Ethical Issues Quiz 3
Dilemma 1"
Amputee patient on Medical Assistance received trans-femoral (A/K) prosthesis from us in October 2015 At amputee clinic here in Pittsburgh a company from Ohio approached the patient and offered them a different knee unit that "would help him walk better". The new knee unit was "better" than one that Medicaid would typically pay for. The prosthetist switched out the knee unit from one they apparently had in the trunk of their car. After the switch, it was apparent that the pin system of the patient's liner was hitting the inside of the knee unit (meaning his ability to "attach" to the prosthesis is now compromised). The prosthetist instructed to patient to go home and "cut off the end of the pin". He also instructed the patient to come to his office to have the prosthetic foot switched out as well, something the patient consequently did. No prescription for the new knee unit was written. No approvals were received from the physician, physical therapist or case manager. There is no official documentation anywhere describing the actual prosthesis he's now wearing. If this patient should fall and get injured, who's liable for the event?
Balance of Factors in Applications of Torah Law
Application example: Abortion Pertinent Background: Until 40 days, the uterine contents are 'like water' Spontaneous discharge is in category of 'menstruation' Afterwards, it has the form of a human and a spontaneous miscarriage is a premature birth Pertinent Background: Birth, miscarriage or menstruation? Menstruation - Purification from 'Niddah' state Birth—Purification process (Leviticus 12:5) Miscarriage—Question of human form or cyst (Talmud, Tractate Niddah) Disposition of remains Purification process
Kashrut and Special prohibition on mixture of meat and dairy products
Are not eaten together Separate utensils for food preparation and dishes (including dishwashing) There is a waiting time between consumption of meat and dairy
Organizational Ethics
Are the principals and standards by which businesses operate Expresses the values of an organization Organizational culture consists of leaders and employees adhering to a code of ethics Is interdependent with the organizational culture - Combination of organizational behavior, industrial psychology, as well as business ethics
Leadership in Promoting an Ethical Climate A morally admirable leaders, director, supervisor, or manager
Article: "The Only True Leadership Is Values-Based Leadership" by Harry M. Jansen Kraemer Jr. Leadership must be rooted in who you are and what matters most to you When you truly know yourself and what you stand for it is much easier to know what to do in any situation It always comes down to doing the right thing and doing the best you can
HOW DOES THE FEDERAL GOVERNMENT ENSURE COMPLIANCE WITH LAWS?
Congress' designated role is to enact not enforce laws so how does it ensure compliance? "Power of the purse strings" e.g. ACA mandate health care coverage verified on federal tax return (1099-C) or subject to penalty (at least through 2018) Congress allocates funds (Congressional Budget Office) via its various departments [How do things start to get difficult? How does the federal gov ensure compliance with laws - Through the power of the purse strings National speed limit - 70; but Texas has certain roads that are above so won't get money from office of transportation]
Toward a Cognitive Model of an 'Torah Jewish' Perspective
Consider Deuteronomy Chapter 29, last verse : Rough translation: The secret things belong unto the LORD our G-d; but the revealed things belong to us and to our children forever, that we may do [conduct our lives according to] all the words of this Torah. Perspective: There is a partnership between us and the Creator. The Torah is our 'user's guide' for "the revealed things"—i.e., for doing our job. We are challenged to live according to Torah, in the face of changing societies and conditions.
Consultation with Rabbinic Authority
Consult with a rabbi or 'poseik' (competent Torah authority) for advice on questions ('sheilos') about proper conduct under Jewish law (halacha) Torah authorities are objective the consultee recognizes that he/she is 'nogayah b'davar' ('in conflict of interest') relative to the outcome Torah authorities have the knowledge and experience to incorporate nuances of the situation Seemingly similar cases (from a lay perspective) may have very different recommendations Consultation may involve HIPAA authorization for Rabbinic discussion with health care professionals The queries are needed to understand how the current scenario fits within parameters of medical halacha Specific information can have a major impact on the advice Remember: The Rabbi who asks is knowledgeable and deserving of professional respect. Attempts at disinformation and obfuscation to bias a decision are transparent.
Ethical Dilemmas in the O&P Marketplace
De La Torre Orthotics and Prosthetics was founded in 1962 by our father, Manuel De La Torre. Having studied in New York City, he started his company in Pittsburgh after developing the orthotics lab at the newly built Harmarville Rehabilitation Hospital in the eastern suburbs of Pittsburgh. His dedication to his craft was evident in every device he made. While he enjoyed helping everyone, Dad was especially passionate about treating scoliosis and working with children in general. The American Board for Certification in Orthotics, Prosthetics and Pedorthics has set up a Code of Professional Responsibility https://www.abcop.org/WhoWeAre/Documents/Code%20of%20Professional%20Responsibility.pdf
Leadership cont.
Decision Making and Organizational Models Three types of hierarchies in organizations (barriers to achieving fair and desirable outcome) In healthcare all three hierarchies overlap (focus on power) 1. Formal 2. Informal 3. Professional
Religious Freedom and the Constitution of the United States
First Amendment Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances. Establishment Clause : "Congress shall make no law respecting an establishment of religion, ..." Free Exercise Clause : "... or prohibiting the free exercise thereof; ..." The term "separation of church and state" is NOT found in the Constitution, but rather stems from its interpretation. First used by Thomas Jefferson in a letter of 1802, the phrase was referenced by the Supreme Court in the 1947 decision Emerson v. Board of Education when it called for "a wall of separation between church and State." Where this wall should stand is still under debate.
