HIPAA and Hospital Systems PDF

Governmental Oversight  The Civil Rights Division (CRD) in the Office for Civil Rights (OCR)  Promotes  and ensures that: People have equal access to and opportunity to participate in certain health care and human services programs without facing unlawful discrimination http://www.hhs.gov/ocr/civ...

Governmental Oversight  The Civil Rights Division (CRD) in the Office for Civil Rights (OCR)  Promotes  and ensures that: People have equal access to and opportunity to participate in certain health care and human services programs without facing unlawful discrimination http://www.hhs.gov/ocr/civilrights/index.html © RW Nithman, 2024 Civil Rights Violations How to file a complaint? Office of Civil Rights (OCR)  Be filed within 180 days of when you knew that the act or omission complained of occurred  Anyone can file a complaint alleging a violation of the Privacy or Security Rule  Under HIPAA, an entity cannot retaliate against you for filing a complaint © RW Nithman, 2024 HIPAA HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT of 1996 © RW Nithman, 2024 HIPAA MORE THAN JUST PRIVACY!! Three main purposes: 1. Health Insurance Portability  Pre-existing conditions, etc 2. Anti-fraud Provisions  Private and Gov’t (focus on private ☺) 3. Administrative Simplification Sections    Electronic claim submission Security Unique Identifiers   © RW Nithman, 2024 NPI; uniformity for payers, providers, states Privacy HIPAA Law Established Federal ‘minimum’ standards  Policies & Procedures that limit information uses, disclosures, and requests to those necessary to carry out the organization’s “work” “reasonable efforts” to prevent security/privacy breach…  Core element of regulation: “minimalism”   Password-protected computers  Network encryption for “data” exchange  Confidentiality messages (emails, faxes, etc.)  As with most Federal laws, States (and organizations) may regulate more strictly than Federal law © RW Nithman, 2024 HIPAA is more than just “privacy” Components of the HIPAA Law: ❑ TITLE I: ❑ HEALTH ❑ TITLE ❑ ❑ ❑ CARE ACCESS, PORTABILITY, AND RENEWABILITY II: REVENTING HEALTH CARE FRAUD AND ABUSE ADMINISTRATIVE SIMPLIFICATION MEDICAL LIABILITY REFORM © RW Nithman, 2024 Key Terms related to HIPAA… ❑ PHI (Protected Health Information) ▪ ▪ Any individually identifying information (examples - slide 12) Past/Present/Future physical or mental aspects of healthcare ❑ Individually Identifiable Health Info: any info created or received by a healthcare provider, health plan, employer, or healthcare clearinghouse ❑ NPI: National Provider Identification Number ❑ Health information: means any information, whether oral or recorded in any form or medium ❑ Clearinghouse: public or private entity that processes or facilitates the processing of nonstandard data elements of health information into standard data elements – conduit for claim submissions. ❑ Health Plan: means an individual or group plan that provides, or pays the cost of, medical care ❑ Healthcare Provider: a provider of medical or other health services, and any other person furnishing healthcare services or supplies. ❑ Covered Entity: an organization that routinely handles protected health information © RW Nithman, 2024 PHI: Individually identifying information…  Name  Geographic subdivisions smaller than State  Zip code (if geographic unit2 hospitals owned, leased, or contract managed by the same organization (AHA, 1998)  Reimbursement challenges /changes (Balanced Budget Act ‘97)  Nation’s Safety-net Hospitals  Provide care for vulnerable populations, those without health insurance or the ability to pay for services  Typically academic & public hospitals  Receive funding from local, state, federal Gov’t agencies  Also bill Medicare/Medicaid, private insurances © RW Nithman, 2024 Integrated Delivery Systems (IDS) Strategic alliances & delivery systems to improve efficiency 1990’s American Hospital Association advocated for IDS ▫ > efficiency ▫ > system accountability: ❖ community needs and health outcomes Variety of delivery components & payment mechanisms ❑ Horizontal Integration ❑ Vertical Integration © RW Nithman, 2024 Physician-Hospital Relationships Vertical integration strategy Integration of Physicians into Management/Governance ▫ Purpose:  Link patient-entry points into a HC delivery system  Physician’s are GateKeepers, Mangers = control     Continuum of care services Lowers physician expenses Maximizes managed care contracting opportunities Hospitals are facing competition form multi-specialty practices in the ambulatory care market Traditional Hospital Structure Board of Directors Administration Medical Staff Other Clinical Departments © RW Nithman, 2024 © RW Nithman, 2024 Paradigm Shifts in Hospital Structure… Patient-focused care! ▫ Organization around perceived patient needs vs. professional disciplines, procedural groups ▫ Product-line Teams  Joint replacement, stroke teams, for example ▫ Matrix System  Dual-management structure  Report to varying managers/layers ▫ Team leader for Product Line, Rehab Mngr (non-clinical matters) © RW Nithman, 2024 Hospital Size ▫ Number