Patients

4 Working in Today’s Healthcare Environment

Learning Objectives

After completing this chapter, you will be able to:

· 1. Define all key terms.

· 2. Describe today’s healthcare environment.

· 3. Discuss the similarities and differences among health maintenance organizations (HMOs), preferred provider organizations (PPOs), and exclusive provider organizations (EPOs).

· 4. Describe five types of medical practice.

· 5. Discuss the term diplomat as it relates to medical specialty boards.

· 6. Identify three categories of licensed nurses and describe their educational requirements.

· 7. Describe five categories of certified healthcare professionals.

· 8. Describe the diagnostic related group (DRG) system of classification.

· 9. State the differences between Medicare and Medicaid.

Key Terms

Associate practice

Capitation rate

Certification

Conscience clause

Copayment

Corporation

Diagnostic related groups (DRGs)

“Donut Hole”

Exclusive provider organization (EPO)

Fee splitting

Fixed-payment plan

Franchise

Franchisee

Gatekeeper

Group practice

Health Care Quality Improvement Act

Health maintenance organization (HMO)

Indigent

Licensure

Managed care organization (MCO)

Medicaid

Medicare

National Practitioner Data Bank (NPDB)

Partnership

Per diem

Preferred provider organization (PPO)

Primary care physician (PCP)

Prospective payment system

Registration

Sole proprietorship

Solo practice

Third-party payers

THE CASE OF MARION AND THE PACEMAKER

Marion is a 92-year-old patient who weighs 78 pounds. She has had poor eating habits for at least 20 years. In addition, Marion had been a heavy smoker all her life and suffered frequent respiratory problems. During the past two years she has become quite forgetful, has suffered a broken hip as a result of a fall out of bed, and has been treated for pneumonia. In spite of Marion’s protests, she is admitted to a nursing home. However, she quickly adjusts to her new home and likes the care and the attention that she receives.

During her third week in the nursing home, Marion develops a cough, high temperature, and respiratory problems. She is hospitalized with a diagnosis of pneumonia. The attending physician suggests that in addition to treatment for pneumonia, Marion will also need to have a pacemaker inserted to regulate her heartbeat.

Marion clearly explained to her family her wishes not to receive extraordinary measures to prolong her life. She also signed a living will indicating her wishes. After thoughtful discussions with other family members, Marion’s daughters tell the physician that they do not want to put their confused mother through the surgical procedure and the pain while recovering from the surgery. Further, they are concerned that their mother will not survive an anesthetic and surgical procedure in her frail condition.

The physician seems to be understanding of this decision. He says that he will place into Marion’s chart their request not to have the pacemaker inserted. However, the floor nurses take the daughters aside on several occasions to tell them that this is not a dangerous procedure and that they should sign a permit for surgery. The nurses make the daughters feel that they are not acting in their mother’s best interests by not signing the surgical permit. Marion returns to the nursing home without a pacemaker. She lives another four years without any cardiac problems.

· 1. Were the nurses carrying out their responsibility as licensed healthcare professionals or were they overstepping their role?

· 2. Were Marion’s daughters acting in the best interests of their mother because they knew that if she had the surgery she could not return to the nursing home where she was receiving good care?

· 3. What should happen when a physician agrees with the family members and the nursing staff does not?

Introduction

Today’s healthcare professionals are immersed in an ever-changing environment. The advent of managed care, a variety of medical practice arrangements, and a multitude of healthcare specialty areas have resulted in the continual need to understand healthcare law. Unfortunately, due to the rise in the number of malpractice suits, many physicians are protecting themselves by ordering multiple testing procedures, some of which might not be needed. In addition, many patients no longer want older, more conservative approaches to testing and diagnosis—and the newer tests are more expensive.

As demonstrated in the above case, all healthcare professionals need to pay attention to the wishes of their patients. And in circumstances where the patient has given family members or others authority to make a healthcare decision on their behalf, healthcare professionals must respect the patient’s wishes. They also should use care not to place their own opinions ahead of the decisions made by physicians and other healthcare professionals in consultation with the patient. However, ethical dilemmas arise when the healthcare professional’s moral and religious beliefs conflict with their role in healthcare. There are no easy, or perfect, answers to these dilemmas.

TODAY’S HEALTHCARE ENVIRONMENT

Healthcare has undergone major changes since 1965 when Medicare and Medicaid became law. The Patient Protection and Affordable Care Act (PPACA), also known as the Affordable Care Act of 2010, is more fully discussed in Chapter 14 .

The growth rate of the older adult population and the remarkable technological discoveries and applications, such as heart and kidney transplants and mobile mammogram units, are just a few of the developments that have caused a rapid expansion of the healthcare system. In addition, insurance companies, managed care plans—such as health maintenance organizations (HMOs) , which stress preventive care and patient education—and government legislation have significantly impacted the way healthcare is delivered.

Currently, about $3 billion a day is spent on healthcare in the United States. However, this does not mean that all Americans are receiving good care, or even any care. We, as a nation, are far from the top in life expectancy at birth. Traditionally, the emphasis in healthcare has been on quality. However, with rising healthcare costs, many U.S. citizens are concerned about the cost of services and access to medical care. Another critical issue is the crisis in health insurance coverage as many Americans do not have adequate medical insurance.

Health insurance includes all forms of insurance against financial loss resulting from illness or injury. Private health insurance is more than a $200 billion business annually. The most common type of health insurance covers hospital care. Relatively new types of insurance are the fixed-payment plans. These are offered by organizations that operate their own healthcare facilities or that have made arrangements with a hospital or healthcare provider within a city or region. The fixed-payment plan offers subscribers (members) complete medical care in return for a fixed monthly fee. HMOs, for example, base their operations on fixed prepayment plans.

