History of Healthcare in America

disadvantages of FFS

Expense, paperwork, denial of services, limited focus on preventative treatment, and lack of medical provider accountability

Intensive case management (ICM)

is a treatment team, community-based helping model focused on helping patients develop and maintain the following skills: Employability Housing Mental health (stability) Social status

Clinical Case Management Model

(sometimes called the rehabilitative model of case management), is a more active model than the brokerage model. Under this model, the case manager takes on the role of a clinical behavioral therapist in addition to providing a connection to services and related biopsychosocial support.

Involuntary Passive Euthanasia

- Patient does not request their own death- someone else decides for them, usually as a result of patient being unable to communicate(coma) or unable to understand their condition - Medical treatment is withheld or discontinued and the cause of death is the same as the condition causing the suffering

Voluntary Passive Euthanasia

- Patient requests their own death- either verbally or in living will. - Medical treatment is withheld or discontinued and the cause of death is the same as the condition causing the suffering.

Social Security Amendments of 1972

A few years later, President Richard Nixon further amended the Social Security Act to provide coverage to disabled persons under 65 years of age in the Medicare program via Public Law 92-603, which amended Title XVII of the Social Security Act. This new provision expanded Medicare to persons who had been receiving Social Security disability benefits for at least two years, and to all persons with chronic kidney disease requiring dialysis.

Karen Ann Quinlan

A 1976 case involving a 22-year-old female who became comatose following a drug and alcohol overdose. Karen required the use of a ventilator due to a persistent vegetative state. Her family fought for years with medical staff to remove her breathing tube based on Karen's wishes she had previously expressed. However, medical professionals were unwilling to remove the ventilator and kept her on life support against both she and her parent's wishes. A legal battle ensued, lasting 10 years. Karen never regained consciousness but remained in a persistent vegetative state and was sustained by feeding tubes and artificial ventilation. Ultimately, the family won the case, and Karen was removed from life support in May 1976. She did begin breathing on her own. She was moved to a nursing home where she lived until her death in 1985; spearheaded the movement on effective execution of patient wishes

Nancy Beth Cruzan

A 1983 case involving a 33-year-old female who sustained major brain injuries following a car accident. Nancy's family request removal of her feeding tubes after doctors ruled that consciousness was not possible. Following seven years of legal battles, Nancy's life support was disconnected. However, another controversy arose when it took 11 days for Nancy to pass—her feeding tubes were removed on December 15, and she died on December 27. This case introduced the argument of the ethics involved in removing tube feedings and effectively starving the individual; spearheaded the movement on effective execution of patient wishes

The foundation of healthcare dates to 1798 based on the passing of the

Act for Relief of Sick and Disabled Seamen

IRBs three foundational principles

Respect for persons—This includes both respecting the autonomy of human subjects and protecting vulnerable individuals from exploitation. Beneficence—This duty requires that research maximizes the benefit-to-harm ratio for individual subjects and for the research program. Justice—This focuses on the duty to assign the burden and benefits of research fairly.

right to die

Advocating for the right of terminal patients to refuse treatment.

The ten essential benefits outlined by the Affordable Care Act included

Ambulatory (outpatient) patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance abuse disorder services, including behavioral health treatment Prescription drugs Rehabilitative services and devices Laboratory services Preventive and wellness services/chronic disease management Pediatric services, including oral and vision care

Health Maintenance Organization Act of 1973

Another piece of healthcare legislation signed by President Nixon, this law promoted a particular type of health insurance—prepaid private group practice service plans, or health maintenance organizations (HMOs), which would become available in addition to traditional fee-for-service plans (Barr, 2011). The law accomplished the following provisions, some of which are still enforced today: Offered federal subsidies to establish new "federally qualified" HMOs. Required employers who offered health insurance to offer an HMO option whenever available. Allowed HMOs to adopt a variety of organizational structures. For instance, the HMO could contract with several hospitals or practices rather than owning its own hospitals, if the plan were chosen. Required primary care physicians to act as gatekeepers of specialists, requiring patients to receive a referral to specialist from a primary care physician. If patients do not receive a referral prior to a specialist appointment, the patient would be responsible for the full amount of the bill.

Major key points of duty to report

As with duty to warn laws, a duty to report statutes can vary greatly by state and even by local county and municipality. Licensed clinicians and other professionals who may be subject to either the duty to warn and the duty to report statute should familiarize themselves with requirements in their respective state. Mandated reporters who fail to report suspected abuse, neglect, or financial exploitation may be sanctioned by their state licensing boards, lose their license to practice, or even be held civilly or criminally liable in court.

Office of Civil Rights (OCR)

Assess whether low-income minority children were unlawfully denied access to medical care

1976

Barry Keene successfully led California to become the first state to legally sanction living wills; New Jersey Supreme Court validated advance directives at the state level.

The Occupational Safety and Health Administration (OSHA)

Before 1970, there were little protections from unsafe working conditions, which led to high injury rates. In response, Richard Nixon introduced OSHA legislation. Under the Department of Labor, OSHA was given the power to both enforce safety standards and levy fines against employers found to be in violation of said law (OSHA). OSHA provides standards for protecting healthcare workers from bloodborne pathogens, provides procedures for needlestick safety, and requires employers to provide employees with safety equipment. Since its inception, the rate of serious workplace injuries declined from 11 injuries per 100 workers in 1972 to 3.6 injuries per 100 workers in 2009. OSHA can fine employers found to be out of compliance up to $132,598 per violation.