Catholic Doctrine
For the Roman Catholic Church, Sacred Scripture and Sacred Tradition are the repository for the Word of God, and the Magisterium affirms that "(a)ll that it proposes for belief as being divinely revealed is derived from this single deposit of faith." (Catechism of the Catholic Church, i.e. CCC, 86)
Goal
Foster understanding of principles to guide practical health interactions with Torah-observant Jewish patients University of Pennsylvania Hospitals document provides a list of common accommodation areas: http://www.uphs.upenn.edu/pastoral/resed/diversity_points.html#jewishpoints
Question 7
From your perspective and experience, what is the most common ethical dilemma that you have been faced with? 1. we've discussed billing fraud, so #2 is....... 2. Stealing our____________ CLINICIANS
Kashrut and Prohibition on eating whole insects (or other organisms)
Fruits and vegetables are inspected for visible 'bugs' Special Status of Wine Requires reliable kashrus supervision Other alcoholic beverages can be problemmatic
Leadership and Administration
Leadership in Promoting an Ethical Climate Everyone should have an understanding of ethical issues for positions of authority - Everyone eventually functions as a supervisors "He who cannot be a good follower cannot be a good leader" Aristotle If you want to be a great leader, begin by asking, "How can I be a better follower?" or, to put it a different way: "How can I make my boss more successful?" Traits of good followers: Judgment, Work ethic, Competence, Honesty, Courage, Discretion, Loyalty, Ego management. Must be able to interact and practice in collaboration with a variety of professionals Chapter addresses the Ethical Challenges of leadership in several contexts: Decision making within different kinds of organizations Patient-related duties and personnel duties (workplace safety) Organizational duties Leadership is more them just being put in charge or getting things done Influencing people to achieve desired ends but...ethically Leadership is a value - the virtue of influencing people in morally desirable ways
Checks and balances
Legislative branch : Congress enacts legislation (agreement of Senate and House of Representatives) Executive branch : President and all attendant government agencies enforce legislation Judicial branch : Supreme Court, and district federal courts interpret legislation in light of the U.S. Constitution U.S. Constitution is said to be a "living and breathing" document. e.g. First Amendment was first narrowly interpreted as applying only to laws enacted by Congress, but by the process of incorporation was later applied to the states.
Government-Subsidized Healthcare
Major examples: EMTALA (Emergency Medical Treatment and Labor Act) Medicare CHIP (Children's Health Insurance Program) Medicaid ACA (Affordable Care Act, a.k.a. "Obamacare") All of these programs have some degree of subsidized care, plus some cost to the patient. No subsidies for: Young adults (18-64), middle-class (> $48k/yr.), who need non-emergency care.
US Federal Government Action on Conscience Protection?
March 25, 2011 45 CFR Part 88 [RIN 0991-AB76] Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws : The Department of Health and Human Services issues this final rule which provides that enforcement of the federal statutory health care provider conscience protections will be handled by the Department's Office for Civil Rights, in conjunction with the Department's funding components. Congress passed the Conscience Protection Act (CPA) in 2016 (S. 304) and 2017 (H.R. 644, S. 301), but neither were enacted into law On June 21, 2017, HHS declared that it will not interfere with California Department of Managed Health Care forcing all health plans in state, including those of religious employers, to cover elective, even late-term, abortions. Subsequently, New York followed California's lead and is being debated in other states such as Virginia, New Mexico and Rhode Island. [Will petition HHS if have religious issue with law Now see California law slide before final point]
Other Key Provisions of the ACA
Medicaid expansion Medicaid available to those <138% of poverty-line (≈$15k/yr.) Federal gov't pays 90% of cost, states cover the rest States not required to expand Medicaid (SCOTUS ruling) Employer mandate: Employers with >50 employees must provide coverage to employees who work >30 hrs./week. Problem: This incentivizes some employers to cut/limit employees' hours, and to not hire.
Kashrut and Milk and dairy products
Milk must come from a kosher animal (e.g., cow, goat or sheep)—certification needed The source of rennet for cheese-making and cheese requires kosher certification
Pain control and the use of morphine
Narcotic pain medications, such as morphine, are often prescribed for terminal patients to alleviate suffering near life's end. These medications which provide pain relief are also associated with rare complications that may potentially hasten a patient's death. The alleviation of pain and suffering is a mitzvah and should not be withheld out of concern for potential adverse effects.. . is clearly halachicly permitted for patients to receive narcotic medication, even when it may possibly hasten their death, when the following conditions are met: The intent is purely to alleviate suffering; not to terminate life. The dose of medicine is gradually increased as necessary to alleviate the pain.
Regarding the term 'Orthodox' Jew
Normative practice includes several areas of Jewish life Kashrut - consumption of only 'kosher' foods and beverages Sabbath (and holiday) observance Laws of Family Purity (Taharat Mishpacha) Laws of Modesty (Tzinyut) Rabbinic consultation for important decisions The term 'Orthodox' simply designates a Torah-observant Jew The term in the press of 'Ultra-Orthodox Jew' has no basis in Judaism Selected photographs promote stereotyping and caricatures based on clothing or national origin Usually depict normative activities as 'oddities' Intent is often derogatory Many find the term offensive
Zubik v. Burwell
Nos. 14-1418, 14-1453, 14-1505, 15-35, 15-105, 15-119, and 15-191 [May 16, 2016] PER CURIAM. DAVID A. ZUBIK, ET AL., PETITIONERS 14-1418 v. SYLVIA BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL.;ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE THIRD CIRCUIT PRIESTS FOR LIFE, ET AL., PETITIONERS 14-1453 v. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ET AL.;ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE DISTRICT OF COLUMBIA CIRCUIT ROMAN CATHOLIC ARCHBISHOP OF WASHINGTON, ET AL., PETITIONERS 14-1505 v. SYLVIA BURWELL, SECRETARY OF HEALTHAND HUMAN SERVICES, ET AL.;ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE DISTRICT OF COLUMBIA CIRCUIT EAST TEXAS BAPTIST UNIVERSITY, ET AL., PETITIONERS2 ZUBIK v. BURWELL Per Curiam15-35 v. SYLVIA BURWELL, SECRETARY OF HEALTH ANDHUMAN SERVICES, ET AL.;ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE FIFTH CIRCUIT LITTLE SISTERS OF THE POOR HOME FOR THE AGED, DENVER, COLORADO, ET AL., PETITIONERS15-105 v. SYLVIA BURWELL, SECRETARY OF HEALTH ANDHUMAN SERVICES, ET AL.;ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE TENTH CIRCUIT SOUTHERN NAZARENE UNIVERSITY, ET AL., PETITIONERS15-119 v. SYLVIA BURWELL, SECRETARY OF HEALTH ANDHUMAN SERVICES, ET AL.; ANDON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE TENTH CIRCUIT GENEVA COLLEGE, PETITIONER 15-191 v. SYLVIA BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL.ON WRIT OF CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE THIRD CIRCUIT [Smaller entities filed lawsuit in own areas and combined became larger case] "Petitioners are primarily nonprofit organizations that provide health insurance to their employees. Federal regulations require petitioners to cover certain contraceptives as part of their health plans, unless petitioners submit a form either to their insurer or to the Federal Government, stating that they object on religious grounds to providing contraceptive coverage. Petitioners allege that submitting this notice substantially burdens the exercise of their religion, in violation of the Religious Freedom Restoration Act of 1993, 107 Stat. 1488, 42 U. S. C. §2000bb et seq." [Not saying can't pursue contraception But believe it is wrong, undue burden on them to have to pay for something against moral code]
Affordable, Quality Care Through Private Insurance?
