Sunday, July 1, 2018

Personal Health Information: The Provider Question


Abstract

According to US Department of Health and Human Services, agencies create regulations under the authority of Congress to help government carry out public policy. One of which is the Health Insurance Portability and Accountability Act’s privacy policy which establishes nationwide standards as regards the use and disclosure of protected health information. This paper will examine it enactment, content and subsequent adjustments/accommodations since establishment in 1996, with a focus on entities or business associate, in charge of any form or media, whether electronic, paper, or oral. The vast amounts of people’s digitized records already collected for billing and claims, in various specialized databases can be a two-edged sword: it has a potential for discovering more about disease processes and care outcomes on the other hand, these also create possibilities for excluding the individual(s) on the records from care. The choice of how providers handle this information is the focal point of the paper.










Introduction

Protected Health Information also known as Personal Health Information is personally identifiable health information that is covered by H.I.P.A.A. created in 1996 (Brown, 2015). H.I.P.A.A. was put forward by Congress and Bill Clinton signed it into law during his presidency. PHI protects information like: Name, Date of Birth, Telephone, Address, Email, URL, Account Details, Medical record, Social Security Number, Personal health device details, Automobile Information, Fingerprint/Life-scan, Passport photo, Voice ID, other demographic/non-demographic data that is uniquely identifying. This addresses the information that is in the care of covered entities and such, are protected by the federal act, it provides patients with various rights as regards to said information. “The regulation does not require a data set to include a certain number of identifiers to be considered PHI. It specifically states that if information identifies an individual, it is PHI” (“Q&A: What Information”, 2011). In the instance where “Name” of the patient that received care is associated with the care gotten and the hospital, that IS demographic information and it is taken as PHI. In this day and age, where most things are digital or going digital through the increasing use of computers and devices, H.I.P.A.A.’s response is the H.I.P.A.A. Security Rule which deals with electronic P.H.I.; applying to healthcare plans, healthcare clearing-houses, electronically transmitted information by healthcare provider, has to do with patient’s transactions, hence laying down security standards for electronically stored PHI.



ACTs

Federal
Pre-H.I.P.A.A., there have been many Health Privacy Statutes and Orders regulation attainment and disclosure. To name a few, The Freedom of Information Act (FOIA), Privacy Act (protecting patient’s records in the care of government agencies, Family Educational Rights and Privacy Act, Veterans Omnibus Health Care Act, Clinical Laboratory Improvements Amendments, Public Service Act, Health Omnibus Program Extension, Public Health Service Act, Federal Confidentiality Requirements for Substance Abuse Patient Records, Section 543, Americans with Disabilities Act, etcetera. Because the American society in general is one that values freedom, choice, and privacy, these laws are merely extensions and reflections of the cultural values of the society codified or not, though these does not take away from its complexity for the healthcare professional.
“The Health Insurance Portability and Accountability Act (H.I.P.A.A.) was developed in 1996 and became part of the Social Security Act. The initial primary purpose of the H.I.P.A.A. is to protect health care coverage for individuals who lose or change their jobs” (Bowers, 2001).
 Under the Administrative Simplification Act Title II: Due to the greater the level of automation in a healthcare facility, the greater the need for ensuring security of the network infrastructure.
Administrative simplification section addresses privacy of individual’s health information, provides for physical and electronic security of PHI, it breaks down the rights of individual’s access to PHI and disclosure. Note H.I.P.A.A. doesn’t directly address treatment consent (Orlowski, 2013).
The Health Information Technology for Economic and Clinical Health Act. (HITECH) over a decade after H.I.P.A.A., it is another federal medical record privacy measure regulating healthcare provider’s actions. Also, after H.I.P.A.A., came a different federal regulation called Genetic Information Nondiscrimination Act (G.I.N.A.) extending in detail, the “providers” not specified in H.I., especially those with access to P.H.I. and restricting use of genetic information by health plans for underwriting. Then recently, days ago it was ruled that there be the addition of whether or not a patient suffers drug/alcohol addiction present or past.

State:
States across the country each have privacy acts both within and without the industry and the general/common tone is similar to that of H.I.P.A.A., some preceding H.I.P.A.A. itself while others came afterwards. For example, California’s version of “H.I.P.A.A.” which is the Confidentiality of Medical Information Act, is under sections of the Civil Code (the data breach) and Health & Safety Code. Even though it has various similar aspects to H.I.P.A.A. it was rather progressive and ahead of the curve in that it was created in the 1970s over two decades before H.I.P.A.A.”
Within said State, there is also the Insurance Information and Privacy Act: which prohibits unauthorized disclosure of personal information by insurers and affiliated entities; hence creating standards for collection, use and disclosure of information attained as in relation to transactions carried out by insurance agents, institutions, support organization etcetera Note, the patient has the right of ensuring the type of information, the content’s accuracy, approval of sharing the PHI and best of all get an explanation of a declined underwriting decision before getting or while under the insurance policy.
Information Practices Act: this covers handling and use of personal information by state agencies. Giving the individual whose information is being used, the right to know and request the names of those who accessed it.
Online Privacy Protection Act: addresses websites that collect personally identifiable information of any kind, requiring the site to notify the individual of what data is being collected (“The Law and Medical Privacy”, n.d.).


