Healthcare And Government

Healthcare And Government

6-1 Small Group Discussion Responses: Healthcare and Government

Initial Post:

Provide an overview of the regulation you were assigned by your instructor. In your post, address the following:

Instructor Assigned:

Emergency Medical Treatment and Labor Act (EMTALA)

Provide a brief description of regulation.

Identify the level of government and the agency responsible for overseeing the regulation.

Describe how the regulation has impacted the healthcare sector and provided an impetus for quality reform.

Additional Information:

Textbook: Jonas’ Introduction to the U.S. Health Care System, Chapter 5

Video: Medicare – This Khan Academy video explains the origins of Medicare and explains how the program works.

https://www.khanacademy.org/partner-content/brookings-institution/introduction-to-healthcare/v/medicare

Video: Medicaid – This Khan Academy video explains the origins of Medicaid and explains how the program works.

https://www.khanacademy.org/partner-content/brookings-institution/introduction-to-healthcare/v/medicaid

Regulations and Guidance: This Centers for Medicare and Medicaid Services (CMS) website provides detailed information on various regulations and includes guidance for meeting requirements.

https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html

Posts:

EMTALA is a federal law that needs any individual who comes to the emergency department to be treated and stabilized, despite their insurance status, though because it was passed in 1986 has stayed an unfunded mandate. Congress passed this Act in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act. Its initial goals and intention are compatible with the ACEP mission and the public trust held by emergency care givers. The unrecompensed care burden is increasing, and many emergency departments are closed, threatening emergency departments’ ability, and decreasing the resources for everyone to care for all patients. The physicians in the emergency department provide the most charity care for all physicians. This Act requires that hospitals that participate in Medicare with emergency departments treat and screen the emergency medical situations of clients in a manner that is non-discriminatory to any person, irrespective of their color, national origin, creed, insurance status, or race.

EMTALA explains an emergency medical situation. The medical situations presenting itself by severe signs of ample seriousness like the unavailability of instant medical attention might fairly be anticipated to happen, putting the health of a person in danger or severe bodily organ dysfunction. Ensuring that the patient is stabilized needs that, within reasonable medical reliability, no material decline in the patient’s status should occur during transfer or discharge from a healthcare facility. The level of government responsible for overseeing this Act is the Department of Health and Human Services. They oversee EMTALA enforcement, which as a department manual mote is a process that is complaint-driven, covering three possible agencies, including the Center for Medicare and Medicaid Services, the Office of Inspector General, and the Office for Civil Rights.

Where the two OIG and CMS may refer to particular cases, the agencies may act based on independently instituted investigations. The CMS supervise the process of regulatory development as part of its overall oversight responsibilities on Medicare. The OIG and CMS are together responsible for enforcing this regulation (Sara Rosenbaum, 2017). This regulation controls the hospital’s conduct. Although in some situations, the physicians can face liability in governmental penalties form for particular types of misconduct, like misrepresenting if the benefits of a transfer overweigh the risk or refusing or failing to appear if on call. This regulation’s private imposition rights expand to hospitals only. Though individuals can sue healthcare facilities over claimed breach of EMTALA, the individual physician cannot be sued. Money damages recovery is limited by the state’s law where the facility is placed, which means the state’s laws that impose caps on medical damages awards would also apply the claims of this regulation.

This Act was initially imposed to protect patients from being denied emergency or being inappropriately transferred due to their insurance status. This regulation affects the healthcare sector in many ways. It is important legislation that controls the healthcare provider’s code of conduct in dealing with clients in the Emergency Room. It explains the circumstances and conditions where a patient may be transferred to another hospital or denied treatment. For healthcare providers and facilities that breach obligations under this legislation, the penalties could be solemn. The healthcare sectors are bound by this regulation; they cannot overlook patient demands in favor of monetary gains (Acep, 2021). Patients who need critical care and immediate attention cannot be sent away or directed to other facilities just because they cannot pay for the services.

References

Acep. (2021). EMTALA fact sheet. https://www.acep.org/life-as-a-physician/ethics–legal/emtala/emtala-fact-sheet/

Sara Rosenbaum. (2017, August 2). The enduring role of the Emergency Medical Treatment and Active Labor Act. Health Affairs. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.0660

Response Posts :

When responding to at least two of your peers, consider the following:

How does the legislation or regulations addressed by your peers help to meet a gap in healthcare?

How do the requirements provided by the legislation or regulations provide support for the legislation you addressed in your initial post?

