What is healthcare law?
the collection of laws that have a direct impact on the delivery of health care or on the relationships among those in the business of health care or between the providers and the recipients of health care
What is a law?
A rule enacted by a government or government agency that details how an individual or group must behave in a given circumstance
What is prescriptive?
Defines something that must be done
What is proscriptive?
Defines something that must not be done
Laws may describe the rules of dealing with certain conflicts:
laws that prioritize surrogate decision maker if the patient has not assigned a health care surrogate
Financial incentive attached to them to increase compliance:
Fines for breaches of (HIPPA) Health Insurance Portability and accountably Act of 1996
Describe how monies will be spent as long as specific criteria are met:
i.e.: Medicare legislation that determined that when an individual reaches the age of 65 or becomes disabled the government will provide health insurance that pays for health care and hospitalization.
What is included in the scope of concept?
-legislation -regulation -litigation
What is legislation?
The process of introducing, adopting, changing or repealing a law
What is regulation?
The process of putting laws into action through the establishment of rules
What is litigation?
The process of seeking help through the courts to address a perceived wrong
What is the primary source of power for the government entities?
US constitution
What are federal laws considered?
The highest source of law and trump all state and local laws
What may power also be derived from?
-state constitutions -executive or judiciary branches of federal and state governments and from laws themselves
What are laws created through?
-legislation -regulatory activities by government agencies -through the process of litigation
What may laws be evolved by?
A legislature identifying an issue and drafting a law that addresses that issue
In that law, authority may be given to who/what?
An existing federal agency to draft rules that support compliance with the policy goals of the initial law
When a situation arises, what does not completely fit within the law as drafted or what?
an individual affected they believe that the law is unconstitutional or in conflict with other laws
When a law is believed to be unconstitutional or in conflict with other laws what can it lead to?
Legal challenge in court where the law will be revised or confirm the law as is
What are the five traditional legal disciplines?
-tort law -contract law -property law -constitutional law -criminal law
What have all legal disciplines done?
Shaped healthcare law to some degree
What are the two legal disciplines where most healthcare laws come from?
constitutional and tort law
What is constitutional law?
What ensures access to healthcare for our poor and elderly
What are examples of constitutional law?
-Roe vs. Wade -Cruzan vs. Missouri
What did Roe vs Wade legalize?
First trimester abortion
What amendment was involved in Roe vs. Wade?
14th amendment
What did Cruzan vs. Missouri clarify?
Law of living wills
What amendment was involved in Cruzan vs. Missouri?
10th amendment -the principle where those who challenge the mandate to buy insurance under the newly enacted Patient Protection and Affordable Care Act of 2010 argue that the federal government has overstepped its bounds
What is tort law?
Shapes and defines our patient care quality parameters: -negligence, malpractice cases
What is contract law?
-Consent forms represent a contract between the patient and the healthcare facility or PCP. -Work agreements of those who provide services of healthcare
What is an example of property law?
Moore vs. UCLA where a patient asserted he had property rights in a cell line that was derived from cells taken from his body (stem cell)
What is criminal law?
Penalties are emerging as enforcement for some healthcare laws -HIPPA purposeful breaches of protected health info can cause an individual to be subject to fines as well as jail time.
What does the state board of nursing hold?
The legal authority for nursing practice and regulates nursing practice
What does the state board of nursing regulate the nursing practice through?
-establishing the requirements to obtain a nursing license -issuing nursing licenses -determining the scope of practice -setting minimum education standards -managing disciplinary procedures
What is the Professional Nursing Practice regulated by?
The states; nurses must hold a state-issued license to practice nursing
Where are details of the practice of nursing found?
In the scope of practice for each state
What should nurses be familiar from and why?
The nurse practice act and scope of practice in the state in which they work because practice can vary from state to state
What does negligence include?
-malpractice -employer/employee liability -criminal liability
What is the legal discipline for malpractice?
Tort law or law of medical liability
What four elements have to be satisfied in order for it to be considered malpractice?
-duty -breach -causation -harm
What is duty?
Arises from a special relationship
What is an example of duty in relationship to healthcare law and the physician?
The patient relationship is seen as a special relationship that gives rise to duty
What is breach?