Pure Food and Drug Act of 1906 and the Establishment of the Modern Food and Drug Administration (FDA)

Before the Industrial Revolution, many people grew and made their own food at home and may have also mixed their own medicines or purchased them from a local apothecary or herbalist. However, by the end of the nineteenth century, many foods and medicines used by Americans came from large manufacturers. Despite this trend, there were no regulatory standards for product labeling, safety, or consistency, or for drug or food products. As a result, many prepackaged foods and drugs purchased by Americans were spoiled, mislabeled, or even poisonous. Manufacturers could also make misleading or inaccurate claims about a specific drug, attesting that it cured everything from sleeplessness to cancer, without penalty. Between the 1880's and the early 1900's, a series of scandals erupted surrounding the poor quality of manufactured foods and drugs in the United States. Many people, including children, became ill or died because foods they consumed or medications that had been mislabeled were mixed with toxic or inedible substances or did not include safe dosing instructions. After the publication of Upton Sinclair's novel, The Jungle in 1906 revealed the abhorrent nature of meat and food-processing in the United States at the time, Congress responded by passing the Pure Food and Drug Act of 1906, which achieved the following (Food and Drug Administration, n.d): Illegalized the manufacture and sale of dangerous, adulterated (mixed with toxic substances), mislabeled, or spoiled foods and drugs Prohibited the interstate transport of unlawful food and drugs under penalty of seizure and prosecution Monitored and enforced food and drug product labeling and advertising Regulated the manufacture and sale of drugs by defining standards of strength, quality, and purity as set by the United States Pharmacopoeia and the National Formulary Required food and drugs match the ingredients listed on their labels Demonstrated and met standards set for the efficacy and safety of a specific drug before it could be sold to the public

Institutional Treatment

Beginning in the 1830's, a social worker named Dorthea Dix began to challenge the public perception of those with mental illness. Dix advocated for better living conditions, and, over a forty-year career, she successfully lobbied for the creation of 32 state psychiatric hospitals. Her idea was to create places where the mentally ill could be treated by professional staff in institutional settings. The goal of this was to improve the overall wellbeing of the patient and encourage families to visit, so the mentally ill could be discharged back into the community being able to manage their illness well. This institutional care model was found to be an effective way to care for the mentally ill. Although this model increased access to mental health services, the hospitals were understaffed. This led to the poor treatment of patients and drew criticism, which grew louder over time. Instead of treatment with the goal of discharge, many of these hospitals turned into long-term care facilities. The discharge rates were low, and rehabilitation was uncommon, leaving patients in the hospital for years to decades at a time. Further, these hospitals became a way for men and families to rid themselves of people in their life. It was common for men to admit their wives into hospitals for diagnoses such as "hysteria" as a form of punishment. A religious group known as Quakers also began advocating for better treatment of the mentally ill in the 1800's. During this time period, those with profound mental illness were even "put on display" for an admission charge at institutions. These facilities were not tasked with treatment or recovery. Instead, they were designed only to provide housing and institutional care. To the Quakers, this was offensive and not an appropriate way to treat other humans. Based on the central Quaker tenant of "God dwells in every man," Quaker's believed the mentally ill could be cured with kindness and respect in a calm, healing environment. Their action played a large role in the development of humane treatment of individuals with mental illness.

Food and Drug Administration (FDA)

Beginning in the 1837's, Congress saw the need for regulations to protect consumers from mis-branded or mislabeled items. Initially regulating agricultural pesticides, the agency grew larger over the years. Now, the agency has a much wider scope and regulates the safety, quality, and efficacy of all food and drugs made available for human consumption (FDA, 2018). The FDA also governs the manufacture of drugs and medical devices, including ensuring manufacturing facilities, pharmacies, and drug distributors maintain a predetermined level of safety and prevent contaminated, spoiled, or dangerous drugs, devices, or foods from entering the U.S. marketplace. Finally, the FDA regulates advertising and product labeling for foods, drugs, and medical devices to ensure that members of the public receive accurate safety and clinical effectiveness information about the drugs and foods that they may wish to purchase or use.

Office of Inspector General (OIG)

Between 1974 and 1976, congressional committees heard days of testimony regarding serious deficiencies in governmental organizations' ability to detect and stop waste, fraud, and abuse. A second set of hearings took place in which Congress learned of "Medicaid Mills": organizations that billed Medicaid billions of dollars for unnecessary tests, prescriptions, and referrals. Prior to 1976, there was no centralized investigative body independent of Health and Human Services (OIG). These hearings culminated in the creation of the Inspector General Act of 1978 (OIG). This act created an OIG within every major agency and department. The office that oversees healthcare is known as the Health and Human Services Office of Inspector General (HHS-OIG). This agency serves as the monitor for all programs and services operating under the HHS. This agency not only detects waste, fraud, and abuse; it also works with federal and state law enforcement agencies to prosecute individuals or organizations that have violated federal health regulations and misappropriated healthcare dollars.

