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Regulating Healthcare - Lecture B
- 1. Introduction to Health Care and Public Health in the U.S. Regulating Health Care Lecture b This material (Comp 1 Unit 6) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 2. Regulating Health Care Learning Objectives - 1 • Describe the role of accreditation, regulatory bodies, and professional associations in health care in the U.S. (Lecture a) • Describe the basic concepts of law in the United States: the legal system, sources of law, classification of laws, the court system, and the trial process. (Lecture b) 2
- 3. Regulating Health Care Learning Objectives - 2 • Describe legal aspects of medicine involving the Affordable Care Act, professional standards in health care, medical malpractice, Tort reform, and Medicare and Medicaid Fraud and Abuse (Lecture c) 3
- 4. Regulating Health Care Learning Objectives - 3 • Describe key components of the Health Insurance Portability and Accountability Act (HIPAA) and describe efforts to promote patient safety in the U.S. (Lecture d) • Discuss the need for quality clinical documentation for the use of the health record as a legal document, communication tool and a key to prove compliance for health care organizations. (Lecture e) 4
- 5. The Legal System in the U.S. • Legislative – House of Representatives – Senate • Executive – The president – Depts and agencies • Judicial – Judges – Courts https://kids.usa.gov/three-branches-of-government/index.shtml 5
- 6. Balance of Power • Separation of powers – Three branches of government – Designed to prevent any one branch from becoming too powerful • Checks and balances – Legislative branch makes laws – Executive branch enforces laws – Judicial branch interprets laws 6
- 7. Sources of Law • Legislative branch makes statutory laws • Executive branch makes administrative laws • Laws made by the courts are called common law or case law 7
- 8. The Judicial System: Courts • Trial court – Hears evidence and hands down verdicts – Can be federal, state, or local • Appellate court – Losing party can appeal – Court usually does not hear new evidence – Reviews case to determine if the law was properly applied to the facts as determined by the trial court 8
- 9. The Judicial System: Jurisdiction • Federal courts – Constitutionality of a federal law – Disputes primarily involving federal law – Disputes between citizens of different states • State courts – Often called courts of common pleas or county courts • City or municipal courts 9
- 10. Comparing Court Systems: An Example U.S. Government State of Ohio City of Cleveland Trial courts U.S. District Court for the Northern District of Ohio Cuyahoga County Court of Common Pleas Cleveland Municipal Court Appellate courts U.S. Sixth Circuit Court of Appeals Ohio Eighth District Court of Appeals Ohio Eighth District Court of Appeals Highest court U.S. Supreme Court Ohio Supreme Court Ohio Supreme Court 6.1 Table: Example of court jurisdiction on various levels of government. 10
- 11. Classification of Laws • Civil or private law – Relationships between people – Relationships between people and organizations – Relationships between organizations – Includes family, property, inheritance, corporate, contract, and tort law • Public law – Relationships between people and the government 11
- 12. Two Kinds of Penalties • Civil law: Exchange of money between the private parties to the lawsuit • Public law: Can result in fines paid to the government and/or imprisonment • The same action can result in both kinds of penalties 12
- 13. Example: Traffic Accident • Drunk driver crashes car, causing serious injury to the driver of the other car • Criminal (public) penalty – State vs. drunk driver • Civil (private) damages – Injured driver vs. drunk driver 13
- 14. General Classification: Private Law 6.1 Figure: Two important sub classifications of civil law are contract law and tort law (OHSU, 2010). 14
- 15. Contract Law • Contract elements – Offer – Acceptance – Consideration: something of value given in exchange for a promise • Express contract – Written or oral • Implied contract 15
- 16. Tort Law • Intentional torts – Battery – Defamation • Negligence – Does not act with a reasonable amount of care – As a result, someone is injured 16
- 17. General Classification: Public Law 6.2 Figure: The two types of Public Law that have the most effect on individuals are criminal law and administrative law (OHSU, 2010). 17
- 18. Litigation: Parties • Adversary system – Each party presents his or her case – Facts determined by neutral fact-finder • Civil case: plaintiff and defendant • Criminal case: government and defendant 18
- 19. Pre-trial Litigation: Discovery • Purpose is to fully develop the facts • Depositions are one kind of discovery – Sworn testimony recorded by court reporter – Parties – Witnesses – Expert witnesses 19
- 20. Administrative Hearings • Sometimes an administrative agency has a system of hearings that is outside the normal court system • The agency may or may not have an appellate level • Usually reviewable in a court of law 20