REALITY

More and more digitized patient’s information would make it possible for researchers and providers to get a chance to find out more about ailments processes and expected consequences. Simultaneously these records offer possibilities of exclusion of individuals from care (for example insurance) or for breeches of confidentiality caused by human error or theft. This continued tradeoff will repeatedly come up in policy analysis and decision making (McLaughlin & McLaughlin, 2015). A way found researchers around this issue is “Pseudonymization, it is a method “used to replace the true identities (nominative) of individuals or organizations in databases by pseudo-identities (pseudo-IDs) that cannot be linked directly to their corresponding nominative identities” (Claerhout and De Moor). “The benefit of using pseudonymization in health research is that it protects individuals’ identities while allowing researchers to link personal data across time and place by relying on the pseudo-IDs.” (as cited by Nass et al, 2009).


Exemptions for Disclosure

The content of PHI may be disclosed to the individual who is the subject of the information, he/she may access the information.
“A covered entity must disclose protected health information in only two situations: (a) to individuals (for their personal representatives) specifically when they request access to, or an accounting of disclosures of their protected health information; and (b) to HHS when it is undertaking a compliance investigation” (“The H.I.P.A.A. Privacy Rule”, n.d.)
Another is that an individual’s PHI can be disclosed immediately after death “1. To law enforcement: when there is a suspicion that death resulted from criminal conduct. 2. To coroners or medical examiners and funeral directors. 3. For research that is solely on the protected health information of decedents. 4. To organ procurement organizations or other entities engaged in the procurement, banking and such. 5. To family and friend(s) in charge of care when individual was alive” (Snell, 2015).
Finally, it can also be fully and legally disclosed, 50 years after their death, as it is no longer protected as such under H.I.P.A.A.


Restricted Restriction

H.I.P.A.A. laws cover health information with a large number of specific entities for example Doctor, Nurse, Other Healthcare Entities. But it does not cover social media network, chat rooms, website, health/non-health applications, Google and similar online activities participated in by the individual mostly unwittingly.
In March this year, under Trump came an initiative called MyHealthEData to further promote access and use of HER data by its owner (the patient), even insurance claim(s) all towards the improvement of care (“H.I.P.A.A: Impacts”, 2018).
There are various ways PHI can be violated by the [provider or healthcare professionals) and here are a few common ways:
1.     Healthcare professionals/employees openly disclosing information with friends, family and co-workers.
2.     E.H.R. mishandling, this is usually hard copies for example x-rays, charts, file and so on.
3.     Illegal access to patient’s records by healthcare professional for whatever reason, rational or otherwise, without consent then it is illegal.
4.     Social breaches, these are more prominent in closer knit areas and populace, where neighbors show concern and healthcare professionals are usually related and see sharing patient’s records as no breach.
5.     Use of personal systems outside the office/facility to access patient’s information may lead to a violation if the content is visible to non-authorized personnel like family and friends or even strangers.
6.     Media, this includes social media, texting and others, even in instances where the patient’s name or identifier is omitted, they might still be recognized as a countless number of people may see it and this may include patient’s family and friends.
7.     Ignorance of what H.I.P.A.A. entails, from little or no training, especially auxiliary members of the team for example interns, volunteers’ etcetera (Zabel, 2018).
Safeguards

Physical: The securing files in locked cabinet or rooms, server room should come with restricted access. Only staff or contractors have access to record rooms. Avoid putting files within reach of patients, families, friends or passerby. Providers should refrain from using real names when discussing with other healthcare professional in presence of others.
Electronic: Use of passwords, user accounts to track who uses what, where and when to better manage access and plug holes if any exist.
Network: Purchase, use and maintenance of internet security for databases. Trained IT experts to maintain and monitor security of all devices both software and hardware alike that contain such confidential information. According to Koegler, all EHR data should be encrypted and all possible points of intrusion should be covered (2017).

Covered Entities(associates): Ensure affiliated entities in the healthcare industry carry out the same measures, a basic standard is non-negotiable, safety precautions must be adhered to when handling patient’s files, as this could result in criminal and civil fines for the provider, also loss of reputation (Zabel, 2016). For example, the successful lawsuit against pharmacist employee and Walgreens resulting in $1.44 million fine for the violation of H.I.P.A.A. in 2013, because in this case, H.I.P.A.A. was used to establish standard of care (“A New Way to Sue”, 2013). It is worthy to note; an eventual uniformity of federal regulations and requirement is H.I.P.A.A.’s aim as the Act doesn’t alter state laws pertaining to public health.

A person named Sean Myers died some days after returning home from a stint in the hospital due to a blood clot complication that could have been avoided if physician had talked to his parents, one of whom had a history of blood clots. Was this death avoidable? where does the physician draw the line and do what is best for patient especially as when what’s best for patient might not be so for H.I.P.A.A. compliance (Andrews, 2016). This is only one of millions of instances where decisions are not clear-cut, but whenever there is class between state and federal, then federal supersedes. Still, as a healthcare professional, the onus is on us to make sound judgement based on facts, integrity, unwavering moral compass that is beyond reproach and continuous updating of skills, training, humane application of knowledge, is priority as it is relevant to health regulations compliance.
















