Assignment LP2.2: HMO and Malpractice The assignment will assess the competency

Question

Assignment LP2.2: HMO and Malpractice The assignment will assess the competency 2. Analyze current and proposed health care financing and delivery systems. Directions: Write a two to three page paper on the legal basis for the immunization of HMOs from being sued for malpractice. Consider such things as: • the relationship of the HMO with its member physicians, • the HMO organizational structure (IPA versus PPO versus staff model and so forth), • the principle of direct liability, enterprise liability, indemnification, ERISA preemption, ostensible agency, and anything else that you believe would fall under an HMO's vulnerability to being sued. An historical perspective would enhance the strength of your paper. Remember to cite sources. Submit this assignment to your instructor via the dropbox “LP2.2 Assignment: HMO and Malpractice.” This assignment is worth 50 points.

Explanation / Answer

The term “health maintenance organization” (HMO) has been used in a variety of way and has limited use as a descriptive term. The term can refer to almost any arrangement by which a corporate entity provides healthcare services and often is used interchangeably with any managed care enterprise.

HMO negligence

When an HMO member suffers an injury because the HMO delayed or refused medical treatment, the HMO can be sued for HMO negligence. In its broadest sense, HMO negligence is a type of medical malpractice that can be defined as the carelessness of an HMO, acting through its physicians, in making treatment decisions for a member that results in harm to that member. Examples include:

Types of HMO law cases

There are several types of cases that can be brought against HMO’s including:

THE APPLICATION OF MALPRACTICE LAW TO HMO CARE

A. HMOs' Structure, Incentives, and Contribution to Health Care Delivery

B. HMOs' Approach to Medical Risk Evaluation

C. Malpractice Standards and HMOs

PROBLEMS wITH THE CURRENT MALPRACTICE APPROACH TO HMOs

A. Inadequate Valuation of the Costs and Results of Reducing Risks

B. Overemphasis on Methods of Care

C. Potentially Excessive Penalties for Noncustomary Care

D. Unduly Narrow Focus on the Risks of Individual Procedures

It should not be expected that unleashing the majority medical custom rule will solve all malpractice problems or greatly ease the intractable difficulties of deciding how much medical care is enough and how safe it should be. It is, however, a modest step in the right direction. The capacity of modem medicine to intervene on behalf of human health is immense and growing rapidly, as is the capacity to gather information in deciding whether and how to intervene. But the ability to finance medical procedures is limited, and choices must be made.

Medical custom and the law of medical malpractice are important influences on these choices-though perhaps less so than are the organization and financing of health care itself. In any case, finding workable approaches to these problems requires additional attention from the medical and legal communities.

It seems likely that only decision-makers motivated to face up to the harsh fact of limited medical resources can be expected to incorporate cost considerations effectively into their risk-reduction calculations.

Current and proposed health care delivery system and financing

America’s health care financing and delivery system is in transition from the traditional open-ended uncoordinated practice, with a culture of physician autonomy, paid on the basis of fee-for-service (“FFS”), to integrated delivery systems (IDS) characterized by multi-specialty medical groups bearing risk for the cost of care, with a culture of teamwork and coordination of care.

This transition is being driven by several factors:

1. The burden of the cost of care in the USA has become intolerable. It is straining public finances at every level of government, crowding out spending on other needs such as education and infrastructure, deficit and debt reduction, national security, and it is taking an increasing share of what otherwise would be wages. This is a heavy burden on public finances.

2. The growing recognition of widespread quality failures, Systems are needed to improve quality.

3. The growing recognition that other countries achieve better population health outcomes at a much lower cost as a share of national incomes

4. Success of integrated delivery systems (IDS) in achieving growing market shares and high quality measures

The predominant form of health care available in the USA is fragmented care, provided by atomistic, unconnected physician practices and a culture of physician autonomy, hospitals, and other providers who are compensated through paymeny.

“Fragmentation” in healthcare delivery means the systemic misalignment of incentives or lack of coordination [among providers], that spawns inefficient allocation of resources or harm to patients.”

In traditional medicine, each physician practice works independently and is paid on the basis of the number of patient visits and procedures performed. Individual physicians treat patients according to their individual opinions as to what care is called for. However, because they are paid per service, providers necessarily face incentives to resolve all doubts by increasing the volume of services provided to their patients.