- 21. Administrative Hearing Example • Social Security Administration (SSA) – Hearing officers – Social Security Appeals Council – Decisions of the SSA appeals board can be further appealed to the U.S. District Court 21
- 22. Regulating Health Care Summary – Lecture b • 3 branches of government: legislative, executive, judicial (the courts) • Courts are divided into: – Trial courts and appellate courts – Federal, state, city/municipal courts • The courts are neutral arenas where the parties to a dispute face off in an adversarial process • 2 main types of law: private and public 22
- 23. Regulating Health Care References – 1 – Lecture b References Administrative Office of the U.S. Courts. The federal court system in the United States. 2010. 3rd ed. http://www.uscourts.gov/sites/default/files/federalcourtssystemintheus.pdf. Accessed January 27, 2017. Administrative Office of the U.S. Courts. Comparing Federal & State Courts. http://www.uscourts.gov/about-federal-courts/court-role-and-structure/comparing- federal-state-courts. Accessed January 27, 2017. Centers for Medicare and Medicaid Services. Guidance to laws and regulations: overview. https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/GuidanceforLawsAndRegulations/index.html?redirect=/GuidanceforLaws AndRegulations. Accessed January 27, 2017. Cornell University Law School Legal Information Institute. Tort. https://www.law.cornell.edu/wex/tort. Accessed January 27, 2017. Social Security Online. Information about Social Security's hearings and appeals process. http://www.ssa.gov/appeals. Accessed January 27, 2017. 23
- 24. Regulating Health Care References – 2 – Lecture b References The Library of Congress. Law Library of Congress. http://www.loc.gov/law. Accessed January 27, 2017. Three Branches of Government. [Online image]. Retrieved on January 27, 2017 from https://kids.usa.gov/three-branches-of-government/index.shtml U.S. Citizenship and Immigration Services. Welcome to the United States: A guide for new immigrants. https://www.uscis.gov/sites/default/files/files/nativedocuments/M- 618.pdf. Accessed January 27, 2017. U.S.A.gov. Branches of Government. https://www.usa.gov/branches-of-government. Accessed January 27, 2017. Charts, Tables, and Images 6.1 Table: Example of court jurisdiction on various levels of government. 6.1 Figure: Two important sub classifications of civil law are contract law and tort law. OHSU (2010). 6.2 Figure: The two types of Public Law that have the most effect on individuals are criminal law and administrative law. OHSU (2010). 24
- 25. Introduction to Health Care and Public Health in the U.S. Regulating Health Care Lecture b This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. 25
Editor's Notes
- Welcome to Introduction to Health Care and Public Health in the U.S.: Regulating Health Care. This is Lecture b. The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S.
- The learning objectives for Regulating Health Care are to: Describe the role of accreditation, regulatory bodies, and professional associations in health care in the U.S. Describe the basic concepts of law in the U.S.: the legal system, sources of law, classification of laws, the court system, and the trial process.
- Describe legal aspects of medicine involving the Affordable Care Act, professional standards in health care, medical malpractice, tort reform, and Medicare and Medicaid fraud and abuse.
- Describe key components of the Health Insurance Portability and Accountability Act, or HIPAA, and current issues concerning privacy and patient safety in the U.S. And discuss the need for quality clinical documentation for use of the health record as a legal document, communication tool, and a key to prove compliance for health care organizations.
- This lecture describes the basic concepts of law in the U.S., including the branches of government, sources of law, classification of laws, the court system, and the trial process. There are three branches of government in the U.S.: legislative, executive, and judicial. At the federal level, the legislative branch consists of the House of Representatives and the Senate. The President of the United States is the head of the federal executive branch, which includes numerous departments and agencies, such as the Department of Labor and the Department of Health and Human Services. The federal court system includes local federal district courts, district courts of appeals, and the U.S. Supreme Court.
- The division of the government into three branches is known as the separation of powers. Each branch has separate and independent areas of responsibility, which is one way the U.S. Constitution ensures that no single branch becomes too powerful. Another way of balancing power is the concept of checks and balances. For example, the President can veto an act of Congress, but Congress can override the veto with a two-thirds majority vote. Another example is that a court can invalidate a statute or regulation that it finds to be outside the constitutional authority of one of the other government branches. The Constitution gives each branch many other ways to limit the power of the other branches.
