Fluent Essays

HA4050D - Healthcare Law Discussion 10.2: Tort Reform A very contentious issue for many years has been tort reform. Before this discussion, investigate both sides of the issue. First, go to the website maintained by the American Tort Reform Association and consider their arguments for tort reform. Then, visit the website of the American Association for Justice (formerly the American Trial Lawyers’ Association) and see what arguments they have stated opposing tort reform. (You may have to search the website for various articles on the subject.)  Be sure to review Chapter 5 of the textbook. You are also encouraged to find your own additional sources on this issue and to critically evaluate the arguments. Then, we will debate the following related issues: 1.Does tort reform reduce malpractice insurance rates and bring down health care costs for consumers? Is it worthwhile? 2.Is capping damage awards fair and effective? Would the good outweigh any negative effects, such as reducing incentives to have careful risk management or disadvantaging worthy plaintiffs who have suffered large non-economic losses? Legal Aspects of Healthcare Administration 13th Pozgar 2019 Jones & Bartlett-Vitalsource [email protected]#magicMAN61Chapter 5 Tort Reform and Risk Reduction Learning Objectives Describe the meaning of defensive medicine. Describe various tort reform programs designed to lower the cost of malpractice insurance. Describe the various ways to manage and reduce the number of malpractice claims. Tort Reform The tort system is inadequate to prevent medical malpractice. Damage awards as deterrents have failed. Exorbitant jury awards and malpractice insurance premiums cost billions of dollars annually. State legislatures call for reform. Physician Practice Defensive Medicine Undertreatment Avoiding high-risk tests and procedures Overtreatment Excessive use of diagnostic tests Tort Reform Schemes Mediation and Arbitration Statute of Limitations Structured Awards Medical Malpractice Screening Panels Collateral Source Rule Contingency Fee Limitations Tort Reform Schemes (cont’d) Countersuits: Frivolous Claims Joint and Several Liability Malpractice caps No-Fault System Tort Reform Schemes (cont’d) Regulations of insurance practices Statutes of limitations Reducing the Risks of Malpractice Risk management Performance Improvement Continuous quality improvement (CQI) Peer review Collaboration Tort Reform A concerted effort must be made to include all health professionals in the process of tort reform. The present system of punishment for all because of the inadequacies of the few has proven to be costly and far from effective. The key to improving quality and controlling costs is cooperation, not alienation. Policymakers have failed in this arena and must return to a commonsense approach to policy development by including those who are most directly involved. Review Questions Describe various tort reform programs designed to lower the cost of malpractice insurance. Should there be limits placed on malpractice awards? Support your opinion. Discuss what a structured award is and how it might reduce the costs associated with large-sum malpractice awards. Review Questions (cont’d) Discuss which of the schemes for tort reform discussed previously you consider most helpful in addressing the malpractice insurance crisis. Describe how risk management, performance improvement, and peer review can be helpful in improving patient care and reducing the number of malpractice claims.Chapter 21 Professional Liability Insurance Learning Objectives Describe the purpose of an insurance policy, including risk categories, and the importance of professionals to carry professional liability insurance. Explain the elements and conditions of an insurance policy. Describe the investigation and settlement of claims. Insurance A contract that creates legal obligations on the part of both the insured and insurer. The insurer agrees to assume certain risks of the insured for consideration or payment of a premium. Under terms of an insurance policy, the insurer promises to pay a specific amount of money if a specified event takes place. Insurance Policies Necessary Elements Identification of Risks Covered Specific Amount Payable Specified Occurrence Insurance Policies Risk Categories Property Loss or Damage Personal Injury or Loss of Life Legal Liability Risk Telemedicine Can Involve Misdiagnosis Healthcare providers should confirm their policies adequately telemedicine services. Obtain written verification of such coverage from the insurer. Insurance Policy Provisions Policy Period