Chapter 19 National Health Insurance & Managed Care LEARNING OBJECTIVES • Discuss the purpose and various titles of the Patient Protection and Affordable Care Act of 2010 (PPACA). • Discuss the Supreme Court’s ruling on the constitutionality of the PPACA. • Describe the common models of managed care organizations. • Explain what can happen if a state fails to comply with the PPACA. PPACA Purpose • Increase # of Americans covered by health insurance • Decrease cost of insurance – Make more affordable through shared responsibility • Eliminate discriminatory acts – Exclusion due to pre-existing conditions, health status, & gender. PPACA Reforms Health Care – I • Eliminate lifetime & unreasonable annual limits on benefits • Prohibit recessions of health insurance policies • Assistance for uninsured due to pre-existing conditions • Require coverage: preventative services & immunizations • Extend dependent coverage up to age 26 PPACA Reforms Health Care - II • Develop uniform coverage documents so consumers can make equal insurance comparisons • Cap insurance company – nonmedical & administrative expenditures • Ensure consumers have access to an effective appeals process – provide a place to turn for help • navigating the appeals process & assessing coverage Supreme Court 6/28/12 • Agreed that the requirement for nearly all Americans to buy health insurance. • Court excised part of law requiring states to expand their Medicaid coverage in a joint federal–state effort, to families with incomes up to 133% of the Federal Poverty Level (FPL). PPACA Titles Title I. Quality Affordable Health Care for All Americans Title II. The Role of Public Programs Title III. Improving the Quality and Efficiency of Health Care Title IV. Prevention of Chronic Disease and Improving Public Health Title V. Health Care Workforce PPACA Titles – II Title VI. Transparency and Program Integrity Title VII. Improving Access to Innovative Medical Therapies Title VIII. CLASS Act Title IX. Revenue Provisions Title IX. Strengthening Quality, Affordable Health Care for All Americans Models of Managed Care Organizations (MCO’s) • Health Maintenance Organizations • Preferred Provider Organizations • Exclusive Provider Organizations • Point of Service Plans • Experience-Rated HMOs • Specialty HMO’s • Independent Practice Associations • Physician Group Practice Models of MCOs – II • Group Practice without Walls • Physician-Hospital Organizations • Medical Foundations • Managed Service Organizations • Vertically Integrated Delivery System • Horizontal Consolidations • Federally Qualified Federally Qualified MCOs • Strictly Voluntary • Must Meet Federal Standards • Less flexibility in – benefits packages – setting premium rates • Must Provide Basic Package of Health Services State HMO Laws – I • Specify what types on entities may operate an MCO. • Require the provisio.

1. Chapter 19
National Health Insurance
& Managed Care
LEARNING OBJECTIVES
• Discuss the purpose and various titles of the
Patient Protection and Affordable Care Act of
2010 (PPACA).
• Discuss the Supreme Court’s ruling on the
constitutionality of the PPACA.
• Describe the common models of managed care
organizations.
• Explain what can happen if a state fails to comply
with the PPACA.
PPACA Purpose
• Increase # of Americans covered by health
insurance
• Decrease cost of insurance

2. – Make more affordable through shared
responsibility
• Eliminate discriminatory acts
– Exclusion due to pre-existing conditions,
health status, & gender.
PPACA Reforms Health Care – I
• Eliminate lifetime & unreasonable annual limits on
benefits
• Prohibit recessions of health insurance policies
• Assistance for uninsured due to pre-existing
conditions
• Require coverage: preventative services &
immunizations
• Extend dependent coverage up to age 26
PPACA Reforms Health Care - II
• Develop uniform coverage documents so consumers
can make equal insurance comparisons
• Cap insurance company
– nonmedical & administrative expenditures

3. • Ensure consumers have access to an effective
appeals process
– provide a place to turn for help
• navigating the appeals process & assessing
coverage
Supreme Court 6/28/12
• Agreed that the requirement for nearly all
Americans to buy health insurance.
• Court excised part of law requiring states to
expand their Medicaid coverage in a joint
federal–state effort, to families with incomes
up to 133% of the Federal Poverty Level (FPL).
PPACA Titles
Title I. Quality Affordable Health Care for All
Americans
Title II. The Role of Public Programs
Title III. Improving the Quality and Efficiency of
Health Care
Title IV. Prevention of Chronic Disease and
Improving Public Health

