Patient rights are continually evolving and are linked to governmental agencies and their regulations. Failure to respect these patient rights may have severe penalties imposed on those individuals, businesses, and ancillary health agencies that violate patient rights. However, if patients have rights, they should remember that patient rights also come with responsibilities. For example, patients need to be responsible to listen and act on the advice of their doctor(s), to tell the truth when asked questions (for example, “Do you use any illegal drugs,” “How many alcoholic beverages do you drink per day” and many others). When there is mutual respect and honesty between healthcare professionals and patients, there is seldom any problems with patient rights.

By Charles Patrick Davis, MD, PhD., emedicinehealth.com. 

What are Patient Rights?

Patient rights are those basic rule of conduct between patients and medical caregivers as well as the institutions and people that support them. A patient is anyone who has requested to be evaluated by or who is being evaluated by any healthcare professional. Medical caregivers include hospitals, healthcare personnel, as well as insurance agencies or any payors of medical-related costs. This is a broad definition, but there are other slightly more specific definitions. For example, a legal definition is as follows; patient rights is general statement adopted by most healthcare professionals, covering such matters as access to care, patient dignity, confidentiality, and consent to treatment.

No matter what definition is used, most patients and doctors are finding that many of the details of patient rights have changed and are continuing to change over time. This article is designed to give the reader a basic introduction to patient rights.

Often, people do not realize their specific rights at the time of their care because those rights are either not clearly defined or included in a bundle of papers that patients need to sign during registration. Some basic rights are that all patients that seek care at an emergency department have the right to a screening exam and patients that cannot afford to pay are not turned away. The details of these rights are detailed in the Emergency Medical Treatment and Active Labor Act (EMTALA) laws in the U.S. In addition, many people think that patient rights are only applicable between themselves and their doctor. This is not the situation; as stated in the first definition, patient rights can be extensive and exist between many people and institutions. Most notably, they can exist between patients, any medical caregiver, hospitals, laboratories, insurers and even secretarial help and housekeepers that may have access to patients or their medical records.

It is not possible in this article to list all of patient’s rights. However, most written rights that doctors and hospital personnel have patients read (and sign) are abbreviated statements that are summaries of all or parts of the American Medical Association (AMA) Code of Medical Ethics. Many of these patient rights have been written into state or federal laws and if violated, may result in fines or even prison time.

This article will focus on the doctor patient relationship and present areas of greatest concerns. Readers should understand that in most instances, when the word “doctor” is used, the reader may substitute many other names such as nurse, caregiver, hospital, insurer, doctor’s office personnel and many others. A patient’s rights in relation to their doctors occur at many different levels, and in all specialties. As stated above, the American Medical Association (AMA) outlines fundamental elements of the doctor-patient relationship in their Code of Medical Ethics.

According to the AMA, physicians should also serve as advocates for patients and promote the basic patient rights.

Communication

Open and honest communication is an integral part of the doctor-patient relationship. The AMA’s Code of Medical Ethics clearly states that it is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions. Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician’s mistake or judgment. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. Only through full disclosure is a patient able to make informed decisions regarding future medical care.

Past patient surveys have found that virtually all patients desired some acknowledgment of even minor errors. For both moderate and severe mistakes, patients were significantly more likely to consider legal action if the physician did not disclose the error. Findings such as these reinforce the importance of open communication between physician and patient.

Informed Consent

Part of communication in medicine involves informed consent for treatment and procedures. This is considered a basic patient right. Informed consent involves the patient’s understanding of the following:

• What the doctor is proposing to do
• Whether the doctor’s proposal is a minor procedure or major surgery
• The nature and purpose of the treatment
• Intended effects versus possible side effects
• The risks and anticipated benefits involved
• All reasonable alternatives including risks and possible benefits.

Closely associated with informed consent, voluntary consent means that the patient understands these concepts; the patient rights include the following:

• Freedom from force, fraud, deceit, duress, overreaching or other ulterior form of constraint or coercion
• The right to refuse or withdraw without influencing the patient’s future healthcare
• The right to ask questions and to negotiate aspects of treatment

A patient must be competent in order to give voluntary and informed consent. Thus, competent consent involves the ability to make and stand by an informed, freely made decision. In clinical practice, competence is often equated with capacity. Decision-making capacity refers to a patient’s ability to make decisions about accepting healthcare recommendations. To have adequate decision-making capacity, a patient must understand the options, the consequences associated with the various options, and the costs and benefits of these consequences by relating them to personal values and priorities.

Some factors may make a patient incapable of providing competent consent either temporarily or permanently. Examples include the following:

• Mental illness or mental retardation
• Alcohol or drug intoxication
• Altered mental status
• Brain injury
• Being too young to legally make decisions concerning health care

Patients that are judged incompetent (often determined by two independent physicians or in some instances, by a legal decree) can have others legally permitted to make medical decisions for the patient.

The Patient’s Bill of Rights

The Affordable Care Act puts consumers back in charge of their health care. Under the law, a new “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health.