Basic health care services by HMO

(a) An HMO must provide or arrange for the provision of basic health services to its enrollees as needed and without limitations as to time and cost other than those prescribed in the PHS Act and these regulations, as follows:

(1) Physician services (including consultant and referral services by a physician), which must be provided by a licensed physician, or if a service of a physician may also be provided under applicable State law by other health professionals, an HMO may provide the service through these other health professionals;

(2)

(i) Outpatient services, which must include diagnostic services, treatment services and x-ray services, for patients who are ambulatory and may be provided in a non-hospital based health care facility or at ahospital;

(ii) Inpatient hospital services, which must include but not be limited to, room and board, general nursing care, meals and special diets when medically necessary, use of operating room and related facilities, use of intensive care unit and services, x-ray services, laboratory, and other diagnostic tests, drugs, medications, biologicals, anesthesia and oxygen services, special duty nursing when medically necessary, radiation therapy, inhalation therapy, and administration of whole blood and blood plasma;

(iii) Outpatient services and inpatient hospital services must include short-term rehabilitation servicesand physical therapy, the provision of which the HMO determines can be expected to result in the significant improvement of a member's condition within a period of two months;

(3) Instructions to its enrollees on procedures to be followed to secure medically necessary emergencyhealth services both in the service area and out of the service area;

(4) Twenty outpatient visits per enrollee per year, as may be necessary and appropriate for short-term evaluative or crisis intervention mental health services, or both;

(5) Diagnosis, medical treatment and referral services (including referral services to appropriate ancillary services) for the abuse of or addiction to alcohol and drugs:

(i) Diagnosis and medical treatment for the abuse of or addiction to alcohol and drugs must include detoxification for alcoholism or drug abuse on either an outpatient or inpatient basis, whichever is medically determined to be appropriate, in addition to the other required basic health services for the treatment of other medical conditions;

(ii) Referral services may be either for medical or for nonmedical ancillary services. Medical servicesmust be a part of basic health services; nonmedical ancillary services (such as vocational rehabilitation and employment counseling) and prolonged rehabilitation services in a specialized inpatient or residential facility need not be a part of basic health services;

(6) Diagnostic laboratory and diagnostic and therapeutic radiologic services in support of basic health services;

(7) Home health services provided at an enrollee's home by health care personnel, as prescribed or directed by the responsible physician or other authority designated by the HMO; and

(8) Preventive health services, which must be made available to members and must include at least the following:

(i) A broad range of voluntary family planning services;

(ii) Services for infertility;

(iii) Well-child care from birth;

(iv) Periodic health evaluations for adults;

(v) Eye and ear examinations for children through age 17, to determine the need for vision and hearing correction; and

(vi) Pediatric and adult immunizations, in accord with accepted medical practice.

(b) In addition, an HMO may include a health service described in § 417.102 as a supplemental healthservice in the basic health services that it provides or arranges for its enrollees for a basic health servicespayment.

(c) To the extent that a natural disaster, war, riot, civil insurrection, epidemic or any other emergency or similar event not within the control of an HMO results in the facilities, personnel, or financial resources of anHMO being unavailable to provide or arrange for the provision of a basic or supplemental health service in accordance with the requirements , taking into account the impact of the event.

The following are not required to be provided as basic health services:

(1) Corrective appliances and artificial aids;

(2) Mental health services, except as required

(3) Cosmetic surgery, unless medically necessary;

(4) Prescribed drugs and medicines incidental to outpatient care;

(5) Ambulance services, unless medically necessary;

(6) Care for military service connected disabilities for which the enrollee is legally entitled to services and for which facilities are reasonably available to this enrollee;

(7) Care for conditions that State or local law requires be treated in a public facility;

(8) Dental services;

(9) Vision and hearing care except as required

(10) Custodial or domiciliary care;

(11) Experimental medical, surgical, or other experimental health care procedures, unless approved as a basic health service by the policymaking body of the HMO;

(12) Personal or comfort items and private rooms, unless medically necessary during inpatient hospitalization;

(13) Whole blood and blood plasma;

(14) Long-term physical therapy and rehabilitation;

(15) Durable medical equipment for home use (such as wheel chairs, surgical beds, respirators, dialysis machines); and

(16) Health services that are unusual and infrequently provided and not necessary for the protection of individual health, as approved by CMS upon application by the HMO.

(17) An HMO may not offer to provide or arrange for the provision of basic health services on a prepayment basis that do not include all the basic health services.

Related Questions

Navigate

• Browse (All)
• Browse A
• Subjects

Integrity-first tutoring: explanations and feedback only — we do not complete graded work. Learn more.