Defense & Settlement Settlements & Awards Coverage: Amount Payable Punitive Damages Conditions of Insurance Policies 1. Notice of Occurrence 2. Notice of Claim 3. Assistance of the Insured 4. Other Insurance 5. Umbrella Insurance Conditions of Insurance Policies 5. Assignment 6. Subrogation 7. Changes 8. Cancellation Liability of the Professional News: $44M Paid in Nurse Practitioner Liability Claims Over Past 5 Years: Report All Professionals Need Insurance. Purpose of liability insurance is to spread risk of economic loss among members of a group who share common risks. As risks increase, premiums increase to cover associated risks. Premiums are placed in a shared risk fund from which funds are drawn to cover costs of lawsuits. Liability of the Professional cont’d Insurance coverage is especially important for Volunteer at a clinic or health fair not sponsored by his or her employer. Independent Contractor providing a service in a patient’s home for an independent agency or registry. Organization covered by an insurance policy that has an exclusionary provision by which the insurance company disclaims liability for a professional’s malpractice actions brought against the insured organization. Liability of the Professional, cont’d Advanced Practice Nurse Practitioner Registered Nurse Private Duty Nurse Students Intentional Tort: Coverage Denied No duty to cover intentional torts Therapist’s sexual affair with patient Sexual assault Medical Liability Insurance Covers Individuals Healthcare institutions Outpatient facilities and clinics Medical Liability Insurance (cont’d) Insuring clause provides payment on behalf of insured if an injury arises from: Malpractice, error, or mistake Acts or omissions on the part of the insured during policy period Medical Liability Insurance (coChapter 22 Managed Care & National Health Insurance Learning Objectives Describe the common models of managed care organizations. Describe the purpose and process of utilization review. Describe the purpose & various titles of the Patient Protection and Affordable Care Act of 2010 (PPACA). Describe the various court rulings involving PPACA. Managed Care Process of structuring or restructuring the healthcare system in terms of financing, purchasing, delivering, measuring, & documenting broad range of healthcare services & products. Constraints of Managed Care Organizations Limitations on the choice of providers by the consumer. Requirements for prior authorization in order to obtain services. Managed Care Models Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs) Exclusive Provider Organizations Point of Service Plans Experience-Rated HMOs Managed Care Models (cont’d) Specialty HMOs Independent Practice Associations Group Practice Group Practice Without Walls Managed Care Models (cont’d) Physician Hospital Organizations Medical Foundations Management Services Organizations Vertically Integrated Delivery System Horizontal Consolidations Managed Care (cont’d) Federally Qualified HMOs State Laws Case Management Firms Third-Party Administrators Managed Care Utilization Review Utilization Review Prospective Concurrent Retrospective Utilization Management Firms Negligent utilization review decisions Managed Care (cont’d) Liability for Nonparticipating Hospitals Employee Retirement Insurance Security Act Reducing Exposure to Liability Health Care Quality Improvement Act (1986) Open enrollment Emergency care Ethics in Patient Referral Act (1989) Managed Care Legal Actions Financial Incentives Disclosed Insurer & Tort-feasor Benefit Denials False & Misleading Statements Managed Care Price Fixing Occurs when two or more competitors come together to decide on a price that will be charged for services or goods Considered a per se violation of the antitrust laws Managed Care Market Power Product Market Geographic Market Provider Exclusion Antitrust & Market Share National Health Insurance PPACA Congress, after months of contentious debate, by a slim margin enacted the Patient Protection and Affordable Care Act (PPACA). PPAC Increases the number of Americans covered by health insurance & decreases the cost of insurance Eliminates discriminatory acts, such as exclusions due to preexisting conditions, health status, & gender PPACA Reforms Immediately in Place Eliminates lifetime & unreasonable annual limits on benefits Prohibits recessions of health insurance policies Provides assistance for those who are uninsured because of preexisting conditions Requires coverage of preventative services and immunizations PPACA Reforms Immediately in Place (cont’d) Extends dependent coverage up to age 2