Solution 1: Employers buy large pools of policies for their employees. Problem: It leaves out those without employer-based coverage. Solution 2 (ACA): Make it illegal for insurance companies to deny coverage or to charge more to sick people. Require all insurance to cover essential health benefits. Require everyone to buy insurance (so insurance companies don't lose money paying for all the sick people). Gov't pays for part of the cost of policies, if you can't afford the full cost. Ban excessive out-of-pocket costs. [ACA is a combination of regulation and subsidies] [[o Require all insurance to cover essential health benefits o Law still stands requiring to buy insurance but no longer a penalty o <$48,000 - government pays part of cost o Ban excessive out-of=pocket costs o Requires companies with 50+ people to cover healthcare if work 30+ more o Does little to control cost, cover as many people as you can under current system]]
Sabbath and Holiday Observance
Special needs for religious practices Restrictions on permissible activities Based upon 39 activities with building the tabernacle in the desert e.g., igniting or extinguishing combustible items (includes operating internal combustion engines [driving]), building, plowing and many other 'normal daily activities') Can create accessibility challenges for patients or family on those days Cannot ask a non-Jew do a forbidden activity for them on the Sabbath or holiday Cannot ask a non-Jew do a forbidden activity for them on the Sabbath or holiday Examples from the Talmud teach by induction If a non-Jew comes into a dark room on the Sabbath and lights and oil lamp for his/her own use, a Jew can also benefit from the light. If the non-Jew adds more oil to the lamp (to provide more fuel for the Jew) before leaving, one may not benefit from the light. If a non-Jew lowers the gang-plank from a ship on the Sabbath and leaves it in place, Jews may use the gangplank.
Application example: Abortion (Fetus status)
Striking a woman and causing a miscarriage requires a monetary payment Exodus 21:22, Shulchan Arukh, Choshen Mishpat 423:1 Decision factors include intent and direct versus indirect action Each case must be considered individually in consultation with competent Rabbinic authority The decision is based upon a consideration of the personal scenario in terms of the halachic perspectives introduced above
Code of Professional Responsibility (Code)
The practice of orthotics, prosthetics and pedorthics (the Profession) is a recognized allied health profession. American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) Credential Holder assumes specific responsibilities to physicians and other appropriately licensed healthcare prescribers, patients, the public, colleagues and to the Profession itself. These responsibilities must be discharged with honor and integrity to assure public confidence in the Profession. The Profession exists for the primary purpose of assisting patients in maintaining functional lives. The ABC Credential Holder shall be responsible for making the greatest possible effort to satisfy the patient's orthotic, prosthetic or pedorthic requirements. The manner in which the patient is served is an essential factor relating to the appropriate ethical professional conduct.
Informal Hierarchies
Also has an influence on organization politics and behavior Access to key decisions makers Organization chart - shows the formal Invisible hierarchy Allow the organization to deal with challenges [secretaries, assistant staff, etc who know whats up]
Right to Life - What is your interpretation?
"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the Pursuit of Happiness." Declaration of Independence "The inalienable right to life of every innocent human individual is a constitutive element of a civil society and its legislation." CCC 2273
Health Care Fugitives: https://oig.hhs.gov/fraud/fugitives/index.asp
If the fines and jail is not enough - there is also an EXCLUSION from participating in Medicare in the future. Which means - you will not be able to be submit claims to any other insurance carriers. And you will not get hired by another company once a background check is done. A good website that reviews the penalties for insurance fraud: Medicare and Medicaid: http://www.medicarefraudcenter.org/
Catechism of the Catholic Church
The Catechism of the Catholic Church is the current publication of the sum of the beliefs of the Catholic Church in book form published under the direction of Pope John Paul II (St. Pope John Paul). Compilation work was inaugurated at Synod of Bishops in 1985, and promulgated on October 11, 1992, on the 30th anniversary of the Second Vatican Ecumenical Council. This was not the first published catechism. In the USA the prior was known as the Baltimore Catechism.
Magisterium
The Magisterium is the Roman Catholic Church's authority or office to establish its own authentic teachings.1 "The task of the interpreting the Word of God authentically has been entrusted to the magisterium of the Church, that is, to the Pope and to the college of bishops in communion with him."2 "Yet this Magisterium is not superior to the Word of God, but is its servant." 3
A Case Study of a Conflict Between Religious Belief and Federal Law
The Patient Protection and Affordable Care Act (ACA) As of 1 August 2011, female contraception was added to a list of preventive services covered by the ACA that would be provided without patient co-payment. The federal mandate applied to all new health insurance plans in all states from 1 August 2012. [Catholic church has a problem with only part of the ACA Mercy hospital - sisters of mercy trained as nurses]
Integrity and Wrongdoing Leadership and Administration Gabard and Martin Chapter 9 & 10
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Understanding Health Care System Challenges of Torah-Observant Jews: A Cultural Primer
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Justice and Healthcare
. - Microlevel: how to allocate organs when scarce - Macrolevel: healthcare in general across society
Question 4
How do you approach an employee about an ethical situation if they've been in practice longer than you?
Question 2:
How do you deal with respecting the prescription if you don't agree with it?
Question 6
How do you handle non-compliant patients (especially ones that have shown disrespect/sexual harassment, etc.?)
Are There Religious Conflicts With Other Issues of Health and Science? The Case of Stem-Cell Research
"Since it must be treated from conception as a person, the embryo must be defended in its integrity, cared for, and healed, as far as possible, like any other human being." CCC 2274 Embryonic stem cell research (ESCR) begins with the intentional destruction of the embryo, which is innocent human life, and therefore is opposed by the Catholic Church.1 Adult and umbilical-cord stem-cell research is supported by the Catholic Church.