National Mental Health Act

Created in 1946 after the end of World War II, this act addressed the large portion of veterans returning home from overseas with profound mental health concerns. This act helped address what is now referred to as post-traumatic stress disorder. It emphasized that strong evaluation and medication management programs were more beneficial to soldiers than institutionalization was. The law also created the National Institutes of Mental Health (NIMH). Much like the National Institute of Health, this organization is responsible for distributing funds to pilot projects, initiatives, and ongoing programs that benefit those with mental illness, ranging from depression and anxiety to post-traumatic stress disorder and intellectual disabilities

Office of the Inspector General (OIG)

Determine whether a hospital or physician has committed Medicare fraud

Title XIX of the Social Security Act

Established Medicaid, which provided public health coverage to poor families receiving Aid to Families with Dependent Children (AFDC). The federal government and the states jointly ran this program, with the federal government providing matching grants and administrative guidance, while the states were given discretion on how to allocate and administer those funds.

Title XVIII of the Social Security Act

Established Medicare Part A and Part B, which covered hospitalization and doctors' visits for persons age 65 and older, with some limited coverage for post-hospitalization skilled nursing care.

State Board of Nursing

Give injections or insert IVs

Data and Information Governance

HIPAA Overview Micro, Mezzo, and Macro Security Measures HIPAA Regulation

Centers for Medicare and Medicaid Services (CMS)

Headquartered in Washington, DC, this agency administers the Medicare and Medicaid federal insurance programs. CMS provides guidance for quality standards in nursing homes and hospitals. CMS also sets clinical diagnostic standards, maintains standardized billing codes (also referred to as ICD codes), and sets national policy standards for the majority of healthcare reimbursement rules, health information technology regulations (such as the security of healthcare records data), and electronic medical records (EMRs). CMS also provides administrative oversight to the Medicare and Medicaid programs throughout the United States. Private insurers usually incorporate all CMS rules and regulations into their own companies and then add additional, privacy provisions specific to their own insurance plans. CMS also rates the quality of U.S. hospitals and nursing homes through its Star rating program. While Medicaid billing, diagnostic, and national policy standards are established by CMS, the implementation, provision, and day-to-day administration of Medicaid are handled at the state level.

Early History of Treatment of Mental Illness

Historically, many cultures have viewed mental illness as a type of punishment or demonic possession. Over time, views on mental illness have shifted from religious or personal problems to illnesses that could respond to treatment. Beginning in the fifth century BC, Hippocrates changed the way people with mental illness were treated. Although he is considered a revolutionary today, his thoughts on treatment of the mentally ill were considered outlandish at the time. Hippocrates challenged views of mental illness and pioneered the idea that mental illness could be treated by changing a person's environment or occupation and even by administering medications. Unfortunately, punitive treatment and negative attitudes persisted among almost all cultures into the nineteenth century in the United States. These attitudes lead to stigmatization and cruel treatment of the mentally ill.

Community Mental Health Centers Construction Act

In 1963, the John F. Kennedy administration took a strong role in changing the mental health system in the United States. Kennedy had a personal interest in mental health. His sister Rosemary Kennedy had been the victim of a failed lobotomy, which was a common procedure for those with profound mental illness or intellectual disabilities. Today, the procedure is not performed and is considered barbaric and untherapeutic. Through this lens of public health, Kennedy believed that many institutionalized individuals could function well with additional community supports. As part of a deinstitutionalization campaign, the Community Mental Health Act was passed. Its goal was to remove people from mental health institutions and create a strong network of centers to address mental health concerns without institutionalization. Deinstitutionalization accelerated rapidly in 1965 with the creation of Medicaid. Since the passage of the act, 90 percent of state hospital beds have been cut.

Uniform Anatomical Gift Act (UAGA)

In 1967, the first successful heart transplant occurred raising questions about the ethical responsibilities of the medical community. In 1968, Congress passed a law to increase organ supplies and protect patients. Prior to this law, there were inconsistent laws throughout the country. The act has been revised twice, in 1987 and in 2006. Both revisions were crafted with the intent of accommodating developments in medicine, including the addition of donor status on driver's licenses to help increase donor supply.

Theresa (Terri) Maria Schiavo

In 1990, 26-year-old Terri Schiavo collapsed at home and went into cardiac arrest caused by a potassium imbalance. The incident left Terri without the ability to function (walk, talk, sit, or eat) and with the requirement of a feeding tube. Terri's husband and parents became involved in a long battle regarding the goals of care for her. Terri's parents wanted her to continue life support, but after 10 years her husband pursued removal. The case went through several appeals and was followed closely in the media. Eventually, the husband won the case, and Terri's feeding tubes were removed on March 18, 2005, almost 15 years after her original injury. She died 13 days later; spearheaded the movement on effective execution of patient wishes

All institutions and professionals practicing in the U.S. healthcare system are subject to regulation. Regulation of healthcare in the United States can consist of the following:

Laws and rules enacted, administered, and enforced by the government (federal, state, and local) Licensing and certification requirements for providing healthcare services Regulatory compliance required by Medicare and Medicaid, known as "conditions of participation," which identify the minimum health and safety standards to operate a healthcare-related business Accreditation of healthcare providers and facilities, both public and private

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Limited the extent to which insurance companies could exclude people with pre-existing conditions, including pregnancy. Required health insurance companies to extend coverage to workers they had been covering under COBRA and whose COBRA coverage had expired under the provisions laid out in the original 1986 statute. Established national standards for the privacy and security of electronic health information, with the following select rules (Centers for Disease Control and Prevention, n.d):Security Rule. Health Information stored electronically which could be used to identify a patient is required to retain the utmost confidentiality, and providers are legally responsible for protecting this information.Privacy Rule. Patients retain full access to their health records and can restrict their disclosure and use.

