understanding health care denials as violations of standards of care
DESCRIPTION
Understanding Health Care Denials as Violations of Standards of Care. Tracy Weitz, PhD, MPA Susan Berke Fogel, JD Jamie Brooks, JD. Today’s Presentation. Brief Review Overall Project Goal Team Project Design Examples of Denials that Violate Standards of Care Recommendations - PowerPoint PPT PresentationTRANSCRIPT
Understanding Health Care Denials as Violations of Standards of Care
Tracy Weitz, PhD, MPA
Susan Berke Fogel, JD
Jamie Brooks, JD
Today’s Presentation
Brief Review Overall Project Goal Team Project Design
Examples of Denials that Violate Standards of Care
Recommendations How to talk about health care refusals Policy directions
The Standards of Care Project: Restrictions on Women’s Health
Goal: To investigate and document whether and to what extent denials of health care and information conflict with professionally-developed, accepted medical standards of care, and to analyze the potential medical and health consequences on patients.
Project Team
National Health Law Program (NHeLP)* Susan Berke Fogel, JD Jamie Brooks, JD
University of California, San Francisco Tracy Weitz, PhD, MPA
Public Interest Media Group Susan Lamontagne Adrienne Verrilli
*Lourdes Rivera, JD, resigned from project 11/07
National Advisory Group
Judy Ann Bigby, MDMassachusetts Dept. of Health[Internal Medicine]
Marcelle Ivonne Cedars, MDUniversity of California, San Francisco[Ob/Gyn nand Infertility]
Don Downing RPhUniversity of Washington[Pharmacy]
Timothy Johnson, MDUniversity of Michigan[Ob/Gyn and Maternal Fetal Medicine]
E. Bimla Schwarz, MD, MSUniversity of Pittsburgh[Internal Medicine]
Robyn Shapiro, JDMedical College of Wisconsin[Health Law Ethics]
R. William Soller, PhDUniversity of California, San Francisco[Pharmacy]
Sara Rosenbaum, JDGeorge Washington University[Health Law]
Nada L. Stotland, MD, MPHRush Medical College[Psychiatry]
Carol S. Weisman, PhDPennsylvania State University College of Medicine[Health Services Research]
Nancy F. Woods, PhD, RN, FAANUniversity of Washington[Nursing]
Sophia Yen, MDStanford Medical Center[Pediatrics]
Overall Project Design
Technical medical reportHow to talk about the issues
included in the reportDissemination of findings to the
health care professional community
Report Components
Provide a new framework for examining health care refusals Locate heath care refusals within the evolution of
health care in the U.S.
Review the religious and ideologically based restrictions and denials of care
Evaluate the effects of denials of care for women with health conditions necessitating information and services
Make policy recommendations
Current Framework
Current frame for “conscience clauses” Conflict between health care providers rights of
conscience and patient’s right to exercise autonomy
Contest of moral perspectives Fails to recognize that health care is unique
Decontexualization promotes issue as a philosophical debate without tangible results
Health Care is Unique
Practicing medicine, providing nursing care, or distributing drugs without a license are forbidden by law
Patients can only obtain certain care from professionals who are extended that privilege by the state
Information and services, therefore, do not take place in an open marketplace
Information and services occur in relationships created by law as inherently unequal
Trends in Health Care
Evidence-based practice Patient-centeredness Prevention
Transforming the provider-patient relationship to optimize health, broadly defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity
Standards of Care
The practices that are medically necessary and services that any practitioner under any circumstances should be expected to render
Requires that all health care professionals provide information and care consistent with the highest standards of scientific evidence, based on individual patient need, and with the goal of maximizing wellness
New Framework
The patient need for information or care includes a general claim to the information and/or services necessary to achieve health and well-being.
Denial of health care information and services can be examined using the lenses being employed to assess health care quality generally: evidence-based practice, patient-centeredness, and prevention.
Health care denials are understood as violations of the standard of care rather than as moral contests.
