Health Law

Health Maintenance Organizations (HMO)

"gate keepers" you had to go to a provider in that network in order for insurance to cover it

ACA

- expands protection by requiring EVERYONE to get insurance, while lowering costs - politically controversial

What were the main goals of ACA?

- increase quality and affordability - lower the number of uninsured (through both Medicaid and private) - expanded standard coverage, no pre-existing conditions

ACA legal challenges

- left most of ACA intact - strike down mandatory Medicaid expansion - penalty tax reduced to $0 - "repeal and replace" failed multiple times

advantages of corporations

- limited liability (owners shielded from personal liability) - continued existence despite death of an owner - taxation separate from individual income taxes - ability to raise capital - can sue or be sued

Medicaid

- mainly funded by states - default insurance for low income families - currently covers more people than Medicare - CHIP (children) - ACA has expanded coverage significantly

arbitration

- often mandatory, use of neutral third party to decide case - decision binding but parties may appeal

supreme court final decision making

- only hears cases granting certiorari

negotiation and settlement

- parties work with attorneys to reach acceptable resolution

involuntary civil commitment

- permitted for up to 72 hours if patient is a danger to self or others-- but CANNOT keep them if deemed incompetent - mental illness does not mean they're mentally incompetent

POSs

- point-of-service plans - you have a provider network and if you needed a service that isn't covered, they will reimburse

patient rights

- privacy (HIPPA) - self-determination - access to and control over one's own health (autonomy) - accept or reject medical treatment - discharge against medical advice (AMA) - access to treatments - information

Not-for-profit corporation

- profit is permitted, but it is NOT its primary purpose - income can NOT be distributed for an individual's private gain - require reporting community benefits - such federal exemption usually entitles org to automatic state exemption - most hospitals

patient responsibilities

- provide full and honest info - ask questions if they do not understand - be compliant with treatment plans that are agreed upon with providers - respect providers and other patients - make good-faith efforts to meet financial obligations

mandate for individuals

- requires most citizens to maintain qualified health insurance unless exempted or pay penalty - in 2017, Trump lowered penalty to $0... which is affecting us who have to pay more for insurance now

4 major sources of law (in order of hierarchy)

1) constitution 2) statutes 3) administrative law (regulations) 4) judicial decisions ("common law")-- based on precedents **each of these exist at the federal and state levels**

responsibilities of the governing board

1) develop policy and strategic plans 2) appoint senior administration and medical staff members 3) delineate clinical privilefes 4) oversee the professional performance of lay administration (non-clinical staff) and the medical staff

Judicial Decisions

1) stare decisis - power of precedent

The Constitution

1) the supreme law of the land 2) sets the standards by which all other laws are judged 3) grant of power from the states to the federal government 4) guarantees essential individual rights

Decipher this legal citation: 35 USC s 123(a)

35 = title 35 USC = United States Code

Second Wave of Hospital-Physician Integration

Clinton healthcare reform, increased cost and stress of practice management, and the Great Recession led to renewed interest in collaborative efforts between hospitals and physicians to reduce costs again

Decipher this legal citation: Daniels v. Weigum 194 Cal. App. 2d 620, etc..

Daniels = plaintiff aka the accuser Weigum = defendant (person being accused) 194 and on = doc stuff

Affordable Care Act - why it was made

Sought to reduce the expense of our healthcare systemby encouraging greater insurance coverage, expanding Medicaid, and some other measures **the idea was to expand our health pool to overall reduce the cost of health insurance**

Decipher this legal citation: Whalen v. Roe, 429 U.S. 589, 1977 U.S.

Whalen = plaintiff Roe = defendant US = federal law

Medicare Part B

covers physician visits

President branch

executive

What are the benefits of precedent?

stability and consistency

Who runs medicaid?

states

deposition meaning

sworn testimony under oath

Medicare Part C

(have to be enrolled in Part A and B) is a private insurance alternative, can include dental and vision

Medicaid expansion

(not successful in all states) expands coverage to all uninsured citizens with income below 138% of federal poverty level

list the litigation process

*all the facts of the case* 1) complaint, answer, reply 2) discovery phase and motions - deposition - written interrogatories - subpoena duces tecum - physical or mental examination of party - request for admission of facts 3) settlement, trial, appeal

ACA: four M's of access

- Mandate for individuals - Mandate for employers - Marketplace for private coverage - Medicaid expansion

Why was the ACA controversial?