• Provides Coverage to Americans with Pre-existing Conditions: You may be eligible for health coverage under the Pre-Existing Condition Insurance Plan.
• Protects Your Choice of Doctors:Choose the primary care doctor you want from your plan’s network.
• Keeps Young Adults Covered: If you are under 26, you may be eligible to be covered under your parent’s health plan.
• Ends Lifetime Limits on Coverage: Lifetime limits on most benefits are banned for all new health insurance plans.
• Ends Pre-Existing Condition Exclusions for Children: Health plans can no longer limit or deny benefits to children under 19 due to a pre-existing condition.
• Ends Arbitrary Withdrawals of Insurance Coverage: Insurers can no longer cancel your coverage just because you made an honest mistake.
• Reviews Premium Increases: Insurance companies must now publicly justify any unreasonable rate hikes.
• Helps You Get the Most from Your Premium Dollars:Your premium dollars must be spent primarily on health care – not administrative costs.
• Restricts Annual Dollar Limits on Coverage:Annual limits on your health benefits will be phased out by 2014.
• Removes Insurance Company Barriers to Emergency Services: You can seek emergency care at a hospital outside of your health plan’s network.

Since the Patient’s Bill of Rights was enacted, the Affordable Care Act has provided additional rights and protections.

The health care law:

• Covers Preventive Care at No Cost to You: You may be eligible for recommended preventive health services. No copayment.
• Guarantees Your Right to Appeal: You now have the right to ask that your plan reconsider its denial of payment.

SOURCE:
HealthCare.gov. Patient’s Bill of Rights

Confidentiality

Law and ethics state that the doctor-patient interaction should remain confidential. The physician should never reveal confidential information unless the patient wants this information disclosed to others, or unless required to do so by law. If the release of information is warranted, information should be released in the form of an official signed document.

Confidentiality is subject to certain exceptions because of legal, ethical, and social considerations.

• When patients are at risk of physically harming another person, or if those patients are at risk of harming themselves, the physician has the legal obligation to protect the potential victim and notify law enforcement authorities.
• All U.S. states and Canadian provinces require all cases of child abuse to be reported to the district attorney’s office and/or child protective services. This includes suspected and confirmed cases of child abuse. Failure of health care personnel to report child abuse and neglect may result in criminal prosecution under the Child Abuse and Prevention Act of 1974. Failure to report child abuse may also result in civil prosecution for malpractice if the child suffers injury or death because the abuse was not reported. This is another special case in which patient confidentiality does not exist. Doctors that reasonably suspect child abuse and report it are not liable if Child Protective Services ultimately find there was no abuse. New changes also extends this law to elderly patients.
• In addition to child and elderly abuse, certain aspects relating to confidentiality does not apply to cases involving some specific communicable diseases, gunshot wounds, and knife wounds that are related to illegal or criminal activity.
• The subject of minors creates a special situation regarding confidentiality. The laws vary from state to state. Most states regard a person younger than 18 years as a minor.
  • An exception is made for emancipated minors, who are considered self-reliant because, for example, they are married or have children themselves. Emancipated minors are usually regarded as adults in reference to their medical care.
  • Minors who live with their parents but are self-reliant and independent are considered mature minors. In some states, a mature minor may be considered an adult regarding medical treatment. In various states and depending on the situation, minors can consent to treatment for contraception, drug and alcohol problems, psychiatric conditions, pregnancy, abortion, and sexually transmitted diseases (STDs, venereal diseases) without the knowledge of their parents. It is best for doctors and patients to know the laws that pertain to the State where the medical situation is to be assessed and treated.

The Right to Healthcare

Most people agree that everyone deserves the basic right to healthcare, but how far that right goes has been the center of America’s healthcare debate; even with the Supreme Court upholding the current new federal healthcare laws, the debate continues, even to the point that the new laws may undergo repeal. Within the existing social structure, inequities in access to healthcare are widespread. Because of numerous inequities in healthcare that often involve such factors as race, socioeconomic status, and gender, politicians have tried for many years to change the healthcare system and are likely to continue to intervene and change these “patient rights.”

America’s health care system consists of a patchwork of healthcare programs and insurance that includes private health insurance, HMOs, Medicaid, and Medicare, among others. However, more than 49 million Americans are uninsured according to 2010 census data, and the government has been forced to pass various laws in order for America’s health care system to provide more equal care.

An example of such a law is the Consolidated Omnibus Budget Reconciliation Act (COBRA). The COBRA regulations are federal legislation that mandates an evaluation of patients who seek medical attention at emergency facilities. If an emergency care institution refuses to provide care, the institution and health care providers are held responsible and liable. These regulations prevent health care institutions from refusing needed care to people without money or health insurance.

• Together, the COBRA laws and the newer Emergency Medical Treatment and Active Labor Act (EMTALA) refer to federal laws related to patient screening and transfer. They require all emergency departments and Medicare-participating hospitals to do the following:
  • Perform an appropriate medical screening examination by a qualified provider to determine whether an emergency condition exists
  • Provide further examination and treatment to stabilize the patient, and if necessary and appropriate, to arrange a transfer
  • Consider patients in labor unstable for transfer, under special conditions (see below).
• EMTALA requires that all emergency departments and Medicare-participating hospitals to screen anyone who is in active labor or is seeking emergency care. If such a screening reveals the presence of an emergency medical condition – such as severe pain, serious threat to life or limb, or active labor – the hospital is required to perform stabilizing treatment to the best of its capabilities.

In order to provide continuing health insurance for the recently unemployed, COBRA provisions also permit continuation of coverage through the workplace. Recently, many federal and civil lawsuits have been filed and both won and lost against HMOs for failing to provide needed care because of the drive to reduce health care costs. The outcome of such lawsuits is sometimes unclear, but the quality of provided care is on the minds of all who obtain health care.