- At the most basic level, the legislative branch makes laws by enacting statutes. The executive branch must approve the laws, and after a law passes, it enforces the law. The judicial branch interprets laws. However, there are many exceptions to this general scheme. Many of the laws passed by Congress do not specify every detail of how the law will be implemented. When this happens, the administrative agency responsible for enforcing the law writes regulations, rules, and policies. For example, Congress passed the Health Insurance Portability and Accountability Act of 1996, commonly known as HIPAA. However, Congress left many of the details up to the Department of Health and Human Services. The HIPAA Privacy Rule is one example of an administrative law that the Department of Health and Humans Services wrote. Sometimes, a dispute comes before a court that involves a situation for which there is no explicit law or regulation. In these cases, the court must interpret existing law to find situations that are similar to the case at hand. It then formulates a rule to apply to the facts. The rules that courts make in this way are known as case law or common law.
- There are two kinds of courts within most legal systems: trial courts and appellate courts. The trial court hears evidence in a dispute, decides which party is telling the truth, and decides the outcome by determining how the law applies to the facts of the specific case. After the trial court makes its decision, the losing party has the right to appeal that decision to a higher court, known as an appellate court. An appeals court consists of a panel of judges. For example, a panel of three judges is common in the federal courts of appeals. In most cases, appellate judges do not hear any witnesses or consider any new evidence. The role of a court of appeals is to decide whether the trial court properly applied the law to the facts of the case. A court of appeals gives great weight to the determinations the trial court made about what evidence was reliable and which witnesses were telling the truth. In the federal system, the party who loses in a court of appeals may appeal to the U.S. Supreme Court. However, the parties do not have an absolute right to further appeal. Each year, the Supreme Court accepts only a small portion of the cases filed by parties from the lower courts, and declines to hear the rest.
- The word “jurisdiction” refers to whether a court has the authority to hear and decide cases. There are many complicated situations involving federal jurisdiction, but most of these cases do not involve ordinary people. The cases that are heard in federal court are those concerning federal treaties with foreign governments, disputes about a federal law, cases about the U.S. Constitution, and disputes between citizens of different states. If a dispute involves matters of state law, it is heard in the courts of that state. States have both trial and appellate courts. If a dispute arises solely out of questions of local law, it is heard in the court for that city. These courts are usually called municipal or city courts. Most local court systems do not have their own system of appeals, so appeals go into the state system.
- The table on this slide is an example of court jurisdiction for various levels of government. For someone who lives in Cleveland, Ohio, there are three separate trial court systems. If a dispute falls under the jurisdiction of the federal courts, it would be heard in the U.S. District Court for the Northern District of Ohio. If a case involves a question of state law, it would be heard in the Cuyahoga County Court of Common Pleas. If the issue involves a violation of the city code, it would be heard in the Cleveland Municipal Court. The appellate court and the high court would depend on which trial court heard the case.
- The law has two major divisions: private and public. Private law is usually called civil law. It deals with relationships between people; relationships between people and organizations such as businesses; and relationships between organizations. Just as private relationships can be complicated, there are many kinds of civil law. For example, family law, also called domestic relations law, concerns the relationships between current or former spouses or between parents and their children. Property law involves disputes about the ownership of land. Contract law and torts law are discussed later in this lecture. Public law deals with the relationships between people and the government. For example, the law says you cannot engage in certain acts, such as stealing. Criminal law and administrative law are two major areas of public law.
- Violation of a civil law usually results in an exchange of money between the private parties to the lawsuit. Violation of a public law usually results in fines paid to the government, and it can also result in imprisonment. The same illegal action may result in both kinds of penalties.
- This slide shows an example of an action that has consequences for both criminal law and civil law. Suppose that someone drives while intoxicated, crashes into another car, and seriously injures the driver of that car. This single incident would likely result in two trials. In the criminal trial, the driver’s penalty could include imprisonment, paying a fine to the state, and losing his or her driver’s license. In the civil trial, the outcome would be paying money to the injured driver to compensate for the injuries. In addition, if someday the drunk driver wants to have his or her driver’s license reinstated, he or she may have to participate in an administrative hearing in the relevant state agency.
- Two important sub-classifications of civil law are contract law and tort law. Contract law involves disputes that arise out of agreements that people have made with one another. Sometimes, disputes arise from interactions about which there was no previous agreement. The basis for resolving these disputes is called tort law. This type of law concerns how reasonable people are expected to interact with each another. The rest of this diagram is explained in the next few slides.