- Not everyone wanted to "pay for other's healthcare" when they didn't even want insurance of their own - was during the 2009 housing crisis so rough times

jurisdiction (personal)

- authority of court over person as opposed to person's property - subject matter is not limited by may be divided into special courts

library of congress

- bill summaries, tracking and public law - monitors legislation under consideration in Congress - free research of federal laws

Trial courts

- burden of proof - discovery process occurs - judge and/or jury hear testimony, view exhibit and interview witnesses, and try to reach verdict

Antidiscrimination Laws

- can't turn people away based on gender, race, etc. - right to care while incarcerated (8th amend)

governing board's duties

- care = act with due care and loyalty - loyalty = no director can gain personally, accept bribed, or compete with the corporation - obedience = ensure that the organization remains loyal to the mission as spelled out in the articles of incorporation

healthcare transparency

- consumers remain in the dark about what they will be asked to pay after visiting a primary care doctor or undergoing an inpatient procedure - no more surprise billing though

jurisdiction (subject matter)

- content/substantive area of case must be related to federal law, treaty or US Constitution - may have exclusive jurisdiction

limited jurisdiction

- for cases of particular subject matter or lesser severity crimes - special jurisdiction such as small claims, domestic relations, etc.

Appellate courts

- hear appeals on final judgements of the state trial courts to determine whether error in law or procedure occurred - no testimony or exhibits reviewed - decides whether reversal or modification in verdic is warranted

multi-institutional systems

- hospitals from large networks (systems) which offer a broad range of services to reach larger swaths of the population

piercing the corporate veil

- if some behavior from the board is so bad and off the law, the judicial system can piece the corporate veil

diversity jurisdiction

- if you have an issues involving parties of two different states - cases must have both elements of: citizens of different states AND amount of controversy more than $75,000 - federal judge applies state law in which lawsuit is filed

what are the 3 alternatives to legal cases?

- mediation - arbitration - negotiation and settlement

what were the goals of the first wave?

- reduce costs - provide full range of services - provide management with admin support - generate economies of scale (can get greater efficiencies because of size) >> hospitals and physicians realized the importance of shared values and interest in this approach

powers of a corporation

- set by state corporation law - limited by bylaws (you have to keep to them and never stray) - common reserved powers (only for the highest level of the organization)

state open meeting & public record laws

- sunshine laws aka open meeting laws or public records laws - in effect for public institutions

Mandate for employers

- tax penalty implemented if adequate, affordable health insurance wasn't offered - coverage for children up to age 26!!!

medical necessity

- there's no universally accepted definition of it... - AMA defines it as "generally accepted standards of medical practice" - efforts to define at federal level have failed - CMS has led way in defining guidelines through precedence ** but it's a big problem in mental health **

For-profit corporation

- to make money for themselves - income may be distributed to shareholders, director, officers, or other individuals for their private gain - can raise capital through investors - pay income and property tax

mediation

- voluntary use of neutral third party to decide case - most efficient when parties agree to accept settlement - documents are NOT filed in public record

joint venture

-a mutual endeavor by two or more organizations for a specific purpose or for a limited duration-- still separate entities, just tackling something together -common relationship between doctors and hospitals (hospitals provide structure, supplies, etc and doctors bring medicine and care)

Administrative Regulations

1) admin agencies are not mentioned in the Constitution yet play a vital role in gov 2) in order to commence rulemaking, federal agency must publish in the Federal Register

Statutes

1) codified in the USC 2) rules of construction help judges interpret statutes

FQDHCs

Federally Qualified Health Center (FQHCs) are community based OP clinics that receive federal grants to provide care to people in underserved areas or who are economically or medically vulnerable

what are the downsides of sunshine laws?