CMS (Centers for Medicare and Medicaid Services)

List clinical criteria for a specific disease diagnosis or treatment for reimbursement

Early 1990s

Local, county, state and federal courts, including the U.S. Supreme Court, began to hear testimony on advance directives violations as the Right to Die movement increased.

FDA

Manufacture and/or sell prescription drugs or medical devices

Medicare and Medicaid Reimbursement

Medicare Overview Medicaid Overview Coding Classifications

Duty to report

Most U.S. states go beyond duty to warn and require a duty to report. The duty to report is also called mandated reporting. Many states have statutes outlining the duties of mandated reporters (clinicians, psychologists, physicians, social workers, teachers, clergy, etc.). In states with mandated reporter laws, these professionals are legally required to tell of abuse, neglect, or financial exploitation of any individual. The reports can usually be made anonymously. Depending on the age of the victim, it will be forwarded to the agency responsible for protecting children or the agency protecting adults. An investigation will occur. Reporting suspected abuse, neglect, or financial exploitation is always advisable as it helps protect the healthcare professional from liability if the victim is subsequently injured.

Welsch v. Likins

One of the first major deinstitutionalization cases, Welsch v. LiIkins was brought forward in 1972 on behalf of numerous mentally disabled persons confined to Minnesota state hospitals. Many patients in Minnesota state hospitals for the mentally disabled were heavily medicated, forcibly restrained, and cruelly treated. The plaintiffs argued that forcibly confining mentally disabled people in state hospitals amounted to cruel and unusual punishment and unlawful imprisonment without appropriate due process. The U.S. District Court ruled in favor of the plaintiffs, stating that the patients had a constitutional right "to a humane and safe living environment while confined under state authority" as well as the right to due process to determine if they could be better cared for in the community, outside of institutions. The Welsch case led to stricter legal requirements for establishing medical justification in a court of law for forcibly confining patients, while also requiring that inpatient care for the mentally incompetent and disabled be humane.

Care Deliver Models

Patient-centered medical home/home neighborhood Population health management Guided care model Accountable care organizations (ACOS)

1991

Physician Orders for Life-Sustaining Treatment (POLST) documents started being used across the United States. The POLST is a document that details the end-of-life care decisions expressed by the patient. Beginning with a conversation with a physician, the POLST form becomes a document that is applicable across treatment settings. The form offers instruction for CPR, medical interventions, antibiotics, and artificially administered nutrition and fluids. This form provides guidance to healthcare professionals to ensure that the medical interventions provided are consistent with the patient's previously expressed desires. Initially used in Oregon, this document is now used across most states.

Social Security Amendments of 1965

Prior to 1965, very little was accomplished at the federal legislative level regarding health policy due to political upheaval associated with both world wars and the Great Depression. The Social Security Act was passed in 1935 but did not contain a healthcare-related provision due to political controversy. However, after World War II, there was a growing political movement to provide a national healthcare program. While this movement did not achieve universal healthcare, the Social Security Act was amended in 1965 by President Lyndon Johnson to establish the Medicare healthcare program for the elderly and the Medicaid program for the poor.

Lobotomy as Treatment

Prior to the advent of modern psychiatric medications, the use of psychosurgery became more widespread. A Swiss neurologist Gottlieb Burckhardt began operating on schizophrenic patients through lobotomy. This procedure involved inserting an ice pick-like instrument through the eyeball and into the frontal portion of the brain. This would destroy the frontal lobe of the patient's brain. This area of the brain is responsible for cognitive skills such as emotional expression, judgment, sexual behavior, and problem-solving. This area drives personality and the ability to communicate. Although barbaric and illegal today, it is estimated that between the 1940's and 1950's, 40,000 to 50,000 lobotomies were performed, leaving these individuals severely impaired and unable to function without assistance.

The Rise of Deinstitutionalization

Public awareness surrounding the abuses suffered by patients in mental institutions and facilities for the disabled began to grow in the 1960s, corresponding with the civil rights movement. For example, media coverage of poor treatment of the disabled in New York's Willowbrook State Hospital caused widespread public outrage when conditions were revealed on television and in newspapers. Presidential candidate Robert F. Kennedy toured the Willowbrook facility and made reforming mental health and mentally disabled institutions part of his 1968 political platform. Popular culture also had an impact, such as bestselling novels like One Flew Over the Cuckoo's Nest, which dramatized the lives of forcibly confined psychiatric patients in the 1950's and early 1960's. This novel was subsequently made into an Academy Award-winning film, bringing even more attention to this issue. The change in how the public viewed the treatment of mentally ill and disabled people brought about the deinstitutionalization movement.

Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Medicare Part D)

Signed by President George W. Bush in 2003, this law enabled Medicare to cover prescription drug costs for the first time in its history through a voluntary program called Part D. The law also introduced changes to Medicare Part B by charging higher premiums to higher-income beneficiaries (individuals with incomes over $85,000 and couples with incomes over $170,000).