- In order for a contract to exist, there has to be a definite offer by one party, unconditional acceptance by the other party before the offer terminates, and consideration. Consideration means that something of value will be exchanged; that is, one party will give something of value in exchange for the promises or assurances of the other party. An express contract is one in which the parties clearly and definitely agree to the basic elements of a contract. The contract does not have to be in writing. The parties can agree to the basic elements of a contract verbally. Sometimes, people act in ways that imply agreement. For example, suppose a person goes into a store, requests a certain item, and holds out the required amount of money. If the merchant takes the money and places it in the cash register, it is implied that the merchant has entered into a contract to give the person the requested merchandise. In a situation like this, the parties have what is legally called a “contract implied in fact.” All of these kinds of contracts are legally binding. The main difference is that the terms of an express, written contract are usually easiest to prove in a court of law. The terms of an implied contract are generally most difficult to prove.
- The two major subgroups of tort law are intentional torts and negligence. An intentional tort occurs when someone deliberately causes harm to another person. There are many kinds of intentional torts. For example, if a man becomes angry at someone, punches that person in the face, and breaks that person’s nose, the man commits an intentional tort called battery. If a woman falsely tells others in her workplace that a coworker has committed fraud, she commits an intentional tort known as defamation. Of course, people can be harmed when no harm was intended. Sometimes things just happen and no one is to blame. On the other hand, if someone acts carelessly or unreasonably and someone else is harmed as a result, a court may find the person responsible even though he or she did not mean to harm anyone. Legally, this is called negligence.
- There are many kinds of public law. The two types that have the most effect on individuals are criminal law and administrative law. The most serious kinds of crimes, such as murder and kidnapping, are called felonies. Less serious crimes, such as disturbing the peace and minor traffic violations, are known as misdemeanors. Both of these fall under criminal law. Administrative law consists of the many rules, regulations, and policies that are written by government agencies.
- Litigation is the process by which disputes are resolved in U.S. courts. The procedure for presenting a case is called the “adversary system.” Each side, or party, to a dispute must present its own evidence. If there is a discrepancy between the facts that each side presents, the judge or jury decides who is telling the truth. In a civil case, the person who claims, or alleges, that he or she has been harmed is called the plaintiff. The person who allegedly committed the wrongful act is called the defendant. Usually, each side has a lawyer. For example, a patient may file a lawsuit alleging that some harm has arisen as a result of wrongful medical treatment. He becomes the plaintiff and the attorney who represents him is known as the plaintiff’s attorney. In this situation, the lawyer who represents the medical professional is called the defense attorney. In a criminal case, the state brings charges against the defendant, who is alleged to have broken some law. The individual who has been harmed is not a party to this proceeding. The title of the attorney who represents the government varies. In the federal system, this is a U.S. attorney. In most state systems, it is a prosecuting attorney or state’s attorney.
- In a civil lawsuit, the parties are entitled to receive information from each other so that they can develop their case to present to the neutral fact-finder. This process is known as discovery. One kind of discovery is a deposition. The parties and other witnesses are sworn in and questioned by one or more of the attorneys involved in the case. A deposition can be far-reaching and include topics that will not ultimately be admissible at trial. Usually, each party is deposed by the opposing attorney. In most cases, many other people know something about the facts of the case. The court can require additional witnesses to appear for questioning. A subpoena is a document issued by a court that orders a person to appear for testimony at a deposition or trial. Another category of people who are often deposed are expert witnesses. These people are not actual witnesses to the events of the case. Instead, they are hired by one of the parties because they have knowledge or expertise that might help the fact-finder understand complicated matters.
- Many administrative agencies of the executive branch of government have their own system of review, outside the normal judicial system. These are known as administrative hearings. The agency may or may not have its own appeals process, but either way, its decisions can usually be appealed to a court of law.
- An example of an administrative hearing process can be seen in the Social Security Administration, or SSA. If someone is denied benefits, he or she can request a hearing from an SSA officer. If the hearing officer still denies benefits, the person can request a review by the Social Security Appeals Council. If the applicant is dissatisfied with the Appeals Council’s decision, he or she may file a case in the U.S. District Court.
- This concludes lecture b of Regulating Health Care. In summary, the legislative, executive, and judicial branches of government are all sources of law. When people have disputes they cannot resolve, they often resort to litigation, which is the process of having the dispute decided in court. Each party presents its own case in an adversarial process. The final outcome is determined by the trial court, which acts as a neutral fact-finder. Appellate courts decide whether the trial court properly applied the law to the facts of the case. Laws are divided into private and public types, each with further subcategories.
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