HIPPA violations

Describe the "three layered cake"

Medicare Part A supported by Democrats Medicare Part B supported by Republicans Medicaid supported by state governments

Is a corporation a citizen?

No! It's an "artificial person" but not a citizen

Does a hospital have a legal obligation to admit all patients?

No, they're required to stabilize a patient, then they can go onto another hospital to be treated if needed

mergers and consolidation pros and cons

Pros: hospital efficiency, can negotiate things better, don't need as much staff cons: too much bargaining power, ability to increase prices without increasing quality

The trial court in the federal court structure is known as the...

US District court

consolidation

a transaction in which two or more organizations combine to form a new corporation, thereby dissolving the predecessor companies; sometimes used as a general term inclusive of merge and acquisition

which type of law is crafted by the executive branch of the government?

administrative

Fee-for-service (FFS) standard

all services provided are reimbursed

what is the board's size determined by?

articles of incorporation or bylaws

RVU

every procedure or thing is assigned a value which helps determine how much physicians get reimbursed for what they do (commonly used in Medicare Part B)

request for admission of facts meaning

facts that can be skipped/not really proven in court because it's not really relevant

Who runs medicare?

federal

what does stare decisis mean?

following precedent in judicial decisions

general jurisdiction

for more serious criminal cases or civil dealing with large sums of money

who are the reserved powers met for in for-profit vs not-for-profit?

for-profit = share-holders not-for-profit = members or the board

articles of incorporation

formal document that corporations live and die by-- it's everything the corporation is about

supreme court

hears appeals from the appellate courts or from trial courts (and they choose what cases they want to take on)

Medicare Part A

hospital coverage, hospice care, and some skilled nursing care

subpoena duces tecum meaning

how medical record, emails, etc. get brought to court as evidence

First malpractice case

husband sued "doctor" (a physician licensure) who did a mastectomy on the wife who had breast cancer and she died of a raging infection (due to lack of sanitation)

who's part of the governing board?

include representatives from local community

Supreme court

judicial

Congress branch

legislative

Municipal courts

local jurisdictions handle minor cases (parking tickets and such)

Peer Review Organizations/Quality Improvement Organizations

looking at quality of care-- released too early, readmitted. etc.

US Court System Structure (federal)

lower: district courts Circuit courts highest: Supreme Court

US Court System Structure (state)

lower: trial/circuit system intermediate court of appeals highest: Supreme Court

Does the US Constitution provide a right to healthcare?

no, universal coverage is not guaranteed

writ of certiorari

petition to have supreme court hear the case

Medicare Part D

prescription drugs

what are the pros and cons of a large multi-institutional system?

pros: more leveraging power. Very useful during the pandemic bc there was always access to supplies, you can negotiate with insurers better cons: efficiency is lower in a bigger system and dealing with a bureaucracy

Medicare (in general)

provides for those over 65, those with qualifying disabilities, or kidney failure. It is our largest insurer. It is the more stable option because in Medicaid, states cut funding for it.

Marketplace for private coverage

purchase private plans and receive premium subsidies and cost sharing reductions based on income

Preferred Provider Organizations (PPO)

removed gate keeping but you still had an expanded list of providers that were covered-- they removed the referral thing

Conditions of Participation (CoP)

required to receive medicare/medicaid funding today

DRGs

required under medicare and medicaid-- all payments included in lump sums. Basically you're reimbursed no matter what is done but now insurance is only paying for certain things

Where are the federal laws codified?

the USC - where all federal statutes are (US Code)

merger (acquisition)

the joining of two or more corporations, whereby one or more organizations transfer assets to another (the survivor) and then is dissolved

What are the drawbacks of precedent?

times and society EVOLVE over time and precedent might not be relevant anymore

First Wave of Hospital-Physician Integration

to combat increasing cost-conscious and competition in the late 1980's, hospitals and physician groups often developed business arranges to reap economic rewards (there were financial incentives)

What are "minutes"?

written record of board meetings. Very legally important