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

Signed by President Ronald Reagan in 1986, this law revised the tax code to incentivize employers to allow their employees to keep employer-based health insurance for a period after losing a job. Under the law, employees could (U.S. Department of Labor, 2016): Keep plan coverage for 18-36 months after leaving employment, depending upon the reason for departure (job loss, job change, death or divorce of a covered family member, reduction in hours, or medical leave). Pay out-of-pocket for the entire plan premium, including the portion previously paid by the employer, once COBRA benefits were in force.

Balanced Budget Act of 1997 (Established S-CHIP)

Signed into law by President Clinton, the Balanced Budget Act of 1997 created Title XXI of the Social Security Act, which established the State Children's Health Insurance Program (S-CHIP) also made changes to the Medicare program. This law achieved the following (MACPAC, n.d): Established block grants for states to offer health insurance to children who were not previously eligible for Medicaid and whose families earned less than 200% of the federal poverty line. Gave states discretion on whether to offer the coverage as part of its existing Medicaid programs or as part of a new program. Expanded options for private Medicare HMO/PPO plans (Medicare Advantage). Encouraged states to offer HMO options to Medicaid recipients.

Office for Civil Rights (OCR)

The OCR ensures that all individuals receiving services from HHS-administered systems or programs are not subject to unlawful discrimination. This office is tasked with ensuring the following acts are appropriately enforced: Civil Rights Act of 1964, Americans with Disabilities Act, the American Equal Access Act, and the Age Discrimination Act of 1975, among others. The OCR also enforces laws, rules, and regulations that protect individuals receiving HHS services or who are enrolled in HHS programs, so they may freely exercise their conscience rights, including the right to refuse care and to personal and religious freedoms. Lastly, the OCR enforces rules and regulations surrounding the privacy and safety of individuals' health information as well as investigate instances where patients' privacy rights may have been violated.

1991

The Patient Self-Determination Act was enacted, which stipulated that all hospitals obtaining medical funding from Medicaid or Medicare must ascertain if patients have or wish to complete an advance directive.

Questionable studies that were undertaken prior to the National Research Act included

The Tuskegee Syphilis Experiment, in which, illiterate, poor African American patients during the segregation era (1932-1972) were injected with syphilis without their knowledge and then left untreated despite the existence of effective medicines. This study was conducted so physicians could observe how syphilis (a dangerous sexually transmitted disease) progressed without treatment. This unethical experiment helped justify the need for the National Research Act of 1974. The Fernald State School Experiment, in which disabled children were injected with radioactive minerals to study the effects of radiation sickness. Henrietta Lacks, in which, in 1951, an impoverished African American's bodily cells were collected during a routine cancer biopsy and then used in scientific research experiments for decades without the patient's informed consent or shared monetary benefit.

euthanasia

The act or practice of permitting a terminally ill patient to die in a painless way; For many, is an act of mercy; ending needless suffering when a patient is in a physical state for which he or she will never regain an acceptable quality of life; is seen as controversial, and laws related to this act are extremely varied across states. Over the past 100 years, physicians like Dr. Kevorkian have made a case to the public for greater acceptance of it. It can take place in many forms. In general, the public has become more accepting of "voluntary", both active and passive. The public remains apprehensive about nonvoluntary, and most people are against involuntary. Indeed, most professionals who study medical ethics agree than involuntary would be inappropriate under almost all circumstances.

1968

The first bill considering the validity of a living will was introduced to the House. The initial bill failed in 1968 and in 1973. A living will is essential when individuals are no longer able to make decisions for themselves, whether physically or mentally. The document provides guidance to both healthcare providers and caregivers responsible for decision-making for the patient. It outlines the patient's wishes for care, acceptable interventions to prolong life, and during end of life care. These documents help alleviate tension and allow the medical team and family to make decisions that are in accordance with the wishes of the patient.

During the 1960s and 1970s, society began to consider the idea of patients having a "right to die."

The idea of advance directives and do-not-resuscitate orders became more common. The advance directive document allows an individual to document what life-saving measures they would want performed if they were no longer able to speak for themselves. This document began to provide guidance to doctors on how to direct treatment of the critically ill person. As a result of advance directive documents, physicians began using a do-not-resuscitate order. This order is notated in the patient's chart and advises all medical staff that, should the patient's heart stop or the patient stop breathing, the patient would not want CPR or any other extraordinary measures to prolong life.

Patient Protection and Affordable Care Act of 2010 (ACA, "Obamacare")

The most recent and comprehensive of health policy legislation enacted in the United States over the past 50 years, the Affordable Care Act was a historical landmark and all prior legislation and policy contributed to its creation. This law accomplished the following (Kaiser Family Foundation, 2014): Provided an expansion of health insurance coverage to more Americans through both individual health insurance exchanges and increased access to employer-provided plans. Minimum requirements of coverage were established with individual and employer mandates, which are enforced by tax penalties. Subsidies and tax credits were provided to individual consumers based on income level and dependents to help cover premiums that helped individuals below or near the federal poverty level obtain coverage at a cheaper cost. Expansion of Medicaid to cover low-income childless adults, although states have the option to refuse to expand Medicaid. Small businesses were given tax credits based on the level of insurance offered to employees.