of beds vs. number of beds staffed ▫ Most hospitals are under 200 beds  Census fluctuations ▫ Larger hospitals are likely tertiary care centers  Services > general, routine population  Trauma, Mental Health, Rehab, etc Hospital Ownership © RW Nithman, 2024 One of three types of ownerships: 1. Not-for-profit (~60% beds, 70-75% admissions) 2. For-profit -or- Investor-owned (~18% beds, 15% admissions) 3. Public (~22% beds, 13% admissions) [Figures 9-5, 10-5 Sandstrom] ❖Approx 2/3 of community hospitals are non-for-profit ❖Tax incentives for not-for-profit hospitals ❖Private investment in hospitals have grown since 1980’s What are the advantages of private investment?? © RW Nithman, 2024 Hospital Ownership (cont.) Public hospitals: primary source of healthcare for indigent & poor City, county hospitals, military & VA hospitals 4. Hybrid Ownership Structure ▫ Ex: not-for-profit sold to a for-profit company and retain minority shares, etc Ethical considerations for Profits © RW Nithman, 2024 Discussion:  Is it ethical to make a profit in healthcare? All hospitals need some profit margin for operations ▫ Not-for-profit: return profit to community or organization ▫ For-profit: distributes profit to shareholders APTA Code of Ethics © RW Nithman, 2024 Principle #1: ▫ Physical therapists shall respect the inherent dignity and rights of all individuals. (Core Values: Compassion, Integrity) Principle #2: ▫ Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients. (Core Values: Altruism, Compassion, Professional Duty) Principle #3: ▫ Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity) Principle #4: ▫ Physical therapists shall demonstrate integrity in their relationships with patients/clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public. (Core Value: Integrity) APTA Code of Ethics © RW Nithman, 2024 Principle #5: ▫ Physical therapists shall fulfill their legal and professional obligations. (Core Values: Professional Duty, Accountability) Principle #6: ▫ Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors. (Core Value: Excellence) Principle #7: ▫ Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society. (Core Values: Integrity, Accountability) Principle #8: ▫ Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally. (Core Value: Social Responsibility) Hospital→Community based care Historical background on community-based emphasis… Medicare Diagnostic-Related Groups (DRG’s) 1983 ▫ Incentivized post-acute level of care ▫ Each level of care- different services at varying costs ▫ Evolvement of the Case Manager! ✓Assist navigation of the “system” Unequal access and ability to finance care Informal vs. Formal Care ▫ African Americans less likely receive institutionalize care  AA & Hispanic Americans: increase use informal care despite inc disability rates © RW Nithman, 2024 Informal post-acute care © RW Nithman, 2024 Approx 2% population, age >75, female ▫ In need or currently receiving informal care Nat’l economic value of informal caregiving: $196B Important social, cultural, and policy implementations 23% of Americans provide informal care to others 71% caregivers (CG) do not live with care recipients Spouse CG reduces formal LT care costs by $28k/yr Child CG reduces formal LT care costs by almost $4k/yr ▫ Female spouses and adult female children ADL’s Informal post-acute care (cont.) 10-40 hours of informal assistance 90% of nearly 3M people with developmental disabilities Not a static process ▫ CG ability ▫ Social context ▫ Burden of care with changing conditions Tremendous economic and social value for society Voluntary Agencies ▫ Education, Support, Advocacy ▫ Health Education & health Maintenance to their constituents ▫ Not-for-profit Family Unit © RW Nithman, 2024 © RW Nithman, 2024 Formal post-acute care Mix of Residential & Professional Sites Assisted Living Facilities ▫ Supervision to min assist level of care Skilled Nursing Facilities (SNF) Sub-Acute Units ▫ Both provide multiple medical/rehab treatments Hospices Adult Day Care Home Healthcare © RW Nithman, 2024 Formal post-acute care oSome service locations combine formal and informal care ❖One’s ability to perceive the environment, think, communicate, perform basic ADL’s determines appropriate level of formal post-acute care. The Affordable Care Act of 2010 Accountable Care Organizations © RW Nithman, 2024 ”…groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.” (CMS.gov) © RW Nithman, 2024 ACO’s Related to PPACA / CMS’ plans to reduce healthcarerelated expenses ❖Coordinated care Goals: oensure that care recipients get the right care at the right time oavoiding unnecessary duplication of services oprevent medical errors ospecial mention of the chronically ill ❖High-quality care + Cost Savings ➔ ACO shares in the savings © RW Nithman, 2024 ACO’s “Shared Savings Program” initiated from CMS’ Innovation Center oStemming from the PPACA oMedicare offers several ACO programs o3 Primary ACO Models oMedicare Shared Savings Program oAdvance Payment ACO Model oPioneer ACO Model © RW Nithman, 2024 ACO’s o Vertical Integration o Horizontal Integration ❑ Advantages of ACO models ❑ Disadvantages of ACO models