Abandonment

The doctor has the duty to continue a patient’s healthcare after consenting to provide medical care unless the patient no longer requires treatment for the illness. The doctor must notify the patient and transfer care to another acceptable doctor if planning to withdraw care. The doctors may be charged with negligent abandonment for ending the relationship with the patient without appropriate referral, transfer, or discharge. Although doctors are free to choose which patients they will treat, doctors should offer optimal care for patients who need emergency first-aid treatment.

Right to Refuse Care – Adults, Parents, and Children

Along with the right to adequate and appropriate healthcare, competent adult patients have the right to refuse health care (it is wise to document that the patient clearly understands the risks and benefits of their decision), but exceptions do occur.

• Patients with an altered mental status because of alcohol, drugs, brain injury, or medical or psychiatric illness may not be able to make a competent decision; then the patient may need to have a person legally appointed to make medical decisions.
• Although laws have established the right of an adult to refuse life-sustaining treatment, they do not allow parents or guardians to deny children necessary medical care.
• In the case of Prince v. Massachusetts, the U.S. Supreme Court ruled: “The right to practice religion freely does not include the liberty to expose the community or child to communicable disease, or the latter to ill health or death. Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion.” Legal advice and Child Protective Services should be sought and informed about these occurrences to avoid counter charges of assault and battery by the parents or child.

Legal Principles in Medicine

One way to look at patients’ rights is to view the legal implications that occur when patients’ rights are violated. Torts, which are defined as civil injustices recognized as grounds for a lawsuit, are often involved in medical injury claims and malpractice claims. Negligence is the basis for the majority of claims involving medical issues in the United States. A civil negligence claim involves a plaintiff and a defendant.

In order to succeed in court, the plaintiff (the patient, in this case) must prove four elements in medical malpractice: (1) a preexisting duty, (2) a breach of duty, (3) damage, and (4) immediate cause.

1. “Duty to treat” implies that the licensed physician agrees to practice medicine and accepts a patient for the purposes of medical treatment. In doing so, a physician-patient relationship is established and a contract to provide care exists. The physician owes each patient the duty to possess and to bring to bear on the patient’s behalf that degree of knowledge, skill, and care usually exercised by reasonable and careful practitioners under similar circumstances, given the current medical knowledge and the available resources.
2. Once a duty to treat has been established, the plaintiff must prove that a breach of duty has occurred. When a health professional fails to comply with minimum standards of his or her specialty, a breach of duty may exist. The physician is expected to act professionally according to the standard of care expected of the similarly trained, reasonable, careful professional under the same or similar circumstances. Unfortunately, the “standard of care” changes over time and frequently is not even clearly defined in many instances.
3. After the plaintiff proves that a duty to treat exists and that a breach of duty occurred, he or she next has to prove that damage has occurred. Damage is demonstrated through personal loss, injury, or deterioration because of the physician’s negligence. Without damage, negligence cannot be established. Damages may include physical and mental disability, pain and suffering, loss of income, present and future medical expenses and death.
4. Causation is the last aspect of negligence. If a duty to treat exists, and the standard of care was not met, the plaintiff must prove that the defendant’s breach of duty reasonably caused the plaintiff’s damage.

In order for the plaintiff to prove negligence of the physician, all four of these components must exist at least in the opinion of a judge or jury that decides the outcome.

Medical Research and Patients’ Rights

The issue of patient rights in medical research has developed over the years because of unethical practices that have occurred in the past. The Nuremberg Code was formulated in 1947 because of the trial of Nazi physicians who had experimented on unwilling subjects. The Code states that “the voluntary consent of the human subject is absolutely essential.”

In 1964, the Declaration of Helsinki softened the stipulations of the Nuremberg Code by allowing the legal guardians of incompetent persons to provide consent on their behalf, at least for “therapeutic” research.

After the exploitation of subjects in the Tuskegee study of syphilis, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created in 1974. The Commission discussed the problem of using vulnerable groups as research subjects. An article in the Journal of the American Medical Association proposed seven requirements that provide a framework for evaluating the ethics of clinical research studies that is generally adopted by medical researchers:

1. Value: Enhancements of health or knowledge must be derived from the research.
2. Scientific validity: The research must be methodologically rigorous.
3. Fair subject selection: Scientific objectives, not vulnerability or privilege, and the potential for and distribution of risks and benefits, should determine communities selected as study sites and the inclusion criteria for individual subjects.
4. Favorable risk-benefit ratio: Within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowledge gained for society must outweigh the risks.
5. Independent review: Unaffiliated individuals must review the research and approve, amend, or terminate it.
6. Informed consent: Individuals should be informed about the research and provide their voluntary consent.
7. Respect for enrolled subjects: Subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored.

Clinical trial: As in medical treatment, patients have the right to refuse to participate in clinical research, and this should not affect their care. Enrollment in a clinical trial also should not prevent a patient from obtaining timely and appropriate medical care.

• The institutional review board (IRB) is the essential element of the current regulatory system for research. The system relies on a local, institution-based review of proposed research. When a study involves human experimentation, almost every major funding agency and academic institution in the United States and Europe requires that the study be approved by a formally organized IRB.
• The purpose of the IRB is to review studies and protect patients from the potential harms of research, especially patients who may not be competent to consent to participate in research. In the past, minority groups have been subject to exploitation by medical research. Research using minority participation involves issues of cultural and linguistic differences and the potential for increased risk of coercion and exploitation.