4. Title V. Health Care Workforce
PPACA Titles – II
Title VI. Transparency and Program Integrity
Title VII. Improving Access to Innovative Medical
Therapies
Title VIII. CLASS Act
Title IX. Revenue Provisions
Title IX. Strengthening Quality, Affordable
Health Care for All Americans
Models of Managed Care
Organizations (MCO’s)
• Health Maintenance Organizations
• Preferred Provider Organizations
• Exclusive Provider Organizations
• Point of Service Plans
• Experience-Rated HMOs
• Specialty HMO’s
• Independent Practice Associations

5. • Physician Group Practice
Models of MCOs – II
• Group Practice without Walls
• Physician-Hospital Organizations
• Medical Foundations
• Managed Service Organizations
• Vertically Integrated Delivery System
• Horizontal Consolidations
• Federally Qualified
Federally Qualified MCOs
• Strictly Voluntary
• Must Meet Federal Standards
• Less flexibility in
– benefits packages
– setting premium rates
• Must Provide Basic Package of Health Services

6. State HMO Laws – I
• Specify what types on entities may operate an
MCO.
• Require the provision of basic care services
– ED
– Inpatient care
– Physician care
– Outpatient care
State Laws – II
• Generally require
– continued coverage if enrollee’s health
status changes
– ability of enrollee to convert to a direct
payment plan
– grievance procedure for enrollees
Case Management Firms

7. • Assist employers & insurers in managing in
managing catastrophic cases.
• Negotiate services & reimbursement with
provider’s who treat patient’s condition.
• Develop a treatment protocol & monitor
treatment.
Third Party Administrators (TPAs)
• Provides services for employers & associations
that have group insurance policies.
• Acts as a liaison between employer & insurer.
• Provides administrative activities
– Claims processing
– Certifying eligibility
– Preparation of reports
Utilization Review
• 3rd party evaluates medical necessity of care
• Process of Reviews of patient care conducted either
by
– Prospective Review

8. – Concurrent Review
– Retrospective Review
• Utilization Management Firms
– perform utilization management activities for
managed care entities, insurers, or employers
Liability for Nonemployee Participating
Physicians
• Patient must reasonably view the entity & not
the physician as the source of care.
• Patient reasonably believes the physician to
be an employee of the entity.
Employee Retirement
Income Security Act
• Designed to ensure employee welfare & benefit
plans conform to a uniform body of benefits law.
• Requires plans to provide participants with plan
information.
• Requires fiduciary responsibilities for those who
manage & control plan assets.
• Establish appeals & grievance process.

9. • Provide participants with rights to to sue for
benefits & breaches of fiduciary responsibility.
Health Care Quality
Improvement Act of 1986
• The purpose of the HCQIA is to provide those
persons providing information to professional review
bodies & those assisting in review activities limited
immunity from damages that may result as a result
of adverse decisions that affect a physician’s medical
staff privileges.
• Immunity does not extend to
– civil rights litigation suits.
– suits filed by U.S. Attorney General.
Managed Care & Legal Actions – I
• Open enrollment
• Emergency Care
• Market Power
• Product Market
• Geographic Market

10. • Ethics and the Denial of Services
Review Questions
1. Describe some of the more common models
of MCOs.
2. What are the advantages and disadvantages
of HMOs?
3. What is the purpose of utilization review?
4. Discuss the various reforms included in the
Patient Protection and Affordable Care Act.
Chapter 18
Medical Records
LEARNING OBJECTIVES
• Describe the contents of medical records.
• Explain the ownership and who can access a
patient’s medical record.
• Explain the importance of maintaining complete and