Olmstead v. LC

The most recent case law which impacts behavioral health care in a major way, this legal case determined that mental illness is a disability condition governed by the Americans with Disabilities Act of 1990. The case was brought by two patients with psychiatric conditions (one also had a developmental disability) in the State of Georgia who were being forcibly confined to a mental health facility rather than living in the community. The United States Supreme Court ruled that mentally ill persons are disabled and as such, they have the guaranteed legal right under the Americans with Disabilities Act to reside in the community rather than in a mental health institution. The case also found that the determination of whether a patient should be confined to an institutional setting or within the community should be made by courts, in partnership with medical professionals. The case also found that moving a patient from the community to a more restricted setting must be medically justified and approved by a court on an individual basis.

Other Potential Ethical Applications for IRBs

The public and privacy advocates have suggested many times that the National Research Act should be updated to address twenty-first-century ethical dilemmas. The rise of social media and the prevalence of access to the internet has led some to question the strength of current protections for individuals. Lack of privacy, lack of informed consent, and other forms of potential mental or physical harm have not been put in the context of newer technology. While no laws have been written surrounding these controversies as of July 2019, you are encouraged to think about how and why these parallels may exist.

Third-Party Insurance Regulations

Third-Party Insurance Regulations

Michael Martin

This 1987 case involved a 35-year-old male who suffered a major brain injury following a car-train accident. Following the accident Michael was unable to walk or talk, was severely mentally impaired, and was dependent on feeding tubes. Michael's condition was severe, but he was not in a vegetative state. Michael regained some movement and had the ability to recognize faces. Five years following the accident, Michael's condition did not improve, and his wife requested the removal of the feeding tubes. However, Michael's sister and mother filed a lawsuit to maintain treatment. Michael's wife and colleagues reported that he verbally acknowledged no interest in being on life support. The court denied the wife's request since Michael did not have a written advance directive; spearheaded the movement on effective execution of patient wishes

Agency for Healthcare Research and Quality (AHRQ; often pronounced "arc")

This agency governs the regulation of the safety, quality, and efficacy of healthcare provided in the United States. AHRQ is headquartered in Bethesda, Maryland, and was initially created in 1989 to utilize multidisciplinary, multi-institutional projects aimed at improving patient outcomes and clinical practices across a variety of settings. The AHRQ has helped reduce the incidence of medical mistakes such as wrong-side surgery and reduced hospital-acquired conditions. AHRQ also establishes and administers federal metrics and scoring systems (performance measures), such as the CMS value-based purchasing program, which applies the best available clinical evidence to medical practice to help prevent unnecessary costs associated with preventable illness and re-hospitalizations.

Centers for Disease Control and Prevention (CDC)

This agency is a component of the U.S. Public Health Service and is headquartered in Atlanta, Georgia. While the Public Health Service was initially implemented in the 1900's to address issues such as immunizations and sanitation, the CDC has grown to be the chief public health agency for the nation. This agency issues policy standards surrounding the control, detection, and prevention of communicable diseases while also responding to public health emergencies. The CDC was established in 1946 and tasked with a difficult task: to prevent the spread of malaria, a parasitic disease contracted through mosquito bites. Lead by Dr. Joseph Mountin, the CDC became the leading public health institution in the nation. Starting with only 400 employees, the CDC now employs over 10,000 employees. Today, the CDC focuses on all communicable diseases and is considered the nation's premiere health promotion, prevention, and preparedness agency. The CDC achieves these goals by monitoring disease activity; tracking and reporting disease statistics; and providing overall public health leadership, research, and disease control standards, which are implemented across the country and around the world (Centers for Disease Control and Prevention, 2017). State and local public health departments model themselves on CDC standards and may collect local disease data, which are then reported to the CDC. The CDC also provides guidance and support to countries across the globe when disease outbreaks occur.

Rogers v. Okin

This case was a class-action suit from 1975 in which numerous patients at Boston State Hospital who were either involuntarily or voluntarily confined to a mental institution sued for the right not to be forcibly medicated in non-emergency situations. This case determined that mental health patients cannot be forcibly medicated in non-emergencies without intervention from a court, or without meeting certain clinical criteria. This case helped establish the right to informed consent as well as the right to refuse treatment by mental health patients which have not been declared legally incompetent and do not pose a danger to add themselves to others—even if they are physically confined to a mental hospital

Health Information Technology for Economic and Clinical Health Act (HITECH)

This law is contemporary and meant to address the changes in healthcare communications brought about by evolving technologies. By addressing HIPAA related concerns that were unforeseen when HIPAA was initially enacted because of new technologies, the HITECH adds an additional layer of protection for patients. The rules within HITECH were enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA). The following are some of the key aspects of HITECH (What is the HITECH Act, 2019): Tightened regulations around HIPAA healthcare privacy enforcement; IT security regulations in healthcare; and related penalties for violations Mandated the use of electronic medical records by all U.S. healthcare providers by 2015; those providers out of compliance after 2015 would face penalties Increased penalties and fines for healthcare providers who repeatedly violated HIPAA privacy protections Offered provisions to protect whistleblowers who reported healthcare fraud (e.g. overcharging for care, charging for services not provided, illegal kickbacks) to law enforcement while also offering financial incentives to those who report wrongdoing An illegal kickback is a financial incentive a healthcare provider might receive for directing a patient to receive a specific, often unnecessary, service from a specific provider