Reviewed on 11/20/2017

REFERENCES:

American Medical Association. Code of Medical Ethics: Current Opinions with Annotations. 2012-2013, 2012, 1-568 pp.

HealthCare.gov. Patient’s Bill of Rights.

Emedicinehealth.com

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What Patient Rights?

By Jim Klein for APRA.

Americans have few laws to protect them when it  comes to their healthcare. The laws that do exist are essentially toothless, generally ignored by the medical industry and unenforced.

The American Hospital Association (AHA) adopted a Patient’s Bill of Rights in 1973 and further revised it in 1992 however these are only guidelines and are not legally enforceable. The AHA Patient Bill of Rights is a list of standards that patients can expect in health care according to the AHA. JCAHO requires hospitals to post a copy of the AHA’s Patient Bill of Rights and most managed care organizations also require contracted physicians to post a copy of the Patient Bill of Rights.

In 2001 a Patient’s Bill of Rights which would have provided comprehensive protection for patients covered by health insurance was considered by Congress but defeated by the health insurance industry, which goes to great lengths to keep its campaigns hidden from the public.

Most states have adopted a version of the American Hospital Association’s Patient Bill of Rights but generally do not uphold their patient rights statutes. This means that those in the medical industry are able to act with impunity. The patient is left to fend for himself against any threat to his health or well-being. Patients are fully exposed and at risk of physical and financial harm whenever they seek medical care.

The Affordable Care Act established a “Patient’s Bill of Rights” which gave people added stability and flexibility to make informed choices about their health. But those rights are being slowly eroded away.

HIPAA

The HIPAA law was created to safeguard and ensure that patient’s medical records and information are kept private, but since 2002 when a change in the law occurred it does not do so. And healthcare providers use it as a convenient excuse to refuse to release information whenever there is any inquiry into treatment that they have provided, even on occasion to the individual who has received treatment, which is illegal.

With the exception of Medicare fraud, which the US Justice Department now vigorously prosecutes, patients are generally left unprotected when it comes to issues regarding medical services received. When harm occurs, in general their only recourse is a expensive lawsuit, which is not feasible for most people unless malpractice has occurred and a lawyer agrees to take the case on contingency (only 2-4% of cases).

So What Do We Do

APRA believes that consumers should have viable, enforced legal rights protecting them with respect to the medical services they receive, just as they have legal rights protecting them as consumers of other types of goods and services.

Establishing a clearly defined set of objective legal standards for the medical treatment of patients in the form of patient rights, that are backed by appropriate penalties for failing to abide by the law, will, for the first time, make anyone in the medical industry who attends to patients accountable for their actions and will remove the opportunity to take advantage of patients without fear of repercussion.

By increasing the risk and opportunity cost and decreasing the benefit, the temptation to treat patients poorly or take advantage of them for personal gain will be significantly diminished.

With such temptations removed patients will have a greater chance of receiving safe, fair and honest treatment, which in turn will offer a better chance for a positive outcome at a lower cost.

When laws are established that require patients to be treated as people in need of medical attention, rather than sources of income, healthcare outcomes will improve and the cost of healthcare will decline. Strong patient rights laws will save lives, reduce medical costs and protect doctors and hospitals as well as patients.

APRA has developed a Patient Medical Bill of Rights which would provide greater protection for patients and, if implemented, could potentially save many lives each year as well as healthcare costs.

Support our fight for fair and reasonable patient rights by joining APRA today.

May 15, 2017.

Editor: Although the publication date of an article may not be current the information is still valid.

By Trisha Torrey, Reviewed by Richard N. Fogoros, MD.  From Verywell Health.

Among the reasons a doctor may dismiss his or her patient are:

1. Patient non-compliance (non-adherence). When the patient fails to follow the treatment recommendations established by the doctor. (Which is why it is so important that you and your doctor make treatment decisions together.)
2. Patient’s failure to keep appointments. Patients make appointments, then cancel them at the last minute, or don’t show up at all. From the provider’s perspective, that means a window of no income in addition to the fact that the patient isn’t getting the help he or she needs.
3. A patient’s rude or obnoxious behavior. No patient should ever be rude or obnoxious. It’s a form of abuse. Just as we patients should fire a doctor who behaves this way, it’s fair that a doctor should fire a patient for such poor behavior, too.
4. Non-payment of bills – money owed by the patient, but usually not the patient’s insurance.
5. If the doctor’s practice is closing. Just like the rest of us, doctors close their practices. They may sell them, or retire from practice, they may die, or just close their doors.
6. A relatively new reason for dismissal seems to be based on the type of insurance a patient has. In recent years, more and more patients report their doctors are firing them for no apparent reason (at least they are not told what the reason is). The one thing these patients have in common is that their health insurers are those that reimburse providers at very low rates. As reimbursements have gone down, the number of patients reporting dismissals from their doctors has gone up. If you aren’t sure why your doctor has dismissed you, you may want to better understand why doctors don’t want to accept some insurance.

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When a Doctor Cannot Legally Dismiss a Patient

There are reasons and times a doctor may not legally or ethically fire a patient, too – most of which are based on state or federal law.