Reference

A New Way to Sue Health Care Professionals Using HIPAA? (2013). Retrieved from http://thehealthcareblog.com/blog/2013/09/06/a-new-way-to-sue-health-care-professionals-using-hipaa/

Andrews, M. (2016). Parents May Be Refused Details of Adult Children's Medical Care. Retrieved from  https://www.npr.org/sections/health-shots/2016/05/31/479751997/parents-may-be-refused-details-of-adult-childrens-medical-care

        Bowers, D. (2001). The Health Insurance Portability and Accountability Act: is it really all that bad? Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305898
       Brown, M. (2015, January 10th). What is Protected Health Information? Retrieved from https://www.truevault.com/blog/protected-health-information.html
      Q&A: What information needs to be compromised to constitute a HIPAA breach? (2011). HIM-HIPAA Insider. Retrieved from http://www.hcpro.com/HIM-262417-865/QA-What-information-needs-to-be-compromised-to-constitute-a-HIPAA-breach.html
      Gresham, G. & Orlowski, A. (2013). Coming of Age in The Healthcare System: Confidentiality, Capacity and Consent. University of California Television. Retrieved from https://www.eff.org/issues/law-and-medical-privacy
     H.I.P.A.A: Impacts and State Actions (2018) Retrieved from     http://www.ncsl.org/research/health/hipaa-a-state-related-overview.aspx
          Koegler, S. (2017). Health Care Providers Need to Comply with HIPAA Regulations and Address These Five Critical Security Issues. Retrieved from https://securityintelligence.com/health-care-providers-need-to-comply-with-hipaa-regulations-and-address-these-five-critical-security-issues/
McLaughlin, C.P. & McLaughlin, C.D. (2015). Health Policy Analysis: An Interdisciplinary Approach. Jones and Bartlett. 2nd ed.

Nass, S.J. et al (2009). Beyond the HIPAA Privacy Rule: Enhancing Privacy, Improving Health Through Research. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK9579/

Q&A: What information needs to be compromised to constitute a HIPAA breach? (2011). HIM-HIPAA Insider. Retrieved from http://www.hcpro.com/HIM-262417-865/QA-What-information-needs-to-be-compromised-to-constitute-a-HIPAA-breach.html

Snell, E. (2015). How Do HIPAA Regulations Apply After Death? Retrieved from https://healthitsecurity.com/news/how-do-hipaa-regulations-apply-after-death

The Law and Medical Privacy (n.d.) Electronic Frontier Foundation. Retrieved from https://m.youtube.com/watch?v=ZsvxzZiQwEs
The HIPAA Privacy Rule (2015). Office for Civil Rights (OCR). Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/index.html
US Code 42 (20 ), Legal Information Institute. Cornell University Publication. Retrieved from https://www.law.cornell.edu/uscode/text/42/1320d-6

Zabel, L. (2016). 10 common HIPAA violations and preventative measures to keep your practice in compliance. Retrieved from https://www.beckershospitalreview.com/healthcare-information-technology/10-common-hipaa-violations-and-preventative-measures-to-keep-your-practice-in-compliance.html

 


See the graphic "Policy Analysis Process and Health Professions" model on page xi of the McLaughlin and McLaughin book. What skills for policy analysis and decision making will you leave class with this week that can be useful to your career?

The expectation of taking this course, both in its duration and afterwards; is the eventual demonstration of an acquired ability to analyze data and make informed recommendations, which in turn trains one to be a problem solver while working in both a team to achieve a common a goal as exercised in week five or working alone to learn and practice helping to align future employer/firm’s policy and action(s) alongside federal and state statutory lines.
As stated in my week one in response to the question of how my interest is related to workplace goals “I plan to share accumulated knowledge of other systems’ viable results attained from interning and class room information, to make recommendations to fix the increasingly worsening state of health care in Nigeria and partake in the correcting of identified issues in the system. My focus with be in health and tech, this is a veritable smorgasbord for collaborative effort in bringing healthcare to millions. The senate has been poised to pass several bills regulating and promoting healthcare services and such, but the implementation and enforcement are lacking” in retrospect, I now see in finer detail what is needed and who the players are in this core portions of healthcare.
According to McLaughlin et al, participation in policy discussions and analysis is key to preparation for a role in leadership (2015), that is essentially what was done in class, the review of various policies, managerial decisions, the central and core responsibility to the patient, quality, the ever changing regulatory policies and governmental expectations, nonstop advances in health technology and a corollary of these changes is that, according to Deming’s approach, being healthcare is a field that will have high variability even without special cause variation (as cited by McLaughlin et al, 2015, p416).
In healthcare policy analysis, there is room to find opportunities brought on by changes in policies. Through the evaluation of the economic viability of proposed policies and proposed policy alternatives it is also possible to spot risks associated with these alternatives. There also is an inexplainably important need in the making of social connections; as information and influence are the ones that help drive policymaking, these include knowing people, sometimes interacting with these players and even occasionally preempting actions of various commissions, advisory bodies, trade associations, professional associations, public interest, consumer etcetera (Gostin, 1995).
In dealing with unavoidable uncertainties to ensure a desired outcome for the organization both in the present and the future, policy analysts must be able to share their extrapolations and communicate effectively what their search turned up for example discussing with peers, stakeholders even doing presentations for investors and other parties.
 Now I can better analyze policies and even the aspects that require continuous industry updating and improvement are clear, hence I have my work cut out for me.