Tarasoff v. Regents of the University of California

This legal case was brought forward to determine whether a psychotherapist and other professionals employed by the University of California, Berkeley could be held liable for the death of a student killed by the psychotherapist's patient. A patient named Prosenjit Poddar, a student at the University of California, Berkeley had reported to his psychologist Dr. Lawrence Moore that he wanted to kill a specific student, Tatiana Tarasoff, whom he had met in a dance class. Poddar became pathologically obsessed with Tarasoff after she rejected his romantic advances. Poddar's psychologist Dr. Lawrence Moore reported these threats to both his supervisors at the UC Berkeley hospital system and to the campus police, recommended Poddar be detained and civilly committed to inpatient psychiatric care as a danger to the community. However, Poddar was not detained. Poddar subsequently shot Tarasoff with a pellet gun, then stabbed her to death. After Tarasoff's death, her surviving family members sued the University of California Board of Regents, arguing that in addition to notifying law enforcement authorities and hospital administrators, the University and Dr. Moore had a duty to warn Tarasoff and her family of Poddar's violent threats made against Tatiana Tarasoff so that she could protect herself. The death of Tatiana Tarasoff occurred in 1969. The California Supreme Court ruled in favor of the plaintiffs, determining in 1976 that the University of California and its clinical staff had a duty to warn Tatiana Tarasoff and her family that a psychotherapy patient had made a specific threat of violence against her. Those working in healthcare professions should always be mindful of the "duty to warn." In its decision, The California Supreme Court famously noted, "the protective privilege ends where the public peril begins."

California Welfare and Institutions Code of 1967

This legal convention originated in the state of California but was based upon the three previously mentioned cases and has now been adopted nationwide ruling that In most states, patients who pose an immediate danger to themselves or others may only be held involuntarily for 72 hours without court intervention.

TRICARE

This program was created to address the concerns of military personnel and their dependents. Traditionally, military personnel were treated at military-based facilities. Seeing a specialist often took months, and some specialties were not offered at all military Veterans Affairs (VA) hospitals. After the Cold War, VA hospitals were overwhelmed by the number of patients. The dissatisfaction grew. As a result, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) was established. This program allows veterans and their dependents the option of being seen in private practices or being seen at VA facilities. TRICARE sets its own rules and regulations for the provision and payment of healthcare to active-duty military personnel and gives Veterans more choices in obtaining healthcare

The Joint Commission (JC)

Unlike the previously described agencies, the Joint Commission is a private nonprofit governance organization overseeing hospitals, healthcare organizations, and other institutions that provide inpatient and outpatient healthcare. It was created in 1951, and, through its accreditation and certification standards, the Joint Commission inspects hospitals and healthcare facilities to ensure that they provide safe and effective care that meets minimum nationally accepted performance standards (accreditation). Most hospitals cannot operate or receive Medicare or Medicaid or private insurance payments if they do not meet minimum Joint Commission accreditation standards;may also award additional recognition to healthcare facilities that meet key optional standards in a unique healthcare specialty, such as disease-specific care or as a comprehensive cardiac center.

strengths of FFS

Unlimited choice of medical providers, no delays in receiving treatment, ownership of the amount of doctor visits, and flexible appointments

nonvoluntary active euthanasia

When patient can not express what they want done bc of things like PVS

Freedmen's Bureau: The First U.S. Government Healthcare Program for the Public

While the U.S. government provided healthcare directly to soldiers up through the Civil War, the government did not directly involve itself in providing healthcare to the public until the end of the war in 1865 with the establishment of the U.S. Department of War Freedmen's Bureau, one of the nation's first government-run and -regulated healthcare programs. Once the Civil War ended, millions of freed slaves were left homeless and often sick and malnourished as they adjusted to life as free people. To help care for these freed slaves and transition them to self-sufficient lives, Congressional legislation initially authorized the U.S. government to build and administer 40 hospitals and hire 120 physicians (many from the U.S. Army) to staff them. In addition to hospitals and medical care, the Freedmen's Bureau established schools, social services, and other support programs for recently freed slaves (National Archives, 2016). From these humble beginnings came a longstanding legislative and policy tradition surrounding the provision and regulation of healthcare in the United States. The following are some of the major legislative and regulatory actions launched since the mid-nineteenth century which still make an impact on today's healthcare landscape.

Dorothea Dix

a jail nurse and social worker in the 1870's, noted that many incarcerated offenders were diagnosed with mental illness. These offenders were often mistreated and suffered from malnutrition. She noticed that there was a lack of mental healthcare; worked with government officials and jail staff to divert mental health offenders from jail systems to community-based treatment facilities; helped lead the way in the creation of laws protecting people with behavioral health issues.

personal health information

a political movement surrounding the data security of computerized records of _____________ began to emerge by the mid-1990s

Analyzing the macro-level trends

affecting population health and gauging the influence of social determinants of health are dependent on the quality of instruments that are used to make these determinations.

Service delivery performance measures

are influenced by social factors and social determinants of health.

Tarasoff v. Regents of the University of California

became a key component of U.S. case law as applied in most (but not all) U.S. states because it established the following (Vitelli, 2014): Under duty to warn, clinicians and other professionals who treat the mentally ill have a duty to break patient confidentiality and warn the person threatened in addition to law enforcement when and if they suspect a client may become violent towards any specific individual or individuals. Clinicians and other professionals who knew a client had the potential to become violent but did not warn or report the threatened person could be held liable if that client later committed violent crimes. States have different interpretations of the Tarasoff case. While at least 40 U.S. states now explicitly require that clinicians and other healthcare and service providers (e.g. social workers) have some level of duty to warn, not all states expressly require it via legal statute or case precedent, ten states do not. Despite these controversies, healthcare professionals should learn the specific laws and rules related to the Tarasoff case and patient privacy laws currently applicable to their state to ensure protection against liable claims for either breaching patient confidentiality or inadvertently endangering the public

The macro trend environment

consists of trends and changes in various areas, including inflation, employment, economics, and GDP.