Arnold Toynbee [A Study of History (revised and abridged), Oxford University Press, 1972, pp. 65-69]
"...From AD 135 to AD 1948 there was no such thing as a Jewish state and not even such a thing as a Jewish 'national home' in the sense of a territory that was substantially Jewish in population without being under Jewish rule. Yet, without the political framework of a state or the territorial basis of a home, the Jews have managed to preserve their separate identity, as a people, from 586 BC—the year that saw the obliteration of the Kingdom of Judah—down to the present day. They have preserved it as scattered minority (diaspora) living among non-Jewish majorities in countries outside the former frontiers of the extinct Kingdom of Judah and hundred or thousands of miles away from its historic capital, Jerusalem..." "This feat is remarkable and exceptional, but it is not unique...If, on these considerations, we take the Jewish diapora as our model for this species of community, we shall find in it the following elements. First, there is the diaspora's determination to retain its historic identity in circumstances in which most communities have resigned themselves to losing theirs. Having been deprived of its state and its home and been reduced to living as a minority—and a scattered one—abroad, the uprooted community has found new means of maintaining its cohesion and continuity under these adverse conditions. !!!It maintains them now through the voluntary observance of an exacting religious and ritual law. !!!!" "The second element is the diaspora's motive for being unwilling to merge itself in the majority among whom it has come to live. It cherishes its separate identity because it believes itself to be the depository of a religious revelation of unique significance and value. The third element in the configuration of the Jewish diaspora is its recognition of the truth that it will fail to survive if it does not provide itself with an adequate economic basis... A diaspora must make its fortune out whatever economic occupations the majority leaves open to it..."
FEDERAL LAWS PROTECTING CONSCIENCE RIGHTS
1973: Public Health Service Act ("the Church amendment") 42 U.S.C. §300a-7(b-e) Receipt of federal funds for health programs will not require hospitals or individuals to participate in abortion and sterilization procedures, if they object based on moral or religious convictions. Forbids discrimination: willingness or unwillingness to perform these procedures may not be a condition of employment, promotion or termination of employment. Protects general conscience rights of individuals in federally funded health service programs. Prohibits entities receiving Federal grant, etc. from discriminating against applicants for training or study (including internships and residencies) because of refusal of applicant to participate on religious or moral grounds. https://ww.hhs.gov/conscience/conscience-protections/index.html 1988 Civil Rights Restoration Act: Prohibits construing a federal sex discrimination provision [Title IX of the Education Amendments of 1972] to require an educational entity to violate its religious tenets (20 U.S.C. §1687). 1996 (42 U.S.C. §238n) Prohibits federal, state and local governments receiving federal funds from discriminating against health care entities (including residency programs) and individual health care 1997 Medicare 42 U.S.C. §1395w-22(j)(3)(B). Conscience protection. 1998 Federal Employees' Health Benefits Plan Reg 48 C.F.R.§1609.7001(c)(7) 1999 Sec. 726 of Title VII of Division E (Financial Services and General Government Appropriations Act) of the Consolidated Appropriations Act, 2016, Pub. L. No.114-113 (federal employees) 2004 Hyde/Weldon Conscience Protection Amendment: Sec. 507 (d) of Title V of Division H (Depts of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act) of the Consolidated Appropriations Act, 2016, Pub. L. No. 114-113. 2010 Patient Protection and Affordable Care Act (PPACA), Pub. L. No. 111-148 Refer to more extensive list at http://www.usccb.org/issues-and-action/religious-liberty/conscience-protection/upload/Federal-Conscience-Laws.pdf
Dilemma 2:
A billing/admin staff member from a previous employer wanted me to change the diagnoses code in the patient's record because the brace that was prescribed for them was not covered under the specific diagnosis that was provided in the prescription. What should I do?
Dilemma 3:
A prosthetics patient presented in the office that transferred from another O&P company. Their prosthesis included a microprocessor knee and dynamic foot. The patient was being evaluated for a new prosthesis but during the evaluation we determined that the patient was not a K3-level patient due to their answers to a questionnaire and the results of their AMP PRO test. What should we do with building out the new prosthesis?
Four elements aimed at creating an ethical culture and behavior
A written code of ethics and standards Ethics training for executives, managers, and employees The availability of ethical situational advice Confidential reporting systems Written rules may include laws regarding sexual harassment, alcohol abuse, drug/substance abuse
What is a Do Not Intubate (DNI) order? Is DNI ever permitted?
A. One of the treatments often utilized at the end of life is artificial (mechanical) respiration. The procedure for introducing a tube into the lungs, which aids in breathing, is called intubation. The tube is connected to a machine (called a ventilator, respirator, or life-support system). The family will be asked about intubation, either separately, or as a part of the DNR order. The medical indications for intubation are many and are not the same in every patient. As with the DNR order, there may be circumstances when it is halachicly appropriate to withhold intubation. B. If artificial respiration (intubation) is withheld, in accordance with the ruling of a Halachic authority, oxygen supplementation via face mask or nasal prongs can still be provided. Oxygen is usually considered basic care and should be provided to all patients for whom it is medically indicated.
Diversity in Jewish Observance
All Jews have an obligation to conduct their lives in accordance with commandments ('mitzvoth') from the Torah Torah provides the framework for a meaningful life Jewish observance of the Torah sustains the universe Jews may vary in the degree to which they discharge that obligation Adherence is voluntary, an exercise of 'bechira' (free-will) Expect client/patient consultation with competent religious authority in many decisions Corollary: Be reticent to rely on a colleague or acquaintance who you believe to be an observant Jew for definitive guidance.
Billing Fraud: 90% of fraud happens in coding
Billing for items not supplied Supplying items that are not billed Misrepresenting as medically necessary non-covered services by using inappropriate procedure or diagnostic codes. Offering incentives to Medicare patients, i.e. waive co-payments or deductibles Definition: Medicare fraud is the claiming of Medicare health care reimbursement to which the claimant is not entitled. There are many different types of Medicare fraud, all of which have the same goal: to collect money from the Medicare program illegitimately.