Insurance companies and other third-party payers , such as HMOs, recognize that persons who are well covered by medical insurance have no incentive to economize. Insurers, however, want to keep their costs for reimbursement as low as possible. Physicians want to order more tests to avoid malpractice suits. Patients want adequate tests and complete care. Keeping these differing viewpoints in mind, who then decides on the allocation of the health resources?

Managed Care

Managed care is a method for restructuring the healthcare system, including delivery of a broad range of services, financing of care, and purchasing. Managed care provides incentives to keep costs of healthcare down by using an administrative structure to manage the enrolled population of patients. The managed care movement is known for its goal of offering medical care at lower costs and decreasing the amount of unnecessary medical procedures. Managed care provides a mechanism for a gatekeeper , such as primary care physician or insurance company to approve all patient referrals and nonemergency services, hospitalizations, or tests before they can be provided. A primary care physician (PCP) acts in a gatekeeper capacity, because he or she is responsible for the patient’s medical care and any referrals to other physicians or services. In addition, patients could select any physician or specialist to treat them.

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One of the fundamental principles of managed care is “managed choice.” Patients have a choice about their medical care but only within certain parameters that are determined by the managed care organizations (MCOs).

Managed care organizations (MCOs) pay for and manage the medical care a patient receives. One of the means an MCO uses to manage costs is to shift some of the financial risk back onto the physician and hospitals—when the costs go up, their income from the MCO goes down. This mechanism poses many ethical dilemmas. MCOs offer a variety of financial incentives, including bonuses to physicians for reducing the number of tests, treatments, and referrals to hospitals and specialists. These incentives can create a conflict of interest for physicians.

The offer of financial inducements to physicians who order fewer tests and hospitalizations for their patients is a widely discussed concern. Many fear that physicians may withhold services from patients in order to increase their own profits. Some of the reasons for these concerns are that MCOs attempt to limit the:

· Choice of physician.

· Treatments a physician can order.

· Number and type of diagnostic tests that can be ordered.

· Number of days a patient can stay in the hospital for a particular diagnosis.

· Choice of hospitals.

· Drugs a physician can prescribe.

· Referrals to specialists.

· Choice of specialists.

· Ordering of a second opinion for diagnosis and treatment.

The managed care movement—with the implementation of health maintenance organizations (HMOs), preferred provider organizations (PPOs), and exclusive provider organizations (EPOs)—sought to bring healthcare costs under control by monitoring healthcare and hospital usage.

· 1. Health Maintenance Organization (HMO)—a type of managed care plan in which a range of healthcare services are made available to plan members for a predetermined fee (the capitation rate ) per member, by a limited group of providers (such as physicians and hospitals). HMOs use a physician as the primary care physician (PCP) to manage and control the enrolled patient’s medical care. This capitation rate replaced the former “fee-for-service” rate which was considered to be more costly. In addition, the HMO places the PCP at some financial risk if there are excessive medical expenses toward the patient’s medical care.

· 2. Preferred Provider Organization (PPO)—a plan in which the patient uses a medical provider (physician or hospital) who is under contract with the insurer for an agreed fee in order to receive copayment (usually $10 to $20) from the insured. PPOs differ from HMOs in two main areas: (a) A PPO is a fee-for-service program not based on a prepayment or a fixed monthly fee paid to the healthcare provider for providing patient services (capitation rate) as with an HMO—physicians and hospitals designated as PPOs are reimbursed for each medical service they provide; and (b) PPO members are not restricted to certain designated physicians or hospitals.

· 3. Exclusive Provider Organization (EPO)—a new managed care plan that is a combination of HMO and PPO concepts. In an EPO, the selection of providers (such as physicians and hospitals) is limited to a defined group, but the providers are paid on a modified fee-for-service (FFS) basis. Unlike a PPO, there is no insurance reimbursement if nonemergency service is provided by a non–EPO provider.

Federal Assistance Programs

Medicare

Medicare is the federal program that provides healthcare coverage for three groups of people: persons age 65 and over; disabled persons who are entitled to Social Security benefits or Railroad Retirement benefits; and end-stage renal disease patients of any age. It was established under Title XVIII of the Social Security Act as part of the Social Security Amendments of 1965. Medicare was designed as a traditional third-party private insurance that emphasized free choice of healthcare. The accounting details were handled by private insurance companies, usually Blue Cross and Blue Shield. Medicare expenditures quickly rose beyond the initial projections. In addition, traditional Medicare reimbursement became very complex in both the administration and review process. This led to several problems, including a long delay for physicians and hospitals to receive reimbursement for providing services (see Figure 4.1 ).

As a result of the rising costs of the Medicare program, a rationing of healthcare under Medicare has occurred. For example, the first $500 of the hospital care costs may have to be paid by the recipients once during each benefit period as a deductible; there is a cutoff of reimbursement of care beyond sixty days; and long-term care is not fully reimbursed. These cost-saving devices result in a fixed allocation of healthcare services for many elderly who will not use a hospital or nursing home facility because they cannot afford the deductible payment. In addition, most Medicare recipients can afford to also pay for supplemental insurance to cover those costs not covered under Medicare.