11. accurate records.
• Describe the advantages and disadvantages of
computerized records.
• Explain what is meant by the medical record
battleground.
• Describe why the medical record is important in legal
proceedings.
Medical Record
Means of Communication
• Documentation of a patient's
– Illness
– Symptoms
– Diagnosis
– Treatment
• Planning tool for patient care
• Document communication (e.g., progress
notes)
Medical Record
Means of Communication – II

12. • Protect legal interests of patient, org, &
practitioner
• Provide database for use in statistical
reporting
• Continuing education
• Research
• Provide info necessary for 3rd-party billing
Managing Information: IM Plan
addresses
• Patient care information
• Flow of information
• Accuracy of information
• Timeliness
• Confidentiality
• uniformity of data collection and definitions
• third-party payer needs
• disaster plans for the recovery of information
• annual review of the plan
• managing change
Medical Record – I
Admission record
• Demographic Data
– Age

13. – Address
– Reason for admission, social security number
– Marital status
– Religion
– Health insurance
• Advance Directives
Medical Record – II
History
• Chief complaint
• History of present illness
• Past medical history
• Allergies
• Current Medications
• Social history
• Family history
• Reproductive History

14. Medical Record – III
Physical
• General appearance
• Vital signs
• Skin
• Lymph nodes
• HEENT
• Neck
• Thorax, Lungs
• Female & male breasts
• Cardiovascular
• Abdomen
• Genitalia
• Rectum
• Musculoskeletal
• Neurologic
• Assessments
– Problem list

15. Medical Record – V
Physical
• Consent Forms
• Assessments
– Physician H & P
– Nursing,
– functional,
– nutritional
– social
• Pain management
records
• Treatment plan
• Physicians’ orders
• Diagnostic reports
– laboratory
– imaging
• Consultation reports
Medical Record – VI

16. • Operative reports
– Post Op Note
– Surgery
• Anesthesia
–Assessment
–Administration
• Medication
administration records
• Pain management
records
• Progress notes
– Nursing notes
– Notations of other
disciplines
• Patient education
• Discharge planning
– social service notes &
reports
– medication use
instructions
– Physician follow-up
Ownership & Release of
Medical Records

17. • Ownership organization or professional
rendering treatment
Ownership & Release of Records
• Ownership
• Request by Patients
– Right to access
• Requests: 3rd Parties
– insurance carriers (for processing claims)
– medical research
– educators
– government agencies
Ownership & Release of Records:
Privacy Exception
• Psychiatric records
• Criminal investigations
• Medicaid fraud
• Substance abuse records

18. Retention of Records Varies
Among States
• In Illinois, the ILL. Supreme Ct. held that a
private cause of action existed under X-ray
retention act. The plaintiff stated claim under
the act, which provides that hospitals must
retain X-rays & other such photographs or
films as part of their regularly maintained
records for a period of 5 years.
– See text case: Rodgers v. St. Mary's Hosp. of
Decatur
Electronic Records
Advantages – I
• Retrieve demographic information &
consultants' reports, as well as lab, radiology,
& other test results
• Improve productivity & quality
• Reduce costs
• Support clinical research
Electronic Records
Advantages – II

19. • Play an ever-increasing role in education
• Allow for interactive computer-assisted
diagnosis & treatment
• Allow for computer-generated prescriptions
• Generate reminders for follow-up testing.
Electronic Records
Advantages – III
• Assist in the decision-making process.
• Aid in standardizing treatment protocols.
• Assist in the identification of drug-drug &
food-drug interactions.
• Used in telecommunications around the
world, transporting picture graphics (e.g.,
computed tomography scans) between
nations.
Computerized Medical Records
Disadvantages
• Increased risk of lost confidentiality
– unauthorized disclosure of information
• High-tech crime
– increases in cyber crime

20. • products & services to combat
cybercrime
– costs to protect networks & critical
infrastructures from cyber-based threats.
Medical Record Battleground
• Tampering
• Angry recordings
– registering complaints by other caregivers &
the org
• Rewriting & replacing notes
Text Cases
• Alteration of Records
• Objection to Record Notations
• Tampering with Record Entries
• Rewriting and Replacing Notes
• Fatal Handwriting Mix-Up

21. Confidential & Privileged Communication
• Breach of Physician-Patient Confidentiality
• Ordinary Business Documents
• Attorney-Client Privilege
HIPAA
Privacy Provision – I
• Patients able to access their record & request
correction of errors.
• Patients must be informed of how personal info
will be used.
• Patient consent for release of info for marketing
purposes required.
• Patients can ask insurers & providers to take
reasonable steps to ensure their communications
are confidential.
• Patients can file privacy-related complaints.
HIPAA
Privacy Provision – II
• Health insurers or providers document their privacy
procedures.