When they fail to follow the standard of care (now evidence-based practice/base practice) that a similar situated provider (prudent provider) would follow when caring for a similar patient
What is causation?
Must be the direct or proximate cause of the harm that the patient experienced
What is harm?
Must be real, physical and measurable. The patient cannot recover from emotional harm alone without an accompanying physical disability
What is malpractice?
-the failure to "follow the standard of care" - the direct cause of arm
When the profession establishes the standard what does malpractice make this?
A unique characteristic of medical malpractice
What are nurses accountable for in malpractice?
A different standard of care
What is an example of a different standard of care in regards to malpractice in nursing?
Nurses with different areas of expertise or specialty practice are held accountable to different standards of care
What is employer/employee liability?
Vicarious liability -employer liable for the acts of its employee if the employee was acting as an agent of the employer and the actions result in injury within that scope of employment
What is vicarious liability?
Professional liability can attach to an employer for the acts of its employee
What are examples of required annual training for professionals in the hospital?
-clinical competencies -HIPPA
What does annual training show the employer?
Demonstrate that employees have appropriate skills training and therefore can be held accountable
What are the interrelated concepts of Healthcare Law?
-homecare economics -health policy -ethics
What are some examples of federal laws in regards to healthcare law?
-Social Security Act of 1965 -COBRA -Patient Self-Determination Act 1991 -Health Insurance Portability and Accountability Act of 1996 -Patient Protection and Affordable Care Act of 2010
What does the Social Security Act of 1965 involve?
Medicare and Medicaid
What does COBRA contain?
A provision that allows individuals to continue group medical insurance provided by an employer after termination of employment
What does Patient Self-Determination Act 1991 involve?
Living wills/advanced directives
What is Patient Self-Determination Act 1991?
Gives patient information regarding advanced directives and advise them of their right to participate in their medical decisions and document in the medical record whether a patient has completed an advanced directive
What is HIPPA 1996?
A federal law designed to protect the privacy of patient health information
What is Patient Protection and Affordable Care Act of 2010 also known as?
ObamaCare
What is covered by Medicare Part A?
covers services and supplies considered medically necessary to treat a disease or condition
What are examples of general things that Medicare Part A covers?
-hospital care -skilled nursing facility care -nursing home (as long as custodial care isn't the only care you need) -hospice -home health services
What are the two ways to find out if Medicare covers what you need?
-talk to your provider or other healthcare provider about why you need the services or supplies and ask if Medicare will cover them -find out if Medicare covers your item, service or supply
What three main factors is Medicare coverage based on?
-federal and state laws -national coverage decision made by Medicare about whether something is covered -local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically neces
What two types of services are covered by Medicare Part B cover?
-medically necessary services -preventive services
What is medically necessary services covered under Medicare Part B?
services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standers of medical practice
What is preventive services covered under Medicare Part B?
healthcare to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best
What are examples of things covered by Medicare Part B?
-clinical research -ambulance services -durable medical equipment (DME) -mental health (inpatient, outpatient, partial hospitalization) -getting a second opinion for surgery -limited outpatient prescription drugs
What is not covered by either Medicare Part A or B?
-long-term care (also called custodial care) -routine dental or eye care -dentures -cosmetic surgery -acupuncture -hearing aids and exams for fitting them -routine foot care
What is Medicaid?
A health insurance program for certain low-income and needy people paid with federal, state and county dollars
What is DRGs?
Diagnosis-related group
What is Diagnosis-related group?
A system to classify hospital cases into one of the original 467 groups
What are DRGs used to determine?
How much Medicare pays the hospital for each "product" since patients within each category are clinically similar and are expected to use the same level of hospital resources
What are DRGs the standard practice of?
establishing reimbursements for other Medicare related reimbursements such as to home healthcare providers
What is the intent of DRGs?
To identify the "products" that a hospital provides
What is an example of a "product" DRGs identify?
An appendectomy
Why was the system of DRGs developed?
In anticipation of convincing Congress to use it for reimbursement, to replace "cost based" reimbursement that had been used up to that point
What doe State Laws include in regards to healthcare law?
-licensing of professionals-scope of practice -licensing of health care institutions -laws relating to public health and disease prevention and control -consent -advanced directives -physician-assisted suicide