TheU.S.HealthSystem:An
Introduc8ontoManagedCare,
Transac8onsandPolicy
ProfessorJessicaMantel
AHLA’sListofWhatHealthLaw
StudentsShouldKnow:
1)
2)
3)
4)
Healthcaredeliveryandfinancingsystem
Federalhealthcarereimbursementprograms
An8-fraud,bribery,andcorrup8onlaw
Federalhealthinforma8onprivacyandsecurity
requirements
5)  Physiciancreden8aling/peerreview/databankrepor8ng
6)  Professionallicensingandenforcement
7)  Corporateprac8ceofmedicineprinciples
8)  Administra8velaw
9)  Commercialinsurancelaw/managedcarereimbursement
10) Taxexemptorganiza8onlaw
AHLA’sListofAddi8onalUsefulTopics:
1)  Typicalhealthcaretransac8ons
2)  Healthan8trust
3)  Medicalmalprac8cecoverageanddefense
4)  Humansubjectsresearch
5)  LifeScienceslaw
6)  ERISA
7)  Physicalandmentaldisabili8es
8)  Bioethics
9)  Securi8eslaw
10) Healthinforma8ontechnologysystemsand
opera8ons
11) Healthcarefinanceandadministra8on
TheRiseofHospitals
•  19thCentury:Charitable,convalescentcare
tothepoor
•  Early20thCentury:Hospitalas“Physicians’
Workshop”
–  Morebusiness-like
–  Independentmedicalstaff
TheRiseofaPowerful
Profession:Physicians
•  Greaterprofessionalcohesiveness:
–  Professionalinterdependence
–  Shortageofphysicians
•  Consequencesofprofessionalcohesiveness:
–  AMA/professionalassocia8onsveryinfluen8al
–  Controloverlicensingstandards
–  Discouragedcontractmedicine
–  Defeatedna8onalhealthreformefforts
TheRiseofPrivateHealthInsurance
•  Typesofplans:
–  Indemnity:Pa8entpaysproviderandplan
reimbursespa8ent
–  ServiceBenefit:Planpaysprovider
–  DirectServices:Organiza8onprovideshealth
servicestosubscriberforfixedpre-payment
•  Thedefeatofdirectservicesplansandlaycontrolledservicebenefitplans
•  Riseofemployer-sponsoredhealthinsurance
TheRiseofPublicHealthInsurance
•  MedicareandMedicaid
•  Benefifedphysiciansandhospitals
•  Promotedgrowthofhealthcareindustry
RisingCosts
•  Causes:
–  Specializa8on
–  Fee-for-service
•  ChallengestoProviders’Authority
–  Changesinreimbursement
–  HMOsandmanagedcare
•  ProvidersRespond
–  Mergersandconsolida8on
HealthCareReform:
TheAffordableCareAct(2010)
SourcesofGovernmentRegula8on
(1) Statutes(Congress/Statutelegislature)
(2) Regula8ons(Governmentagency)
(3) Agencyguidance(Governmentagency)
Regula8ons
Defined:Aruleissuedbyanagencyhavethe
forceandeffectoflaw
Process:No8ceandCommentRulemaking
1.  No8ceofProposedRulemaking
2.  Publiccomments
3.  FinalRule
WhereLocated?:CodeofFederalRegister(CFR)
Guidance
Defined:Publica8onsthatcommunicateagency’sinterpreta8onof
relevantstatutesandregula8ons.
–  Clarifiesambiguityinastatute/regula8on
–  Signalshowagencyintendstoimplement/enforceastatute/regula8on
–  Agency’sopiniononhowastatue/regula8onappliestospecificscenario
LegalEffect:Doesnothavetheforceandeffectoflaw,butmaybe
prac8callybinding
WhereLocated?:Allover
–
–
–
–
–
Agencywebsite
No8cespublishedinFederalRegister
Preamble(i.e.,discussionsec8on)ofFinalRule
Manualsguidingregulateden88es
Manualsguidingagencypersonnel
*Lawyersshouldalwaysreviewrelevantagencyguidancebefore
advisingclient!
HelpfulSourcesforHealthLawyers
•  Backgroundsources:
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–
–
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HealthLawPrac8ceGuide(ThomsonReuters)
AHLAPublica8onsandTeleconferences
MedicareExplained(CCH)
KaiserFamilyFounda8on
CongressionalResearchService
HHSWebsite
•  CurrentAwareness:
–
–
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–
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AHLAListserveandTeleconferences
BNAHealthLawUpdates
KaiserFamilyFounda8onListserve
Mondaq(compendiumoflawfirmbulle8ns)
HHSListserves