22. • Health insurers or providers designate a privacy
officer & train their employees.
• Providers may use patient info without patient
consent for
– purposes of providing treatment
– obtaining payment for services
– performing non-treatment operational tasks of
the provider's business.
Charting & Helpful Advice - I
• Complete & pertinent entries
• Timely entries
• Legible entries
• Clear & meaningful entries
• Complete
Charting & Helpful Advice - II
• Avoid
– defensive & derogatory notes
– erasures & correction fluids
– criticism

23. – complaints
– tampering with the chart
Charting & Helpful Advice - III
• Secure records pending legal action
• Obtain legal advice
• Entries made by others must not be ignored.
– patient care is a collaborative
interdisciplinary team effort.
– Entries made by health care professionals
provide valuable information in treating the
patient.
REVIEW QUESTIONS – I
1. What are basic purposes of medical record?
2. Discuss advantages & disadvantages of
computer-generated medical records.
3. Medical record is sole property of the
hospital & should never be released. Discuss
your opinion on this statement.
4. How long should patient records be

24. maintained?
Chapter 17
Legal Reporting Requirements
LEARNING OBJECTIVES
• Describe various forms of child abuse, how to
recognize it, and reporting requirements.
• Describe various forms of elder abuse, how to
recognize it, and reporting requirements.
• Discuss the importance of reporting births and
deaths.
• Explain why it is important to report communicable
diseases, adverse drug reactions, and infectious
diseases.
LEARNING OBJECTIVES - II
• Explain how and why physician incompetency is
reported.
• Understand the importance of incident reporting,

25. sentinel events and the purpose of “root cause
analyses.”
• Describe the elements of an effective corporate
compliance program.
Child Abuse
A child is one who has suffered intentional
serious mental, emotional, sexual, and/or
physical injury inflicted by a family or other
person responsible for the child's care. Some
states extend the definition to include a child
suffering from starvation.
Child Abuse – II
• Reporting Child Abuse
• Detecting Abuse
– Physical Signs
• bruises
• burns
• broken bones
Child Abuse – III

26. • Behavioral Indicators
– diminished psychological & intellectual
functioning
– failure to thrive
– no control of aggression
– self-destructive impulses
– decreased ability to think & reason
– acting out & misbehavior
– habitual truancy
Good Faith Reporting
• Reasonable cause to believe injuries not
accidental.
• Professional not acting in bad faith to injure
another in filing an abuse report.
• Psychologist Immune from Liability
Failure to Report Child Abuse
• Psychologist

27. – failure to report past abuse
• Nurse
– failure to document and report
• Physician
– Text Case: Entitled to Immunity
Elder Abuse
Signs of Abuse – I
• Unexplained or unexpected death
• Development of "pressure sores“
• Heavy medication & sedation used in place of
adequate nursing staff
• Occurrence of broken bones
• Sudden emotional outbursts, agitation, or
withdrawal
• Bruises, welts, discoloration, burns, etc.
• Absence of hair and/or hemorrhaging below scalp
• Dehydration/malnourishment without illness
• Hesitation to talk openly
Elder Abuse
Signs of Abuse – II
• Implausible stories
• Unusual or inappropriate activity in bank accounts

28. • Signatures on checks & other written materials that
do not resemble patient's signature
• Recent legal changes or creation of a will, when
person is incapable of making such decisions
• Missing personal belongings, including jewelry
• An untreated medical condition
• Patient unable to speak for himself or herself, or see
others, without presence of caregiver/suspected
abuser
Documenting Abuse – I
• Caregivers
– record symptoms and condition
• Witnesses
– record information provided by witnesses
• Photographs
– photograph injuries
– Preserve the evidence
– use of rape kits
Documenting Abuse – II