Reference

Gostin, L. (1995). Society’s Choices: The Formulation of Health Policy by the Three Branches of Government. Pp335-336. Retrieved fromhttps://www.nap.edu/read/4771/chapter/17

 

McLaughlin, C.P. & McLaughlin, C.D. (2015). Health Policy Analysis: An Interdisciplinary Approach. Jones and Bartlett. 2nd ed. Pp 297-417

 

1) What is your topic and how is it related to healthcare policy analysis and decision making? 2) What have been the main challenges to your research process so far? How did you address solve those obstacles? Include APA6 references for a few of your peer reviewed journals. Part 2-Thinking about your leadership skills, what do you have to contribute to healthcare policy analysis related to chapter 14?

The topic is on Protected Health Information (PHI), privacy section of the Health Insurance Portability and Accountability Act (HIPAA): discussing the facts and analyzing from the point of view of the provider, how it affects decisions made for and with the patients. There have been some articles on PHI since 1996 country-wide, but the common themes in said articles are the 1. The big paradigm shift it brought to how patients’ records are handled, used and accessed: reflects varying speed of implementation and integration in the different states; for example stake holder engagement (McLaughlin & McLaughlin, 2015). 2. Providers sometimes being caught in the middle between either disclosing to family/friend of patient, so as to obtain information needed for treatment OR following HIPAA rules to the T, but to the detriment of their patient’s care (Andrews, 2016). 3. Involuntary breach of PHI through theft, loss or security incursion is more common place in recent times than previously thought (McLaughlin & McLaughlin, 2015). 4. Considerable number of the write-ups available online are by Department of Health and Human Services. 5. Where to draw the line for researchers between PHI and Research-related Health Information (RHI) (“What is and is not Protected Health Information”, n.d.). 6. Patient’s accounts reflect a significant amount ignorance of the actual protection afforded under HIPAA and certain misconceptions on what to expect from their care providers etcetera. Challenges are being addresses by searching specifically for articles, accounts of experiences and blogs by hospitals, healthcare professionals, insurance companies and such, to further shed light on the collective translation of PHI on the provider’s side of the divide.


Reference 

Andrews, M. (2016, May 31st). Parents May Be Refused Details Of Adult Children's Medical Care. Retrieved from https://www.npr.org/sections/health-shots/2016/05/31/479751997/parents-may-be-refused-details-of-adult-childrens-medical-care

McLaughlin, C.P. & McLaughlin, C.D. (2015). Health Policy Analysis: An Interdisciplinary Approach. Jones and Bartlett. 2nd ed. Pp 371

What is and is not Protected Health Information (PHI) in Research Settings (n.d.) U.C. HIPAA Implementation Taskforce. Retrieved from https://cphs.berkeley.edu/hipaa/WhatIsandIsNotPHI.pdf


Bibliography 

Bowers, D. (2001). The Health Insurance Portability and Accountability Act: is it really all that bad? Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305898/

Brown, M. (2015, January 10th). What is Protected Health Information? Retrieved from https://www.truevault.com/blog/protected-health-information.html

Gresham, G. & Orlowski, A. (2013). Coming Of Age In The Healthcare System: Confidentiality, Capacity And Consent. University Of California Television. Retrieved from https://www.eff.org/issues/law-and-medical-privacy

McLaughlin, C.P.& McLaughlin, C.D. (2015). Health Policy Analysis: An Interdisciplinary Approach. Jones and Bartlett. 2nd ed. 

The Law And Medical Privacy (n.d.) Electronic Frontier Foundation. Retrieved from https://m.youtube.com/watch?v=ZsvxzZiQwEs

The HIPAA Privacy Rule (2015). Office for Civil Rights (OCR). Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

US Code 42 (n.d.), Legal Information Institute. Cornell University Publication. Retrieved from https://www.law.cornell.edu/uscode/text/42/1320d-6

What is and is not Protected Health Information (PHI) in Research Settings (n.d.) U.C. HIPAA Implementation Taskforce. Retrieved from https://cphs.berkeley.edu/hipaa/WhatIsandIsNotPHI.pdf

How do your values and ethics impact policy decisions in your future/current/past professional healthcare role? Provide an example.

