Managing Health Care

A major theme throughout this text is that you can control many factors that influence your health. An outgrowth of this attitude is the self-care movement, which is the trend toward individuals taking increased responsibility for prevention or management of certain health conditions. Armed with correct information, you can manage many aspects of your health care that were once thought possible only with the help of a physician.

Answers to the following questions provide clues to the use of health-care services, providers, and products and facilitate the self-care approach to wellness:

When should you seek health care?

What can you expect from a stay in the hospital?

How can you select a health-care professional?

When To Seek Health Care

Many people tend to fall into two extreme groups regarding health care: those who seek health care for every ache and pain and those who avoid health care unless experiencing extreme pain. Both groups unwisely use the health-care establishment. Those in the first group fail to understand that too much health care can be ineffective or even harmful. They also fail to recognize the powerful recuperative powers of the body. An estimated 80% of patients who seek medical care are unaffected by treatment, 10% get better, and 9% experience an nitrogen condition in which they get worse because of the medical treatment. Those in the latter group fail to recognize the value of early diagnosis and detection of disease. This is especially true for men; 30% of men have not been to a doctor in a year or more, one-third have never had their cholesterol checked, and three fourths have not been checked for prostate cancer during the previous year.

Perhaps the best way to find a balance between too much and too little health care is to establish a physician-patient relationship with a general practitioner. The general practitioner may be a family practice physician or an internist who specializes in internal medicine.

It is important to visit your doctor while in good health. This permits your doctor to serve as a facilitator of wellness and provides a benchmark for interpreting symptoms when they occur.

A second important way to balance health care is to trust your instincts. Nobody knows when some thing is wrong with your body better than you do. Health and illness are subject to a wide variation in interpretation. If you are attuned to your body, you are your own best expert for recognizing signs and symptoms of illness.

Several signs and symptoms warrant medical attention without question. Internal bleeding, such as blood in urine, bowel movement, sputum, or vomit, or blood from any of the body’s openings requires immediate attention. Abdominal pain, especially when it is associated with nausea, may indicate a wide range of problems from appendicitis to pelvic inflammatory disease and requires the diagnostic expertise of a physician. A stiff neck when accompanied by a fever may suggest meningitis and justifies immediate medical intervention. Injuries, many first aid emergencies, and severe disabling symptoms require prompt medical care.

There is debate as to when medical care is needed in the case of fever. An elevated temperature may be a sign that the body’s immune system is responding to an infection and working to destroy pathogens, or disease-producing organisms. On the other hand, if left untreated for an extended time, a fever may cause harm to sensitive tissues in the body, such as connective tissue found in joints and tissues in the valves of the heart.

The normal body temperature of 98.6° F was studied at the University of Maryland. Findings involving 700 temperature readings of 148 adults over a 3-day period suggest that the normal body temperature is 98.9° F. The study attributed the difference to less accurate techniques when the earlier standard of 98.6° F was established. Body temperature varies with exercise, rest, climate, and gender. Fever means a reading over 99° F. It is not usually necessary for an adult to seek medical care for a fever. Home treatment in the form of aspirin, acetaminophen, and sponge baths usually lowers fever. You should consult your physician if fever remains above 102 0 F despite your actions or, in the case of a low-grade fever (99 0 to 100 0 F), if there is no improvement in 72 hours. You should consult a physician if fever lasts more than 5 days, regardless of improvement. Symptoms, such as sore throat, ear pain, diarrhea, urinary problems, and skin rash, may be the cause of the fever and should be treated as such. Fever in young children should be discussed with a physician.

National Health Care System In Japan And Taiwan – Would It Be Possible For Us?

Every society is affected by any national changes or new movement introduced; therefore, an issue one may think is unrelated to his environment can very well affect him through chains of cause and effect.

Health care is an immediate issue that concerns all of us. We all experience it and need it. Let’s serious ask ourselves if the current health care system is satisfactory and available to everyone. Should health, medicare and treatments be available to only selected groups? Many people are voting for the presidential candidate who can restore the present health care system or who can pioneer a better healthcare distribution for our country. Personally, I hope to see a change that health care is available and affordable to everyone.

Being able to receive basic health care is a fundamental need of all people. Fulfilling this fundamental need makes people feel secured, and it makes sense that people with better health can contribute more to the society. A realistic and reachable standard of health should be set for all people. This effort needs a non profit driving entity to establish and to maintain it. People’s life and health should not be compromised for the profit of few organizations.