Figure 4.1 Medicare and Supplemental Private Insurance Cards

Medicare patients have a right to appeal care that may be denied under existing Medicare rules and regulations. As a result of a court case, new rules by the Department of Health and Human Services for HMOs went into effect in August 1997. In the case of Grijalva v. Shalala (Donna Shalala was secretary of the department when the suit was filed), an Arizona court found that a 71-year-old Medicare patient, whose healthcare coverage was refused by her HMO, was denied the right to appeal when her request for home healthcare was refused by her HMO. The judge ruled that the Department of Health and Human Services, which oversees Medicare, was at fault for failing to force HMOs to follow federal law that mandates allowing appeals when there are denials for treatment. Under the current rules, a Medicare patient in an HMO may appeal when there are denials for treatment (Grijalva v. Shalala, 946 F. Supp. 747, Ariz. 1996).

Diagnostic Related Groups (DRGs)

Another method of rationing healthcare was implemented in 1983, when Medicare instituted a hospital payment system— diagnostic related groups (DRGs) —that classifies each Medicare patient by illness. DRGs, now used for all patients, are designations which categorize diagnoses and treatments into groups that are used to identify reimbursement conditions. There are currently nearly 1000 illness categories of medical conditions under the DRG system.

Hospitals receive a preset sum for treatment of an illness category, regardless of the actual number of “bed days” of care used by the patient. This method of payment provides a further incentive to keep costs down. However, it has also discouraged the treatment of severely ill patients due to the high costs associated with their care. In addition, patients are often discharged before they are ready to take care of themselves. This has resulted in hospital readmissions and, in some extreme cases, deaths that could have been prevented if the patient had remained under hospital supervision a few days longer.

Medicaid

Medicaid is a federal program implemented by the individual states, with the federal government paying 57 percent of Medicaid expenditures. Enacted at the same time as Medicare, it provides financial assistance to states for insuring certain categories of the poor and indigent (a person without funds). There is a growing concern that these two programs operate at cross purposes, as they serve some of the same beneficiaries, and that better coordination of the two programs is needed. Cases of abuse and fraud are reported within both programs. For example, there are cases of physicians and others employed in the healthcare field submitting bills for reimbursement under these two programs for patients they have never treated.

Rationing also takes place in the Medicaid program. For instance, several state Medicaid programs have resisted funding procedures such as liver transplants. The state of Oregon voted to abolish Medicaid funding for liver transplants and instead fund intensive prenatal screening programs. Voters apparently believed that the millions spent to save a few lives with liver transplants are better spent on effective prenatal screening that would help to prevent premature births and thus save more lives.

Individual states enact their own legislation to direct the way funds such as Medicaid are spent. Ethical dilemmas surface as patients on Medicaid find they have little or no access to funds within their own state. For example, while this does unfortunately happen, hospitals have gotten themselves into trouble for discharging a patient too early. Hospitals have been found guilty for negligently discharging patients because adequate discharge planning was not implemented.

Medicaid patients in long-term-care facilities are required under the law to use their own excess income to help to pay for their care. This means that they must use their own income before Medicaid will assist them. This has proved to be a burden for married couples, because it may impoverish the spouse as well as the patient. Some states have enacted laws in which the spouse may separate his or her financial resources from the patient’s. In other words, the total amount of resources is divided in half so as not to leave the patient’s spouse without a home or other resources. Some states offer nursing homes a per diem , or daily rate, payment for a patient’s care. Other states may use a prospective payment system in which the payment amount or reimbursement for care is known in advance.

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High costs in drugs for patients on Medicare and Medicaid has meant that some elderly and disabled patients resort to splitting pills in two or skipping them entirely. This can result in further hospitalization. In addition, there is often a “donut hole” or gap, causing an amount of out-of-pocket costs the patient must pay for medications even though they are on Medicare. In some cases, the poor, elderly, and disabled have gone hungry in order to pay for their life-saving medications.

Ethical Considerations of Managed Care

Managed care, including Medicare and Medicaid, has many flaws. Because the basis for a managed care approach is an economic one of cost containment, those who know how to use the system will fare better than the poor and less educated. The wealthy patient may receive better care than the poor patient. For example, the wealthy Medicare patient may be able to carry a supplemental health insurance policy to cover the items, such as prescription drugs and long-term care, which are not fully covered under Medicare. Other ethical considerations and questions concerning managed care include the following:

· Some physicians will not accept patients who are on Medicare. They are concerned that the reimbursement is not sufficient to treat patients who may require a great deal of care as they age.

· Many believe it is difficult, if not impossible, to provide a decent minimum standard of care or treatment to everyone under the managed care concept.

· Are all the families and patients who agree to a managed care contract at the closest clinic fully informed of the consequences of trying to obtain healthcare elsewhere?

· Is a bait-and-switch approach being used by the MCO in which the patient is lured into joining a managed care plan only to realize that only minimal services are provided in such areas as rehabilitation or long-term care?

· Are the patient’s interests being sacrificed to the bottom line? In other words, does a profit for the MCO become more important than the patient?

· Do the wealthy have better access to care and treatment?

Medicare and Medicaid laws prohibit physicians referring their patients to any service, such as physical therapy or dialysis centers, in which they may have a financial ownership or interest. In addition, physicians must be cautious that their patient charges do not violate Medicare’s fee-for-service reimbursement rule.

Managed care poses the question of how to maximize the services available to the maximum number of people. This ideal equity approach would bring access to healthcare for all at an appropriate level. This would result in a relationship between access, cost, and quality of care. However, changing any one of these three elements (access, cost, and quality of care) impacts on the other two areas. For example, if we provide more access to care without increasing the cost, then quality will be negatively affected. If there is a proposal to increase quality and access to care, then there will be an increase in cost. In the current healthcare system, the public perception is that managed care has sacrificed quality and access for cost.

