Crimes are generally classified as misdemeanors or felonies. A misdemeanor differs from a felony in the severity of the crime committed. A misdemeanor is a crime that is not considered to be severe and which when committed does not cause any harm to other people. Examples of crimes classified as misdemeanors include petty theft or driving under the influence of alcohol. On the other hand, felonies are crimes considered to be too severe and which when committed cause grave bodily harm to other people. Examples of felonies include violent robbery, rape and murder. Due to the degree of severity involved, the punishment imposed on people who have committed misdemeanors is less serious and includes either a fine or imprisonment for a period of less than one year, or both. The punishment imposed on people who commit felonies is more serious and mainly involves imprisonment in a state or federal prison for a period of more than one year (Maurer and Smith, 2004). In some states, felonies such as murder are punishable by the death sentence.
Criminal law is highly applicable in the healthcare sector chiefly because the healthcare professionals are in charge of the safety and lives of their clients. As a result, the actions taken by healthcare professionals can either have a positive or a negative impact on the lives of patients. It is therefore important for healthcare professionals to enter into a contract with their clients. A contract would not only protect the clients from harm but would also protect the healthcare professionals from any outcome resulting from negligence or violations of the contract on the part of the client. Maurer and Smith (2004) argue that, “the purpose of a written contract is to provide evidence of what the parties are mutually agreeing to do,” (p.132).
Violations of the criminal law by healthcare professionals are quite common in healthcare organizations. A good example of criminal violation involves a healthcare professional who believes that his/her opinion concerning the value of a client’s life is more important and therefore decides to accelerate the death of a client suffering from a chronic illness. This action is considered by law to be equal to murder and is therefore a felony. Other laws that are applicable to healthcare professionals include laws that protect the vulnerable populations such as children, the elderly and the disabled. Healthcare professionals who violate criminal laws and professional contracts are subject to punishment either by the state board of healthcare professionals or by the state/federal government depending on the nature and severity of the offense committed (Maurer and Smith, 2004).
Certain offenses committed by healthcare professionals such as mercy killing, incorrect diagnosis and negligent subscription of drugs can be grounds for the suspension or revocation of a healthcare professional’s license. In addition, because the healthcare professionals are in a delicate situation in which they can easily have an effect on the safety and health of their clients, they are required to conform to acceptable and healthy personal habits and abstain from harmful habits such as substance abuse. Healthcare professionals who engage in such a habit risk having their licenses suspended until they rectify their habits. Apart from license suspension/revocation, other punishments imposed on healthcare professionals include fines, imprisonment, parole and the loss of professional privileges such as promotion (Maurer and Smith, 2004). It is therefore important for healthcare professionals to conform to the criminal laws and the terms and conditions of their contracts.
Reference
Maurer, F.A. and Smith, C.M. (2004). Community/public health nursing practice: health for families and populations. New York: Elsevier Health Sciences.
There are four fundamental elements of a contract. The first element is that the contract must be entered into between two or more parties. Second, the parties that want to enter into a contract must be competent enough to agree with the terms and conditions of the contract. This requires the parties to be sober in mind and to be knowledgeable about what they are doing. The third element is that the contract signed by the parties must provide something of value to all the parties concerned. An agreement in which only one party gains at the expense of the other party is not considered to be a good contract. The last element is that contracts must be lawful. They should be guided and governed by existing laws. The absence of any of the mentioned elements renders the contract non-binding to the parties. Contracts can either be written or in oral form (Buchbinder and Shanks, 2007).
Stages of negotiation and areas of concern
Negotiation of a contract between a managed care organization and another party usually begins when the MCO sends a request for proposal (RFP). Once this is done, the potential providers must carry out some background research on the MCO to gain insight into the type of MCO it will deal with as well as the business practices and approach of operation of the MCO. At the same time, the MCO evaluates the applicants to assess their capabilities. Negotiations between the applicants and the MCO are then carried out through open communication which helps to create a mutual agreement and understanding between the parties involved. It entails extensive dialogue, debate, and conciliation by both parties which center on the results and attainment of agreement. The negotiation must result in the provision of something valuable to each of the parties. All parties must recognize the potential merits and demerits of the contractual agreement based on their goals, resources, and capabilities. The success of the negotiation is normally achieved through a contract. Gibelman and Whiting (1999) argue that “contracts are usually the result of a negotiating process,” (p.183). Areas of concern during the negotiation process include responsibilities and roles of each of the parties in the contract; the extent and type of client’s details that should be provided to the MCO; the maintenance and access of records; and the need for supervision.
Provisions for performing illegal activities
Some contracts have clauses that can provide loopholes for the parties to engage in illegal activities. In such situations, it is advisable for the parties of the contract to carefully examine all the terms and conditions of the contract to ensure that they do not violate their professional codes of conduct (Gibelman and Whiting, 1999).
Severability clause
A severability clause is a clause that asserts that if a portion of a contract is invalidated by a court, it does not have any negative impact on the validity of the rest of the contract. This clause is applicable in contracts in which there exist provisions that cannot be enforced. The unenforceable provision will thus be severed from the contract/agreement but the remaining provisions of the contract will still be valid. Filsinger (2004) states that “the clause may be especially important where there is a non-competition provision in the contract, to ensure that if the non-competition clause is found invalid, the rest of the contract will remain in force,” (p.81). An unenforceable provision, therefore, does not nullify an entire contract.
Reference List
Buchbinder, S.B. and Shanks, N.H. (2007). Introduction to healthcare management. London: Jones & Bartlett Publishers.
Filsinger, E. (2004). Employment law for business and human resources professionals. London: Edmond Montgomery Publication.
Gibelman, M. and Whiting, L. (1999). Negotiating and contracting in a managed care environment: Considerations for practitioners. Health & Social Work, 24(3), 180-190.
Numerous scandals have surfaced both in the private sector as well as the public sector. The basic underlying factor is that they happen in the eyes of auditors and other overseers charged with the responsibility of ensuring integrity in the accounting procedures. Cunning manager liaise with crafty accountants to produce fictitious financial statements which when put under the normal public eye, appear flawless and help the perpetrators embezzle funds at the institution or post favorable results to cheat the public. Attempts to use the normal audit procedures to unearth the well thought-out and planned schemes are ineffective. This paper discusses the concept of forensic accounting and analyses the case of Healthsouth healthcare providers in the light of the use of forensic accounting to unravel and prosecute the case.
Forensic accounting is a form of accounting or auditing biased towards acceptability in court. The term ‘forensic’ means ‘usable in court’. Forensic accounting combines investigative skills with accounting and auditing skills to bring out evidence of fraud that is admissible in a court of law. While normal accounting focuses on the numbers, forensic accounting looks behind the numbers. It incorporates ideas of business realities in judging the authenticity of some critical transactions. It incorporates litigation support as well as investigative accounting. Critical areas of application are in fraud detection, claims analysis, damage computation and expert witness testimony (Larry, 2003, Par 3-6).