Professional Hierarchies
Built on the traditional roles in the healthcare decision making Physician at the top, nursing, PT, OT, etc.
Former Enron exec advises TCU students to do the right thing
By Steve Kaskovich, 29 March 2017 FORT WORTH; Andy Fastow has two props he uses in speeches to explain how he ended up as one of the country's most famous corporate criminals. First, he holds up the trophy he received when he was named "CFO of the Year" in 2000 for his work at Enron Corp. Then he holds up the federal prison ID card he was issued when he served nearly six years for wire and securities fraud. "I got both of these for doing the same deals," Fastow told a roomful of business students at Texas Christian University on Tuesday. The government showed that Enron executives had used accounting tricks to hide billions in debt and enrich themselves While the financial maneuvers technically followed the rules, the overall scheme was intended to mislead investors All of his deals were approved by a bevy of gatekeepers: Enron's accountants, outside auditors, attorneys and the board of directors, and no information was withheld
Leadership in Promoting an Ethical Climate
Concept of leaders as setting forth incentives (self interest), salary, medical coverage, work environment Procedural values such as fairness, trust, and honesty Transforming leadership involves more - engage the full person, end result values, such as liberty, equality and patient values (healing and respect for autonomy) Three dimensions of promoting Ethical Climate (discussed and affirmed) 1. Moral responsibility - Profits or personal power do not become number one or only priority 2. Trust and trustworthiness - Strong sense of mutual trust, conviction of professionals, participate beyond their narrowly assigned duties 3. Effective conflict resolution - Professional behaviors and skills
Our Dilemma #1 is addressed here:
C4.3 — Solicitation The ABC Credential Holder shall not, either directly or indirectly, solicit the patronage of individual patients by way of intimidation, threats, harassing conduct, undue influence, coercion, duress, remuneration, unwarranted promises of benefits or in violation with any third party payer rules. The ABC Credential Holder shall not solicit a patient who is apparently in a mental condition that impairs his/her personal judgment to make decisions concerning the devices or Services being offered. The ABC Credential Holder shall not solicit a patient in a manner that is inconsistent with his/her/its obligation to act in a dignified manner as set forth in Code C4.1. C4.1 — Dignity The ABC Credential Holder has the responsibility to conduct himself/herself/itself in a manner that will assure the dignity and status of the Profession. Examples of unacceptable behavior include, but are not limited to, inappropriate conduct with a patient, falsifying documents, misusing the certification credential, slandering or libeling another, disparaging existing or former employers, disparaging existing or former employees and misrepresenting one's capacity as a provider of Services.
What constitutes human life?
Catholic doctrine : Life is sacred from the moment of conception until the moment of natural death. "Human life must be respected and protected absolutely from the moment of conception. From the first moment of existence, a human being must be recognized as having the rights of a person - among which is the inviolable right of every innocent being to life."
Formal Hierarchies
Chain of Command and outline the distribution of decision making authority in each position Two avenues for improving formal hierarchies to enhance ethical conduct: 1. External controls (leadership) - Share and prescribe the conduct of the individuals in the organization - Code of ethics 2. Internal controls - Consist of the internalized values of employee that guide the individuals in the absence of external controls - may require training (creating ways for employees to report suspicious behavior)
Application: Terminal Illness and End-of-Life
Complex interplay of issues Positive duty to preserve life and heal the sick Positive duty to alleviate suffering Positive duty not to hasten death Positive duty not to prolong suffering Recognition medical professionals lack omniscience Case-by-case determinations in consultation with competent Rabbinic authority A few issues are outlined in Rabbinical Council of America document, http://www.rabbis.org/pdfs/hcpi.pdf Caution from that document: "This document is intended to provide general halachic guidance to patients and families involved in making difficult medical decisions that frequently arise at the end of life..." Caution from that document: "... It is not intended as a source for halachic decisions, nor is it a substitute for the essential dialogue among patients, families, rabbis and doctors..." Caution from that document: "... All end-of-life issues and questions should be presented to a Halachic authority, preferably, when possible, before they become urgent or emergency decisions."
Distributive Justice
Distributive justice = fair allocation of scarce (i.e. limited) resources Main question: How do we allocate health-care to those who need it in a just or fair way? Specifically: How much, and what kind, of government involvement in health care should exist? 1. Subsidies 2. Regulations [[Right now in this country: a lot of subsidies, a lot of regulations, and a free market for some]]
Question 5
Do you feel obligated to give O&P care/advice outside of the clinic or when you're not at work?
Kashrut = Meat
Domesticated and non-domesticated animals that chew their cud and have split hooves Kosher slaughter by qualified professional (shochet) Inspection for anomalies (including defective slaughter) that would result in the animal dying in the next year (termed a 'treifa') Processing to remove residual blood Prohibition on eating 'gid hanasheh' of domesticated animals, often mistranslated as 'sciatic nerve', as well as certain fats
Corporate downfalls when the organization lack ethical practices as a mandatory basis for their business structure and corporate culture
Enron WorldCom VA Medicare Fraud
Ethics in O&P
Ethics is guided by your personal values system. Personal ethics will drive professional ethics in every situation. What are your values? Do you know?
Addendum: Seven Laws for Descendants of Noah (non-Jews)
Have system for social justice No blasphemy (do not curse Supreme Being) No idolatry (no worship of anything created by humans or in nature) Restrictions on sexual relations (incest, bestiality, etc.) No homicide No theft Do not eat parts that are cut from a live animal Source: Talmud, Tractate Sanhedrin 56a
Question 3
Have you ever lied to a patient for any reason?
Power and Authority
Having power is having the ability to cause change, directly or indirectly and is required element in leadership You may acquire power by being perceived as having - Special knowledge or skills - Access to information - Control over resources affecting the actions of the group Power can be used for good or evil, Leadership is a virtue
Kashrut and Fowl and Eggs
Include domestic chickens, ducks, geese, turkeys and pigeons Biblically excluded list of birds Kosher slaughter by qualified professional (shochet) Processing to remove residual blood Only eggs from kosher birds may be eaten; must inspect for blood spots Commercial frozen eggs require kosher certification
Conscience Protection Act
January 2018 : Proposed new Division on Conscience and Religious Freedom within the U.S. Department of Health and Human Services (HHS) Office for Civil Rights Goal: to enforce civil rights laws within HHS-funded programs including conscience protection Regardless of division existence, HHS continues to have oversight responsibility for enforcing federal conscience laws regarding health services March 22, 2018, the CPA was not included in the appropriations bill. Without designated funding, there is little to no enforcement of federal conscience protection laws, even the 1973 PHSA anti-discrimination provisions. [Will the conscience protection act go forward? Funds have to come from somewhere which meant it lost support]
Who is a Jew?