In spite of the potential problems with managed care, it is not an inherently unethical system of healthcare. Under this system, monitoring and control of the excessive use of testing and surgical procedures have improved. In addition, a reputable MCO can provide better preventive programs and healthcare screening for early detection of disease. It can also reduce the unnecessary testing, treatments, and hospitalizations that were present under the old fee-for-service (FFS) system.

Health Care Quality Improvement Act (HCQIA) of 1986

Congress passed the Health Care Quality Improvement Act in response to a growing concern about medical malpractice. The act provides for peer review of physicians by other physicians and healthcare professionals. The act also provides protection from lawsuits (liability) that whistleblowers may face when they report issues of potential malpractice. The main purpose of this act is to improve the quality of medical care. The act also sets up a National Practitioner Data Bank (NPDB) which assists with the peer review of physicians. The NPDB collects information about physicians’ medical malpractice losses and settlements, investigations into licensure, and other damaging professional conduct. The NPDB has become a resource for organizations, such as state licensing boards, that require information about the qualification of doctors and dentists, in particular. This data bank information has become a necessary requirement when physicians are seeking medical staff hospital privileges. The data bank does not disclose this information to the general public.

TYPES OF MEDICAL PRACTICE

In the early part of the twentieth century, the main form of medical practice was the solo practice set up by a family practitioner within a designated town or geographic area. Over the years, the practice of medicine and the legal environment have changed. Few physicians make house calls any longer. However, patients now expect to be able to reach their physicians on a 24-hour basis.

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The increase in the number of patients who have initiated malpractice lawsuits has necessitated not only increased insurance coverage costs for physicians and patients, but different methods of practice.

Other forms of medical practice have become popular, including some that meet patient needs for around-the-clock coverage and some that provide the opportunity for a group of physicians to share insurance premium costs, staff, and facilities investments.

Solo Practice

In solo practice , a physician practices alone. This is a common type of practice for dentists. However, physicians generally enter into agreements with other physicians to provide coverage for each other’s patients and to share office expenses. Physicians are becoming increasingly reluctant to enter into solo practice because of the large burden of debt they incurred during their medical training and the high cost of operating an independent office.

A type of solo practice called sole proprietorship is one in which a physician may employ other physicians and pay them a salary. However, the sole proprietor of the medical practice is still responsible for making all the administrative decisions. The physician–owner pays all expenses and retains all assets.

The advantages of this type of practice include being able to retain all of the profits and to make the major decisions concerning policies and staffing. However, in a sole proprietorship, the owner is responsible and liable for the actions of all the employees. In addition, the physician may have to work long hours to provide his or her patients with the care they need. It is often difficult to find the correct balance of qualified physicians to help out during vacations and illnesses of the solo practitioner. This form of practice is diminishing rapidly due to increasing expenses and the lack of another physician to share the patient load.

Partnership

A partnership is a legal agreement to share in the business operation of a medical practice. A partnership may exist between two or more physicians. In this legal arrangement, each partner becomes responsible for the actions of all the other partners. This responsibility includes debts and legal actions unless otherwise stipulated in the partnership agreement. It is always advisable to have partnership agreements in writing. A document or “certificate of doing business as partners” is registered in the local county clerk’s office.

The advantages of a partnership include greater earning power than a physician just working alone can realize. There are also other physicians in a partnership to carry any burden of patient care, liability, overhead expenses, or capital requirements to improve the office facility. The disadvantages often relate to personality conflicts. In addition, all the partners in the group must share in the liabilities even if only a few of the members are responsible for incurring them (see Figure 4.2 ).

Associate Practice

The associate practice is a legal agreement in which physicians agree to share a facility and staff but not the profits and losses. They do not generally share responsibility for the legal actions of each other, as in a partnership. The legal contract of agreement stipulates the responsibilities of each party. The physicians act as if their practice is a sole proprietorship.

The legal arrangement of an associate practice must be carefully described and discussed with patients. Patients may mistakenly believe that there is a shared responsibility by all the physicians in the practice. This can lead to legal difficulties if one physician is accused of committing malpractice.

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To avoid the appearance that a partnership exists when one does not, physicians must be sure the signage on their offices, their letterhead and other stationery, and the manner in which the staff answers the telephone are not misleading.

Figure 4.2 Physicians in Partnership

Group Practice

A group practice consists of three or more physicians who share the same facility (office or clinic) and practice medicine together. This is a legal form of practice in which the physicians share all expenses and income, personnel, equipment, and records. A physician may be a member of a group practice as a partner or as an employee. Some areas of medicine frequently found in group practice are anesthesiology, rehabilitation, obstetrics, radiology, and pathology. In some cases, physicians who practice in a single specialty area such as radiology join together in group practice. The membership of a group practice can be quite large, and thus it may be a difficult setting to work in for those who prefer to work alone. In some cases, the income level may not be as high as in a more limited type of partnership due to the large number of physicians creating the expenses (see Figure 4.3 ).

A group practice can be designated as a health maintenance organization (HMO) or as an independent practice association (IPA). Group practices have grown rapidly during the last decade, and large groups of more than 100 doctors are not uncommon. A large group practice often forms a legal professional corporation.

Professional Corporations

During the 1960s, state legislatures passed laws (statutes) allowing professionals—for example, physicians and lawyers—to incorporate. A corporation is managed by a board of directors. There are legal and financial benefits to incorporating the practice.

