Incident 2: Miriam Hospital

The Dilemma:

In 1980, the hospital changed the analyzing machine to run blood tests from a six channel analyzer to a twelve channel analyzer. When the insurance company (Blue Cross) was billed for the test (only the twelve channel analyzer test was used), both tests were unintentionally charged due to a computer programming error. This created a double-billing situation, and Miriam hospital received funds for both the twelve channel test and for the six channel test. In 1982, a professional standards review organization clerk uncovered the double billing error and informed the hospital. The error was first eliminated and then later re-instated by a “top official.” Later that year, a Blue Cross auditor uncovered the double billing error and contacted the hospital for access to their program. The top official instructed the manager of data processing to remove evidence of that the error had been found, eliminated and then re-instated, thus allowing Miriam to claim innocence of any knowledge. Eventually a indictment was brought against Miriam for obtaining money under false pretenses, conspiracy and filing false documents. Were these charges rightly brought against Miriam?

Analysis:

1. Almost $2.8 million was over-charged and received by Miriam. 2. Miriam claimed that they were just following a rule which stated that the same

accounting methods be used until the end of the fiscal year. 3. Two data-processing personnel were forced to quit because of allowing third

party access to Miriam’s computer system, which was a violation to hospital policy.

Personal Opinion:

This scenario brings to light several questions: Why was evidence erased if they truly believed they were just following procedures and that what they were doing was legal? Why were two employees being forced to quit, unless there was a need to get rid of those close to the situation? What would happen if they did this same thing to the government? What would Miriam do if the tables were turned? Was the reimbursement rule that Miriam was supposedly following meant to encourage this fraud?I think the answer to these questions lies in one fact: that Miriam knew that if they came clean, they would have to return the $2.8 million dollars, where as, if they could just eliminate the error at the beginning of 1983, know one would catch the error. However, my question is, how could Miriam believe that the error wouldn’t eventually be caught. If there was a sudden sharp decrease in testing reimbursement, an auditor would surely have asked why and investigated further. If they tried to continue “getting away with it,” an auditor would surely have caught the error sooner or later, like what occurred in 1982. This leads into the question about the reimbursement rule. This rule more in likely covers changes in accounting methods such as switching beginning dates of the quarter, switching to different inventory or depreciation calculation methods, or the addition of deletion of services. However, this rule probably does not cover nor condone fraudulent behavior. This further leads us to the preponderance of how the government would react. Actually, we know exactly how they would react according to the False Claims Act of

1986 or to the HIPAA act of 1996. Needless to say, Miriam would be in serious trouble if they defrauded the government instead of Blue Cross. Either way, fraudulent behavior of this type is incorrect and should be prosecuted to the fullest extent of the law. I believe that fraud, professional/corporate negligence and employment contract breach and coercion should also be added to the list of charges. In-fact, to send a message to others, all the managers involved should be fired, civilly charged and prosecuted. A system of checks should be put in place, such as a yearly billing audit check and policies that state if any errors or inconsistencies are found, that they be immediately reported to involved parties so that a determination can be reached on how to proceed. This will prevent further fraudulent behavior and allow more open and trusting communication between HSO’s.

Incident 5: Protecting the community

The Dilemma:

Legionnella is a bacteria that causes legionnaire’s disease and one that can easily spread through a hospital via the air conditioning system. Legionnaire’s disease is potentially life threatening if not diagnosed and treated early, or especially in elderly people, immuno-compromised people, or others with medical issues. Most of these types of people are found in a hospital. In 1977, an outbreak of Legionnella occurred at University hospital, with a cooling tower implicated as the source of the infection. It was understood that treatment of the water system with chlorine would kill most bacteria, including Legionnella. However, after the outbreak of 1977, no policy or standing order was created to treat the water with chlorine. In 1982, another outbreak occurred. Chlorination of the water was then immediately implemented; however the number of cases or deaths resulting from this outbreak is unknown from the article. The administrator and several others came to the decision that the outbreak should be kept from the community and that there would be no limit on admissions to the hospital. The only communication that occurred about this incident was a confidential letter to all the physicians stating that they should keep in mind the potential for risk when making an admissions decision. No emergency policy was made to prevent the admissions of those with respiratory issues or any other issues that would make them susceptible to Legionnella. Did the hospital administrator make the correct decision about not telling the community about the outbreak? Analysis:

1. In the original 1977 outbreak, a number of patients were affected and several died.

2. Further outbreaks could have been initially avoided if the water system was treated with chlorine.

3. University hospital acted in a negligent manner by not initially treating the water system.

4. The administrator stated several reasons for not divulging the outbreak

a. He didn’t want to start a panic.

b. He wanted to prevent loss of confidence in the hospital from the community.

c. He wanted to prevent a drop in the census.

d. The medical staff created a protocol in response to the situation by stating that any unexplained onset of acute-pneumonia was to be treated with a potent antibiotic shown to be effective against Legionnella.

Personal Opinion:

I’m going to begin this opinion with a general description of corporate negligence.

“Corporate negligence is a doctrine under which the hospital is liable if it fails to uphold the proper standard of care owed to the patient, which is to ensure the patient’s safety and well-being while at the hospital.”

Several forms of corporate negligence exist including: complying with the law, providing a safe environment, and providing all pertinent information to patients that may affect their decision to seek treatment at the hospital. University hospital acted negligently by breaching all of these duties owed to their patients. Firs, once an outbreak was identified, proper agencies must be notified (for example, the CDC) and proper precautions must be taken to prevent the spread of the disease. Also, the community should be notified about the outbreak and that all steps are being taken to solve the crisis. Second, University hospital acted negligently after the first outbreak by not providing the proper chlorine treatment to the water supply to prevent future outbreaks. In-fact, this is the most serious charge of them all; with this breach constituting gross negligence and even possibly criminal negligence. Thirdly, patients have the right to all knowledge that would effect their decision as to where to seek treatment. This not only is negligence, but could also be fraudulent behavior. University hospital should have a suit brought against them with these three charges. The administrator should also have civil charges brought against him since it was his decisions that caused further outbreaks and by allowing pre-disposed patients from still entering the hospital. There was no need to deceive the community, and I highly doubt that if proper communication and notification took place, the census would have dropped dramatically. The fall-out from this conspiracy was more detrimental than what was trying to be prevented in the first place.

Incident 6: Decisions

The Dilemma:

A DNR (Do-Not-Resuscitate) order is an order stating that if a patient stops breathing or if their heart stops that they do not want either be intubated or given CPR. Most people who have these types of AMD (advanced medical directives) are terminally ill patients or patients with extremely debilitating diseases/disorders. Mrs. Nickleby is person with severe MS who currently lives in a nursing home. She has been having frequent asthma attacks recently, and the nurses at the nursing home noticed that Mrs. Nickleby’s physician ordered a DNR code in the event she has a cardiac arrest during one of her

attacks. To the knowledge of the staff, Mrs. Nickleby has not discussed this issue with her doctor. Is this DNR valid? If so, how?

Analysis:

1. The patient is receiving care at the nursing home from her physician. A witness was not present when the DNR was ordered.

2. The patient has been getting more depressed over the course of the past asthmatic episodes.

3. None of the nurses have heard Mrs. Nickleby express any discontent or opinion about not wanting to live.

4. One of the nurses has a serious problem with the order because it goes against her professional values.

5. None of the staff members noticed the Doctor discussing this or any issue with any of the family members.

Personal Opinion:

DNR’s and other AMD’s are not always enforceable, especially if family members have other demands or if the staff disagrees with the order. In this case, there is a reasonable doubt that the DNR order is completely genuine. The current DNR should be considered null and void, and any time the issue is discussed in the future, the physician, an ethics committee administrative representative and all involved near relatives should be present. If the decision is finalized that a DNR is to be created, the physician, the ethics committee member, and patient must all sign the order. Further, a policy should be created that delineates that anytime a patient is considering a DNR, that they sign a form to start the above process. In essence, the DNR occurs in stages: 1). Form for consideration of a DNR. 2). Advisement with physician, ethics committee member and family members. 3). Contemplation time of not less than 2 weeks. 4). Signing of DNR by patient, physician and ethics committee member.