• Doctors may not discriminate based on race, color, religion, national origin, sexual orientation, gender identity or any other attribute that is nationally recognized as discrimination. The courts have ruled that a patient cannot be dismissed because he or she is HIV-positive. If you feel as if you have been discriminated against for one of these reasons, contact your state health department.
• Doctors may not dismiss a patient in the midst of ongoing medical care, called “continuity of care.” For example, a pregnant woman cannot be dismissed by her doctor within a few weeks of delivery. A cancer patient cannot be fired before his chemo or radiation treatments are completed. However, a patient who has been on a primary care doctor’s roster, but hasn’t visited that doctor in a year or two might be dismissed. That is not considered ongoing care.

How the Patient Dismissal Takes Place

Some states have laws that govern the process a doctor should use to fire his patient. However, in most cases, the dismissal protocol is based more on ethics and responsibility to the patient than what the law may or may not tell them they must do. These guidelines are mostly intended to keep the doctor out of hot water (at least) or to help avoid a lawsuit.

The best situation a patient who is being dismissed can hope for is a postal letter which provides him or her with 30 days notice, access to their medical records, and suggestions for new providers. At the least, the patient may receive no notice whatsoever.

Few states oblige the doctor to declare the reason for dismissal. Some guidelines even tell the doctor not to mention the reason for firing in order to avoid an argument from the patient.

What to Do If Your Doctor Dismisses You

If your doctor fires you, you have a few options:

• If you want to go back to that doctor, you may want to attempt to repair the relationship with your doctor. This will involve knowing what the reason was that you were dismissed (which may, or may not, be apparent).
• If you prefer to move on to a new doctor, then be sure to get copies of your medical records from the doctor who fired you, then follow the guidelines for changing doctors.

Some “don’ts” to remember as you make this transition:

• Don’t get overly argumentative, obnoxious or aggressive. It could result in your being blackballed.
• Don’t ask the doctor who is dismissing you for a referral. Your better bet is to find someone on your own, someone who is independent from the doctor who has fired you.
• Don’t complain about the old doctor. It does not move you forward, and may give your new doctor a reason not to engage with you as a patient.  []

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According to a recent publication from the Commonwealth Fund, based on a broadly inclusive set of performance metrics, the U.S. health care system performance ranks last among 11 high-income countries.

Among the 11 nations studied in this report – Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in 2010, 2007, 2006, and 2014.

“Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity.”

The United States spends far more on health care than other high-income countries, with spending levels that rose continuously over the past three decades. Yet the U.S. population has poorer health than other countries. Life expectancy, after improving for several decades, worsened in recent years for some populations, aggravated by the opioid crisis. In addition, as the baby boom population ages, more people in the U.S.—and all over the world—are living with age-related disabilities and chronic disease, placing pressure on health care systems to respond.

Timely and accessible health care could mitigate many of these challenges, but the U.S. health care system falls short, failing to deliver indicated services reliably to all who could benefit. In particular, poor access to primary care has contributed to inadequate prevention and management of chronic diseases, delayed diagnoses, incomplete adherence to treatments, wasteful overuse of drugs and technologies, and coordination and safety problems.

This report uses recent data to compare health care system performance in the U.S. with that of 10 other high-income countries and considers the different approaches to health care organization and delivery that can contribute to top performance. We based our analysis on 72 indicators that measure performance in five domains important to policymakers, providers, patients, and the public: Care Process, Access, Administrative Efficiency, Equity, and Health Care Outcomes.

Our data come from a variety of sources. One is comparative survey research. Since 1998, The Commonwealth Fund, in collaboration with international partners, has supported surveys of patients and primary care physicians in advanced countries, collecting information for a standardized set of metrics on health system performance. Other comparative data are drawn from the most recent reports of the Organization for Economic Cooperation and Development (OECD), the European Observatory on Health Systems and Policies, and the World Health Organization (WHO).

The United States ranks last in health care system performance among the 11 countries included in this study. The U.S. ranks last in Access, Equity, and Health Care Outcomes, and next to last in Administrative Efficiency, as reported by patients and providers. Only in Care Process does the U.S. perform better, ranking fifth among the 11 countries.

CARE PROCESS

The United States ranks in the middle on Care Process (5th), with stronger performance on the subdomains of prevention, safety, and engagement. The U.S. performs slightly below the 11-country average in the coordination subdomain.

The U.S. tends to excel on measures that involve the doctor–patient relationship, performing relatively better on wellness counseling related to healthy behaviors, shared decision-making with primary care and specialist providers, chronic disease management, and end-of-life discussions.

The U.S. also performs above the 11-country average on preventive measures like mammography screening and older adult influenza immunization rates. However, the U.S. performs poorly on several coordination measures, including information flows between primary care providers and specialist and social service providers. The U.S. also lags other countries on avoidable hospital admissions.

ACCESS

Overall, the United States ranks last on Access. The U.S. has the poorest performance of all countries on the affordability subdomain, scoring much lower than even the second-to-last country, Switzerland. The U.S. ranks ninth on the subdomain of timeliness.

ADMINISTRATIVE EFFICIENCY

The United States ranks 10th on Administrative Efficiency. Compared to the other countries, more U.S. doctors reported problems related to coverage restrictions. Larger percentages of U.S. patients also reported Administrative Efficiency problems compared to those in other countries (except France).