Sources of Restriction
Individual conscience clauses Statutory/regulatory shields from liability First introduced in 1970’s regarding abortion Current broadly worded laws regarding anything
“objectionable”
Politically-driven Linking funding to promotion of particular type of
care provision or information gag
Institutional Religious, political, or financial
Catholic Health Facilities
Broadest religiously-based health care restrictions Control > 16% of the hospital beds in the US 5 largest Catholic hospitals reported nearly $30
billion in net patient revenues in 2004 Governed by the Ethical and Religious Directives
for Catholic Health Care Services (The Directives) Promulgated by the U.S. Conference of Catholic Bishops The Directives present “a theological basis for the Catholic
health care ministry” Prohibit services including abortion, sterilization, most forms
of assisted reproductive technology, and contraceptives Contain no exceptions for rape, incest, or health
e.g. no exception for use of condoms to prevent HIV/AIDS
Effects of Denials of Care
Review of published medical standards and practice guidelines from leading professional associations, aka standards of care
Compare the expected standards of care with restrictions and denial of health care and information
What Standards of Care are Violated?
Reproductive and Sexual Health Pregnancy Prevention Pregnancy Termination Pregnancy Attainment
Pregnancy Prevention
In 2000, 34 million ♀ needed a method of pregnancy prevention
Many reasons to prevent pregnancy Personal, social, economic Medical
As a general standard of care CDC Preconception Guidelines ACOG Guidelines for Women’s Health
Every patient encounter include FP counseling and contraception options
Healthy People 2010 goal to reduce unintended pregnancies
As a specific standard of care for medical conditions
Use of Medications Contraindicated in Pregnancy
Acne Tx Accutane Standard of Care (FDA iPLEDGE requirements)
Patient use of 2 forms of contraception NFP, fertility awareness, and withdrawal not
allowed Physician counseling on contraception monthly
Consequences of pregnancy Major birth defects (35%) Increased risk miscarriage Premature birth
Health Conditions Require Medical Stability Prior to Pregnancy
Diabetes Standard of Care (ACOG and ADA)
Use of effective contraception at all times until metabolic control and actively seeking conception
Consequences of pregnancy Miscarriage, IUFD Fetal malformation or macrosomia Maternal death, blindness, heart failure,
kidney failure
Other Conditions Requiring Medical Management Prior to Pregnancy
EpilepsyMajor Depressive DisorderLupusHeart Disease
Ex. of Denials of Contraceptive Information and Care Individual
Provider failure to include or refusal to provide information on contraception in course of health care visit
Pharmacist refusals to fill prescriptions
Politically-driven Abstinence-only-until-marriage counseling and care
restrictions
Institutional Lack of insurance coverage for contraception when other
prescription drugs are covered Catholic ERD-no information or services to be provided
by health care providers or institutional services
Pregnancy Termination
In 2000, 1.3 million ♀ needed a pregnancy termination
Many reasons to terminate a pregnancy Personal, social, economic Medical
Standards of care Within the care guidelines for conditions Often obscured by language choice or as implied
but not listed
Ectopic Pregnancy
Pregnancy develops outside the uterus Standard of care
Treatment determined by individual clinical presentation and patient preference for intervention and future fertility (ACOG and RCOG)
Consequences of continued pregnancy Non-viable fetus Rupture, internal bleeding Maternal death Infertility
Ex. of Ectopic Care Denials
Individual Physician refusal to treat ectopic due to presence
of heart beat Politically-driven Institutional
ERDs Analyze ectopic pregnancy treatment within
context of prohibition on abortion Can not perform “direct” abortion Can perform some interventions under
principle of “double effect” i.e salpingectomy (removal of tube)
Policies differ by institution
Mid-trimester Premature Rupture of Membranes (PROM)
Standards of care Pt preference for expectant management
or induction of labor (i.e. abortion) (ACOG)
Complications of lack of care Infection, rare maternal sepsis Severe bleeding, aka hemorrhage Infertility Death
Ex. PROM Denials of Care
Individual Physician refusal to perform abortion Nurse refusal to participate in care for patient
Politically-driven Lack of public funding for procedure State bans on performance of abortions in publicly-
funded facilities
Institutional ERD prohibition on abortion if no double effect option
(i.e. presence of infection) Lack of skilled providers to perform D&E Refusal to make direct transfer of care to another facility
Other Conditions Necessitating Access to Abortion Care
Preeclampsia / EclampsiaFetus incompatible with life
Anencephaly
Uncontrolled medical conditions Diabetes Lupus Heart Disease
Policy Recommendations
Patient-Needs-First Systems and Policy Structures
Limit refusal allowances To individuals For care, not information or referral Meet specific criteria for objection
Ensure composition and distribution of care providers to ensure access to care
Treat denials as violations of standards of care with equivalent consequences
Thank You!