McLaughlin considered values as preferences, needs, motivators, concepts and situational needs; these values influence the world view and choices of policy decision makers and followers alike. Values affect and shape policy making with respect to both organizations and individuals. Hence decision-making is a highly value-laden process (as cited by Shams et al, 2016, p 3)
As healthcare professionals, the quality of policy decisions made must be to high ethical standards and beyond reproach, making the presence of value and ethics relevant in the various policies that affect the industry.
Going by one of the basic principles arrived at when defining “Health” in a seating of the World Health Organization, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, or economic or social condition” (as cited by McLaughlin & McLaughlin, 2015, p 193).
In reality sometimes there are distinctions, patients at times refuse care based on their religious values which in turn impact the treatment they allow themselves receive. On the other side of the divide, what if the distinction of religion is based on healthcare professionals’ individual values. The focus here being how religious values dictate the actions of those giving care. There have been cases of providers refusing certain duties “expected” of their role(s). For example, some healthcare professionals, based on their belief system, will not perform: blood transfusions, abortions, prescribe certain medication, administer a rape kit -that is the “morning after pill”, treat patients of the opposite gender, etcetera. 
The Hippocratic oath states to do no harm but the strength of this has been diluted over the centuries, with other standards gaining prominence. The argument is ongoing, as givers of care, the physical plus emotional well-being and totality of quality experience is part of the expectations of patients and this expectation should ordinarily not be denied care. Still, increasingly providers voice out on how they should not have to compromise even when there is a value of life -above all else (ethics and personal or organizational beliefs inclusive).
The American Medical Association’s Code of Ethics, which are not "laws" per say, has some guidelines for healthcare professionals to follow in this scenario.
Section 1.1.7: Physician Exercise of Conscience: “Physicians are expected to uphold the ethical norms of their profession, including fidelity to patients and respect for patient self-determination. Yet physicians are not defined solely by their profession. They are moral agents in their own right and, like their patients, are informed by and committed to diverse cultural, religious, and philosophical traditions and beliefs” (McDonnell, 2017).
There are also statutory protections afforded such conduct under state legislation containing “conscience clauses” and the First Amendment, which protects actions guided by sincerely-held religious beliefs under federal constitution (Patsner, 2008). And more recently, the creation of the office of Conscience and Religious Freedom Division at the Department of Health and Human Services was made to hear complaints from medical professionals, who feel they are being pressured into providing medical services that conflict with their religious beliefs, ethics and values as individuals. The office has recourse in the case of a violation, they could issue a corrective action (Khazan, 2018).
“The issues of ethics and values are not just limited to professional decisions, but also play an important role in all analyses of policy alternatives” (McLaughlin & McLaughlin)
As long as there are people involved in policy making there will always be debate with regards to the right route to take to ensure the highest quality and ethical standards possible for patients. The onus is on healthcare professionals to keep north as the AMA Code of Ethics also states, “The relationship between a patient and a physician is based on trust, which gives rise to physicians’ ethical responsibility to place patients’ welfare above the physician’s own self-interest” (McDonnell, 2017).








Reference 

Khazan, O. (2018, January 23rd). When the Religious Doctor Refuses to Treat You. The Atlantic. Retrieved from https://www.theatlantic.com/health/archive/2018/01/when-the-religious-doctor-refuses-to-treat-you/551231/

McDonnell, J. (2017, January 8th). Doctors Can Now Refuse Treatment Out Of "Religious Freedom" Retrieved from https://www.theodysseyonline.com/doctors-refuse-treatment-religious-freedom.amp

McLaughlin, C.P.& McLaughlin, C.D. (2015). Health Policy Analysis: An Interdisciplinary Approach. Jones and Bartlett. 2nd ed. Pp 193

Patsner, B. (2008). Refusing to Treat: Are There Limits to Physician "Conscience" Claims? Retrieved from https://www.law.uh.edu/healthlaw/perspectives/2008/(BP)%20conscience.pdf

Shams, L., Sari, A. A. & Yazdani, S. (2016). Values in Health Policy: A Concept Analysis. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5088722/

Case Study: Global Health Coverage

Global Health Coverage
  1. What difference did it probably make that BRPP is an ESOP owned by the union members or that the national union is busy recruiting health care workers as members?
  2. What are the ethical implications of a reward of up to $10,000 for the employee to go to India for a major procedure?
  3. If you were a hospital administrator, how would you react when a num- ber of patients and companies began to ask to bargain about prices, including presenting price quotes from companies like IndUShealth?
  4. What would be the difference in the bargaining position of an academic medical center and a large tertiary community hospital system?
  5. How might state and national governments respond to this increasingly popular phenomenon?


1. Employee Stock Ownership Plan aka ESOP is a kind of employee benefit plan, it is similar to profit sharing plan. It affords the employees the chance to be owners of the business through stock- option, bonus, receipt or by joining a cooperative (Coren & Rodrick, 2016). ESOP was formally established as qualified retirement plans in the U.S. under Employee Retirement Income Security Act (ERISA) of 1974 almost 7,000 companies are active now, with 13.5 million participants (Staloch, 2015). There are benefits to employee stock ownership plan, like tax benefit to employees, retirement benefits at no monetary cost, encourages intrapreneurship. Though strong management is required for success, as democratic as unions are, they do not always possess great managers at the helm. ESOP through union is longer term investor that will not seek to sell hurriedly unlike individual employees or venture capitalists. Union for BRPP employees afforded them shield and protection; Creates collective power for employees, as some ESOP do not give individual employees power to make relevant decisions. Bargaining power from belonging to a group, to better the work environment and company remuneration. Union will better negotiate for employees for example having patients travel to India for “cheaper” healthcare services. Especially as ESOP requires a level of financial transparency, the Union is aware what the company can afford and protects employees from “cheap” management decisions. Pool rates are available for health insurance, by taking advantage of their numbers. Maintenance of health benefits for union members is paramount to the union as they know that to the company ESOP is be a tax exempt trust/deductible and the company had started to make profit again. On the other hand, “Union control of company policy through stock ownership plans can be weak. A study from the New York Federal Reserve said less than 3 percent of plans give unions a majority stake as was seen with 45% in BRPP. In many plans, employees’ shares don’t carry voting power (as at Chrysler). The stock ownership plans affect union behavior, too. According to the Federal Reserve study, stock ownership plans overall make the union “a less demanding negotiator,” and produce lower wage demands and fewer strikes” (Gaus, 2009). Unions have other ways of getting management's attention, short of selling the company. Some choose the traditional “union” weapon. Union members are conditioned to be suspicious of management (Bell, 2006). 

