1. Medical Law and Ethics
Chapter 4
Today’s Healthcare Environment

2. Today’s Health Care Environment
Major changes since 1965 with Medicare and Medicaid
Increased life expectancy = more older adults
Technological discoveries
Preventative care and patient education stressed (but not funded)
Government legislation

3. Today’s Health Care Environment
Fixed-payment plans—medical care for a fixed monthly fee
Third-party payers

4. Managed Care Organization (MCO)
Gatekeeper
Health Maintenance Organization (HMO
offers a wide range of services to members for a predetermined fee by a limited group of providers
Preferred Provider Organization (PPO
patient must use a medical provider who is under contract with the insurer for an agreed-upon fee
Exclusive Provider Organization (EPO)
combines the concepts of HMO and PPO

5. Federal Assistance Programs
Medicare
Health care coverage for elderly or seriously disabled or with end stage renal disease or other debilitating ailments regardless of wealth or income
Rationing of health care

6. Medicaid Medicaid: A joint Federal–State program
Federal program implemented by individual states
Financial assistance to insure poor and indigent
Rationing takes place
Not all providers accept Medicaid coverage

7. Diagnostic Related Groups (DRGs)
Classifies Medicare patient by illness
467 illness categories
Hospitals receive preset sum for treatment of category regardless of “bed days” used
Discourages treatment of severely ill patients; patients often are discharged before ready

8. Ethical Considerations of Managed Care
Wealthy may have greater access to care and treatment than poor patients
Must provide minimum standard of care to everyone
Patients must be fully informed of consequences of obtaining health care elsewhere
Bait-and-switch
Profit may be more important than patient

9. Types of Medical Practice
Solo practice
Sole proprietorship
Partnership
Associate practice
Group practice
Professional corporation

10. Ethics of Fee Splitting
Fee splitting: one physician offers to pay another for referral (unethical and illegal)
Fee splitting vs. referrals
Franchise: business run by individual to whom franchisor grants exclusive right to market product or service in certain market area (ethical)
Franchisees: persons or companies that hold a franchise

11. Medical Specialty Boards
Seek to improve quality of medical care
Encourage physicians to further education and training
Evaluate candidates who apply and pass exam
Board-certify those who pass

12. Medical Specialty Boards
American College of Surgeons
Fellow of American College of Surgeons (FACS)
American College of Physicians
Fellow of American College of Physicians (FACP)

13. Allied Health Professionals
Licensed personnel include:
Registered nurse
Nurse practitioner
Licensed practical nurse
Pharmacist

14. Allied Health Professionals
Certified personnel include:
Lab technologist
Medical assistant
Medical transcriptionist
Lab technician
Pharmacy technician

15. Conscience Clause Enacted by several states
Employees may have a moral or religious objection to assisting with certain procedures (sterilization, abortion)
Employee cannot be discriminated against under the state’s statute