29. • Suspected abuse should be defined clearly &
objectively.
• Witnesses: Reporters of abuse must describe
statements made by others as accurately as
possible
– what actions were taken, by whom, when, where,
etc.
– Info should be included about how witnesses may
be contacted.
Documenting Abuse – III
• Photographs: It may be necessary to
photograph wounds or injuries.
– hospital emergency room or the police
department can be asked to photograph in
emergency situations.
Births & Deaths
• Reportable by statute
• Necessary to maintain accurate census records
• Suspicious Deaths

30. Suspicious Deaths
• Referral to medical examiner
• Violent deaths
• Criminal activity
• Medical Examiner
• Determines cause of death
• Provides information for criminal
investigation
Communicable Diseases
• Reported to protect citizens from infectious
diseases
• Reporting required by statutes
Adverse Drug Reactions
• harmful reactions that occur as a result of
administration of a drug or combination of
drugs
• Report adverse drug reactions to the FDA
– FDA https://www.accessdata.fda.gov

31. – FDA, 10903 New Hampshire Avenue Silver Spring,
MD 20993
– 800-332-1088 or 888-463-6332
https://www.accessdata.fda.gov
HOSPITAL-ACQUIRED INFECTIONS
• 2006, Archives of Internal Medicine
– up to 98,000 deaths annually
• Approximately 30 states have requirements to
report infections
• 2010 PPAHCA requires acute care hospitals to
report hospital-acquired infections or be
subjected to reduction in Medicare
reimbursement.
Physician Competency
• Health Care Quality Improvement Act of 1986
–Authorizes National Practitioner Data Bank
to collect & release information on
competence & conduct of health care
practitioners.

32. National Practitioner
Data Bank
• Reporting requirements
• Required queries
– Medical Staff Privileges
• Who should report?
• Data bank queries
• Confidentiality of data bank information
Incident Reporting
• Hospital Incident Reports
– do not place in patient’s record
– direct reports to legal counsel to help prevent
discovery
• State Reportable Incidents
– defined by state law/regulations
• Infections
• patient injuries
• Failure to Report

33. JCAHO Reportable
Sentinel Events
• Events that result in an unanticipated death or major
permanent loss of function
• Sentinel Events include
– Suicide
– Unanticipated death of a full term infant
– Infant abduction
– Rape
– Hemolytic transfusion reaction
– Wrong site surgery
JCAHO Reportable
Reporting Sentinel Events
• http://jointcommission.org/
• The Joint Commission, One Renaissance
Blvd. Oakbrook Terrace, IL 60181
• Washington DC Office, 601 13th Street,
NW Suite 560 South, Washington, DC 20005
• Phone: 630-792-5800

34. • Fax number: 630-792-5005
http://jointcommission.org/
Root Cause Analysis – I
A process for identifying the basic or causal
factors that underlie the variation in
performance including the occurrence or
possible occurrence of a sentinel event.
Root Cause Analysis – II
• Thorough
• Credible
• Investigation involves general & special causes
• Researching literature
• Searching for best practices
• . . . implementing & monitoring change
REVIEW QUESTIONS – I
1. What is child abuse?
2. Who should report child abuse?

35. 3. Describe the signs of elder abuse.
4. Why was the HCQIA of 1986 enacted?
5. Describe the purpose of the National Practitioner
Data Bank.
6. What is a sentinel event?
7. Discuss the process of conducting a root-cause
analysis.
Chapter 16
Acquired Immune Deficiency
Syndrome
LEARNING OBJECTIVES
• Describe what AIDS is and how it is spread.
• Discuss confidentiality concerns for AIDS
patients.
• Describe how AIDS patients are discriminated
against.
• Explain the importance of AIDS related