Jews by birth: strictly matrilineal descent Jews by conversion Legal process by a qualified religious court (Beit Din) Acceptance of Torah obligations Immersion in a ritual bath (Mikveh) If male, circumcision according to Jewish law by a mohel ('ritual circumciser') Public announcement of Hebrew/Jewish name
Kashrus - consumption of only 'kosher' foods and beverages Sabbath (and holiday
Kashrut: Consume only 'kosher' foods and beverages Kosher prepared foods can be identified by certification symbols (not all symbols are reliable) http://www.crcweb.org/agency_list.php Kosher foods must be prepared with kosher utensils and appropriate supervision Common Fallacy: Suggestion that Laws of Kashrut are health laws Kashrus: Specific areas of Jewish law for Meat Fowl (and eggs) Fish Milk and dairy products Special prohibition on meat and dairy together Prohibition on insects and other whole organisms Special status of wine
Kashrut and Fish (aquatic organisms)
Kosher defined by fins and scales Kosher fish include salmon, trout, tuna, flounder, carp and herring Non-kosher fish include catfish, sturgeon, swordfish, sharks, pufferfish and all 'shellfish' Flesh, roe, gelatin and bones are considered 'pareve'—neither meat nor dairy Meat and fish are not consumed simultaneously or placed on the same plate
A Cultural Mismatch
Notes from a obstetrical chart for an Torah-observant Jewish couple: I have some real concerns about this couple. Although they attended childbirth preparation classes, the father wasn't physically supportive of his wife. Oh, he was verbally supportive, but he wouldn't touch her at all, not hand-holding or back-rubbing! Any time we checked his wife or gave her physical care, he left the room and didn't return until we called him back. He refused to enter the delivery room, too! He stayed in the labor room reading! In the recovery room, he kept his distance. None of the hugging and kissing we usually see after the birth. They both say they're happy with the baby and yet they won't call her by name. The example shows a misunderstanding of normative behavior Standards of modesty (tzniyut) Jewish law of niddah- physical contact between husband and wife is limited during times of discharges from the uterus Jewish practice for naming a child
Laws of Family Purity (tarahat mishpacha)
Often misunderstood (and misrepresented) Limits physical contact between a husband and wife surrounding periods of uterine blood discharge. Wait a time period after discharge ends Woman immerses in a ritual bath ('mikva')
Modest conduct (tzniyut) is a positive value that governs interactions between men and women
Often misunderstood (and misrepresented) Modesty in dress Modest womens' clothing (skirt length, sleeve length, and neckline) Married women cover their hair Standards of propriety for physical contact (male-female touching, embracing, or shaking hands)
Where do the cases stand?
On May 16, 2016, the Court vacated prior judgments and remanded (without decision) the separate cases to their respective United States Courts of Appeals for the Third, Fifth, Tenth, and D.C. Circuits. Petitioners have clarified that their religious exercise is not infringed where they "need to do nothing more than contract for a plan that does not include coverage for some or all forms of contraception," even if their employees receive cost-free contraceptive coverage from the same insurance company. Supplemental Brief for Petitioners 4. The Government has confirmed that the challenged procedures "for employers with insured plans could be modified to operate in the manner posited in the Court's order while still ensuring that the affected women receive contraceptive coverage seamlessly, together with the rest of their health coverage." [Women are still able to get contraception These employers do not need to pay for coverage which is against their believes Employees must get contraception through another route (which could be through same insurance company), just not covered by employer Contract for the plan does not have it ]
Workplace Safety
Organization personnel duties is to provide a safe workplace, OSHA Occupational Safety and Health Administration Act (1970) Two Legal rights - Rights to register a complaint - Can refuse to work if they believe that a serious injury or death may occur Hospitals and Healthcare settings are particularly vulnerable to hazards - Gas and liquids - Blood borne pathogens
Organizational Duties
Organizational Duties - Risk Management 1. Monitor compliance width Local, State and Accrediting agency regulations 2. Monitor for safety and patient violations Fair allocation of resources Maintaining Teamwork (fair share and fairness) Upper Managements Duties 1. Decision Making and complexity increases 2. Juggle numerous competing Interests
Guiding Principles
Overarching Concepts of 'Sokona Nefashos' (danger to life) and 'Pikuach Nefesh' (risk to lives) Actions to preserve a human life have an overarching value Examples: Non-kosher food and Sabbath restrictions Exceptions: idol worship, murder and forbidden sexual relations Context-dependent application can be nuanced
Response 2: Egalitarianism
People in wealthy nations have a positive right to needed healthcare. One (common) version of Egalitarianism: All people have a positive right to equality of opportunity. Opportunity = the ability to obtain basic goods (e.g., money, material goods, social status, occupations, political power, etc.), based on one's skills, talents, and effort. Argument for the right to health-care: 1. Everyone has a positive right to equal opportunity. 2. Poor health limits people's opportunity. 3. Therefore, everyone has a positive right to health care. This is the exact same basic argument for public education - thus, if you're against a right to health care, then you either need to be against public education too, or else explain what the relevant difference is. [- Give people the right to healthcare up to age 18?]
Toward a Cognitive Model of an 'Torah Jewish' Perspective cont
Perspective: There is a partnership between us and the Creator. The Torah is our 'user's guide' for "the revealed things"—i.e., for doing our job. We are challenged to live according to Torah, in the face of changing societies and conditions. The Torah provides comprehensive for our conduct. Halachic guidance often needs to be provided on a case-by-case basis by an objective decisor. It is hoped that this presentation has succeeded in conveying a better appreciation of some aspects of a Torah 'world view.'
