Ch 3 Working in Health Care

Learning Outcomes 3.1 Define licensure, certification, registration, and accreditation. 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 3.3 Discuss the composition of the health care team and the roles of its members. 3.4 Define the major types of medical practice management systems. LO 3.1 Define licensure, certification, registration, and accreditation. LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. LO 3.3 Discuss the composition of the health care team and the roles of its members. LO 3.4 Define the major types of medical practice management systems.

Learning Outcomes (cont.) 3-3 Learning Outcomes (cont.) 3.5 Define the different types of managed care health plans. 3.6 Discuss the federal legislation that impacts health care reimbursement and prohibits fraud and abuse in health care billing. 3.7 Define telemedicine, cybermedicine, and e-health, and discuss their roles in today’s health care environment. LO 3.5 Define the different types of managed care health plans. LO 3.6 Discuss the federal legislation that impacts health care reimbursement and prohibits fraud and abuse in health care billing. LO 3.7 Define telemedicine, cybermedicine, and e-health, and discuss their roles in today’s health care environment. 3

Licensure Mandatory credentialing process established by law, usually at the state level Required in every state for physicians, nurses, other health care practitioners LO 3.1 Define licensure, certification, registration, and accreditation.

Certification Voluntary credentialing process 3-5 Certification Voluntary credentialing process Usually national in scope Usually sponsored by a non- governmental, private-sector group Signifies that an applicant has attained a certain level of knowledge and skills LO 3.1 Define licensure, certification, registration, and accreditation. 5

3-6 Question Tell whether the following statement is true or false. Registration is an entry in an official registry or record, listing the names of persons in a certain occupation who have satisfied specific requirements. True False LO 3.1 Define licensure, certification, registration, and accreditation. 6

3-7 Answer True Registration is an entry in an official registry or record, listing the names of persons in a certain occupation who have satisfied specific requirements. The list is usually made available to health care providers. LO 3.1 Define licensure, certification, registration, and accreditation. 7

3-8 Registration An entry in an official registry or record listing the names of persons in a certain occupation who have satisfied specific requirements An applicant can add his or her name to the list. An applicant can attain a certain level of education and pay a fee. LO 3.1 Define licensure, certification, registration, and accreditation. 8

3-9 Accreditation Official authorization or approval for conforming to a specified standard Joint Commission accredits: Health care practitioner education programs Health care facilities Managed care plans LO 3.1 Define licensure, certification, registration, and accreditation. 9

Obtaining a License in Another State 3-10 Obtaining a License in Another State Reciprocity A state accepts a person’s valid license from another state If a state does not grant reciprocity, the person must take the required examination to obtain a license LO 3.1 Define licensure, certification, registration, and accreditation. 10

Doctor of Medicine (MD) Degree 3-11 Doctor of Medicine (MD) Degree Graduation with Bachelor’s Degree from 4-year pre-medicine course Graduation from a 4-year medical school In the U.S. a school accredited by the Liaison Committee on Medical Education LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 11

U. S. Medical Licensing Examination 3-12 U. S. Medical Licensing Examination Commonly called medical boards Take part 1 after first year of medical school Take part 2 during fourth year of medical school Take part 3 during the first or second year of postgraduate medical training LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 12

National Board of Medical Examiners 3-13 National Board of Medical Examiners Certifies physicians as NBME diplomate Following completion of residency and medical boards To specialize physicians must complete 2 - 6 more years training LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 13

Doctor of Osteopathy (DO) vs. MD 3-14 Doctor of Osteopathy (DO) vs. MD Both have 12+ years education. Both prescribe drugs and perform surgery. DOs focus on the musculoskeletal system and correction of joint and tissue problems. MDs focus on allopathic medicine, using drugs/surgery for cures. LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 14

Reasons Physicians Specialize 3-15 Reasons Physicians Specialize Higher financial compensation Decreased prestige for generalists Medical training usually provided in tertiary care settings Decreased exposure to generalist role models Lack of attractiveness of general practices LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 15