36. education.
AIDS
• Deadliest epidemic in human history.
• Collection of specific, life-threatening,
opportunistic infections & manifestations that
are result of underlying immune deficiency.
• Caused by HIV, highly contagious blood-borne
virus is most severe form of HIV infection.
• Destroys body's capacity to ward off bacteria
& viruses that ordinarily would be fought off
by immune system.
Spread of AIDS
• Body Fluids
– Breast Milk
• Blood transfusions
• Sexual Transmission
– Vaginal secretions
– Semen
– Partner’s Right to Know
• Healthcare Workers Transmission

37. Confidentiality
• Patients have a right to privacy.
• An individual’s HIV status must be kept
confidential.
• Patient information can be shared with other
health professionals
– for purposes of patient care on a need to
know basis.
Unauthorized Disclosure
• Estate of Behringer v. Med, Ctr, at Princeton
– Hospital & lab director breached duty by
allowing a surgeon’s test results to be
placed in medical record.
– Hospital should have taken reasonable
precautions to prevent disclosure.
Proper Disclosure
• Tarrant Cty. Hospital District v. Hughes
– wrongful death action alleging patient
contracted AIDS from blood transfusion
administered in hospital.

38. – societal interest in maintaining an effective
blood donor program did not override
plaintiff's right to receive such information.
– court order prohibited disclosure of donors'
names to 3rd parties.
Duty & Right to Confidentiality
• Right to know when caring for patients with
highly contagious diseases.
• Times when duty to disclose out ways rights to
confidentiality.
• A prisoner has limited privacy rights.
• Prison authorities have strong interest in
preventing the spread of HIV.
Confidentiality
Sexual Partners
• Person has right to know when his or her
partner has tested positive for HIV.
• Physicians expected:
– counsel HIV-positive patient to notify
sexual partners or
– to seek help in doing so from public health

39. officials.
• Some states have developed informational
brochures & consent, release, & partner
notification forms.
Mandatory Testing
• U.S. District Court found routine testing of
firefighters & paramedics for AIDS virus does
not violate individual's 4th Amendment or
constitutional privacy rights.
– caregivers high-risk group for contracting &
transmitting HIV to public.
– city has compelling interest & legal duty to
protect public from contracting virus.
• Anonymous Fireman v. Willoughby
Discrimination
• Access to Health Care
– Right to Treatment
• Education
• Employment
• Insurance Benefits

40. Negligence
• Administration of Wrong Blood
• Failure to Make Timely Diagnosis
• Patient Wrongly Notified She Had AIDS
• Insurance Company Fails to Disclose HIV
Status
Reporting Requirements
• AIDS is reportable communicable disease in
every state.
• Physicians & hospitals must report with
patient's name—to government public health
authorities.
AIDS Emergency Act
• Provide emergency assistance to localities that
are disproportionately affected by HIV
epidemic & make financial assistance available
to States & other public or private nonprofit
entities to provide for development,
organization, coordination & operation of
more effective & cost efficient systems for

41. delivery of essential services to individuals &
families with HIV.
OSHA & AIDS
• OSHA requires health care organizations to
implement strict procedures to protect
employees against AIDS virus.
• OSHA requires strict adherence to guidelines
developed by CDC.
• Complaints investigated by OSHA can result in
issuance of fines for failure to comply with
regulatory requirements.
Protecting Caregivers – I
• Personal Protective Devices
– Gloves
– Masks
– Gowns
– Goggles
• Engineering Controls
– sharps disposal containers
– ventilation systems
Protecting Caregivers – II

42. • Work Practices
– hand washing
– use of needles
– safe collection, transporting & disposal of body
fluids
• Practice Universal Precautions
– infection control guidelines
– prevent contact with patient blood & body fluids
– Assume all patients infected for blood-borne
diseases such as AIDS & hepatitis B
CHAPTER REVIEW – I
1. Describe how AIDS patients are discriminated
against.
2. Discuss the privacy and confidentiality issues of HIV-
positive patients.
3. Should a hospital be permitted to publish identity of
AIDS patients in order to protect other patients and
staff?
4. Is AIDS a reportable disease? Why?
5. What steps can be taken to help prevent spread of
AIDS