Before moving to Japan, I was covered under my parents’ insurance policy in the United States. Their policy covered children of the family until the age of twenty-four. Upon graduating from university, I moved to Japan and started my first job there. I joined the Japanese national health insurance through the company I worked for. There are basically two types of health insurance in Japan: national health insurance and employer-sponsored health insurance. Usually, under employer sponsored insurance, the insurance premium is calculated according to income, number of dependents, and the company’ subsidies. For someone who is self-employed or unemployed, the national health insurance costs a minimum of 13300 yen, or about $110 per month plus a small percentage of income for those who are self-employed. In other words, everyone can get insurance from around $100 dollars a month. Unlike the Medicaid program in the U.S. which is only available to certain low-income groups with specific requirements for eligibility, the Japanese health insurance is available to every citizen and legal residents. There is a ceiling to what the Japanese National insurance covers, but it covers all the basics and beyond.

In most cases in Japan, patients choose their doctor and hospital. There is no limitation to the doctors or hospital they can visit. This is a true competition among the clinics, hospitals, and medical practitioners, not for profit, but for quality. The same insurance that people have in Japan gives them the freedom to get second opinions and naturally eliminates those doctors whose practices are in question. The doctor visits, treatments, and medicine are not free; one is responsible for thirty percent of their medical bills. Japanese health costs are much lower than the costs in the United States. Thirty percent of the medical bill is still a reasonable amount one can afford. There are also special cases or categories of illness for which the insurance would give more coverage. If one is late on his payment, his insurance will not automatically be invalid. The insurance will still cover the person as long as he makes up the missed payments. After all, some people do run into difficulties in life at one point or another. Sounds to good to be true? Well, It’s real.

Taiwan, a place with no world recognition politically, has one of the top public health care system in the world. After moving to Taiwan due to my husband’s transfer a year a go, I learned and appreciated the system where universal or national health care is available to all more than ever. When speaking of universal, national, or pubic health insurance, people often turn their attention to the well-debated and discussed health care system in Canada. There are those whose views are negative, claiming that the medical service in a single-payer insurance system may not perform at its ultimate, and those whose views are positive, saying that they do not live in fear of ever having to face bankruptcy for outrageous medical bills. From my informal inquiries, more Canadian I came across favor their national health care system. Most of those who favor their national health care system commented that people of Canada are more secured in having their basic physical and psychological needs met.

In Taiwan, there is also government-sponsored universal health care for not only their citizens but also for foreign residents who live in Taiwan. Foreign residents can apply for the government-sponsored insurance after proving their legal status of residing in Taiwan. The insurance fee starts from the basic 600NT, or around $18 a month. For people in higher income brackets, their insurance is calculated based on a percentage of their income over the 600Nt. Fees are waived for retired soldiers, those who are physically challenged, and people who have economic disadvantages.

Interestingly, Taiwan’s national health insurance has only been established for little more than two decades, since 1985. The government policy-makers studied health care system from different foreign countries and composes the first Taiwan national health care from the ideas and methods of the system of other countries. It was said that Taiwan’s national insurance system is like a completed puzzle made from pieces of which fit its country and people. This insurance now covers the entire population, including foreign legal residents. According to research funded by Taiwan’s National Health Research and Taiwan’s Bureau of National Health Insurance, the cost of health care did not rise after the universal coverage was established (Jui-Fen & Hsiao, 2003.) What does that tell us?

A basic health care program can greatly reduce the consequences of illness left untreated. Basic health care does not mean free of charge or mindless spending without control. To build a healthy nation, we should take a closer look at the current U.S. health insurance. After all, a sound nation starts with the health of its people.

Patient Abandonment – Home Health Care

Elements of the Cause of Action for Abandonment

Each of the following five elements must be present for a patient to have a proper civil cause of action for the tort of abandonment:

1. Health care treatment was unreasonably discontinued.

2. The termination of health care was contrary to the patient’s will or without the patient’s knowledge.

3. The health care provider failed to arrange for care by another appropriate skilled health care provider.

4. The health care provider should have reasonably foreseen that harm to the patient would arise from the termination of the care (proximate cause).

5. The patient actually suffered harm or loss as a result of the discontinuance of care.

Physicians, nurses, and other health care professionals have an ethical, as well as a legal, duty to avoid abandonment of patients. The health care professional has a duty to give his or her patient all necessary attention as long as the case required it and should not leave the patient in a critical stage without giving reasonable notice or making suitable arrangements for the attendance of another. [2]

Abandonment by the Physician

When a physician undertakes treatment of a patient, treatment must continue until the patient’s circumstances no longer warrant the treatment, the physician and the patient mutually consent to end the treatment by that physician, or the patient discharges the physician. Moreover, the physician may unilaterally terminate the relationship and withdraw from treating that patient only if he or she provides the patient proper notice of his or her intent to withdraw and an opportunity to obtain proper substitute care.