Professional corporation members are known as shareholders. Some of the benefits that can be offered to employees of a corporation include medical expense reimbursement, profit sharing, pension plans, and disability insurance. These fringe benefits may not always be taxable to the employee and are generally tax deductible to the employer. While a corporation can be sued, the individual assets of the members cannot be touched (as they can in a solo practice). In some cases, a physician in solo practice will take legal steps to incorporate in order to provide some protection of assets. A corporation will remain until it is dissolved. Other forms of practice, such as the sole proprietorship, stop with the death of the owner. Today, most medical practices are corporations. Table 4.1 describes the types of medical practice along with the advantages and disadvantages of each.

Figure 4.3 Group Practice

© Robert Kneschke/fotolia

TABLE 4.1 Types of Medical Practices

Type of Practice	Advantages	Disadvantages
Solo practice (only one physician)	Physician retains independence; simplicity of organization; physician retains all assets	Difficulty raising capital; sole responsibility for liability and management functions; inadequate coverage of patients’ needs; practice may die with the owner
Sole proprietorship	Physician retains all assets; autonomy; physician hires other physicians to provide assistance	Pays all expenses; responsible for all liability
Partnership	Legal responsibility is shared among partners; work, assets, and income are shared	Partners may have personality differences; all partners are liable for actions of the other partners
Associate practice	Work is shared	Legal responsibility is not shared by all members all members
Group practice	All expenses and income are shared; all equipment and facilities are shared	Income may not be as great as when a physician practices alone; possible personality clashes among members
Single specialty	Expenses and staff are shared	Possible competition among specialists within the group
Corporation	Protection from loss of individual assets; many fringe benefits offered; corporation will remain until it is dissolved	Income may not be as great as in other forms of practice

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Physicians are moving away from solo practice and forming partnerships or corporations to better serve patient needs, share the costs of insurance, and, in the case of corporations, provide legal protection.

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Remember that in all forms of practice, the physician is responsible for the actions of his or her employees.

THE ETHICS OF FEE SPLITTING

Fee splitting occurs when one physician offers to pay another physician for the referral of patients. Fee splitting has long been considered unethical and is a basis for professional discipline. The payment of a referral fee is also considered a felony in states such as Alaska, New Mexico, Vermont, and California. However, the most prohibitive statements against accepting a fee for referrals are at the federal level. The Medicare and Medicaid programs both contain antifraud and abuse provisions. These provisions declare that anyone who receives or pays any money, directly or indirectly, for the referral of a patient for service under Medicare or Medicaid is guilty of a felony punishable by five years’ imprisonment, a $25,000 fine, or both.

Fee splitting is not the same as referrals to a hospital franchise , such as a pharmacy or radiology department. In this case, the holder of the franchise, or the franchisee , may legally pay the hospital in proportion to the amount of business received from hospital patients.

It is not necessarily considered fee splitting if the franchisee is paying an amount equal to expenses incurred. For instance, in a California case, a court held that a radiologist’s payment of two-thirds of his receipts to a hospital did not constitute fee splitting because the evidence showed that fees paid to the hospital were equal to expenses incurred by the hospital to furnish the diagnostic center (Blank v. Palo Alto-Stanford Ctr., 44 Cal. Rptr. 572, Cal. Ct. App. 1965).

MEDICAL SPECIALTY BOARDS

Of the 9 million people employed in the healthcare system, there are approximately 600,000 physicians, 35,000 doctors of osteopathy, and 150,000 dentists. Of the 600,000 physicians, only 150,000 practice primary patient care: family medicine, internal medicine, obstetrics, and pediatrics. The majority of physicians work in specialty fields such as anesthesiology, psychiatry, or a surgical specialty. Many physicians now work at salaried staff positions in hospitals, as members of group practices, for a corporate-sponsored medical care firm, or for community clinics.

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It’s important that the physician’s support staff, including nurses, physician assistants, certified medical assistants, and technicians, understand the different medical specialty categories because they are often the ones who respond to patients’ questions regarding these specialties.

Currently, 23 specialty boards are covered by the American Board of Medical Specialists. Included among these specialties are the American Board of Allergy and Immunology, American Board of Anesthesiology, American Board of Emergency Medicine, American Board of Internal Medicine, American Board of Surgery, and American Board of Urology. The specialty boards seek to improve the quality of medical care and treatment by encouraging physicians to further their education and training. The board evaluates the qualifications of candidates who apply and pass an examination. The physicians who pass the board review become certified as diplomats. As board-certified physicians, they may be addressed as either diplomats or fellows, a designation they can use after their name—for instance, Paul Smith, M.D., Diplomat of the American Board of Pediatrics.

Due to the dramatic advances in medicine over the past two decades, there continues to be an interest in specialization among physicians. Transplant surgery, including liver, kidney, lungs, and pancreas, has expanded the need for medical and surgical specialties. A description of some of the more common medical and surgical specialties is found in Table 4.2 .