The scandal involving Healthsouth accounting amazed the Americans. The institution is one of the largest healthcare providers focusing on rehabilitation services. It has over 1900 health facilities in the US, Australia, Canada and Puerto Rico. It offers in-patient and out-patient rehab services as well as surgery. The number of hospitals worldwide stands at 330. HealthSouth’s stock trades on the New York Stock Exchange (NYSE). On June 8, 2009 the closing price was $12.76 meaning that the company has a market capitalization of about $1.1 billion (Leonard, Peter, & Lorraine, 2009, Par4).
In the year there were findings that the company had consistently overstated its income since 1986. The then chief executive Richard Scrushy was charged with fraud. As the company rose, Scrushy had become one of the highest paid CEO’s in the US earning $8.5 million in salary, $23 million in bonuses, $4.8 million in stock option awards and $700000 in compensations. His shareholding value rose to over $287 million. In May, 2002, Scrushy sold some $75 million worth of shares and another $25 million in June. In the year 2002, the CEO was strongly advised to tackle the issue of the massive overvaluations accumulated over the years. Later he sought to use an illegal method to correct an existing illegality. He stated that the changes instituted in Medicare could lower reimbursements, a statement which caused a more than half fall in the share prices with allegations that the CEO used applied insider information in selling the stocks (HealthSouth press release, 2003, Par 4).
The Security Exchange Commission had to institute a civil case against the company. Preliminary findings of forensic investigations showed that the company had been inflating revenues and incomes. The intention of overstating the incomes was to increase stock earnings. The Practice is said to have started just after the company went public but the table below shows some intentional misstatements between year 1999 and 2002 (Department of Justice, 2003).
Income (Loss) before Income Taxes and Minority Interests (in $ millions)
1999Form10-K 2000form10-K2001 Form10-K Mid 2006
Actual $ (191) $194 $9 $157
Reported 230 559 434 340
Misstated Amnt 421 365 425 183
Misstated %age 220% 188% 4,722% 19%
As can be seen, the accountants deliberately increased profits from a loss of $191 millions to $230 in the year 1999. In the year 2000 a profit of $194 million was increased to $559 million. For year a paltry $9 million profit was hiked to $434 million. These are very significant alterations which under normal circumstances would not pass the auditors eye but it did. This continued to happen even after an employee wrote to the auditors indicating areas which could have problems.
HealthSouth’s 1999 provision for doubtful accounts was completely incomparable to other years’ bad-debt expense. A complete lack of consistency existed in terms of annual write-offs for uncollectible receivables. This indicated that HealthSouth used bad-debt reserves to manipulate earnings
Scrushy led the group named ‘the family’ within the company to fix accounts to meet expectations. The group regularly held meetings to find ways of inflating quarterly earnings and making adjustments. They utilized their knowledge of the Generally Acceptable Accounting System applicable in the US. A critical requirement is that any increase in earnings must be in tandem with increases in net assets for the balance sheet to balance and the stock values to go up.
In this case, the company increased earnings and at the same time overstated the value of assets while understating liabilities. In doing this, the accountants used some selected accounts which offered leeway for easier manipulation.
One way commonly used was by reducing the contractual adjustment account. This account estimates the difference between the amount billed to patients and that paid by the insurers. Due to the fact that the account is an estimate, it was difficult to verify the truth in the numbers presented. Statements to give credit to estimates were used.
In trying to balance the balance sheet, the accountants falsified assets and liabilities. The fixed assets accounts were mostly used with the Plant, Property and Equipment (PP&E) account being the most inflated. Thousands of phony assets were invented to feed the PP&E. Accounts marked as ‘AP summary’ and recorded with different values as well as below the thresholds used by auditors in determining which accounts to investigate. To ensure the additions were not detected, they kept them within reasonable thresholds. They also faked relevant documents such as invoices and inflated inventory accounts at the many facilities by different values hence making it difficult for auditors to establish trends in the accounts (Corporate Narc, n. d, Par 2-5).
The result was that the PP&E account had been inflated by $1Billion while the total assets were inflated by $1.5 Billion.
The entire fraud was well planned and executed taking adequate care to cover up all the loopholes. The normal audits conducted by Ernst & Young over years had failed to capture the fraud.
Engaging forensic audits enabled the discovery of the fraud. The statements issued regarding the effect of the changes in Medicare were not just that for the forensic auditors. They meant that the company was attempting to over emphasis the effects to justify drops in share prices. The forensic auditors identified the unjustified increase in assets because they understood the need to ensure the balance sheet was balanced. It is with these understanding that the forensic accountants were able to unravel the plot. They were also keen on the contractual agreement accounts as they are prone to manipulation. In forensic auditing motive is very crucial (Freeman, 2008, Par 5).
Forensic accounting therefore looks at the financial transaction with suspicion especially in cases where the environment is enticing towards lies. It looks at the transaction in the context of the applicable accounting system and more importantly, the legal framework allowing suitability of to establish valuation. Despite the fact that Richard was acquitted, his successor pleaded guilty to the fraud case in the understanding that the forensic audit was able to unravel the truth and more importantly the evidence collected and prepared by forensic experts was admissible in the courts. Other officers were also jailed for different periods depending on their roles in perpetrating the fraud. A critical lesson learnt from the case was that users of financial statements must be very diligent in examining all components of the financial statements and their relationships to each other. This should have been the catch for the firm.
Therefore the practice of forensic accounting is crucial in unraveling high profile fraud that has been ingeniously concealed to escape the normal auditor’s eye. An understanding of the legal aspects of transactions is important just like the business environment is. At the same time, auditors should strive to dig deeper into statements in a bid to reduce such cases. Ernst and Young, the auditing company was not thorough with the audits.
Reference List
Corporate Narc, (n. d). Richard Scrushy HealthSouth Corporation Scandal. Web.
The patients with individual health care coverage plans represent a significant part of California’s overall patient population. The gaps in the current legislation allow insurance carriers to make wrongful rescissions of the patients’ insurance contracts without providing sufficient justification for their decisions. Assembly Bill 2 (AB 2) which was introduced by De La Torre was aimed at restricting the power of the insurance companies for rescinding the individually purchased health care plans but was vetoed by the governor because of its ineffectiveness.
Overview of the health problem
Though the majority of Americans receive health insurance plans from their employers, individually purchased health plans are an important source of health care coverage for a substantial group of Americans. The categories of the population which cannot be involved in the group insurance plans include early retirees, self-employed people, workers of the organizations which do not offer health insurance to their employees. For example, in 2002, about 6 million Americans purchased private non-group plans (Shi & Singh, 2008, p. 203). As opposed to group insurance plans, the individually purchased health care insurance allows determining eligibility and proper pricing of the coverage in every single case, taking into account the current individual’s health condition. For this reason, high-risk individuals are often deprived of an opportunity to receive a privately purchased health care plan. The option of developing an individual health care coverage plan for every single patient can cut both ends and can be recognized as an advantage or disadvantage depending upon the situational context.