Reference
Bell, D. (). Worker-Owners and Unions: Why Can't We Just Get Along? Retrieved from http://www.dollarsandsense.org/archives/2006/0906bell.html Gaus M. (2009).
Employee Stock Ownership, But Not Control. Retrieved from http://www.labornotes.org/2009/05/employee-stock-ownership-not-control?language=es
Rosen, C. & Rodrick, S. (2016). Understanding ESOP: How an Employee Stock Ownership Plan (ESOP) Works. National Center For Employee Ownership. Retrieved from https://www.nceo.org/articles/esop-employeestock-ownership-plan
Miller, G. (201, July 5th). Advantages and Disadvantages of an ESOP. Retrieved from https://www.axial.net/forum/advantages-disadvantages-esop/ Staloch, C. (2015).
Employee Stock Ownership Plans: The Pros and Cons. Retrieved from https://www.di.net/articles/employee-stock-ownership-plans-the-pros-and-cons/


2. Risking patient’s life (in this instance Carl Garrett): a. Standard of care is not the same and can not be accounted for with certainty ie there is guess work involved in selecting a foreign provider. b. Even with local healthcare services, there are unforeseen variables that the providers have no control over despite rigorous regulatory over watch and well trained providers, a foreign healthcare service just increases the odds of mishap at different points and c. Higher chances of risk to patient’s life with the strain of traveling on someone needing treatment. Medical tourism as it is referred to, may serve as a powerful force for the inequitable delivery of health care services globally (Johnston et al, 2010). Cutting costs is not a good enough reason to export care of staff, there should be ways to leverage on the company’s 2,000 plus staff strength through pools. Especially as it is clear that other investigations and findings that should be done are reviewed with the cheaper price blurring the objectivity of the employers. This affects a national revenue source, the nation loses incomes even local insurance companies lose current/potential clients and providers(hospitals) lose clients and incomes. Even though payments for procedures GLOBAL MEDICAL COVERAGE 4 and post will be done in India, the BRPP staff still have to come to the US for follow up care that will not accurately reimbursed for. “A study conducted by the European Union shows that in the United Kingdom there has been a rise in hospital infections of patients who have recently returned from a hospital in India and Pakistan” (Clark et al, 2013). Employers should not expose their employees to such for lower healthcare cost. “The Centers for Disease Control and Prevention (CDC) estimates that up to 750,000 United States residents travel abroad for care each year” (“Traveling for Treatment”, n.d.). These numbers show it is tried by more than just a few people, even insurance companies offer this to individual patients but the responsibility and ethical expectations conferred on a an employer is way more and different from that on an insurance company. Alternatively there are cities with providers within the U.S. with relatively lower cost for example South Florida or lower cost providers like Bridge Health.

Reference
Clark, P.A., Adegunsoye, A., Capuzzi, K. M. & Gatta, D. J. (2013). Medical Tourism: Winners and Losers. Vol 14. Retrieved from http://ispub.com/IJH/14/1/2962
Johnston, R., Crooks, V.A. & Kingsbury, P. (2010, September 24th). What Is Known About The Effects Of Medical Tourism In Destination And Departure Countries? A Scoping Review. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2987953/#!po=3.40909
Traveling for Treatment: Weighing the Risks of Medical Tourism (n.d.). Retrieved from https://hcahealthcare.com/hl/?/620199/Traveling-for-Treatment--Weighing-the-Risks-of-MedicalTourism

 3. The first thing will be to explain the differences between IndUShealth and the hospital I run: Firstly, IndUShealth is not as regulated as hospitals in the US, IndUShealth answers to only JCI which has no teeth unlike the several strict regulatory bodies US hospitals answer to. Second, Lower standard of care, despite affiliation GLOBAL MEDICAL COVERAGE 5 with world class hospitals like Johns Hopkins in the US, it is not the same as being world class itself; IndUShealth is not an island, it is within a system that, for all intents and purposes is a third world nation, riddled with problems associated with third world systems. Thirdly, medical tourists have little legal recourse if things go wrong during procedure or post-op, but in a US hospital, there are often many recourses. According to Dr. James Stuzin, "The liability and the responsibility that physicians have to their patients in America is very high, and that doesn’t necessarily exist in foreign countries if you have a problem" (as cited by Mahar, 2008). Fourthly, Cultural and Linguistic differences, its harder to communicate your ailments before procedure and harder achieve follow up with a long distance physician. Fifth, Privatization of healthcare road has been on the up and up, hence these organizations even with seemingly costs savings have the ways they make up for some of the differences that wont be to the patients benefit (Cortez, n.d.). Sixthly, Cost which is the main driving factor for medical travel/tourism hinges on cheaper labour, lower taxes, money exchange rate differentials, local equipment etcetera but the cost of high standards is not cheap, which is what is obtainable in US hospitals. Still I will not want to lose clients for my hospitals, be it individuals, employers or insurance companies. IndUShealth is designed to attract those seeking cheaper medical procedures, hence has the luxury of providing VIP treatment for medical tourists and ignoring the “local” cases which they are obligated to perform but US hospitals just offer a standardized quality of care for all including medical travelers.