Criteria for Granting State License 3-16 Criteria for Granting State License LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. Figure 3-1 16

Revocation of a Physician’s License 3-17 Revocation of a Physician’s License Conviction of a felony Unprofessional conduct Personal or unprofessional incapacity LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 17

3-18 Medical Practice Acts Define what is meant by practice of medicine in each state Explain requirements and methods for licensure Establish medical licensing boards Establish ground for suspension or revocation of license Give conditions for license renewal LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 18

Fraud Falsifying medical credentials 3-19 Fraud Falsifying medical credentials Billing government agency for services not rendered Falsifying medical reports Falsely advertising to a patient secret cures or special curative powers LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 19

Question Tell whether the following statement is true or false. 3-20 Question Tell whether the following statement is true or false. LPNs and LVNs are licensed health care team members who work under the supervision of physicians or RNs. True False LO 3.3 Discuss the composition of the health care team and the roles of its members. 20

3-21 Answer True LPNs and LVNs are licensed health care team members who work under the supervision of physicians or RNs.They perform many of the same duties as RNs with some exceptions. LO 3.3 Discuss the composition of the health care team and the roles of its members. 21

Respondeat Superior Latin for “Let the master answer” Physicians are legally responsible for their own acts of negligence and those of employees working within the scope of their employment. LO 3.4 Define the major types of medical practice management systems.

Types of Medical Practice 3-23 Types of Medical Practice Sole proprietorship Partnership Professional Corporation Group practice LO 3.4 Define the major types of medical practice management systems. 23

3-24 Managed Care Corporations that pay for and deliver health care to subscribers for a set fee using a network of physicians and other health care providers Indemnity: coverage of an insured person against personal loss of money from medical expenses LO 3.5 Define the different types of managed care health plans. 24

Cost-Containment Measures 3-25 Cost-Containment Measures Co-insurance Co-payment Deductible Formularies Utilization review LO 3.5 Define the different types of managed care health plans. 25

Question Tell whether the following statement is true or false. 3-26 Question Tell whether the following statement is true or false. Co-insurance refers to flat fees insurance subscribers pay per service. True False LO 3.5 Define the different types of managed care health plans. 26

3-27 Answer False Co-payment refers to flat fees insurance subscribers pay per service. Co-insurance is the amount of money insurance subscribers must pay out of pocket. LO 3.5 Define the different types of managed care health plans. 27

Types of HMOs Group model HMOs Prepaid packages Staff model HMOs 3-28 Types of HMOs Group model HMOs Prepaid packages Staff model HMOs Individual practice association Preferred provider organization Physician-hospital organizations LO 3.5 Define the different types of managed care health plans. 28

Types of HMO Plans Point-of-service plans Open access plans 3-29 Types of HMO Plans Point-of-service plans Allow plan members to seek health care from non-network physicians, but plan pays highest benefits for care given by PCP or referral by PCP Open access plans Subscriber can see any in-network health care provider LO 3.5 Define the different types of managed care health plans. 29

Legislation Affecting Health Care 3-30 Legislation Affecting Health Care Patient Protection and Affordable Care Act (PPACA) Health Care and Education Reconciliation Act (HCERA) Health Insurance Portability and Accountability Act (HIPAA) Healthcare Integrity and Protection Data Bank (HIPDB) LO 3.6 Discuss the federal legislation that impacts health care reimbursement and prohibits fraud and abuse in health care billing. 30

Legislation Affecting Health Care 3-31 Legislation Affecting Health Care National Practitioner Data Bank (NPDB) Federal False Claims Act (FFCA) Patient Bill of Rights Act LO 3.6 Discuss the federal legislation that impacts health care reimbursement and prohibits fraud and abuse in health care billing. 31

3-32 Telemedicine Remote consultation with physicians or other health care professionals via telephone, closed-circuit television, fax machine, or the Internet Cybermedicine direct online contact between physician and patient E-health increasing use of the Internet as a source of consumer information about health LO 3.1 Define telemedicine, cybermedicine, and e-health, and discuss their roles in today’s health care environment. 32