The Knox-Keene Health Care Service Plan Act of 1975 is the current law that regulates the issues of rescinding the privately purchased health care plans. Under this legislative act, the non-renewal of the individual health care coverage plan can be justified only by the specified circumstances, including nonpayment, fraud, or intentional misrepresentation of health or material facts. Bill AB 2 which was introduced by Assembly member De La Torre in California was aimed at protecting the patients with individual health care coverage by developing standardized review procedures and a legal framework for defining whether rescinding of particular insurance plans would be appropriate. The problem with the current regulations concerning the legal procedures for rescinding the privately purchased insurance plans and the appropriateness of the suggested improvements caused the prolonged debates of the bill which finally was vetoed by the Governor on October 11, 2009.
The severity of the health problem
The lack of access to affordable insurance plans is a severe problem for California where the percentage of the uninsured population is greater and the percentage of employer-sponsored patients is smaller than in the rest of the United States.
Considering the peculiarities of the insurance market of California, the experience of the state provides useful lessons for the federal policymakers. According to statistics data from 2008, only 54 percent of Californians obtained employer-sponsored insurance health care plans (Coffman, 2009, p. 2). As to the rest of the patient population, 10 percent of them obtained privately purchased insurance plans, while 44 percent preferred the services of commercial insurance companies (Coffman, 2009, p. 2). Within recent years, there has been a tendency towards the enrollment of the patients with employer-sponsored plans into the individual health care coverage plans.
California’s individual health insurance market is loosely regulated and cannot fulfill the demands of all the patients who need individually purchased healthcare coverage plans. For example, the health insurance carriers can reject an individual health care plan for a patient because of the state of health and belonging to a high-risk group. Another problem is the waiting periods which are justified by the insurance carriers with the preexisting conditions of the patients. The existing laws do not presuppose any restrictions on the rates or their increases. California’s insurance carriers are allowed to take into account the age, gender, and state condition of a patient while setting the premiums for individually purchased health insurance plans. The recent research comparing the premiums on individual insurance policies for 40-year old men and women in California has shown that the premiums for females were 10-39 percent higher than the premiums for the individual health care coverage for males with a similar health condition (Coffman, 2009, p. 3). The aggressive medical underwriting causes difficulties for patients who apply for individual health care coverage. In case of an individual’s health is not perfect, his/her chances to receive individual health care coverage are limited.
Within recent years, measures have been imposed for limiting the influence of age and gender parameters on the variations in the premiums for individually purchased health care coverage. For example, California’s 2007 health reform bill was aimed at introducing the principle of age bands into the procedures of defining the size of the premiums in every single case. The Bill AB 119 introduced by Jones was an attempt to limit the use of greater premiums for women than men, justifying it with the statistics data. The act under analysis is Bill AB 2 which was introduced by De La Torre was aimed at restricting the insurance carriers’ rights for non-renewal of individual health care plans by developing more specific procedures for post-claims underwriting and limiting the conditions under which the carrier can cancel a policy.
Taking into account the peculiarities of the development of California’s insurance market, the lack of regulations that would restrict individual variations and increases in the premiums for the privately purchased health care coverage plans are concerned with the majority of the state population. Effective measures need to be imposed for changing the existing state of affairs and along with making the insurance coverage affordable, paying attention to the protection of the consumers with individually purchased health care coverage plans.
Overview of the bill AB 2
Bill AB 2 which was introduced by De La Torre was aimed at protecting the consumers with privately purchased health care plans by restricting the list of the circumstances under which their plans can be rejected or not renewed by the insurance carriers.
Pointing at the main drawbacks of the existing Knox-Keene Health Care Service Plan Act of 1975, the opening part of the bill overviews the existing regulations for providing the individual health care coverage as well as canceling it, enumerating the specified circumstances which can justify non-renewal of the insurance project. In the existing law the specified circumstances are defined as “nonpayment, fraud or deception in the use of services or facilities, or for good cause as agreed upon in the contract” (Bill number AB 2, para. 2). To fill the gaps in the current legislation, the developers of the activities offered to improve the existing procedures for evaluating every individual’s health history and defining the size of the premiums for the patients who are interested in the privately purchased health care coverage plans. Bill AB 2 requires completing the medical underwriting by the insurers before issuing the health care coverage plan, describing the specific procedures before providing the health care plans, canceling them, and reporting all the cases of the individual insurance plans which have been canceled during the previous calendar year. “The bill would prohibit an insurer from canceling or rescinding an individual health care service plan contract … unless specified conditions are met with regard to whether an applicant intentionally misrepresented or intentionally omitted material information in the plan” (Bill number AB 2, para. 5).
Bill AB 2 explores the issues of standardization of the patients’ application forms and the procedures of reviewing every single health history before issuing the individually purchased health care coverage. According to bill AB 2, the standard application forms include only “questions designed to ascertain the health history of the applicant and shall be based on the medical information that is reasonable and necessary for medical underwriting purposes” (Bill number AB 2, para. 12). For example, an HIV test cannot be included in the application forms as obligatory information.
The expected outcomes of the implementation of the bill AB 2
The primary goals of the developers of the bill AB 2 included the development of the standardized application forms and procedures for providing and canceling the individually purchased health care coverage plans. The intention of the developers of the bill was not only to make the privately purchased health care plans more affordable but also to protect the rights of the consumers by regulating their relations with the insurance carriers and restricting the circumstances under which the latter can rescind the individually purchased insurance contracts.
The fact that the practices of wrongful rescissions have been rather frequent among Californian insurance carriers as well as the necessity of reformation of the current legislation has been recognized by the political parties and Arnold Schwarzenegger as the governor of the state. Acknowledging the necessity of reformation in the sphere of the Californian insurance industry, the political leaders, physicians, and medical organizations have united their efforts for developing effective measures and improving the existing state of affairs. The expected outcomes of AB 2 include the standardization of the application and cancellation procedures to reduce the scope of variations in the premises and minimize the risks of wrongful rescissions. Focusing on the protection of the rights of the health care consumers and putting an end to the unfair rescissions of the insurance carriers, the developers of the bill attempted to impose measures for restricting the opportunities of the insurance companies for the cancellation of the health care coverage contracts. The promoters of the bill expect that its enactment would make the individually purchased insurance plans more affordable and reliable.
The enactment of AB 2 affects the financial interests of the insurance carriers by limiting their opportunities for the unlawful rescissions of the contracts. During the hearing of the cases of the three insurance companies, it was cleared out that the coverage of more than 20, 000 has been canceled depriving them of $ 300 million of payment without the lawful justification of these decisions (De La Torre 2009). Focusing on the financial profits and ignoring the universal values, some of the insurance companies offered bonuses to employees who managed to rescind insurance contracts. Struggling for their financial interests, the insurance companies are the main opponents to the bill AB 2 who tried to lobby the enactment of the bill.
Despite the governor’s acknowledgment of the importance of reformation of the insurance industry, he vetoed the enactment of AB 2, explaining it with the ineffectiveness of the suggested reforms.
Problems with the enactment of the bill
Taking into account the fact that the protection of the patients’ rights is concerned with the reformation of the whole insurance industry, the enactment of AB 2 is associated with particular difficulties.