In the home health setting, the physician-patient relationship does not terminate merely because a patient’s care shifts in its location from the hospital to the home. If the patient continues to need medical services, supervised health care, therapy, or other home health services, the attending physician should ensure that he or she was properly discharged his or her-duties to the patient. Virtually every situation ‘in which home care is approved by Medicare, Medicaid, or an insurer will be one in which the patient’s ‘needs for care have continued. The physician-patient relationship that existed in the hospital will continue unless it has been formally terminated by notice to the patient and a reasonable attempt to refer the patient to another appropriate physician. Otherwise, the physician will retain his or her duty toward the patient when the patient is discharged from the hospital to the home. Failure to follow through on the part of the physician will constitute the tort of abandonment if the patient is injured as a result. This abandonment may expose the physician, the hospital, and the home health agency to liability for the tort of abandonment.

The attending physician in the hospital should ensure that a proper referral is made to a physician who will be responsible for the home health patient’s care while it is being delivered by the home health provider, unless the physician intends to continue to supervise that home care personally. Even more important, if the hospital-based physician arranges to have the patient’s care assumed by another physician, the patient must fully understand this change, and it should be carefully documented.

As supported by case law, the types of actions that will lead to liability for abandonment of a patient will include:

• premature discharge of the patient by the physician

• failure of the physician to provide proper instructions before discharging the patient

• the statement by the physician to the patient that the physician will no longer treat the patient

• refusal of the physician to respond to calls or to further attend the patient

• the physician’s leaving the patient after surgery or failing to follow up on postsurgical care. [3]

Generally, abandonment does not occur if the physician responsible for the patient arranges for a substitute physician to take his or her place. This change may occur because of vacations, relocation of the physician, illness, distance from the patient’s home, or retirement of the physician. As long as care by an appropriately trained physician, sufficiently knowledgeable of the patient’s special conditions, if any, has been arranged, the courts will usually not find that abandonment has occurred. [4] Even where a patient refuses to pay for the care or is unable to pay for the care, the physician is not at liberty to terminate the relationship unilaterally. The physician must still take steps to have the patient’s care assumed by another [5] or to give a sufficiently reasonable period of time to locate another prior to ceasing to provide care.

Although most of the cases discussed concern the physician-patient relationship, as pointed out previously, the same principles apply to all health care providers. Furthermore, because the care rendered by the home health agency is provided pursuant to a physician’s plan of care, even if the patient sued the physician for abandonment because of the actions (or inactions of the home health agency’s staff), the physician may seek indemnification from the home health provider. [6]

ABANDONMENT BY THE NURSE OR HOME HEALTH AGENCY

Similar principles to those that apply to physicians apply to the home health professional and the home health provider. A home health agency, as the direct provider of care to the homebound patient, may be held to the same legal obligation and duty to deliver care that addresses the patient’s needs as is the physician. Furthermore, there may be both a legal and an ethical obligation to continue delivering care, if the patient has no alternatives. An ethical obligation may still exist to the patient even though the home health provider has fulfilled all legal obligations. [7]

When a home health provider furnishes treatment to a patient, the duty to continue providing care to the patient is a duty owed by the agency itself and not by the individual professional who may be the employee or the contractor of the agency. The home health provider does not have a duty to continue providing the same nurse, therapist, or aide to the patient throughout the course of treatment, so long as the provider continues to use appropriate, competent personnel to administer the course of treatment consistently with the plan of care. From the perspective of patient satisfaction and continuity of care, it may be in the best interests of the home health provider to attempt to provide the same individual practitioner to the patient. The development of a personal relationship with the provider’s personnel may improve communications and a greater degree of trust and compliance on the part of the patient. It should help to alleviate many of the problems that arise in the health care’ setting.

If the patient requests replacement of a particular nurse, therapist, technician, or home health aide, the home health provider still has a duty to provide care to the patient, unless the patient also specifically states he or she no longer desires the provider’s service. Home health agency supervisors should always follow up on such patient requests to determine the reasons regarding the dismissal, to detect “problem” employees, and to ensure no incident has taken place that might give rise to liability. The home health agency should continue providing care to the patient until definitively told not to do so by the patient.

COPING WITH THE ABUSIVE PATIENT

Home health provider personnel may occasionally encounter an abusive patient. This abuse mayor may not be a result of the medical condition for which the care is being provided. Personal safety of the individual health care provider should be paramount. Should the patient pose a physical danger to the individual, he or she should leave the premises immediately. The provider should document in the medical record the facts surrounding the inability to complete the treatment for that visit as objectively as possible. Management personnel should inform supervisory personnel at the home health provider and should complete an internal incident report. If it appears that a criminal act has taken place, such as a physical assault, attempted rape, or other such act, this act should be reported immediately to local law enforcement agencies. The home care provider should also immediately notify both the patient and the physician that the provider will terminate its relationship with the patient and that an alternative provider for these services should be obtained.

