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MHS-2320 Study Guide - Spring 2019, Comprehensive Final Exam Notes - Medicine, Medicaid, Informed Consent


Department
Medicine, Health, and Society
Course Code
MHS-2320
Professor
Juleigh Petty
Study Guide
Final

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MHS-2320

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Power of government in regulation of business of medicine
- Blind man and the elephant
- Relative regulation of government varies upon where you look - hard to make overarching claim
- Regulation of the business of medicine - who regulates?
- American Medical Association vs Department of Health and Human Services
- In practice, third player of insurance companies
- Busy fighting off the government, and ended up controlled by insurance companies
- 3 players - government may limit power of medical profession and limit power of insurance
companies
Main Takeaways
- Medicine is a profession and a business
- The size of the government’s role in the regulation of the business of medicine varies depending on
where you look
- Physicians fought off government regulation of the finance and content of healthcare and now face
patwork of regulation by the government and “regulation” by private insurers
Key Laws
- Cobra 1986
- Hipaa 1996
- ERisa 1974
- Insurance mandates
Stone - Role of Govt
- Government has more power towards the top of this list than at the bottom
- Funding of care
- About half for health care in this country
- Organization of the finance of care
- Medicare, medicaid, VA, Tax laws that encourage employers to give it
- Ensuring that people are insured
- Encouraging employers
- Regulating the content of health insurance
- Done at the state level, changed with Affordable Care Act
- Regulating the content of health services
- Federal govt plays a relatively small role in telling physicians what they have to do
- Play a role primarily because its the largest health insurer in the country
Key Laws Government Insurance
- Cobra 1986
- Requires that employer-provided insurance plans extend health benefits 18-36 months after
certain events (termination, death, divorce) that would end insurance benefits
- Costs more - insured person pays the portion of the insurance premium previously covered
by employer - still less than buying it on open market
- Ensured that not everything fell apart when you lost your job
- HIPAA 1996
- Employer-provided insurance cannot
- Refuse to insure based on pre-existing conditions
- Charge employees different rates based on medical conditions
- Employer-provided insurance can
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- Exclude coverage of particular medical conditions
- Charge different companies and groups of employees different rates
- Increasing medicare/medicaid limits on business of medicine
- Finance of care
- Wage and price controls (1971-1974)
- Professional standards review organizations (1972)
- Medicare economic index (1975)
- Diagnostic related groups (1983)
- Limits on full fee recovery (1984)
- Budget Acts of 1986, 1987, 1989, 1997 - establishing price maximums, reducing
charges, establishing sustainable growth rate formula
- Content of care
- Preferred drug list
- Accreditation of organization
- Require reimbursement for particular conditions and procedures
- Refuse reimbursement for conditions caused by medical errors
- Increasing power of private insurance on business of medicine
- Same limits as medicare/medicaid plus
- More discretion to exclude coverage of particular medical conditions and services
- More stringent utilization review processes
- Compensation arrangements with physicians to discourage expensive treatments
(bonuses, withholds)
- Rules that change more often - change constantly, hard to track what will be
covered
- Little public accountability
- ERISA 1974
- Applies to employer self-funded insurance plans
- Preempts state insurance mandates
- Insurance plans’ liability limited to cost of denied benefit and attorney fees (remaining
liability for harm is with medical providers )
- Key point: increases power of insurance companies to determine standard of care
- Increasingly, companies are using self-funded plans
- In favor of insurance companies
- Government as the umpire of market relations
Insurance Mandates
- What must insurance coverage?
- Federal
- Minimum hospital stays for newborns and mothers - 24hr min
- Mammograms
- Reconstructive surgery after mastectomy
- Mental health parity
- State
- Numerous - dozens per state
Regulation and Physician Autonomy
- Increased government regulation of insurance industry
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