Chap 9: QI, Law & Ethics

Question 1

What does the AHRQ do?

Answer 1

Fosters the utilization of evidence-based medicine.

Question 2

What is ERISA?

Answer 2

The employee retirement income security act of 1974, establishes minimum standards for pension and other health insurance plans provided by private employers. It is a federal law that preempts state laws in most cases.

It forbids financial awards to beneficiaries for pain and suffering and punitive damages for gross negligence in the mismanagement of the healthcare plans.

Question 3

What is the difference in funding between Medicare and Medicaid?

Answer 3

Medicare is federally sponsored. Medicaid is jointly funded, federal and state.

Question 4

Who runs the HEDIS system? Which accrediting organization?

Answer 4

NCQA

Question 5

Which government department runs CMS? What does this department eliminate in 2008.

Answer 5

Health and human services

Effective 2008 CMS eliminated Medicare hospital reimbursement for the cost of eight complications if they occur in the hospital.

Question 6

Which law gave legal protection to peer review?

Answer 6

HCQIA, healthcare quality improvement act

Question 7

HCQIA establish his immunity from liability as long as several requirements are met. What are they?

Answer 7

Time frames, including for appeal, notification of the physician, including ability to be represented by an attorney, aware of the hearing process, witnesses etc., the case cannot be related to a civil rights claim, and importantly the main objective must be to improve care, not to remove a troublesome staff member. The peer review action MUST affect clinical privileges

Question 8

Under HCQIA, if peer review action is taken, it should be reported to whom?

Answer 8

The national practitioner data Bank. NPDB
This includes professional review actions including suspension, revoking clinical privileges or restriction while under investigation, professional board actions, malpractice payments and settlements, exclusion from Medicare-Medicaid programs and sanctions. Basically everything on the credentialing application form. Assumption is that a healthcare entity employing a physician has queried this databank to confirm information onon the credentialing form.

Question 9

What are the two main titles of HIPAA?

Answer 9

Title I: address issues related to healthcare access, portability, and insurance affected by change or loss of employment.

Title II: privacy, transactions, security, unique identifiers and enforcement. Also covers fraud and abuse.

Unique identifier for submission includes the NPI number.

Question 10

What are the four specific elements required to prove negligence?

Answer 10

1. A duty to treat
2. Breach of duty to provide average care
3. Causation
4. Evidence of injury-damages

Question 11

It’s medical malpractice is established, there are two types of damages: compensatory and punitive. What is the difference between these?

Answer 11

Compensatory may be for past or future cost, pain, anguish or loss of income.

Punitive: to send a message and punish the defendant.

Question 12

What is the name of the antitrust act that affects healthcare.

Answer 12

Sherman

Question 13

What is the difference between arbitration and mediation?

Answer 13

In arbitration a third-party makes the decision.

In mediation a third-party bring the two or more parties together with the assistance of a mediator, but does not involve a binding decision.

Question 14

Beauchamp and Childress define what forming principles of bioethics?

Answer 14

Respect for autonomy, including informed consent.
Beneficence and nonmaleficence.
Justice: equal access to care.

Question 15

What are the six IOM aims?

Answer 15

1. Safe
2. Timely
3. Effective (scientific)
4. Efficient (reduce cost/waste)
5. Equitable
6. Patient centered