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Learning Objectives• Develop a basic understanding of ethical principles.• Utilize a framework for ethical decision making. • Gain a basic understanding of HRSA guidelines and
compliance.• Gain a basic understanding of FTCA guidelines and
compliance.DISCLAIMER: this presentation does not constitute legal advice, but information &
education only
Let’s begin…
Ethical Principles in HealthcareThese may sound familiar:•Autonomy•Beneficence•Non-maleficence•Veracity/Fidelity •Justice/Fairness
Ethics – General Discussion• Not going to address all ethical theories today, however…
in general - difficult “right” and “wrong” decision making• Traditionally divided into three fields which may NOT
sound so familiar:1. Meta-ethics* 2. Normative ethics*3. Applied ethics**
Reference: Brown University
Applied Ethics – Examples?• Obligatory: right to do “it” and
wrong not to do “it”*• Impermissible: wrong to do “it” and
right not to do “it”*
• Permissible: neither right nor wrong to do “it”*• Supererogatory: “it” is right to do, but
not wrong if you don’t do “it”* Reference: Brown University
Ethics Considerations in Healthcare
Intersection of ethics/ethical principles and…1. Personal morals?2. Standard of Care or Scope of Practice issues?3. Unprofessional conduct? 4. Compliance concerns? (and HRSA)5. Risk mitigation? (and FTCA)6. Law/legal issues? (and FTCA)
Ethical Dilemmas – Personal Morals2012 Medscape/WebMD survey of 24,000 physicians*INSURANCE: would you drop a longtime patient if their insurance did not pay well?YES – 27%NO – 41%IT DEPENDS – 33%
DEFENSIVE MEDICINE: is it acceptable to perform “unnecessary” procedures defensively because of malpractice concerns?YES – 23%NO – 55%IT DEPENDS – 22%
Unprofessional Conduct, Ethics and the Law
For a Doctor of Osteopathy which of these are unprofessional/unethical*• Misdemeanor involving moral turpitude?*• Charging a fee for services not rendered or dividing a professional fee
for patient referrals?• Failing to establish and maintain adequate records on a patient?• Signing a blank, undated or predated prescription form?• Engaging in sexual conduct with a current patient or former patient
within 3 months after the last medical consultation?*• Disruptive behavior in a professional setting?*• Failing to disclose a licensee’s license number and the board’s
address and phone number if you provide medical care by computer?**
Reference Arizona Revised Statutes 32-1854
Ethical Decisions - FrameworkMy recommended framework for sound ethical decisions based
on a practiced approach:1. What is the ‘real’ ethics issue2. Gut√3. It depends…do any duties or exceptions apply?4. Options & desired outcome 5. Available resources – patient & you/your organization6. Justify your decision (meta-ethics) – if needed
© 2016 Denise Atwood PLLC
Ethical Framework applied to Case Studies
Ethics Case Study – Standard of care
– Dr. G. is the only physician at RURAL HOSPITAL that performs colonoscopies.
– The nurses who assist Dr. G. observe that he rarely reaches the cecum which would be the standard of care.
– The nurses, feeling the procedure is incomplete, sought intervention from the hospital administrator - who seems hesitant to intervene.
– After two years of not getting assistance from the administrator, the nurses announce they will no longer assist Dr. G. during colonoscopies.
– What is the hospital’s / administrator’s ethical obligation?
Ethics Case Study – Refusal of Care
• At Mr. K’s 1st appointment, he tells you he has gained 50 pounds in the past year (after quitting smoking) and has shortness of breath when walking up an incline.
• Mr. K. is 40 years old, weighs 310 pounds and is pale. • Clinically the N.P. thinks Mr. K. has nephrotic syndrome
and maybe a potential kidney malignancy. • Mr. K. states he has no insurance so he does not wish
to pursue further testing. Mr. K. does not want to be a ‘charity case’ and is refusing to let you talk to Mrs. K.
• What do you do at the administrator?• What are some exceptions to patient confidentiality?
Ethics Case Study – Refusal of Testing
• At her follow up appt. 70 y.o. Mrs. C. is refusing recommended diagnostic evaluation for cancer.
• The doctor informed you that Mrs. C’s refusal at this point will impact her future treatment decisions and options.
• She is able to articulate the information given to her, but she is unwilling to proceed and does not want her son to know her medical condition.
• Mrs. C. appears to have decision-making capacity and states she does not want to spend her last days being treated for cancer.
• Should the Medical Director override Mrs. C’s decision not to undergo further evaluation by talking with her son?
• What is the hospital’s / administrator’s ethical obligation?
Switch gears…
HRSA and FTCA - Overview
• What does FTCA stand for? • Why is it important for a Federally Qualified Health
Center (FQHC) and its providers?
References / Resources at then end of the slide deck The following discussion DOES NOT address exceptions for Health Care for the Homeless or Public Housing Primary Care Programs
HRSA, FQHC and FTCA – The Connection
• FQHCs may be granted malpractice liability protection with the Federal government acting as their primary insurance coverage (grants immunity).
• FQHCs must submit an initial deeming application to the HRSA and must meet certain requirements to attain deemed status.
• Renewal applications for redeeming must be submitted on an annual basis.
• A deemed FQHC, its employees, and eligible contractors working within the approved scope of project are considered federal employees and are immune from lawsuits for medical malpractice.
HRSA, FQHC and FTCA – The Connection
• So, a patient who alleges acts of malpractice by a deemed FQHC cannot sue the FQHC or provider(s) directly, but must file the claim against the U. S. Government.