Application example: Abortion (and other gynecologic procedures)
Pertinent Background: Menstruation and laws of family purity Menstruating woman is in a state of 'niddah' (technically, zivah gedola)—no physical contact (including sexual relations) with husband Bleeding or simply 'opening the womb (e.g., cervical dilation) as part of a gynecological procedure can produce 'niddah' state After seven discharge-free days, she immerses in a ritual bath for purification, which ends the state Mishnah (Talmud) from tractate Oholot "If a woman suffers the travails of a difficult labor, the fetus must be cut up and removed in pieces, for her life takes precedence over its life. If the majority (greater part) has emerged [from the birth canal], it must not be touched, for one life does not supersede another life." Pertinent Background: Maimonides (Rambam),Hilchot Rotzeach Chap. 1 [7]... a person pursuing another person with the intention if killing him, even if the 'rodef' (pursuer) is a minor, every Jewish person is commanded to attempt to save the person being pursued, even if it is necessary to kill the 'rodef'. Maimonides (Rambam),Hilchot Rotzeach Chap. 1 [7] What is implied? If the rodef was warned and continues to pursue the intended victim, even if the warning is not acknowledged, he should be killed because he continues the pursuit... If there is no way to save the intended victim without killing the rodef, one should kill him, even though he has not yet killed. Maimonides (Rambam), Hilchot Rotzeach Chap. 1 [9] It is a commandment 'not to take pity on the life of a rodef.' On this basis, our Sages ruled that when complications arise and a pregnant woman cannot give birth, it is permitted to abort the fetus, either with a knife (surgically) or with drugs (medically). For the fetus is considered to be a rodef after the mother... Maimonides (Rambam),Hilchot Rotzeach Chap. 1 [9] ... If the head of the fetus has emerged, it should not be touched, because one life does not supersede another. Although the mother may die, this is the nature of the world.
A Right to Healthcare?
Positive vs negative rights: Positive right to X = Obligation of others (e.g. society) to give you X. "You're entitled to X" Negative right to X = Obligation of others not to interfere with you getting X The question of justice in healthcare: Do people have a positive right to healthcare, i.e. should the gov't subsidize healthcare? The problem: If the gov't doesn't subsidize healthcare, then many people will not be able to get needed care, through no fault of their own. [[Why is a need more important than a want? - Healthcare in most cases about staying alive or "life-sustaining care" "quality of life care" - What do you have the right to? o What choices do you get? o Providers: UPMC v. Highmark - Who has the right?]]
Private Insurance vs. Single Payer
Single payer health-care = gov't-run "insurer" provides care to all citizens and/or legal residents. E.g., UK's NHS, Canada's Medicare. Possible two-tier system: private insurance option for added coverage. Question: How do we ensure everyone has access to affordable, quality healthcare, without single payer? The problem with private insurance: Insurance companies don't want to cover sick people! Therefore, either they won't offer policies to the sick (those with "preexisting conditions")... ...or they'll do so only at extremely high (unaffordable) cost.
The Veterans Health Administration Scandal of 2014
Reported pattern of negligence in the treatment of United States military veterans. In some hospitals, the staff falsified appointment records to appear to meet the 14-day target. Some patients died while they were on the waiting list; reports differ about whether they died because of the delay. Defenders agreed that it was unacceptable to falsify data, but the 14-day target was unrealistic in understaffed facilities like Phoenix Some believe that the attack on the VHA system are motivated by others who want to discredit a government program that works well.
Catholic Church in the U.S.
Responsible to the Holy See, i.e. the Pope, also known as the successor of Peter and the Bishop of Rome Under the leadership of the United States Conference of Catholic Bishops [USCCB, www.usccb.org] All citizens are subject to civil laws What recourse is there when there is a conscientious objection to the law?
De La Torre O&P Values:
Serving others with compassion and respect Conducting ourselves with integrity in every situation Working together as a team, committed to excellence Encouraging a spirit of creativity Taking pride in our work So, what does that look like? "Do to others as you would have them do to you." Luke 6:31 (NIV) "A man reaps what he sows" Galatians 6:7 (NIV) If you're honest or fair, you will experience honest gain If you're dishonest or unfair, you will experience dishonest gain (which will come back to haunt you at some time)
California Law
Supreme Court Case No. 161140 The National Institute of Family and Life Advocates (NIFLA) v Becerra October 2015, California Reproductive FACT (Freedom, Accountability, Comprehensive Care, and Transparency) Act requires all licensed medical centers to post a notice stating, "California has public programs that provide immediate free or low-cost access to comprehensive family planning services (including all FDA-approved methods of contraception), prenatal care, and abortion for eligible women. To determine whether you qualify, contact the county social services office at [insert the telephone number]." At issue: pro-life pregnancy centers, including those housed within the walls of religious institutions, contend that publicly posting said advertisements is contrary to conscience protection {go back to previous slide June 2017 point}
Response 1: Libertarianism
That is unfortunate, but not unjust—no one has a positive right to healthcare. One (common) version of Libertarianism: People do not have positive rights to anything from the gov't. It is unjust to redistribute resources, i.e. take from person A and give to person B. Redistribution is a form of theft, backed by coercion (threats); it is robbery on a societal level. [[- Matter of luck of the family you were born to - Response: All contributing to a system that allows us to make money o Luck + collective input into the system is part of what allowed you to make money o A small percentage of what you make is collectively everyone's = why we get taxed o Infrastructure, education to get a job and make money, federal bank, credit for a business, - Argument (also conservative): Entitlements involve disincentives and free-loading o So not going to work harder o If threshold is 15,000 and you get $5000 a year of worth through Medicaid, not going to be incentivized to get that bonus to make 17,000 and not qualify o Can't deny those who are working their hardest and can't advance to inhibit those who may be gaming the system]]
Integrity and Wrongdoing Chapter 9