The insurance companies as the major interest group tried to protect their profits by lobbying the bill. During the last day of the legislative session, the army of lobbyists consisting mainly of representatives of the insurance companies organized demonstrations in Sacramento, expressing their protest against several legislative bills and AB 2 was one of the major points of their petition (De La Torre 2009). Still, these lobbyists’ actions did not have any impact on the governor’s decision to veto the bill because, after the hearing of the cases of the insurance companies, their attempts were associated only with their wish to preserve the opportunities of wrongful rescissions as one of their important sources of income.
Another problem with the enactment of the bill was preconditioned with the governor’s criticism of the formulations and the effectiveness of the measures which were suggested by the developers of the legislative bill.
Recommendations regarding AB 2
The recommendations for enhancing the effectiveness of the measures offered by AB 2 include more detailed formulations of measures that need to be imposed for restraining the insurance carriers’ opportunities for making wrongful rescissions and gaining financial profits at the cost of the health care consumers’ interests.
Justifying his veto of the bill, the governor mentioned the lack of effectiveness of the offered measures as the main argument which prevented him from signing and approving the bill. “I would support a bill that provides strong statutory protections for consumers against inappropriate rescissions by health plans” (Governor’s veto, p.5). Explaining his decision to veto the bill with the lack and ineffectiveness of the legislative act itself, the governor did not point at the ways for possible improvement of the document, not specifying the major gaps which need to be improved in further projects of the bill.
While formulating the measures which need to be imposed for improving the existing situation in California’s insurance industry, the legislators need to take into consideration the rest of the bodies which participate in the process of handling the conflicts in the sphere of individual health care coverage legislation, such as the Department of Managed Health Care and Department of Insurance for complimenting their efforts instead of criticizing them or denying their importance.
Conclusion
The bill AB 2 was vetoed by the governor who had recognized it as ineffective. Though the fact that the measures need to be imposed for improving the existing situation in the sphere of California’s insurance industry, AB 2 requires further improvements of formulations and a more detailed description of regulations and standards to be used in the application forms and procedures before rescinding the individually purchased health care coverage plans.
Reference List
Bill number AB 2. Individual health care coverage. Web.
Coffman, J. (2009). Reforming the private insurance market: Lessons from California for national health reform. Web.
De La Torre, H. (September 2009). Governor Schwarzenegger: Do the right thing, sign Assembly Bill 2. The Huffington Post.
Governor’s veto. Aroundthecapitol. Web.
Shi, L. & Singh, D. (2008). Delivering health care in America: A systems approach. Sudbury, MA: Jones and Bartlett Publishers.
List the title and case citation in a proper legal format.
MEAD V. HOLDER
NO: 1:10-CV-00950
UNITED STATES DISTRICT COURT FOR
THE DISTRICT OF COLUMBIA.
303 U.S. 444:
Describe the facts of the legal case chosen
According to plaintiffs in the case mentioned above, the amendment of the health care and education reconciliation act is unconstitutional. This act was enacted to enable the majority of Americans to access health care at a cheaper and affordable cost. On their part, the plaintiffs argue that contributing a minimum amount of cash for a health insurance policy whose failure could result in a cash penalty is unconstitutional. According to the act, the minimum amount is to be paid by each citizen to the Health Insurance Company to cater to health programs for the citizens (Hopkins, 2012). On the other hand, failure to contribute the minimum amount could result in a penalty of one U.S. dollar. Further, the plaintiffs argue that by paying the health insurance fund, they will not cope with their personal medical care. Further, the plaintiffs argue that they are in good health and would not require to have a medical cover because it is possible for them to cater to the medical bill if a need arises. Additionally, they argue that they do not qualify for the exemption of the affordable care act (ACA) and hence they may be required to pay for health beginning the year 2014.
Consequently, none of the plaintiffs qualify for Medicaid and they have further stated that even if they were qualified for it, they would not take it. In view of this, the plaintiffs believe that the federal government does not have the power to force anyone to pay for the policy or even impose a penalty for non-compliance (Hopkins, 2012). Additionally, they argue that by the year 2020, they could have a hard time paying for the policy because this may call for an adjustment of their fiscal policy which may affect their spending. Further, the plaintiffs argue that the policy contradicts their religious beliefs because they believe that God is the provider of all their needs. Additionally, they argue that this could mean that they will have to ask God to provide an extra financial back up in order for them to cater for the medical cover.
Describe the issues of the legal case
The United States passed a law that requires every citizen to take a medical cover failure to which one could be entitled a penalty. In connection to this, the plaintiffs went to the court to seek for amendment of the law because they find this unconstitutional. The plaintiffs argue that the cover could make them go against their religious beliefs. Connectively, they believe that God is the sole provider of everything. Connectively, it means that they have to pledge to God so that he could give them extra cash to cater for the cover that they had not budgeted for. Additionally, they have been paying for their personal medical checkup and could not like to deviate from the norm (Hopkins, 2012). In general, they argue that they are in a position to take care of their medical issues without having the cover. Further, the plaintiffs argue that
they will be required to adjust their fiscal policies in order to cater for the medical cover. The plaintiffs argue that they are in good health and could not hesitate to pay for their personal medical bill if happened to be sick.
Describe the holdings of the legal case
The court ruled out that the plaintiffs do not particularly specify which payments they make from their own pocket that could not be covered under the medical insurance fund. According to the court, they ought to have specified this so as to support their claims (Hyatt & Hopkins, 2011). Further, the court resolved that the complaint must give facts that could make the defendant more liable. The court argued that the plaintiffs must have been injured in a fact and there should have been a
relationship between the injury and the conduct. The court argued that by the year 2014, the case would have shifted to another direction which in turn could affect the ruling. Further, the judge argued that there are always pre-enforcement challenges that are found in almost every case. In his view, if the enforcement was perfect when there could be no complaints from the plaintiffs. The plaintiffs have clearly stated that the expected injuries could take place by the year 2014. The court views this as certain and not based on mere speculations and hence it adds value to the plaintiff’s evidence. Due to the fact that the plaintiffs have really proved to the court that the injury is to occur in the year 2014, which is a relatively short period, the court has put that into consideration while making its ruling. Other than future financial injury, the plaintiffs have proved to the court that they will have to adjust their spending and do away with some charitable donation to afford the health insurance fund.
Additionally, the court has also put into consideration the fact that the policy is meant for the good of the citizens and therefore the plaintiffs have not shown clearly why they should not contribute to the health insurance fund.
Describe the reason for the legal case
The plaintiffs are seeking the amendment of the law that demands every citizen in the U.S. to take a medical insurance cover so that the government can be able to cater for medical funds relating to all the citizens (Hyatt & Hopkins, 2011). In addition, the plaintiffs are not willing to pay the medical insurance cover because they find this unconstitutional. They have taken the case to the court since they want the law to be amended.