TABLE 4.2 Medical and Surgical Specialties

Medical Specialty	Description
Adolescent medicine	Treats patients from puberty to maturity (ages 11 to 21)
Allergy and immunology	Treats abnormal responses or acquired hypersensitivity to substances with medical methods such as testing and desensitization
Anesthesiology	Deals with administration of both local and general drugs to induce a complete or partial loss of feeling (anesthesia) during a surgical procedure
Cardiology	Treats cardiovascular disease (of the heart and blood vessels)
Dermatology	Treats injuries, growths, and infections to the skin, hair, and nails
Emergency medicine	Focuses on the ability and skills to quickly recognize, prioritize (triage), and treat acute injuries, trauma, and illnesses
Family practice	Treats the entire family regardless of age and gender
Geriatric medicine	Focuses on the care of diseases and disorders of the elderly
Hematology	Specializes in blood and blood-forming tissues
Hospitalists	Specializes in caring for patients while they are in the hospital. Usually trained in internal medicine or family medicine.
Infection control	Focuses on the prevention of infectious disease by maintaining medical asepsis, practicing good hygiene, and promoting immunizations
Internal medicine	Treats adults who have medical problems
Neurology	Treats the nonsurgical patient who has a disorder or disease of the nervous system
Nephrology	Specializes in pathology of the kidney, including diseases and disorders
Nuclear medicine	Specializes in the use of radioactive substances for the diagnosis and treatment of diseases such as cancer
Obstetrics and gynecology	Obstetrics treats the female through prenatal care, labor, delivery, and the postpartum period; gynecology provides medical and surgical treatment of diseases and disorders of the female reproductive system
Oncology	Treats benign tumors and cancer-related tumors
Ophthalmology	Treats disorders of the eye
Orthopedics	Specializes in the prevention and correction of disorders of the musculoskeletal system
Otorhinolaryngology (ENT)	Specializes in medical and surgical treatment of the ear (otology), nose (rhinology), and throat (laryngology)
Pathology	Specializes in diagnosing abnormal changes in tissues that are removed during surgery or an autopsy
Pediatrics	Specializes in the care and development of children
Physical medicine/rehabilitative medicine	Treats patients after they have suffered an injury or disability
Preventive medicine	Focuses treatment on the prevention of both physical and mental illness or disability
Psychiatry	Specializes in the diagnosis and treatment of patients with mental, behavioral, or emotional disorders
Radiology	Specializes in the study of tissue and organs based on x-ray visualization
Rheumatology	Treats disorders and diseases characterized by inflammation of the joints, such as arthritis
Surgery	Corrects illness, trauma, and deformities using an operative procedure
Surgical Specialty	Description
Cardiovascular	Surgically treats the heart and blood vessels
Colorectal	Surgically treats the lower intestinal tract (colon and rectum)
Cosmetic/plastic surgery	Surgically reconstructs underlying tissues
Hand	Surgically treats defects, traumas, and disorders of the hand
Neurosurgery (CNS)	Surgically intervenes for diseases and disorders of the central nervous system
Orthopedic	Surgically treats musculoskeletal injuries and disorders, congenital deformities, and spinal curvatures
Oral (periodontics/orthodontics)	Treats disorders of the jaws and teeth by means of incision and surgery as well as tooth extraction; treats malocclusion (misalignment) of teeth
Thoracic	Surgically treats disorders and diseases of the chest

American College of Surgeons

The American College of Surgeons also confers a fellowship degree upon applicants who have completed additional training and submitted documentation of 50 surgical cases during the previous three years. A successful candidate becomes a Fellow of the American College of Surgeons (FACS).

American College of Physicians

The American College of Physicians offers a similar fellowship and entitles the applicant to become a Fellow of the American College of Physicians (FACP) in a nonsurgical area.

The designation doctor (Dr.) is the proper way of addressing—verbally or in writing—someone who holds a doctoral degree of any kind. In the medical field, the title of doctor indicates that a person is qualified to practice medicine within the limits of the degree received; in other fields, the title means that a person has attained the highest educational degree in that field. Several designations for doctor are listed in Table 4.3 .

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The term doctor comes from the Latin word docere, meaning “to teach.”

TABLE 4.3 Designations and Abbreviations for Doctors

Designations	Abbreviations
Doctor of Chiropractic	D.C.
Doctor of Dental Medicine	D.M.D.
Doctor of Dental Surgery	D.D.S.
Doctor of Medicine	M.D.
Doctor of Optometry	O.D.
Doctor of Osteopathy	D.O.
Doctor of Philosophy	Ph.D.
Doctor of Podiatric Medicine	D.P.M.

ALLIED HEALTH PROFESSIONALS

A physician works with a variety of trained personnel, depending on the area of specialization. Healthcare professionals are also called allied healthcare practitioners. There are specific requirements for healthcare professionals, including licensure, certification, and registration as well as a means of establishing competency. In addition, programs for educating healthcare professionals may seek accreditation such as through the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (See more about the JCAHO in Chapter 3 .)

Licensure , generally issued at the state level, is a mandatory credentialing process that allows an individual to legally perform certain skills. As dictated by law, there is usually a requirement to pass certain tests and exhibit the ability to perform certain skills. For example, nurses and pharmacists must graduate from an accredited educational program and pass a national examination that shows competency in their chosen medical field. Licensed personnel, including registered nurses, nurse practitioners, licensed practical nurses, and pharmacists are licensed in the state in which they practice. Licensed medical professionals can place their license in jeopardy, or even lose their license to practice their profession, if they abuse drugs or alcohol, steal from their employer or patients, lie about their education and training, or commit a criminal act.

Certification is a voluntary credentialing process usually offered by a private professional organization, such as a school, college, or other accreditation body. Certification indicates that the allied health professional has met the standards set by the certification entity. The individual programs will have requirements to adequately perform certain skills. Certified, but not licensed, personnel include physician assistants or registered/certified medical assistants, certified medical transcriptionists, laboratory technicians, and ultrasound technologists.