The ACA's

focus was to provide healthcare treatment for patients with preexisting conditions, increase access to healthcare, provide value-based care, and reduce hospital readmissions.

Public attention to healthcare

highlighted the rising costs of healthcare and the need for government intervention to regulate costs.

Unite for Sight

identified several key individuals who helped the broader public understand the issues facing those who may struggle with mental health. Subsequently, these individuals helped lead the way in the creation of laws protecting people with behavioral health issues.

Macro-level economic factors

impact health in a variety of ways such as unemployment, the working poor, chronic homelessness, and felons.

Clifford Beers

in the early 1900's, as a mental health patient and businessman, documented his experience during an insane asylum placement following a nervous breakdown in his text A Mind That Found Itself. Beers spoke out about inhumane treatments such as sexual assault, starvation, and medication overdosing and under-dosing, along with violence in state hospital systems; work led to the creation of the National Mental Health Association and started the mental hygiene movement, which aimed to improve the treatment of patients in psychiatric institutions; helped lead the way in the creation of laws protecting people with behavioral health issues.

Institutional Review Boards (IRBs)

is an ethical governance body that reviews the design of scientific studies using human study subjects to ensure the safety and ethical acceptability of the research proposals; the role to determine whether a given scientific research study will do unnecessary harm or exploitation to human subjects; composed of a variety of professionals with backgrounds in science, medicine, ethics, and law. Lay members of the community are also often included and all provide a valuable perspective in determining whether a research proposal is ethical and causes no human harm; make recommendations to universities and research teams within universities as to whether a research study should be undertaken; were created in response to a series of hearings in the United States Congress spearheaded by Senator Edward Kennedy in 1974. The National Research Act was signed into law by President Richard Nixon. Named the National Research Act, it provides clear guidance for ethical decision-making in human-subject research

Strengths-based Care Management Model

is guided by personalized guided concepts: Self-worth Self-determination Self-regulation ;a rapidly moving helping approach that is used to service individuals, families, associations, and organizations.

Behavioural health

is the scientific study of behavior, emotions, and biological factors associated with mental well-being; is the connection between behaviors and physical health

Behavioral health conditions include

mood disorders (depression), anxiety disorders (phobias, obsessive-compulsive, etc.), self-sabotaging behaviors (self-neglect, low self-esteem, self-harm, etc.), personality disorders, and psychotic disorders such as schizophrenia (Boober, 2011).

Joint commission

open or reaccredit a hospitals

By examining the sociohistorical context and laws

people can better appreciate the advancements made throughout history to provide individuals who have mental health issues a more holistic, comprehensive approach to treatment that now focuses more on treatment and adaptation as opposed to punishment by

The Patient Self-Determination Act (PSDA) of 19900

placed requirements on medical providers and healthcare organizations to provide patients with the opportunity to complete advance directives; focused on central concepts such as: To inform patients about laws related to their right to execute advance directives To determine whether patients have an existing advance directive To recognize patients' medical wishes To not discriminate against patients who have completed advance directives Advance directives are referred to in both emergency situations when a patient is unable to make medical decisions and is actively declining and when the physician along with the family are trying to clarify the goals of care.

State medical licensure board

prescribe medications

There are four main types of value-based systems

share risks, bundles, global capitation, and shared savings

Case Law

simply means the law as it is established by the outcome of former legal cases brought before a court; impacts how healthcare is practiced and regulated in the United States in the following ways: It is the role of courts and judges to interpret laws and the U.S. Constitution as well as state laws and constitutions. Sometimes these laws are ambiguous, unfair, or inappropriately applied. Citizens and organizations can seek to redress grievances through the courts for clarification on what laws require and what they do not require. Judicial decisions, which interpret laws in a manner that changes or expands how they are applied or enforced, become part of case law.

advance directives

sometimes called a living will, is a legal document that provides instructions on a patient's medical treatment wishes; guides the family and medical team on what medical procedures and treatments should be pursued during an emergency; relieves loved ones from the stress of making critical end of life decisions.

The formation of Medicaid and Medicare services

spearheaded healthcare insurance policy regulations

Death with Dignity

started in the early 1990s emerged, allowing terminally ill patients the right to medical supervision and support to end their lives; is regulated by state legislation and offers patients a peaceful, humane, and dignified death, which limits physical pain and suffering at the end of life; was originated in Oregon with the practice of prescribing life-ending medications to terminally ill patients wishing to end their lives

Brokerage Case Management Model

supports the "brokering" of resources between a case manager and a client. This section will provide you with the following information on the brokerage model of case management: Origins Advantages Ideal applications Shortcomings

voluntary active euthanasia

the intentional administration of lethal drugs or other means of producing a painless death with the person's informed consent

involuntary active euthanasia

the intentional administration of lethal drugs or other means of producing a painless death without the person's informed consent

Fee-for-service (FFS)

was established as a derivative of Medicare and Medicaid.

nonvoluntary passive euthanasia

when the person so killed is incompetent and incapable of giving consent