• If the case is accepted, the Federal government assumes responsibility for costs related to a claim resulting from the performance of a medical, surgical, dental, or related function.
• There is no cost to a participating health center or its providers. These claims are reviewed and/or litigated by the U.S. Department of Health and Human Services, Office of the General Counsel and the Department of Justice according to FTCA requirements.
HRSA and FTCA - Overview
• How many HRSA Health Center Program Requirements are there?
• Overview to follow with detail on several requirements from a compliance perspective.
References / Resources at then end of the slide deck
The following discussion DOES NOT address exceptions for Health Care for the Homeless or Public Housing Primary Care Programs
HRSA – Health Center (HC) Program Requirements
1. Needs Assessment: HC demonstrates & documents needs of its target population and service area2. Required and Additional Services: HC provides all required primary, preventive, enabling health
services and additional health services as appropriate and necessary, either directly or through established written arrangements.
3. Staffing Requirement: HC maintains a core staff as necessary to carry out all required primary, preventive, enabling health services and additional health services as appropriate and necessary, either directly or through established arrangements and referrals. Staff must be appropriately licensed, credentialed and privileged.
4. Accessible Hours of Operation/Locations: HC provides services at times and locations that assure accessibility and meet the needs of the population to be served.
5. After Hours Coverage: HC provides professional coverage for medical emergencies during hours when the center is closed.
6. Hospital Admitting Privileges and Continuum of Care: HC physicians have admitting privileges or other arrangement to endure continuity of care
7. Sliding Fee Discounts: HC has a system in place to determine eligibility for patient discounts adjusted on the basis of the patient’s ability to pay.
HRSA – Health Center (HC) Program Requirements
8. Quality Improvement/Assurance Plan: HC has an ongoing QI/QA program that includes clinical services and management and that maintains confidentiality of patient records.
9. Key Management Staff: HC maintains a fully staffed HC management team as appropriate for the size and needs of the center. Prior approval by HRSA of change in the Project Director/Executive Director/CEO position is required.
10. Contractual/Affiliation Agreements: HC exercises appropriate oversight and authority over all contracted services, including assuring subrecipient(s) meets HC program requirements.
11. Collaborative Relationships: HC establish and maintain collaborative relationships with other HC providers, including health centers in the service area of the center. HC secures letter(s) of support from existing HC.
12. Financial Management and Control Policies: HC follows generally accepted accounting principles (GAAP) and assures an annual independent financial audit is performed.
13. Billing and Collections: HC has systems in place to maximize collections and reimbursement for its costs including written billing, credit, and collection policies.
14. Budget: HC has a budget that reflects the costs of operations, expenses, and revenues.
HRSA – Health Center (HC) Program Requirements
15. Program Data Reporting Systems: HC has systems which collect and organize data for program reporting and which support management decision making.
16. Scope of Project: HC maintains its funded scope of project.17. Board Authority18. Board Composition19. Conflict of Interest Policy: HC bylaws or written corporate board approved policy include
provisions that prohibit conflict of interest by board members, employees, consultants, and those who furnish goods or services to the HC. NO board member shall be an employee of the HC or an immediate family member of an employee. The Chief Executive may serve only as a non-voting ex-officio member of the board* (*recommended but not required)
HRSA - Compliance• Required and Additional Services established
through written arrangements.
HRSA & FTCA - Compliance1. Staffing Requirement: Staff must be
appropriately licensed, credentialed and privileged.
2. FTCA deeming requirements3. State law requirements4. Health center policy requirements5. Accreditation requirements*
HRSA & FTCA - Compliance• Quality Improvement/Assurance Plan: HC has
an ongoing QI/QA program that includes clinical services and management and that maintains confidentiality of patient records.
• FTCA deeming requirements• State licensing requirements • Accreditation requirements
HRSA - Compliance• Contractual/Affiliation Agreements: HC
exercises appropriate oversight and authority over all contracted services, including assuring subrecipient(s) meets HC program requirements.
HRSA - Compliance• Conflict of Interest Policy: HC bylaws or
written corporate board approved policy include provisions that prohibit conflict of interest by board members, employees, consultants, and those who furnish goods or services to the HC.
• Define conflict of interest?• Potential ethical implications?
HRSA – Quality/Compliance Tools
• We are always happy to share!• If you would like copies of the Sun Life
Quality Agenda or Dashboard template or Credentialing/Privileging audit tool, please email me @ [email protected]
Ethics references / resources• Bonde, S., et. al. (2013, May). A framework for making
ethical decisions. Brown University. Retrieved from https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisionsBaylor College of Medicine, Center for medical ethics and health policy online at https://www.bcm.edu/centers/medical-ethics-and-health-policy/
• Geisel School of Medicine, Handbook for rural health care ethics. A practical guide for professionals online at http://geiselmed.dartmouth.edu/cfm/resources/ethics/
• Stanford Medicine, Center for biomedical ethics online at https://med.stanford.edu/bioethics/about.html
HRSA references / resources
• HRSA, (2014, February). Health Center Program Requirements. https://bphc.hrsa.gov/about/requirements/hcpreqs.pdf
• HRSA, (n.d.). About the Federal Torts Claims Act. https://bphc.hrsa.gov/ftca/about/
• HRSA, (CY 2017). FTCA Deeming Application Evaluation Self Checklist. https://bphc.hrsa.gov/ftca/healthcenters/selfchecklist.pdf
• HRSA, (n.d.). Conflict of Interest. https://bphc.hrsa.gov/programrequirements/draftcompliancemanual/chapter13.html
Questions?