Discuss the main points of the legal case
The main points in this legal case are for the plaintiffs to prove to the court that in fact by imposing the law on every citizen to pay the medical insurance fund is unconstitutional. Further, they have to prove to the court that the imposition of the policy could inconvenience them especially financially. Additionally, they also have to prove to the court beyond a reasonable doubt that they could undergo financial injury both at present and in the future. They should also prove how the law could affect them religiously. On the side of the defendant, they should show that the policy is constitutional and prove to the court that it is actually meant to improve the well-being of the citizens and does not infringe citizens’ right (Hyatt & Hopkins, 2011). The judge on his part has to look at the evidence brought before the court by the two parties and decide which evidence holds water.
References
Hopkins, B. R. (2012). Tax-exempt organizations and constitutional law: Nonprofit law as shaped by the U.S. Supreme Court. Hoboken, New Jersey: John Wiley & Sons, Inc.
Hyatt, T. K., & Hopkins, B. R. (2011). The law of tax-exempt healthcare organizations. Hoboken, N.J: Wiley.
Nowadays, it is being often suggested that healthcare should be made accessible to just about anyone, regardless of what happened to be the would-be treated patient’s social status. This suggestion, however, does not hold much water. In this paper, I will explain why.
One of the reasons why people need to see doctors periodically, is that the practice in question is assumed to contribute to extending one’s lifespan. If it was not up to this, it would be highly unlikely for an individual to be willing to go as far as taking its clothes off in front of a physician. However, there can be very little rationale for people to try to live longer, unless their lives happened to be enjoyable.
The validity of this suggestion can be illustrated, in regards to the fact that, as time goes on, more and more countries allow their terminally ill citizens to apply for euthanasia. Apparently, if one’s existence happened to be full of pain, there can be no reason in trying to extend it. This brings us to answer the question of what is the foremost precondition for one’s life to be enjoyable?
This, of course, would be the concerned person’s material riches. After all, it does not require a scientist to realize that, for as long as a particular person happened to be rich, he or she will be in the position to enjoy life to the fullest. What it means is that the idea that poor people should be entitled to healthcare does not make any logical sense – these people’s lives are miserable, by definition, and there is nothing doctors can do to help the situation.
Another reason why only rich people deserve healthcare, has to do with geopolitics. The line of argumentation, behind this suggestion, is as follows:
The idea that, regardless of how much money they happened to have in the bank, people may enjoy equal access to healthcare is clearly Socialist and potentially Communist (Russo 735). This simply could not be otherwise – people’s universal access to healthcare can only be ensured in the society, where the rich are being forced to share their riches with the rest of this society’s members. It is understood, of course, that this idea is being deeply inconsistent with the American way of life.
After all, it is specifically the U.S. citizens’ endowment with the strongly defined sense of greed/egoism, which makes the country’s economy to function in the way it does. However, the way it functions is good – something that can be easily illustrated, in regards to the hordes of illegal immigrants who try to sneak into this country each year.
In other words, those who advocate the idea of universal healthcare, act on behalf of the third party, which happened to be China – the world’s only ‘superpower’ that continues to proclaim its commitment to the ideology of Communism. These people are nothing but the agents of foreign influence. What it means is that they should be arrested for helping China to undermine the integrity of American society from within.
Nevertheless, it would be wrong to believe that denying the access to healthcare for poor people may only benefit the rich – the former themselves should be interested in enacting this state of affairs. The reason for this is that, as practice indicates, healthcare professionals often act on behalf of the country’s pharmacological companies.
This explains why, as of today, the professional adequacy of a physician in America is being considered reflective of the amount of drugs that he or she is capable of prescribing to a patient, even when there is no reason for the latter to be drug-treated, in the first place (Mathis A6). What it means is that, as of today, one’s willingness to be checked by a physician means that the concerned person consciously strives to sustain damage to its health.
Poor people, however, are not being in the position to afford suffering from illnesses, as it would reduce the measure of their existential competitiveness. The reason for this is that, it is not only that poor people aspire to fill their stomachs with food, but they also remain in the state of competition with each other, while addressing this task.
Therefore, when it comes to dealing with illness, on their part, these people should act in the similar manner with what it happened to be the case with stray cats – they should try eating some medicinal grass.
By doing it, they will be able to save money and to contribute to increasing the overall measure of the evolutionary fitness of America’s population of the poor. After all, there can be only two consequences to a poor person’s decision to eat medicinal grass – it is either he or she recovers, or continues to remain ill and consequently dies – hence, ceasing to be a burden to the society.
Conclusion
I believe that the earlier provided line of argumentation is fully consistent with the paper’s initial thesis. Apparently, it is indeed thoroughly appropriate to suggest that only rich people should be entitled to healthcare.
Works Cited
Mathis, G. “Has the Pharmaceutical Industry ‘Bought Off’ Congress.” New Pittsburgh Courier 02 May 2007: A6. Print.
Russo, A. “Communism: An Idea to Be Divided.” South Atlantic Quarterly 113.4 (2014): 729-741. Print.
According to Dick, Steen and Detmer (1997), the role of laws is to provide a legal framework for workers in the healthcare discipline to follow when handling patient data. Laws enable health care workers to enforce the safety of patients under the ‘National Patient Safety Goals’ framework that provides guidelines for the performance of healthcare service providers to observe when executing their duties.
Healthcare laws define the methods for protecting user requirements that are necessary for effective communication, accurate acquisition of patient data, better administration and safety of medications, low risk exposure to AIHs, and the prevention of the administration and use of wrong medication and procedures to reduce patient infections (Dick, Steen & Detmer, 1997).
Different statistical trends show variations in the the way the laws are adopted and applied across different healthcare organisations. The reasons for the variations include the size of the hospitals, the cost of implementing the systems, different patient testing and validation approaches, the nature of different medical societies, hospitals, clinicians, and varying consumer behaviors (Dick, Steen & Detmer, 1997).
Healthcare law requirements and patient data
According to Dick, Steen and Detmer (1997), “the collection and analysis of patient data is done in a way that ensures that high quality data is made available at the right time to support the management of patient information and delivery of healthcare services to the patients in time” (p.32). Here, patient health records are the primary tools that provide legal description of patient information.
The practice of collecting and analysing information is based on different models that include the AHIMA’s Data Quality Management Model that is defined into four steps that include application, collection, storing or warehousing, and analysis.
According to Dick, Steen and Detmer (1997), the analytical part characterizes the analytical steps that are consistent with the laws based on different domains that include data accuracy, accessibility, definition, relevancy, granularity, timeliness, precision, currency, consistency, and comprehensiveness.
Accurate data contains the right values such as patient names and IDs, the data items that are collected as per the prescribed laws and regulations, and the data that is required to be included in the collection and analysis phases. Current and real time data is the only up to date and reliable data that is made available for use across different organisations for processing the day-to-day transactions.
Data analysis is done to ensure that data that includes patient names and other details are accurately encoded and continually validated and verified when it is recorded. The right the data mining tools are used to ensure accurate access and analysis of comprehensive data using a combination of different tools that include the Medicare Case Mix Index (CMI) tool and comprehensive data is used to ensure pertinent data causes a positive impact on the results.