Other less serious circumstances may, nevertheless, lead the home health provider to determine that it should terminate its relationship with a particular patient. Examples may include particularly abusive patients, patients who solicit -the home health provider professional to break the law (for example, by providing illegal drugs or providing non-covered services and equipment and billing them as something else), or consistently noncompliant patients. Once treatment is undertaken, however, the home health provider is usually obliged to continue providing services until the patient has had a reasonable opportunity to obtain a substitute provider. The same principles apply to failure of a patient to pay for the services or equipment provided.

As health care professionals, HHA personnel should have training on how to handle the difficult patient responsibly. Arguments or emotional comments should be avoided. If it becomes clear that a certain provider and patient are not likely to be compatible, a substitute provider should be tried. Should it appear that the problem lies with the patient and that it is necessary for the HHA to terminate its relationship with the patient, the following seven steps should be taken:

1. The circumstances should be documented in the patient’s record.

2. The home health provider should give or send a letter to the patient explaining the circumstances surrounding the termination of care.

3. The letter should be sent by certified mail, return receipt requested, or other measures to document patient receipt of the letter. A copy of the letter should be placed in the patient’s record.

4. If possible, the patient should be given a certain period of time to obtain replacement care. Usually 30 days is sufficient.

5. If the patient has a life-threatening condition or a medical condition that might deteriorate in the absence of continuing care, this condition should be clearly stated in the letter. The necessity of the patient’s obtaining replacement home health care should be emphasized.

6. The patient should be informed of the location of the nearest hospital emergency department. The patient should be told to either go to the nearest hospital emergency department in case of a medical emergency or to call the local emergency number for ambulance transportation.

7. A copy of the letter should be sent to the patient’s attending physician via certified mail, return receipt requested.

These steps should not be undertaken lightly. Before such steps are taken, the patient’s case should be thoroughly discussed with the home health provider’s risk manager, legal counsel, medical director, and the patient’s attending physician.

The inappropriate discharge of a patient from health care coverage by the home health provider, whether because of termination of entitlement, inability to pay, or other reasons, may also lead to liability for the tort of abandonment. [8]

Nurses who passively stand by and observe negligence by a physician or anyone else will personally become accountable to the patient who is injured as a result of that negligence… [H]ealthcare facilities and their nursing staff owe an independent duty to patients beyond the duty owed by physicians. When a physician’s order to discharge is inappropriate, the nurses will be help liable for following an order that they knew or should know is below the standard of care. [9]

Similar principles may apply to make the home health provider vicariously liable, as well.

Liability to the patient for the tort of abandonment may also result from the home health care professional’s failure to observe, examine, assess, or monitor a patient’s condition. [10] Liability for abandonment may arise from failing to take timely action, as well as failing to summon a physician when a physician is needed. [11] Failing to provide adequate staff to meet the patient’s needs may also constitute abandonment on the part of the HHA. [12] Ignoring a patient’s complaints and failing to follow a physician’s orders may likewise constitute a tort of abandonment for a nurse or other professional staff member.

1. Lee v. Dewbre, 362 S.W.2d 900 (Tex. Civ. App. 7th Dist. 1962).

2. Kattsetos v. Nolan, 368 A.2d 172 (Conn. 1976).

3. 61 AM. Jur. 2d, Physicians and Surgeons § 237 (1981).

4. See, e.g., Tripp v. Pate, 271 S.E.2d 407 (N.C. App. 1980).

5. Ricks v. Budge, 64 P.2d 208 (Utah 1937).

6. M.D. Nathanson, Home Healthcare Answer Book: Legal Issues for Providers 212 (1995).

7. See, generally, E.P. Burnzeig, The Nurse’s Liability for Malpractice (1981).

8. Sheryl Feutz-Harter, Nursing Caselaw Update: In appropriate Discharging of Patients, 2 J. Nursing L. 49 (1995).

9. Id., 53.

10. See, e.g., Pisel v. Stamford Hosp., 430 A.2d1 (Conn. 1980) (nurses were held liable for failing to monitor the condition of a patient).

11. See, e.g., Sanchez v. Bay General Hosp., 172 Cal. Rptr. 342 (Cal. App. 1981); Valdez v. Lyman-Roberts Hosp., Inc. 638 S.W. 2d 111 (Tex. 1982).

12. Czubinsky v. Doctors Hosp., 188 CAl. Rptr. 685 (1983).