Reference
Cortez, N. (n.d,). Patients Without Borders: The Emerging Global Market for Patients and the Evolution of Modern Health Care. Indiana University. Retrieved from http://ilj.law.indiana.edu/articles/83/83_1_
Cortez.pdf Mahar, M. (2008). Medical Tourism: The Big Picture. Retrieved from http://www.healthbeatblog.com/2008/08/medical-tourism/


4. Academic medical tertiary community hospital system provides specialized consultative care, usually on referral from primary/secondary medical personnel, it has personnel and facilities for special investigation and treatment. (“Patients’s Care: Tertiary Care”, n.d.). The bargaining power it has with BRPP is that it has a broader range of services and more physicians, cheaper than what BRPP currently runs inhouse. And a tertiary is more specialized in its focus areas due to the variety of specialities: psychiatric, pediatric,, cancer treatment etcetera. BRPP mostly had male workers above age 48 and this means several health risk factors which is the bargaining edge for tertiary hospital system. Another edge is, now that the BRPP must find local options for union members, it will have to come up with better ways to get the desired discounts where/when possible especially because tertiary hospitals can accommodate more patients due to a larger pool of patients to spread cost over.

Reference
Patients’s Care: Tertiary Care (n.d.). Johns Hopkins Medicine. Retrieved from https://www.hopkinsmedicine.org/patient_care/billing-insurance/insurance_footnotes.html



5., Some speak for medical tourism, for example “Assuming risks are effectively communicated, medical tourism offers a net positive gain on the United States‘ health care system and should be supported” (Muzaurieta, n.d.) or “Medical tourism will help drive costs down in the U.S.,” - the CEO of GlobalChoice (counterpart of IndUSHealth) etcetera. Some against, according to Deloitte’s consumer survey, the people most willing to consider going abroad for care are young and healthy—the very people who cross-subsidize care for the old/sick by paying into the health care system (as cited by Mahar, 2008). Whatever the myriad of reasons, governments responses should factor them in: these majorly includes but is not limited to a. Lower cost of healthcare procedures in some other countries. b. Insurance initiative and proposed the idea to customers (reduce insurance companies’ spending. c. Employers initiative backed by promises of bonus. d. The procedure(s) not having been approved by the FDA in the US yet. e. Procedures that are not covered by insurance and its paid for out of pocket by patients, so he/she seeks cheaper GLOBAL MEDICAL COVERAGE 7 alternatives. It is worthy to note that these exclude US patients who seek treatment abroad under collateral care (those already on holiday/tour when the healthcare need came up) or expatriates living abroad. Through creation and enactment of relevant policies, non-monetary incentives for local healthcare insurance companies, intensified efforts on reviewing procedures still on the queue for FDA approval, programs to increase number of physicians through subsidized academic training etcetera. There are no tangible advantages to the US government from outbound medical tourism as most healthcare costs are related to supply-side factors hence there are barely savings when demand is reduced. Infact if patients receive bad treatment abroad, they still come back home to correct these issues if it doesn’t lead to loss of life. On the flip side the government of the provider nations bear the brunt of certain losses for example, 1. Redistribution and misappropriation of the local amenities to foreigners. 2. Inequality of service and access to services for its citizenry. 3. Brain Drain of healthcare professionals from rural and local hospitals to urban-tourist serving medical centers. 4. Causes price increases for the care available, medical tourism results in a two-tier system of health care in the destination country, one tier for the local poor and one for medical tourist foreigners etcetera Whichever national government is under purview, none has a duty of care to create policy to prevent medical tourism affecting the other(s). Global Medical Coverage is a reality of globalization, it’s growth may be slowed by individual governments improving their state healthcare system gradually but it can not be stifled or stopped.

Reference
 Mahar, M. (2008). Medical Tourism: The Big Picture. Retrieved from http://www.healthbeatblog.com/2008/08/medical-tourism/
Muzaurieta, J.L. (n.d.). Surgeries And Safaris: Creating Effective Legislation Through A Comparative Look At The Policy Implications, Benefits, And Risks Of Medical Tourism For The American Patient. Retrieved from https://sites.temple.edu/ticlj/files/2017/02/29.1.Muzaurieta-TICLJ.pdf

Choose a policy issue, law, ordinance, etc. related to healthcare that interests you related to your past/current/future work. Provide 1-2 paragraphs of financial or political evaluation of such policy using the tools presented in your text this week. You may also select a process outside of the book if you wish, as long as it is legit and your team can support it. Give the reference so we know where this policy is from.

Co-Author: Tamina Pfiffer

One of the pressing healthcare issues in 2018 that has been an issue in other countries as well in the recent past is the pricing of prescription drugs.
The issue to be investigated is the rising cost associated with prescription drugs that has seen an upward trend in the recent past and has been started to be evaluated as a political investigation of policy revision.
In 2017 the Food and Drug Administration has passed a Reauthorization Act in 2017 which, has for the first time in the history of that topic, been approved by both chambers, allowing for expedited access to the market generics and biosimilar.
With this recent enactment and policy change the patient access to affordable drugs was accelerated by having the policy change the timelines and review of generic drug applications (FDA, 2018).
Political evaluation on this issue has to include scanning the fours variables of a political feasibility assessment. For the above issue of prescription drug cost, the main actors determining the price for drugs, or inhibiting the market availability of generic drugs have to be identified, which include but are not limited to the pharmaceutical sponsors and ancillary supplier. When looking at the input and interplay one has to determined the impact a policy change in generic entry has on the pricing in the phase of pricing before patent expiration as the pricing in this phase might be higher to recoup anticipated earlier generic entry. Also other implications such as the threshold of adoption by industry stakeholders and patient advocate groups have to be evaluated. One can financially argue for the patient however, one has to see the profit margin for pharmaceutical sponsors and the ethical and financial effects it might have on the entire industry and how it might deteriorate the market (McLaughlin & McLaughlin, 2015).
From a political standpoint, therefore it could be a threat to the American pharmaceutical market as well as ethical implications that might lead to financial, political, and economic changes by having an increasing number of generic providers entering the market.