The role of healthcare law in health informatics
Dick, Steen and Detmer (1997) argue that the healthcare law in health informatics is crucial for defining the methods and standards that healthcare professional use for the acquisition, storage, retrieval, processing, and transmission of patient data in a secure and acceptable way that is compliant with the law.
Compliance is curial in the way the data is handled because different acts such as the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to avoid the penalties that accompany those who violate the law. The HIPAA act regulates the electronic handling of patient data and provides the regulations, guidelines, and protocols for handling the data (Dick, Steen & Detmer, 1997).
The ACDM guidelines and data handling protocols were identified by the Electronic Data Transfer Special Interest Group (SIG) to enhance the performance of healthcare organisation. The data handling protocols are used to define the status of the patients’ documents and the amendment and change status to be included. The clinical protocol requires the medical personnel to append their signatures on the distribution list showing the timescale and key activities that are done by the health workers.
The protocol for data handling procedures for patient safety is used to identify universally accepted methods of dosing surgical and non-surgical patients undergoing invasive procedures to reduce health risks, improve the safety of medications, identify patients at risk, how to effectively communicate with care givers and to identify appropriate procedure verification processes and procedures (Dick, Steen & Detmer, 1997).
For instance to be Health Insurance Portability and Accountability Act (HIPAA) (HIPAA) compliant, the health institution must adhere to the HIPAA compliant requirements that include adhering to the training and development standards, employing IT professionals to management the information systems, passwords protection and updates, and above all, ensuing that the privacy rules are enforced adequately.
Adequate compliance to HIPAA requires compliance of administrative procedures that include data backups, disaster recovery plans, and formal mechanisms of data processing, security management practices, and effective incident handling techniques, implementation of physical and technical controls and safeguards, and use of technical security mechanisms.
Analysing patient data for compliance
Typically, one of the approaches of ensuring that patient data is analysed to ensure compliance is by enforcing automating compliance with the PHI policies. The Patient Health Information (PHI) provides that patient data should be kept confidential and secure to be assured that the handling procedures are consistent with the PHI data protection laws.
Among the “laws that organisations need to comply with include the data protection act that was created to ensure that patient data is kept private and confidential based on the eight principles of data protection” (Dick, Steen & Detmer, 1997). Under the “Data Protection Act 1998, the unlawful processing, or disclosure of personal data to a third party, is a criminal act” (Dick, Steen & Detmer, 1997).
The processing and analysis of personal data for the sake of compliance should be based on the eight principles of the data protection act that include lawful and fair processing, lawful access, observation of data processing laws in accordance with the rights of the affected person, observation of data integrity laws across national boundaries, and accurate and up to date use of personal data (Dick, Steen & Detmer, 1997).
Here, the processing ecosystem should be protected to make patient data safe in when being accessed, processed, and stored. For instance the HIPAA provides guidelines for the protection of patient data that covers the “healthcare providers, health plan administrators, healthcare clearinghouses, schools, and universities” (Dick, Steen & Detmer, 1997).
In summary, the standards for data protection are used to ensure entity authentication, audit access control, confidentiality, integrity, and compliance with the federal laws and regulations. Confidential data can only be revealed to the right party who can be authenticated to verify the legitimacy of their claims to access patient data so that the integrity of the data is not compromised.
Reference
Dick, R. S., Steen, E. B., & Detmer, D. E. (1997). The Computer-Based Patient Record: An Essential Technology for Health Care. New York: National Academies Press.
Medical professionals are guided and governed by statutes that are set by different states. These rules are set and implemented by governing bodies. In Illinois, this is done by the Illinois Department of Professional Regulations (IDPR) who oversees the provision of certificates and regulations of health care delivery. According to Anass & George (2003) “for a medical professional to practice; they need to have a license.” For them to be licensed, they need to have a certain level of education and qualifications. These are to be verified by the IDPR before the professionals are authorized to practice. Humans are to mistake, and they are inevitable. Depending on their cause, they have different consequences. Likewise, professionals are likely to make mistakes during their practice. These mistakes can be caused by ignorance of regulations or through human mistakes. If this happens, patients or consumers are the ones who are affected or suffer, and therefore, they would like to raise complaints with the relevant administration. In these scenarios, there are specific procedures that they are supposed to follow. This paper will find out the role of Illinois statutes in regulating professional conduct in health care and also how the statutes help to fight criminal liability that may arise in health care provision.
Certification and authorization of medical professionals
For professionals to legally practice in any field, they are required to be certified or licensed by certain organizations (Pound, 2007). This also applies to medical professionals. Certification or licensure of the medical professionals in Illinois has to be verified by Illinois Professionals Licensing Consultants (IPLC). It comprises attorneys and investigators who formally worked with the Illinois Department of Professional Regulation. The role of this group is to safeguard and promote the health safety of the public through ensuring that professionals have all the qualifications required before licensure and to implement relevant Illinois statutes.
Before medical professionals are legally allowed to practice, they are supposed to have undertaken certain procedures. These include:
Certification: It is the process through which recognition of an individual with certain qualifications is done by a non-governmental agency. Certification proves that an individual possesses skills in certain areas and is in a position to undertake them without any difficulty. Examples of these qualifications include successful graduation from a recognized program, acceptable passing of qualifying examinations, or having fulfilled certain levels of work experience. Health care professionals in Illinois require this according to Illinois medical statutes to qualify for a license.
Licensure or authorization: Annas (2003) defined licensure as “the process through which a government agency provides permission to individuals or professionals to practice their profession making them accountable and prohibits the rest from legally performing” (34). Licensure defines the areas in which a professional is allowed to practice and the extent he or she is limited to. Licensure is meant to guarantee that the public is protected by ensuring that there is a set level for professional competence. This is offered and regulated by IPLC.
Credentialing: Credentialing is the process in which a health professional is allowed to practice in a hospital setting. It is utilized to designate that a person has fulfilled established governmental or non-governmental standards set to be recognized as qualified and to be allowed to practice. In Illinois, this is governed by the Illinois Department of Public Health (IDPH) under the Illinois statutes. This is an important procedure as it eliminates all the possibility of providing wrong or incorrect information to practice.
Potential criminal liability related to these procedures
In the process of acquiring legal authorization for practicing, individuals are supposed to undergo the above-mentioned procedures. This may make some individuals engage themselves in activities that may amount to illegal acts under Illinois statutes. One of the common criminal liabilities is providing wrong information about themselves or their abilities.
In credentialing, individuals are required to provide personal information. This information plus others that will be retrieved from the individual by the IDPH will be utilized to ascertain whether a person is legible to practice medicine. With this pressure on individuals and their need to practice building their careers, they might provide wrong information that will lead to them being authorized to practice. This is one of the key illegal practices that individuals may be engaged in. Others include providing fake documents to verify their certifications or acquiring a license through corruption. This may amount to prosecution in the court under state laws for fraud, corruption, or endangering public health.