The ABC Credential Holder shall be trustworthy and honest (C 3.4) Explores compliance issues: moral issues that arise when individual including professionals, patients and family members make wrong decisions. Even though it is reasonably clear what is required of them. Compliance Issues: Sexual Harassment Harassment among Employees, Workplace Harassment of Patients Problems of drug abuse by professionals Fraudulent Billing Whistle-Blowing Family Violence (Abused Spouses, Abused Children)
Must remember that authority does not always equal responsibly
The Case 10.3, In Over One's Head A PT who subdivision provides home care to medically compromised children with complex health care needs Operates at a lose, close by not taking on new patients Provide services for only 6 months - other arrangements Reporter - high profile story, bad publicity, administrator reversed her decision Issues that are in conflict, should be made at the high end of the organizations hierarchy Recognizing the limits to authority - Presenting the problem to the board - Forced to accept a level of decision making that was beyond the scope of her job description and training - Last Opportunity to provide leadership
Leadership in Promoting an Ethical Climate The four principles of values-based leadership
The four principles of values-based leadership Self-reflection - what you stand for, what your values are, and strive for greater self-awareness Balance - the ability to see situations from multiple perspectives and differing viewpoints while maintaining an open mind True self-confidence - accepting yourself as you are, weaknesses, limitations, continuous self-improvement Genuine humility - keeps life in perspective, helps you value each person you encounter and treat everyone respectfully
Traits of ethical leadership
Traits of ethical leadership 1. Justice - An ethical leader is always fair and just. They have no favorites, and treat everyone equally. 2. Respect others - respect that is given to all members of the team by listening to them attentively, valuing their contributions, being compassionate, and being generous while considering opposing viewpoints. 3. Honesty - followers trust honest and dependable leaders. 4. Humane - they place importance in being kind, and act in a manner that is always beneficial to the team. 5. Focus on teambuilding - they foster a sense of community and team spirit within the organization; a genuine efforts to achieve goals that benefit the entire organization - not just themselves. 6. Value driven decision- all decisions are first checked to ensure that they are in accordance with the overall organizational values. 7. Encourages initiative - employees thrive and flourish. Employees are rewarded for coming up with innovative ideas, and are encouraged to do 8. Leadership by example - no only talking the talk, this type of leader also walks the walk. 9. Values awareness - regularly discuss the high values and expectations that they place on themselves, other employees, and the organization. 10. No tolerance for ethical violations - expects employees to do the right thing at all times, - enforcement
The Role of Religious Freedom in Health Care Funding and Mandates
Understanding Catholic Christian doctrine relative to U.S. law and contemporary health care
The 10 Worst Corporate Accounting Scandals of All Time
Waste Management Scandal (1998) What happened: Reported $1.7 billion in fake earnings. Enron Scandal (2001) What happened: Shareholders lost $74 billion, thousands of employees and investors lost their retirement accounts, and many employees lost their jobs. WorldCom Scandal (2002) What happened: Inflated assets by as much as $11 billion, leading to 30,000 lost jobs and $180 billion in losses for investors. Tyco Scandal (2002) What happened: CEO and CFO stole $150 million and inflated company income by $500 million HealthSouth Scandal (2003) What happened: Earnings numbers were allegedly inflated $1.4 billion to meet stockholder expectations. Freddie Mac (2003) What happened: $5 billion in earnings were misstated. American International Group (AIG) Scandal (2005) What happened: Massive accounting fraud to the tune of $3.9 billion was alleged, along with bid-rigging and stock price manipulation Lehman Brothers Scandal (2008) What happened: Hid over $50 billion in loans disguised as sales Bernie Madoff Scandal (2008) What happened: Tricked investors out of $64.8 billion through the largest Ponzi scheme in history. Satyam Scandal (2009) What happened: Falsely boosted revenue by $1.5 billion
Question: 1
What are some of the most important ethical principles you think all O&P [companies] have when interacting with (vendors)?
Relationship of Catholic Doctrine to Civil Law
What is the basis for Catholic Christian beliefs? Does this doctrine correspond to U.S. law? What responsibility do Catholics have when there is a conflict between the two?
Leadership
Widely applicable value rather than the sole province of managers Captains Model: One key leader; military or sports (primary responsible and authority) Shepherd model: emphasizes the benevolent nurturer of employees Development of leadership as a quality in all individuals 1. Self-governance 2. Ultimately responsible for his or her own actions 3. Sensitive and responsive to those committed to his or her care Health-care organizations may establish structure to assist leaders in solving organizational ethical problems 1. Institutional ethics committees - administrative decisions or clinical concerns 2. Organization enforce expectations that ethical behavior will permeate the entire cultural climate 3. Engage in decision making strategies that emphasize the right thing to do instead of what is more expedient or what is solely the best interest of the department or organization 4. Failing to do so can be very costly
Key Sources and Terms
Written Torah ('TaNach') Chumash: 'Five Books of Moses' 'Navi': Books of the Prophets Prophecy ended with Malachi 'Ketuvim' Includes Book of Esther, Koheles ('Ecclesiastes'), Ruth, Tehillim ('Psalms'), Eicha ('Lamentations'), Daniel, Ezra, Nehemiah, Divrei Yamim ('Chronicles'), Job, Shir HaShirim ('Song of Songs'), and Mishlei ('Proverbs') Oral Torah (Mishnah and Gemara) Knowledge transmitted orally to Moses at Mount Sinai Oral transmission continued strictly until Roman rule after destruction of the Second Temple Redaction of the Mishnah completed c. 190 CE Gemara included the Babylonian Talmud and Jerusalem Talmud Essential for understanding how Jews interpret and apply the Written Torah Halacha: Torah law derived from Written and Oral Torah Continuous inquiry and development to meet changes in society and living conditions though periods of 'Geonim' (c. 589-1038 CE), 'Rishonim' (through early fifteenth century CE), and 'Acharonim' Very extensive literature through contemporary works Philosophy and Mussar (Ethical Conduct) Kuzari (R. Yehuda HaLevy, Spain, 12th c CE) Reishis Chochma (R. Eliyahu de Vidas (Israel, 16th c CE) Tomer Devorah (R. Moshe Cordevero, Israel,16th c CE) Philosophy and Mussar (Ethical Conduct) Mesillat Yesharim, Derech Hashem, Da'at Tevunot (R. Moshe Chaim Luzzatto [Ramchal], Amsterdam, 1740s) Nefesh HaChaim (R. Chaim of Volozhin, early 19th c. CE) Ohr Yisroel (R. Yisroel Salanter [Lipkin] and followers, Lithuania, late 19th c. CE) Sefer Chofetz Chaim & Sefer Shemirat Halashon (Chofetz Chaim, Russia, 20th c. CE)