The American Association of Medical Assistants (AAMA), founded in 1956, is a key association in the field of medical assisting. This organization is responsible for the medical assistants’ certification process. Certification indicates that a candidate has met the standards of the AAMA by achieving a satisfactory test result. A certificate, or legal document, is issued to a person who has successfully passed the examination (see Figure 4.4 ).

Registration indicates that a person whose name is listed on an official record or register has met certain requirements in their particular profession. The registry list of names can then be accessed by healthcare providers to determine if a potential employee has met certain requirements. For example, registered nurses’ names are listed in the registry of the state in which they hold a license. The American Medical Technologists (AMT) association provides oversight for the registration and testing of medical assistants, medical technologists, and phlebotomists. This association, in cooperation with the AMT Institute for Education (AMTIE) has developed a continuing education (CE) program and recording system.

Figure 4.4 Health Professionals Working Together

The AMT, a nonprofit certifying body, provides a Registered Medical Assistant (RMA) certification for medical assistants who meet the eligibility requirements and who can prove their competency to perform entry-level skills through written examination. The RMA is awarded to candidates who pass the AMT certification examination.

Nonphysician health professionals also cannot practice medicine outside of their own licensure and expertise. If one acts outside the area of his or her competency and the patient is injured as a result, that healthcare practitioner is liable for malpractice or, in other terms, medical negligence. In this situation, the healthcare practitioner could be fined and/or lose his or her license. For example, it is against the law for a licensed practical nurse (LPN) or medical assistant to prescribe medications: this function lies only within the domain of a physician, nurse practitioner, or physician assistant. A phlebotomist is not licensed to discuss the results of a patient’s laboratory tests with the patient: only the physician is licensed to interpret and discuss this information with the patient.

MED TIP

Physicians and their staff who assist with hiring personnel have a responsibility to check the licensure and certification of all employees. For example, patients expect that when they see the initials R.N. after an employee’s name that person is trained and licensed as a registered nurse.

Accreditation agencies for allied health educational programs include the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Accrediting Bureau of Health Education Schools (ABHES). This accreditation, which is voluntary, requires that the educational facilities maintain particular standards which usually include an internship. (See Table 4.4 for a description of healthcare occupations.)

TABLE 4.4 Healthcare Professions

Occupation	Description
Certified Medical Assistant (CMA)	Duties are grouped into two categories: administrative and clinical. Works in a variety of healthcare settings including physicians’ offices and clinics. Must graduate from an accredited program and pass a national certification exam.
Certified Medical Transcriptionist (CMT)	Types dictation recorded by a physician or surgeon. Must pass a certification exam. Works in medical records departments in hospitals and other healthcare facilities.
Certified Professional Coder (CPC)	Evaluates medical orders using the Health Care Procedure System (HCPCS) used for billing purposes.
Dental Assistant	Works under the supervision of a dentist to prepare the patient for treatment, take dental x-rays, and hand instruments to the dentist.
Dental Hygienist	Works directly with the dental patient to clean teeth, take x-rays, and discuss results of the patient’s dental exam with the dentist.
Electrocardiograph Technologist	Operates electrocardiograph (EKG/ECG) machines to record and study the electrical activity of the heart.
Emergency Medical Technician (EMT/paramedic)	Provides emergency care and transports injured patients to a medical facility. Works for ambulance service or a hospital
Laboratory or Medical Technologist (MT)	Performs laboratory analysis, directs the work of laboratory personnel, and maintains quality assurance standards for all equipment. Also referred to as clinical laboratory scientist.
Licensed Practical Nurse (LPN)	Performs some, but not all, of the same tasks as the registered nurse. Must graduate from a recognized one-year program and become licensed by the National Federation of Licensed Practical Nurses. Works under the supervision of physicians and registered nurses.
Medical Records Technician	Skilled in health information technology; maintains medical records in healthcare institutions and medical practices.
Nurse Practitioner (NP)	A registered nurse who has additional training in a specialty area such as obstetrics, gerontology, or community health. This nurse usually holds a master’s degree.
Occupational Therapist (OT)	Provides treatment to people who are physically, mentally, developmentally, or emotionally disabled in the area of personal care skills; goal of OT is to restore the patient’s ability to manage activities of daily living.
Pharmacist	A licensed professional who orders, maintains, prepares, and distributes prescription medications.
Pharmacy Technician	Prepares and dispenses patient medications.
Phlebotomist	Draws blood from patients; certification is required in some states.
Physical Therapist (PT)	Provides exercise and treatment of diseases and disabilities of the bones, joints, and nerves through massage, therapeutic exercises, heat and cold treatments, and other means.
Physician Assistant (PA)	Assists the physician in the primary care of the patient. Requires additional education similar to a master’s level program; must work or have an internship experience and pass an accreditation exam. Works under the supervision of a physician.
Registered Nurse (RN)	A professional caregiver who has successfully completed a national licensure exam known as the National Council Licensure Examination (NCLEX).
Respiratory Therapist (RT)	Evaluates, treats, and cares for patients who have breathing abnormalities.
Social Worker	Provides services and programs to meet the special needs of the ill, physically and mentally challenged, and older adults.
Surgical Technician	Trained in operating room procedures and assists the surgeon during invasive surgical procedures.
Ultrasound Technologist (ARRT)	Uses inaudible sound waves to outline shapes of tissues and organs.
X-Ray Technologist (radiologic technologist)	Uses radiologic technology such as nuclear medicine and radiation.

MED TIP

Patients often refer to anyone wearing a white laboratory coat as “doctor” or a white uniform as “nurse.” Always correct patients and tell them exactly what your position is. If you are a student, be sure to wear an identifying badge so that you will not be asked to perform an action outside of your scope of practice.

