Western State University
College of Law
Health Law 268, Julie Simer
Introduction to Health Law
Text: The Law of Health Care Finance and Regulation by Hall, Bobinski & Orentlicher,
Aspen 2005
This class is an introduction to the field of health law. The focus of the class will be on
understanding the financial underpinnings of the health care delivery system. The class
will explore the three main sources of revenue in the field of health care: government
reimbursement, insurance/managed care, and private funding. The class will discuss why
there is a need for regulation in this area and how that regulation is designed to prevent
abuse in the process of revenue flowing from one participant in the system to another.
The class will also discuss how public policy decisions affect health care delivery and
vice versa.
Grading: The class will be based 20 percent on participation, 20 percent on a Midterm
Case Presentation and 60 percent on a final exam. For the midterm, each student will be
asked to summarize a case involving a health law issue and discuss how the payment for
health care affects the parties and the decision.
No class on May 29 or 31. (Instructor Attending the ABA Development Conference)
1 What is Health Law?
Chp 1, pg 1-33
6/5
Is a hospital required to provide respiratory support of an anencephalic infant
under the Emergency Medical Treatment and Active Labor Act (EMTALA)?
Is the state liable for denying payment under Medi-Cal (California’s Medicaid Statute)
for additional days of hospital stay when discharge results in the patient going home
prematurely and eventually losing her leg? Will the merger of two hospitals substantially
lessen competition in violation of section 7 of the Clayton Act, 15 U.S.C. section 15?
The first class will discuss the myriad of issues that encompass the field of health
law from tort liability issues (informed consent, the duty to treat, and malpractice) to
finance and delivery issues (insurance coverage, managed care decisions, and rationing)
to bioethics (such as the right to die, physician-assisted suicide and organ transplant) The
articles in the reading section which follow the cases discuss medical judgment and the
imprecise nature of medical decision-making.
What jobs are available for healthcare lawyers, and what skills are required?
2 America’s Health Care Crisis
Chap 1, pg 33-82
6/7
The second class discusses the history of health care and the evolution of the
health care payment system. The discussion will center on who is entitled to health care
and who should pay for it. The class will discuss the moral and political themes of
rationing health care and how public policy addresses these issues. The class will discuss
whether non-profit health care providers are different from for-profit providers. The
articles in this section discuss health care access, public policy, and cost control. The
class will be asked for their ideas on how to allocate health services while also
controlling costs. The class will also discuss various methods of cost control from
government regulation to utilization review and which participants in the health care
delivery system have interests in controlling costs.
3 The Duty to Treat, Hospital Liability,
Patient Confidentiality
Chap 2, pg. 83 - 133
6/12
This class will discuss a series of cases analyzing the duty of a provider to provide
treatment and the liability for negligent treatment or treatment without informed consent.
The class will discuss the EMTALA statute which requires emergency room stabilization.
The class will also discuss the HIPAA statute that attempts to insure confidentiality of
patient information.
4 Managed Care Liability
Chap 2, pg. 133-158
6/14
The cases in this section discuss the liability of a managed care company to the
patient and the hospital. The class will discuss cases involving the ERISA statute and its
preemption over actions by the patient against the managed care company.
5
Insurance & HMO Regulation
Chap 3, pg.159-233
6/19
This class will discuss the California Dept. of Managed Care and the Department
of Insurance and their role in regulating managed care and insurance within the state of
California. This section will also discuss the Knox-Keene Act and the regulations
promulgated by the DMHC and the Department of Insurance.
6 Health Insurance Coverage
Chap 3, pg 234- 289
6/21
This class will discuss concepts such as “medical necessity”, “reasonable and
customary charges” and “carve-outs”. The class will discuss the line of cases involving
disputes over insurance coverage and how these issues become important in analyzing
health care contracts.
7 Midterm Case Presentation
No Reading
6/26
Students select one California case from the casebook or recent news and write a
three-page paper on the health care issue involved and how it resolves any of the issues
covered in our first six class sessions. Some students will be asked to discuss their paper
in class and the rest of the class will be asked to comment.
8 Provider Reimbursement & the Uninsured
Chap 2 pg. 290-330
6/28
This class will discuss the cases that involve cost-based reimbursement,
prospective payment and capitation payment. The articles for discussion provide a
historical framework to describe the evolution of payment to the provider. The class will
discuss Medicare and Medicaid and well as the growing problem of uninsured patients.
9 Prohibitions on Self-Referral
Chap 4, pg. 546-569
7/3
This class will discuss the statutes known as STARK I and STARK II and their
accompanying regulations. The class will discuss how fraud and abuse regulations are
important to insure proper referrals by physicians without the influence of self-interest.
The class will discuss the Safe Harbors under these statutes. Further, the class will
discuss regulation of fraud and abuse by the various governmental agencies both state
and federal, including the OIG, the Justice Department and Postal Service Inspectors.
10 Kickback Prohibitions
No Reading
7/5
This class will discuss the Anti-Kickback statute and its exceptions. The class
will discuss how kickback issues are prosecuted and how they are important in
contracting between health care entities.
11 Facility Regulation
Chap 4, pg. 359-387
7/10
This class will discuss the various entities that regulate hospitals such as the Joint
Commission for Accreditation of Hospital Organizations. The cases to be discussed
involve issues that arise over licensing of hospitals and accreditation. The loss of
accreditation and its impact on Medicare and managed care reimbursement will be
discussed.
12 Corporate Form & Regulation
Chap 4, pg. 390-434
7/12
This series of cases discusses the corporate and non-corporate form of providers
and class action lawsuits relating to non-profit status of providers. The class will also
discuss prohibitions on the corporate practice of medicine.
13 Medical Staff Structure
12 Chap 4, pg. 439-475
7/17
This class will discuss the medical staff and the relationship of physicians to
hospitals. The class will discuss medical staff bylaws and liability of hospitals with
respect to credentialing of physicians. The class will also discuss Independent Physician
Organizations and their role in managed care networks.
14 Antitrust Law
13 Chap 4, pg 475-545
7/19
This class will discuss the implications of anti-trust statutes as they affect mergers
and acquisitions in the health care industry. The cases also raise issues involving medical
staff boycotts and price-fixing. The class will also discuss the nursing shortage, the
patient-to-nurse staffing legislation and nurse’s union issues.
15 Bioethics & Health Care Reform
Chap 3, pg 330-356
TBA
This class will discuss cases involving bioethical issues such as the right to die,
refusal of treatment and physician-assisted suicide. The class will discuss how bioethical
issues raise moral issues that impact public health care policy. The class will also discuss
how health care should be reformed and whether a system of universal insurance
coverage will improve the American health care system. What must judges know about
gene therapy, genetic discrimination, genetically modified foods, human cloning and
stem-cell research?
16 Review
This is a review for the final exam.
No Reading
TBA