EQUITY

The United Kingdom, the Netherlands, and Sweden rank highest on measures related to the equity of health systems with respect to access and care process.

In contrast, the United States, France, and Canada have larger disparities between lower and higher-income adults. These were especially large on measures related to financial barriers, such as skipping needed doctor visits or dental care, forgoing treatments or tests, and not filling prescriptions because of the cost.

HEALTH CARE OUTCOMES

The United States ranks last overall in Health Care Outcomes. However, the pattern of performance across different outcomes measures reveals nuances. Compared to the other countries, the U.S. performs relatively poorly on population health outcomes such as infant mortality and life expectancy at age 60. The U.S. has the highest rate of mortality amenable to health care and has experienced the smallest reduction in that measure during the past decade (Exhibit 4). In contrast, the U.S. appears to perform relatively well on 30-day in-hospital mortality after heart attack or stroke. The U.S. also performs as well as several top performers on breast cancer five-year relative survival rate and close to the 11-country average on colorectal cancer five-year relative survival rate.

Causes of Poor Performance

The country’s performance shortcomings cross several domains of care including Access, Administrative Efficiency, Equity, and Health Care Outcomes. Only within the domain of Care Process is U.S. performance close to the 11-country average. These results are troubling because the U.S. has the highest per capita health expenditures of any country and devotes a larger percentage of its GDP to health care than any other country.

The U.S. health care system is unique in several respects. Most striking: it is the only high-income country lacking universal health insurance coverage. The U.S. has taken an important step to expand coverage through the Affordable Care Act. As a 2017 Commonwealth Fund report showed, the ACA has catalyzed widespread and historic gains in access to care across the U.S. More than 20 million Americans gained insurance coverage. Additional actions could extend insurance coverage to those who lack it. Furthermore, Americans with coverage often face far higher deductibles and out-of-pocket costs than citizens of other countries, whose systems offer more financial protection. Incomplete and fragmented insurance coverage may account for the relatively poor performance of the U.S. on health care outcomes, affordability, administrative efficiency, and equity.

Several new U.S. federal initiatives—notably the Affordable Care Act—have promoted actions to improve U.S. health care system performance. In addition to extending insurance coverage to millions of Americans, recent legislation includes initiatives to spur innovation in health care delivery by changing payment incentives for providers. But health systems can be slow to change. Additional legislative and policy reforms may be needed to close the performance gap between the U.S. and other countries.

The U.S. could learn important lessons from other high-income countries. For example, the U.S. performs poorly in administrative efficiency mainly because of doctors and patients reporting wasting time on billing and insurance claims. Other countries that rely on private health insurers, like the Netherlands, minimize some of these problems by standardizing basic benefit packages, which can both reduce administrative burden for providers and ensure that patients face predictable copayments.

The U.K. stands out as a top performer in most categories except for health care outcomes, where it ranks with the U.S. near the bottom. In contrast to the U.S., over the past decade the U.K. saw a larger decline in mortality amenable to health care (i.e., a greater improvement in the measure) than the other countries studied. (The U.S. has had the smallest decline, or lowest level of improvement.) In the early 2000s, the U.K. made a major investment in its National Health Service, reforming primary care and cancer care in addition to increasing health care spending from 6.2 percent of GDP in 2000 to 9.9 percent of GDP in 2014. The reforms and increased spending may have contributed to the rapid decline in mortality amenable to health care in the U.K.

There is a striking contrast between the U.S’s poor performance on infant mortality, life expectancy, and amenable mortality and its relatively better performance on in-hospital mortality after heart attack or stroke. Researchers have noted that the only modest decline in the rate of amenable mortality in the U.S. may be attributable to better management, once diagnosed, of hypertension and cerebrovascular disease that lead to cardiovascular mortality. These findings highlight the combined impact of a lack of universal insurance coverage and barriers to accessing primary care, and suggest that the U.S. could make gains by investing more in preventing chronic disease. The high level of inequity in the U.S. health care system intensifies the problem. For the first time in decades, midlife mortality for less-educated Americans is rapidly increasing.

In conclusion, the performance of the U.S. health care system ranks last compared to other high-income countries. Despite spending nearly twice as much as several other countries, the country’s performance is lackluster. This report points to several areas that the U.S. could improve, building on recent health reforms, to achieve better performance. The success of U.S. initiatives to reduce readmissions and hospital-acquired conditions suggest the country’s health care can be improved. To gain more than incremental improvement, however, the U.S. may need to pursue different approaches to organizing and financing the delivery system. These could include strengthening primary care, supporting organizations that excel at care coordination and moving away from fee-for-service payment to other types of purchasing that create incentives to better coordinate care. These steps should ensure early diagnosis and treatment, improve the affordability of care, and ultimately improve the health of all Americans.

January 12, 2018. 

Editor: Although the publication date of this article may not be current, the information is still valid.

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U.S. health system is still lagging behind other countries

By Rabah Kamal and Cynthia Cox,  Kaiser Family Foundation.

The Peterson-Kaiser Health System Tracker is launching a new Health System Dashboard that will track U.S. health system performance over time across four domains: health spending, quality of care, access and affordability, and health and wellbeing. The dashboard examines trends in the U.S. health system, compares the U.S. to a group of other large and wealthy countries (“comparable counties”), and also highlights differences and disparities across demographic groups. Data in this dashboard come from a variety of sources, analyzed by Kaiser Family Foundation experts, and the tool will be updated continuously as new information becomes available.

