CHAPTER 1: LAW & THE HEALTH SYSTEM: AN INTEGRATED APPROACH PGS 1- 12
1. Two health systems:
A. Health care system devoted largely to improving individual health outcomes
(1) Study of the health care system focuses on financing, organizing, & delivering of personal medical services.
B. Public health system is devoted to safeguarding & improving health outcomes in the population.
(1) PH system focuses on interventions designed to improve morbidity & mortality (M&M) in the community.
2. Law & Public Health
A. PH is defined by law
(1) Law creates PH agencies, designates their mission, provides their authority, & limits their actions to protect a sphere of freedom outlined by the Constitution.
B. Fundamental challenge of agencies is how to use the law as a tool to improve the public’s health.
3. Law & Personal Health Care
A. Health care executives interact w/ attys on a daily basis on issues ranging from regulatory policy, antitrust, & liability to labor relations & joint ventures.
B. The law provides regulatory oversight of physician practices, legislation mandating that certain insurance benefits must be provided, & judicial ruling imposing liability for substandard medical care.
C. Distrust b/t legal and medical professions is deep and has adverse implications for patient care.
(1) PH and health care are mutually dependent and interactive.
a. Boundaries b/t the 2 did not emerge until the early to mid-20th century.
(2) From 18th – beginning of 20th century
a. PH dominant concern in the US
b. Most of the nation’s investment in health involved disease prevention & sanitation
(3) Mid-20th century
a. advances in medical technology and hospital care permitted more intensive and effective individual medical treatment.
b. Development of biomedical model & focus on individual treatment of disease uncoupled medical care from PH’s population-based approach.
c. Personal health care began to supplant PH as the dominant system
d. Spending on PH declined and increase on personal health
(4) Later-20th century
a. Medical care dominated resource, public and media attention
b. Bioterrorism – PH reemerges in awareness of public and policy makers
(5) Present – Both systems undergoing significant changes (financing & organization)
a. Biomedical system
(i) Medical care driven by market forces opposed to becoming a gov’t function
(ii) Since 1990s emergence of managed care – has eroded physician dominance in medical delivery
b. PH system
(i) LHD (local health dept) are moving away from providing direct services (family planning & primary care)
(a) Concentrating on providing population-based core PH functions (health education, surveillance, policy development)
(ii) Conventional wisdom is that PH services will either shift to private sector or provided through public-private collaborations.
(6) Still interdependent
a. Health of population depends on both systems
b. Both contributed to expanded longevity, a reduction in the overall burden of disease (i.e., reductions in tobacco-related M&M)
c. Example – Obesity
(i) Individual social choices in eating patterns and exercise habits
(ii) Environment (misleading marketing and advertising materials, lack of fresh fruit & veggies in low income areas) encourages poor eating choices.
(iii) Complex medical problems
(a) insurers debating whether to cover the increasing health care costs of treating obesity
(b) long-term care providers are dealing w/ the costs of purchasing equipment to lift obese pts.
(iv) Reducing obesity problem (M&M costs) require both intervention at the individual pt. level & at the population level.
(v) Pellman v. McDonald’s Corp. (2203) – Πs alleged the became overweight & developed health problems related to obesity (diabetes, coronary heart disease, etc…) & other adverse health effects as a result of ∆s conduct & business practices in marketing fatty foods to consumer.
d. Injury prevention
(i) PH policy perspective
(a) Mandating the use of helmets for motorcyclists & bicyclists is appropriate b/c it would reduce injury-related M&M costs.
i. Such regulation potentially interfere w/ personal freedoms & social choices
ii. Failure to mandate helmets results in higher E/R dept. & related health care costs.
(b) Process of PH regulation has a direct impact on the personal health care system
e. Focusing on similarities b/t the 2 systems will reveal interesting policy connections & suggestions for the development of legal doctrine.
(i) i.e., privatization of both systems increases the importance of legal oversight.
f. Moral questions –
(i) To what extent should & individual’s social & behavioral choices affect the personal health care he/she receives?
(ii) If an individual’s health status is a function of factors beyond their control (i.e. genetic / environmental factors) should that mitigate the individual’s responsibility for unhealthy lifestyle choices?
(iii) Should PH eschew interventions in areas involving individual lifestyle choices?
B. Current Legal Connections
(1) Development of judicial doctrine
a. during ascendance of personal health care, legal system supported rulings that ensured physic
Courts look to other areas of law to develop legal rules when new technology appears
D. Interdisciplinary Approach
(1) PH is dependent on epidemiology & biostatistics for providing scientific basis of decision-making
(2) Medicine is dependent on science (evidence-based medicine) to determine appropriate clinical decisions.
(3) Approach problems through ethical reasoning, a population-based perspective & quantitative & scientific reasoning
E. Professionalism & Accountability
(1) Key feature of the law is to ensure accountability of social institutions in both public & private sectors
a. Through legal doctrine (tort) & regulatory policy (quality care regulation)
(2) Private law concepts (patient-physician relationship) can be applied to PH systems in ways that will improve its ability to meet its responsibilities to protect the public’s health.
6. CLASS NOTES
A. Public Health
(1) Historically PH was at it’s height in first half of the 20th century when their was a concerted effort to deal with problems:
a. i.e. epidemics, chronic problems (nutrition / work environment), mandatory restraints (seat belts)
(i) Leading case: Jacobson mandatory immunization
b. These problems did not get resolved in the market place – consumers didn’t have the info.
(2) Defines what the scope of authority of government agencies
B. Individual Medicine
(1) Individually related (injuries, sickness, etc…)
(2) Most resources for PH shifted over to IM – some have shifted back to PH b/c of bioterrorism
(3) Providers (where most of the jobs are for lawyers – most money is)
(4) Regulators (gov’t entities that look at how care is provided, insurance regulate their reimbursements)
(5) Consumers (patients, employers paying for the health insurance)
(6) Revolution – ascendancy of managed care
a. Independent health, UNIVERA, Blue Cross – Blue Shield (before we pay for this you have to call us and get prior approval)
(7) Canada has single payer system : US takes individual pieces to address issues, i.e. Medicare, Medicaid (elderly and poor), Children, Veterans – still 45 million people uninsured