Professional misconducts
In the world of today, integrity standards are slowly declining. This is also affecting the medical profession. The professionals engage in misconducts that they are aware of. Some of the misconducts are sexual harassment of patients while they are under medication and cannot control themselves, performing procedures on individuals without disclosing full information on their side effects, performing procedures without the patient’s consent, not being careful to observe all the requirements before offering treatment to their patients or delaying performing a procedure that is required immediately (Annas, 2003). All these and many others constitute professional misconducts under the medical statutes of Illinois.
This is an example of professional misconduct that occurred in one of the medical facilities in Illinois. A lady patient is being prepared to undergo surgery. In the process of her receiving medication, the theatre assistant was touching her un-appropriately since she was semi-conscious and could not respond too much. When she regained her full consciousness, she approached the assistant and to get some answers as to why he did what he did. The assistant became more aggressive and beat her. The securities were the ones who saved the day.
Civil complaint process
In the happening of professional misconduct, patients or consumers are the ones who suffer. When this happens, they may want to file complaints. It might be a simple process but the consequences might cause a major influence on the professional. The process requires the complainants to file complaints forms and forward them to the administration of the medical facility. If the complaints aren’t handled appropriately, the patient or consumers can write a letter to the Joint Medical Board explaining their complaints against a certain professional. After the administration gets complaints, it may want to deal with them or they might forward the case to the Joint Medical Board.
Once the board gets the complaints, there are several procedures that they are to follow under the medical statutes and other procedural acts of Illinois (Annas, 2003). For any actions to be taken against an individual there needs to be evidence to back the allegations. To get the necessary verification, the joint medical board and the administrations need to have investigations carried out. This can be done by IDPR or the Department of Health and Human Services. These bodies are tasked with validating the allegations raised against the medical professional and providing evidence that links the individual to professional misconduct. Once they accomplish verification, they are tasked with recommending appropriate measures to deal with the issues raised and on how to compensate the patient.
Once the board gets appropriate evidence that will implicate the medical professional, it sermons the individual to appear before it on a specified date. When this happens, the individual has a chance to explain his or her side to the board, plead his case giving the reasons that led him or her to perform the acts that have caused him to appear before the board (Annas, 2003). After considering all the facts and information before the board, the board takes necessary steps under medical statutes to punish the misconducts that were caused by the professional’s ignorance or misconduct. This could take different dimensions including suspending or revoking the license completely, making the professional pay for damages caused by his or her misconduct or even the board may file a legal case against the individual in a court of law on behalf of the patient.
Potential criminal liability related to professional misconduct
Several criminal liabilities may arise from professional misconduct. From the example given above, if that woman would initiate a criminal proceeding against the theatre assistant, it would be sexual harassment state laws and would attract jail time if the lady wins the case. Another criminal liability could be manslaughter if a patient dies due to medical professional ignorance (Pound, 2007). Also, if a professional gives wrong medication due to lack of proper testing this could amount to them losing their license and if a case is filed it could be manslaughter. Intentional giving of wrong drugs to a patient due to the professional’s relationship with the patient would amount to murder. All these misconducts are punishable under Illinois medical statutes and general laws, and it would be disastrous to the medical career of the individual involved.
Conclusion
According to the Illinois medical statutes their organizations are set to govern the medical profession. Professionals in this field are to conduct themselves according to the regulations and procedures set by the organization. In case they decide to go against them they are punishable under law.
Reference List
Annas, G. (2003). The Rights of Patients. (3rd Edition). Carbondale: Southern Illinois University Press.
Pound, R. (2007). Social Control through Law. New Brunswick, NJ: Transaction Publishers.
Corporate criminal liability can be stipulated under the Criminal code, where a person can be convicted of a crime so long as it has proven beyond a reasonable doubt and that he was in a guilty state of mind. (Geraghty 14). Within the context of criminal law, corporate criminal liability provides the limits within which a corporation, when regarded as a legal person, can be found liable for omissions and errors employed by natural persons. At times, corporate criminal liability is explained as a branch of the vicarious liability. This is when it is described allowing a distinction from the circumstance where a statutory offence. Under this condition, the wording evidently draws a connection between a corporation and a liability. The wording could further identify with the corporation specifically being identified as the joint principal (Gobert 18).
Vicarious liability applies to the ability to hold one accountable for the general misconduct of an agent in some form of collective or joint activities. For instance, the employer-employee relationship, the respondent superior doctrine holds that employers personally liable for the actions of their employees for negligence on their part. For instance, the under the Healthcare entities, hospitals may be held vicariously liable for the negligence of their Doctors who are under their scope of employment. (Killbert, 13) Under the respondent, superior doctrine, it became law in order to compensate parties that were injured in line of work by their employer i.e. hospitals can insurer their premises so as to compensate the injured parties other that their employees thus escaping liability for actions done on their behalf.
Where their negligent acts concerning health officials, their employer is illustrated an independent official thus they’re not vicariously liable hence, whether a party is a independent official or an employee generally depends on the means and manner which the party in question was to work under the said circumstances for example where the health plan does not control manner in which a Doctor treats his/her patient the principal will not be held liable for the negligent acts of the Doctor.
However, entities under the health care can be held liable for temporary employees. A good illustration of this is how surgeons can be held accountable for acts of their nurses who are under his/her management whether there actual staff or not. However, a Doctor cannot be held liable for the negligence of a Surgeon who acts on his own accord during surgery. “Ostensible” being agents can be held vicarious liable for negligence, this usual depends on whether the Surgeon in question does appear to the injured party as an agent to the health plan and it should be proved beyond reasonable doubt for example the public being presented with advertising materials showing that an injured party thought that the surgeon was an ostensible agent then they can impose vicarious liability on the health plan on the grounds that the Surgeon was negligent in his actions. (Killbert, 56.)
In determining whether an employee was acting in capacity in regard to his/her employment is important in determining whether the employer will be held vicarious liable for the acts hence in many healthcare amenities, hospitals are not held vicariously liable for acts that are considered not to be in the line of duty of the employee, for example when a patient is personal molested sexually by an employee the employer will not be sued vicariously.
Hence the employer must make sure the necessary measures are in place to provide for a competent workforce.
Apparent agency being where a health institution is held vicariously liable for negligence of his/her employees is only where there is an actual agency relationship between the later and the employer. Hence for a hospital to be liable, the plaintiff must prove that the manner in which the employee/ agent acted would make a reasonable man to construe that the person was negligent. Also the plaintiff must prove that the agent consisted with prudence and showed authority in that the hospital had the fore thought and acquiesced in them but incase the patient knows or ought to have known that the physician was an agent then vicarious liability will not be accepted.
The decision undermines the importance of clarity on consent forms those that are used by the hospitals hence they should state that the patient will be attended by an independent practitioner. This will defiantly reduce the standards of medical practices for example hospitals can make the independent medical practitioner wear lab coats without the hospital logo hence in the real sense there cannot be perfect compliance. (Gobert 11).