In this post we take a step back to look at the bigger picture of what these data tell us about how well the health system is working. We find signs that the U.S. health system is improving in its ability to promote health and provide high-quality care, with some recent improvement in the accessibility of that care and a slowing of spending growth. However, the U.S. health system is not always keeping pace with similar countries, with gaps in health outcomes widening in a number of areas.

Below is a sample of findings across 10 key indicators of health system performance, with more details on each of these indicators in the dashboard (which tracks more than 50 indicators over time).

1. Life expectancy at birth has improved over the past decades, rising by more than 5 years since 1980. However, comparable countries have an average life expectancy of 82 years – 3 years longer than the U.S. life expectancy of 79 years – and the gap is growing.
2. Disease burden, a measure that accounts for both longevity and quality of life, has improved significantly over the past quarter century, dropping 16% between 1990 to 2015, with particular improvement seen for circulatory diseases. Disease burden rates are 25% higher in the U.S. than comparable countries on average, and the gap has widened slightly.
3. The rate of hospital-acquired conditions (such as adverse drug events or surgical infections) has improved, declining an estimated 21 percent from 2010 to 2015. This suggests that patient safety may have improved.
4. Thirty-day mortality following hospital admission improved in recent years for heart attack and stroke (decreasing 8% and 4%, respectively) but worsened for heart failure (increasing 6%) from 2009 – 2015. While not all deaths are preventable, lower rates of death shortly following a hospital stay may suggest care has improved. Relative to comparable countries, 30-day mortality is lower in the U.S. following hospital admissions for heart attack and stroke.
5. The rate of potentially preventable hospital admissions has improved, decreasing 23% from 2005 to 2013. Relative to comparable countries, admission rates are higher in the U.S. than in comparable countries for several diseases that could possibly be prevented, like congestive heart failure (68% higher), asthma (194%), and diabetes (38%) – though admission rates for hypertension are lower (by 24%) in the U.S relative to the average of comparable countries.
6. Due to recent gains in health coverage as a result of the Affordable Care Act, the uninsured rate among the nonelderly dropped from 18% in 2010 to 10% in 2016. Even with 91% of the total U.S. population now insured, coverage lags behind comparable countries, all of which provide essentially universal coverage.
7. Fewer adults are reporting problems paying medical bills. From 2011 to 2016, there was a 10% drop in the percent of adults reporting being worried about their ability to pay medical bills.
8. The share of Americans delaying or foregoing needed care due to costs improved, dropping from 13% in 2009 to 9% in 2015. The rates of delayed or forgone medical care for people in worse health reached an all-time low (18%) in 2015.
9. Health spendingper person has grown steadily from $355 per capita in 1970 to $9,990 in 2015. More recently, from 2010 to 2015, per capita spending grew an average of 3.6% per year. Over the past five years, health spending in the U.S. has even grown more slowly than in comparable countries. On average, other wealthy countries spend about half as much per person on health than the U.S.
10. Health spending continues to grow faster than the economy, but the difference has moderated in recent years. U.S. healthcare spending accounted for 17.8% of GDP in 2015 – much more than comparable countries, where health spending averages 10.8% of GDP.

Although there is general improvement across many indicators, there are often disparities across racial or ethnic groups, genders, and income levels. Where possible, the dashboard data are broken out across demographic groups to highlight these disparities.

May 19, 2017

Even with an in-network hospital, insurance may not cover ER physicians 

When her husband, Charles, showed signs of heart trouble in January, Donna Baker didn’t hesitate to drive him to the emergency department at nearby Mease Countryside Hospital.

Only later did the Bakers learn that, while Mease Countryside is part of their health insurance network, the physician who treated him there is not. The ER doctors are employed by a separate company that doesn’t accept their United HealthCare plan. The result? The Bakers got stuck with a $1,235 doctor’s bill.

Surprised as they were, it’s increasingly common for even careful consumers to get socked with high bills after unknowingly being treated by out-of-network providers. Consumer advocates cite the problem as a key driver of medical debt as patients are getting squeezed between fee-seeking physician practices and cost-cutting insurers.

Such fights mean higher bills for patients. When emergency rooms and the doctors who work there aren’t on the same plans, even diligent consumers don’t stand a chance, said Karen Pollitz, a senior researcher with the Kaiser Family Foundation. “There’s nothing you can do as a consumer. I mean, how can you possibly shop?” she said. “This notion of consumer choice just falls apart when it comes to emergency services.”

• • •

When a medical provider agrees to be within an insurance network, fees are negotiated in advance. Medical providers who are outside a patient’s insurance network may receive some payment from the insurer — but then can “balance bill” the consumer for more.

Patients routinely go to in-network hospitals for a procedure or a test only to learn later that treating physicians — often an anesthesiologist or radiologist — were not in their network’s plans. Though it isn’t always easy, checking ahead to discover the insurance status of everyone involved in scheduled care is at least possible in theory. That’s not at all true in the case of an emergency.

• • •

The Affordable Care Act does prohibit most insurance plans from charging higher copayments or coinsurance amounts for out-of-network emergency services. But it does nothing to stop balance billing by the out-of-network doctors and hospitals. And the law’s new limits on how much consumers must pay out of pocket — $6,350 for an individual and $12,700 for a family this year — apply only to in-network care.