Conscience Clause

Because many employees in a variety of healthcare settings have religious or moral objections to assisting with certain procedures, such as sterilization and abortion, several states have enacted legislation called a conscience clause . These clauses state that hospitals may choose not to perform sterilization procedures and that physicians and hospital personnel cannot be required to participate in such procedures or be discriminated against for refusing to participate. In 1979, a Montana nurse-anesthetist was awarded payment (damages) from a hospital that violated the Montana conscience clause. The hospital had fired her for refusing to participate in a tubal ligation (Swanson v. St. John’s Lutheran Hosp., 579 P.2d 702, Mont. 1979).

On the other hand, there have been situations in which employees do not wish to leave their work setting even though they are morally unable to assist with sterilization or abortion procedures. In one New Jersey case, a court held that a hospital could transfer a nurse from the maternity ward to the medical-surgical staff because the nurse refused to assist in sterilization or abortion procedures. The court ruled that the transfer was not illegal because the nurse did not lose her seniority and it did not alter her pay (Jeczalik v. Valley Hosp., 434 A.2d 90, N.J. 1981).

There are numerous examples of healthcare providers and patients clashing over the right to refuse to give treatment if it violates a person’s beliefs. This conflict stimulates bitter debate over religious freedom versus patients’ rights. Patients claim their rights are being ignored. Healthcare workers claim they are victims of religious discrimination when they are discharged or fired for refusing to provide service or care to patients. For example, a Chicago ambulance driver refused to transport a woman who was having an abortion, a Texas pharmacist refused to fill a prescription for a rape victim who was seeking the morning-after pill, and a California fertility clinic refused to give assistance to a gay woman who was requesting artificial insemination. Some respiratory therapists have objected to removing terminally ill patients from ventilators; gynecologists have declined to prescribe birth control pills; and some anesthesiologists have refused to provide anesthetics in sterilization procedures or to participate in executions.

Patient advocates claim that there is a long tradition in medicine that medical professionals have an ethical, as well as a professional, responsibility to place the patient’s needs first. Believers in a “right of conscience” or the “conscience clause” in medicine believe that U.S. citizens should not be forced to violate their moral and religious values. This debate is not new. After the 1973 Roe v. Wade decision allowing abortion, several states passed laws to protect doctors and nurses who did not want to participate in performing an abortion. Oregon’s law in 1994 to legalize physician-assisted suicide allows doctors and nurses to decline to participate.

Many such conflicts are quietly and informally handled. In some cases an employee will seek a position elsewhere; in others, a coworker will step in to assist with a procedure, usually without the patient’s even knowing of the change. The ethical dilemma facing both patients and healthcare workers becomes critical during an emergency. This is especially difficult in poor or rural areas where there are few options for care. There is currently no perfect solution, legal or otherwise, to this problem.

POINTS TO PONDER

· 1. What impact will managed care have upon your career as an allied health professional?

· 2. What type of practice does your physician/employer have? If it is not a solo practice, what are the other specialties involved in the practice?

· 3. What are the advantages of forming a corporation?

· 4. Why is it important to include the medical specialty and initials indicating a particular degree or license after one’s name?

· 5. What should you say if a patient refers to you as “doctor” or “nurse” even though your degree is in another discipline?

· 6. How should healthcare plans balance the interests of all the enrolled patients with the interests of a patient who has special medical needs and extraordinary expenses?

· 7. In the interest of maintaining a successful practice, should a physician refuse to provide care for patients who are uninsured or minimally insured?

· 8. Consider the question of ethics that arises when we ask ourselves if we are reducing unnecessary tests, as the HMOs and others believe we should, or if we are limiting tests for patients who really need them.

DISCUSSION QUESTIONS

· 1. Discuss your role as a medical professional in relation to the physician and other healthcare providers.

· 2. Discuss the impact that managed care is likely to have on your career in healthcare.

· 3. What can be done to ensure that MCOs provide ethical care for all patients?

· 4. Discuss “managed choice” as described in this chapter. Is there a choice?

REVIEW CHALLENGE

Short Answer Questions

· 1. What are the differences between Medicare and Medicaid?

· 2. What are the advantages and disadvantages of a group medical practice for a physician?

· 3. What are some of the areas that might be limited to patients under an MCO?

· 4. Explain the titles for the following abbreviations: D.P.M._____ O.D._____ D.O._____ D.M.D._____ M.D._____ D.C._____

· 5. Explain the titles for the following abbreviations: NP _____ CMT _____ CMA _____ RT _____ PT _____ ARRT _____ PA _____ ART _____

· 6. Explain the differences between licensure, certification, and registration.

· 7. What is the purpose of a conscience clause?

· 8. What is the National Practitioner Data Bank (NPDB)?

· 9. Explain the difference between a per diem payment system and a prospective payment system.

Matching

Match the responses in column B with the correct term in column A.

Column A		Column B
_____	1. HMO	a. preferred provider organization
_____	2. EPO	b. physicians agree to share expenses of a facility
_____	3. PPO	c. health maintenance organization
_____	4. solo practice	d. managed by a board of directors
_____	5. associate practice	e. financial assistance for the elderly
_____	6. sole proprietorship	f. exclusive provider organization
_____	7. corporation	g. one physician may employ others
_____	8. third-party payer	h. financial assistance for the indigent
_____	9. Medicaid	i. physician practices alone
_____	10. Medicare	j. insurance company