This in the actual sense makes for plaintiffs to sue against hospitals in vicarious liability claims to the extent of frustrating the medical practitioners’ because it’s a burden and it has led to more appropriate way in which one can build a case make it grounds to sue and that being the case it surly seems as downward trend to the standards that had been set down by the medical practitioners.
Works Cited
Geraghty, Martin. Corporate Criminal Liability. Vol. 39 American Criminal Law Review, 327, 2008.
Gobert, Joseph. Corporate Criminality: New Crimes for the Times. London: Oxford Publishers, 2010.
Killbert, Zachary. Basics of Managed Care Liability and HMO Malpractice. New York: CRC Publishers, 2007.
Medicare is an important part of the healthcare ecosystem in the US. It ensures that many Americans have access to healthcare. This paper reviews five aspects of Medicare.
Impact of Medicare on Licensure, Certification, or Accreditation
The US medical system requires healthcare facilities and professionals to apply for licensing before offering medical services. The issuance of licenses depends on compliance with state laws and federal regulations (American Health Lawyer Association, 2013). Healthcare facilities must be at a minimum acceptable standard to receive licenses to offer medical licenses. On the other hand, healthcare professionals must also meet given criteria to qualify for a license. Licenses ensure that healthcare facilities and professionals have the capacity to offer a certain minimum standard of care.
Certification of healthcare facilities and healthcare professionals is a means of verifying the credentials of the facility and the healthcare professionals. Certificates usually give patients the confidence that healthcare providers have the skills needed to handle their concerns. On the other hand, it gives patients the assurance that the healthcare facility taking care of their needs maintains the requisite standards of care in the eyes of the authorities.
Accreditation is a voluntary process where a healthcare institution subjects itself to evaluation by an accrediting agency (Niles, 2010). Accreditation is important because it helps an institution to communicate to the stakeholders its commitment to quality in various aspects of its operations. The Joint Commission runs several voluntary accreditation programs for healthcare institutions. These programs can help healthcare institutions to demonstrate their commitment to quality as participants in Medicare.
How Does Medicare Influence Clinical Quality?
Medical services depend on the facilities and standards of a healthcare institution, as well as the skills of the medical personnel in the facility. In this sense, Medicare influences clinical quality in two ways. First, Medicare reimbursements depend on the quality of care provided by physicians. Secondly, Medicare reimbursements depend on the quality of care provided by healthcare institutions.
The Physician Quality Reporting System (PQRS) developed by the Joint Commission ensures that physicians send quality reports to qualify for incentive pay (LaTour & Eichenwald, 2013). Physicians can qualify for incentive pay for their quality reports show that they have offered high-quality services to their patients. On the other hand, physicians who do not file quality reports run the risk of losing some money by pay adjustments from the Joint Commission. If they fail to file their reports, they risk earning less money.
The Hospital Value-Based Purchasing (HVBP) Program helps to guarantee clinical quality in healthcare institutions (American Health Lawyer Association, 2013). The goal of this program is to ensure that hospitals focus on the quality of care, and not just the quantity of care given to patients.
The main aspects considered under this program include the process used by the hospital to handle patients, the experience of the patients during care, the outcome of the medical interventions given by a healthcare institution, and the efficiency of the process (American Health Lawyer Association, 2013).
How does Medicare Influence Reimbursement?
Medicare influences reimbursement in the following ways. First, Medicare, under the Joint Commission, has rates dictating how much physicians should charge for each service (American Health Lawyer Association, 2013). These rates are indicative of the health services that physicians can charge patients.
Secondly, Medicare provides prospective payments to hospitals as a cost-cutting measure (Omachonu & Einspruch, 2010). Healthcare institutions receive a fixed amount of money based on the number of patients they will serve, and based on the average cost of providing these services. The model of prospective pay came into being as a cost-cutting measure. The thinking was that hospitals would become cost-conscious if they suffer a penalty for offering expensive services. In this regard, hospitals keep the balance of any money given to them under Medicare prospective pay if they do not spend it on healthcare. On the other hand, the hospital must find new resources to cater for any shortfalls if they spend more money than the sums allocated to them under Medicare. These limits make hospitals more cost-conscious.
The third way in which Medicare influences reimbursements is by incentive pay programs affecting physicians and healthcare institutions (Niles, 2010). Physicians are liable to a pay adjustment if they fail to submit quality reports, while at the same time, they are eligible for incentive payments if they submit quality reports. In this regard, Medicare dictates the reimbursements made to physicians and healthcare institutions.
How Medicare Influences Patient Access
Medicare influences patient access in three ways. First, Medicare provides a reliable source of funds for healthcare institutions. The institutions can only access these funds if they offer healthcare services. Therefore, healthcare institutions have an incentive to offer services. Secondly, Medicare improves access to healthcare by providing a source of funding for healthcare. Many people who have no funds for healthcare or an insurance cover to take care of their healthcare needs tend to put off seeking medical attention until their health situation deteriorates (Niles, 2010). In this regard, Medicare reduces the tendency of avoiding to seek medical attention.
Role of the Health Informatics Professional in Medicare
The Health Informatics Professional plays a very critical role in Medicare. Medicare is data-intensive because of the regulatory demands and the need to measure its effectiveness on a continuous basis. The three main roles that they play are as follows. First, the Health Informatics Professional provides guidance in the development of the tools needed to assess the effectiveness of Medicare programs (Niles, 2010). Secondly, the Health Informatics Professional provides the skills needed to make projections on the cost of healthcare and to work out the possible implications. Thirdly, the professional provides the skills needed to evaluate the qualitative aspects of healthcare.
Impact of Medicare on the Health Informatics
Medicare continues to transform health informatics in many ways. Medicare is data-driven. Therefore, the only way Medicare can exist is in an environment of health informatics. Medicare requires detailed reports in standard forms that support systemic evaluation. This means that every healthcare institution must invest in data entry and analysis equipment related to system management. This shows that Medicare is leaving a lasting influence on health delivery by promoting data-driven and evidence-based approaches. To healthcare
Medicare is also influencing the development of health informatics through the development of conceptual tools for managing health care (LaTour & Eichenwald, 2013). Prospective reimbursement was a new concept to the healthcare fraternity. Traditionally, people paid for medical services after receiving medical attention. Insurance companies still use this model. However, Medicare provided the basis for radical change in how to finance healthcare.
Medicare is also making healthcare professionals keen on the use of data. The experiences of these professionals percolate into the entire healthcare ecosystem, even where Medicare does not exist. In this sense, Medicare is transforming modern healthcare delivery models.
References
American Health Lawyer Association. (2013). Medicare Conditions of Participation (Conditions for Coverage). Web.
LaTour, K. M., & Eichenwald, S. (2013). Health Information Management: Concepts, Principles, and Practice. New York, NY: AHIMA. Web.
Niles, N. J. (2010). Basics of the U.S. Healthcare System. Sadbury, MA: Jones & Bartlett Learning. Web.
Omachonu, V. K., & Einspruch, N. G. (2010). Innovation in Healthcare Delivery Systems: A Conceptual Framework. The Innovation Journal: The Public Sector Innovation Journal, 15(1), 1-20. Web.