The approach to have better access should be the goal, however it might be more policies that would decrease the research costs and thereby decrease the price for originals instead of the above policy issues as it raises more issues in the long-term both economically, financially, and politically.

References
FDA., (2018). Generic Drug User Fee Amendments. Retrieved from: https://www.fda.gov/ForIndustry/UserFees/GenericDrugUserFees/default.htm

McLaughlin, C. P., & McLaughlin, C. D. (2015). Health Policy Analysis: An Interdisciplinary Approach. New York: Jones and Bartlett.

Discuss your interests or concerns in terms of technology in the healthcare workplace. -Offer an example. What improvements can be made to this system for a benefit to patients? -Relate this to chapter 8 in terms of the process, regulation, and opportunities you see.

The policy analysis process being focused on below is a “problem identification” as ascribed by McLaughlin & McLaughlin, specifically “What is the intended out- put?“ (2014).
For the future, there promises to be technological breakthroughs that will facilitate the digitization of medical records and as predicted by President Obama in 2009, “cut waste, eliminate red tape and reduce the need to repeat expensive medical tests.” (Campbell, 2017). This epitomizes the expected output and results of the changes that the Electronic Health Records is supposed to bring over the next decade.
EHR includes demographics, medications, progress notes, vital signs, people’s medical history, immunizations, lab results and reports. (Electronic Health Records, n.d.).
Data collection; piecing together of various data into useful information is integral to the future of healthcare and technology. This feat has been optimally maximized in the retail industry, where consumer database has been used to either improve customer experience, create bespoke advertising, target demography, communicate preemptively etcetera.
Even McLaughlin & McLaughlin said that “In the application of information technology, the health care sector lags behind other industries” (2014).
Following historical trend and projections, connectivity through the use of technology in healthcare as with Moore’s law in its prime is growing exponentially in scale year on year; be it with record keeping, monitoring outpatient’s welfare via devices, patient-submitted electronic data, PHR, artificial intelligence, etcetera. Patient’s records are now available online, intensifying level of connectivity between providers.
Healthcare is intermittently reactive, it needs to be continuous and proactive (Kraft, 2014), there have been strides going increasingly in this direction using technology but the policy/ies involved are constantly playing a botched job of ‘catch up’ with technological advancements, security exposures, hacking etcetera. 
Policies associated with technology has been limited, especially as advances in technology, its adoption and implementation have brought both improvement and issues (McLaughlin & McLaughlin). 
The Health Information Technology for Economic and Clinical Health Act (HITECH) gave the Department of Health and Human Services (HHS) the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health IT, including electronic health records and a private and secure electronic health information exchange.
Hence the EMR is a veritable source of comparable resource data for research support and clinical/medical breakthroughs, for example TREWS (Targeted Real-time Early Warning Score) which analyzes data gathered from thousands of patients on EHR and identifies subtle sign of certain diseases in people and those without the signs (Saria, 2016). So despite such mortality reducing breakthroughs, its clear the level and type of information available in it makes it prone to breach and/or abuse, that is major source of concern for those in the healthcare environment. Authorization is important to the viewing or sharing of any documents that can be described as legal health record, the policies protecting  the records to an extent is quite effective yet breaches occur due to ignorance, due to certain loop holes/exemptions and so on.
Going forward, the extent to which value is added to the quality of services offered will be dependent on the strength of policy which governs, the making, storage and use of electronic health records. The security measures put in place to safeguard access, content etcetera need to be clear and repercussions unforgiving to deter those thinking of willful abuse of privilege. The U.S. continues to lead the charge in patient’s privacy laws.





Reference 

Campbell, J. (2017). The Value of EMRs: Broken Promise or Unintended Consequences? Retrieved from https://hitconsultant.net/2017/11/06/value-emrs-broken-promise-unintended-consequences/

Electronic Health Records (n.d.). Center for Connected Health Policy. Retrieved fromhttp://www.cchpca.org/electronic-health-records

Kraft, D. (2014). Next Steps In Health & Medicine: Where Can Technology Take Us? TEDx Berlin. Retrieved from https://www.youtube.com/watch?v=zrW3-yzWt5Q&t=7s

McLaughlin, C.P.& McLaughlin, C.D. (2015). Health Policy Analysis: An Interdisciplinary Approach. Jones and Bartlett. 2nd ed. Pp 189

Saria, S., (2016, October 12th). Better Medicine Through Machine Learning. TEDx. Retrieved from https://m.youtube.com/watch?t=658s&v=Nj2YSLPn6OY

Personal Health Information: The Provider Question

Abstract According to US Department of Health and Human Services, agencies create regulations under the authority of Congress to help ...