38. Conduct a Web search for "patient care partnership." This document, published by the American Hospital Association, replaces the previous Patients' Bill of Rights, which was never actually a law. What six points are listed under "What You Can Expect"?

39. Use the Internet to find two ethical issues affecting health care practitioners. List those issues below. How will those issues affect your health care profession?

40. Conduct a Web search for "state telemedicine laws." Does your state have laws governing telemedicine? If so, briefly summarize them.

Resources

Accenture Web site: www.accenture.com.

American Telemedicine Web site: www.americantelemed.org.

Chretien, Katherine C. and Terry Kind. "Social Media as a Tool in Medicine," American Health Association Journal, 2013; 127: 1413-1421. Accessed 12/8/2013 at http://circ.ahajournals.org/content/127/13/1413.full.

Conn, Joseph. "No Longer a Novelty, Medical Apps Are Increasingly Valuable to Clinicians and Patients, Modern Healthcare," December 14, 2013. Accessed at www.modernhealthcare.com/article/20131214/ MAGAZINE/312149.

Joel, Lucille A. Kelly's Dimensions of Professional Nursing. New York: McGraw-Hill, 2011, chap. 17.

Chapter 3 I Working in Health Care 81

Kubasek, Nancy, et al. Dynamic Business Law. New York: McGraw-Hill/Irwin, 2009.

Liuzzo, Anthony L. Essentials of Business Law. New York: McGraw-Hill, 2010.

Mappes, Thomas A., and David DeGrazea. Biomedical Ethics. New York: McGraw-Hill, 2005, chap. 3.

Moini, Jahangir. Medical Assisting Review. New York: McGraw-Hill, 2008, chap. 8.

"Social Media 'Likes' Healthcare: From Marketing to Social Business," Health Research Institute, April2012.

Telephone interview November 5, 2007, with Dr. Carmen Paradis, Dept. of Bioethics, Cleveland Clinic. She provided a copy of the Cleveland Clinic Health System's "Code of Ethical Business and Professional Behavior," quoted in Ethics Issue 1.

82 Part One I The Foundations of Law and Ethics