 

Classmate #1:

LeeAnn Woodmancy posted Feb 10, 2021 8:49 PM to Group F

This week my discussion post is about the False Claims Act and other Healthcare Fraud Legislation. This act is a federal law that makes is a crime to make a false accusation against any federal health care program.(“False Claims Act | Total health care,” n.d.) Some examples of this act would include billing for services not provided or even billing for the same service more than once. Making false claims and statements to get payment for services is also against the law. According to the office of the Inspector General, there are other fraud and abuse laws. The Anti-Kickback statute, the Physician Self-Referral Law and the Civil Monetary Penalties Law. Like the other laws, all deal with making sure that the Healthcare stays as free from fraud as possible. (Office of Inspector General, Department of Health and Human Services, n.d.)

Each of these laws are federal and will be prosecuted at a federal level. There are fines involved, and possible imprisonment. Providers could lose the right to practice medicine and be punished to the fullest extent of the law.

The regulation of the False Claims act has recovered money that would have been lost before. By following laws, the Healthcare system can keep the costs down vs. raising healthcare costs more. These laws are in place to keep practices and provider accountable for their actions and keeping the medical community’s cost down.

 

References

Office of Inspector General, Department of Health and Human Services. (n.d.). Fraud & abuse laws | Physician roadmap | Compliance | Office of Inspector General | U.S. Department of Health and Human Services. https://oig.hhs.gov/compliance/physician-education/01laws.asp

False Claims Act | Total health care. (n.d.). Total Health Care. https://thcmi.com/false-claims-act/#:~:text=The%20False%20Claim%20Act%20is,or%20otherwise%2C%20which%20is%20funded

Office of Inspector General, Department of Health and Human Services. (n.d.). Fraud & abuse laws | Physician roadmap | Compliance | Office of Inspector General | U.S. Department of Health and Human Services. https://oig.hhs.gov/compliance/physician-education/01laws.asp

Vogel R. L. (2010). The false claims act and its impact on medical practices. The Journal of medical practice management : MPM, 26(1), 21–24.

 

Classmate #2:

Seth Young posted Feb 11, 2021 12:06 PM

For our second group discussion, I was assigned the Medicare Access and Children’s Health Insurance (CHIP) Reauthorization Act (MACRA) of 2015. to the Center for Medicare & Medicaid Services (CMS) (2019), MACRA is a bipartisan legislation law that created the Quality Payment Program (QPP) that: repeals the Sustainable Growth Rate (SGR), establishes a framework for rewarding clinicians for value over volume, streamlines quality reporting programs into one system under Merit-Based Incentive Payments System (MIPS), gives bonus payments for participation in eligible alternative payment models (APMs), and reauthorizes two years of funding for the Children’s Health Insurance Program (CHIP). In addition to the previously mentioned information, as of April 2019, MARCA requires the removal of Social Security Numbers (SSNs) from all Medicare cards.

Concerning the level(s) of government involved, MARCA was introduced and passed by the legislative branch (House of Representatives then-Senate), and then signed into law by the executive branch, Barack Obama. As the overseeing agency, the CMS evaluates the performance of providers and influences the usage of quality reporting measures through offering financial and limited technical support. (Bhattacharya et al., 2017).

Upon review, the majority of changes pertained to assuring the quality by implementing a value-over-volume form of measurement to determine the Medicare payout to providers (repeals of SGR and MIPS). However, through participation in the QPP in alignment with MIPS and APM; by providing high-quality and cost-effective care, qualifying physicians can receive pay incentives to combat their losses in the removal of the SGR. Not to mention, MACRA also expanded the funding of CHIP and removed SSNs from all Medicare cards to protect patient-financial information. This regulation was created to establish accountability and regulate the quality of the healthcare delivery system. Through MACRA, the CMS c a standard of care by overseeing and determining the cost-effectiveness and quality based upon the previously mentioned incentive-based programs. All in all, taking the provisions and improvements into consideration, MACRA established an impetus for change for the quality of care, but healthcare delivery systems as well.

References

Bhattacharya, J., Lin, E., & MaCurdy, T. (2017, September). The medicare access and CHIP reauthorization act: Implications for nephrology. Journal of the American Society of Nephrology. Retrieved February 11, 2021, from https://jasn.asnjournals.org/content/28/9/2590

Centers for Medicare & Medicaid Services. (2019, November 18). MARCA. Retrieved February 11, 2021, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs

 
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