Balance billing of Medicaid patients is prohibited by law, said Cheryl Fish-Parcham, deputy director of health policy at Families USA, a Washington consumer group. And it’s rare for Medicare patients to be balanced billed, though patients enrolled in privately run Medicare Advantage plans sometimes face charges from out-of-network providers.

Florida is one of about a dozen states that do offer additional protections. Under state law, out-of-network medical providers can’t balance bill HMO members for emergency services. Consumers with other types of insurance plans, such as popular PPOs, do not have that same protection.But few HMO members seem aware they’re entitled to the protection, said Steve Burgess, Florida’s consumer advocate for insurance.

• • •

Tampa Bay area patients say that when they call about their bills, the insurers and physician groups typically point fingers at each other. Both insurers and ER contractors say they’re willing to work with patients on their bills. But some patients don’t know that, or figure it isn’t worth trying.

Condensed from the Tampa Bay Times.

Originally published on Sept.19, 2014 

Although the publication date of an article may not be current the information in the article is still valid.

In 2013 a report in the Journal of Patient Safety stated that preventable medical errors that occur in hospitals are the third leading cause of death in America after heart disease and cancer. But hospitals and doctors will not discuss medical errors or advise patients how they can protect themselves. And the U.S. government does not recognize medical errors as a cause of death.

• Up to 3.65 million people will become victims of preventable medical errors.
• Over 1 million will be harmed (more than 2,700 a day).
• Up to 440,000 will die (more than 1,200 a day).
• At a total cost of approximately $1 trillion. In 2015 the U.S. military budget was $598 billion.

The April 2011 edition of the journal Health Affairs found that medical errors and other “adverse events” are rampant. This study found that mistakes occur in one out of every three hospital admissions. And these errors didn’t occur in mediocre hospitals, either. The study involved three high-quality teaching hospitals that were not named but were described as having “advanced patient safety programs, initiatives, and research projects.”

> An App is Helping Hospital Patients Protect Themselves  

An investigation by the Office of Inspector General, Department of Health and Human Services released January 6, 2012 found that most errors are not reported and even in the case of errors that are reported and investigated changes are seldom made which would prevent them in the future.

Here are the categories under which serious reportable events (SRE) fall according to the National Quality Forum:

• Surgical or invasive procedure events
• Product or device events
• Patient protection events
• Care management events
• Environmental events
• Radiologic events
• Potential criminal events

Why is such a list important?
It is actually used to command quality from those who deliver healthcare to Americans. For example, Medicare, Medicaid and some private insurers will not reimburse doctors or facilities when one of their patients is a victim of an SRE. The Joint Commission, which is the accreditation body used by most U.S. hospitals, takes reported SREs into account when reviewing the facility for its updated accreditation. According to the NQF, as of 2011, about half of all states use the SRE list to assess the quality of their healthcare facilities, too. Patients benefit in two important ways from the SRE list: We know what medical mistakes and events we need to try to prevent on our own. The list of SREs is a list of unacceptable outcomes, one that helps us determine what preventive measures we need to take and one that outlines which ones might result in a lawsuit. When payers refuse to pay providers for making these mistakes, that puts the pressure on providers to figure out how to avoid adverse events. That can contribute to a safer environment for patients.

> An App is Helping Hospital Patients Protect Themselves  ​

But there are also problems with the list:  As in the past, the current list of never events or serious reportable events does not mention some medical errors that are just as devastating to patients, such as:
– Healthcare-acquired infections
– Missed diagnoses, misdiagnosis or lack of diagnosis
– Lack of follow up – post-hospital discharge or unreported test results that result in harm

If a provider knows they won’t be reimbursed because a serious reportable event took place they may try to cover up the event that does occur. Patients report having suffered these events only to learn later that their records have been amended, actual events have been removed from the records and that their only recourse is to deal with the facility’s risk management department, whose job is to protect the hospital from lawsuits. At that point they have no choice but to contact a lawyer for help.

Types of Preventable Medical Errors 

Diagnostic 
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing

Treatment 
Error in the performance of an operation, procedure, or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatment or in responding to an abnormal test
Inappropriate (not indicated) care

Preventive 
Failure to provide prophylactic treatment
Inadequate monitoring or follow-up of treatment

Other 
Failure of communication
Equipment failure
Other system failure

> An App is Helping Hospital Patients Protect Themselves  

Some examples of preventable medical errors:

• Unnecessary surgery
• Surgery on the wrong person or body part
• Wrong procedure
• Surgical instruments and sponges left in bodies
• Undue Exposure to Radiation – i.e. unnecessary CT scans leading to development of cancer
• Medication errors
• Healthcare associated infections – i.e Clostridium Difficile (C.Diff), MRSA, VRE, CRE, caused by unclean conditions, materials, equipment or instruments resulting in severe sepsis and septic shock that can lead to death
• Bedsores/pressure ulcers
• Medical device failures
• Patient falls
• Blood clots
• Failure to Rescue  – i.e. in-hospital strokes that are not immediately diagnosed and treated
• Blood and imaging test mix-ups, mistakes and unreported test results
• Hospital acquired acute renal failure
• Airway safety failure
• Iatrogenic delirium (delirium caused by improper treatment, especially in the ICU)
• Procedural harm
• Lack of follow up – post-hospital discharge or unreported test results that result in harm