Medicare Parts A–D
Part A = Inpatient hospital / hospice; Part B = Outpatient doctor visits / labs; Part C = Medicare Advantage (private HMO/PPO plans); Part D = Prescription Drugs.
EMTALA Mandate
Emergency Medical Treatment and Active Labor Act: Mandates medical screening exam and stabilization of emergency conditions/active labor regardless of ability to pay.
HMO vs. PPO
HMO: Lowest cost, requires primary care gatekeeper, no out-of-network coverage. PPO: Higher premium/flexibility, direct specialist access, covers out-of-network.
Impaired Physician
First action: Protect patient safety. If immediate patient danger, stop the physician and notify supervisor; report to hospital Physician Health Program (PHP).
Healthcare Payment Models & Insurance Architecture
Modern healthcare delivery shifts financial risk between payers, providers, and health systems:
| Payment / Insurance Model | Financial Structure & Risk Bearing | Physician Incentives | High-Yield Board Traps & Features |
|---|---|---|---|
| Fee-for-Service (FFS) | Payer pays for each individual test, procedure, and office visit rendered | Incentivizes volume (more procedures = higher revenue); risks overtreatment and fragmented care | Traditional indemnity plans; no incentive for preventive care or population health |
| Capitation (HMO) | Insurer pays fixed dollar amount per patient per month (PMPM) regardless of services utilized | Incentivizes efficiency, preventive care, and cost containment; physician bears financial risk of overutilization | Requires Primary Care Physician (PCP) 'gatekeeper' to refer to specialists; no coverage for non-emergency out-of-network services |
| Preferred Provider Organization (PPO) | Insurer contracts with network providers at negotiated discounted fee-for-service rates | Higher premiums and deductibles; patients do NOT need gatekeeper referral for specialists | Covers out-of-network providers at a higher coinsurance cost to the patient |
| Accountable Care Organization (ACO) | Network of doctors, hospitals, and healthcare providers sharing collective financial accountability for a patient population | Incentivizes high-quality, coordinated care; providers share in cost savings if quality benchmarks are met (Value-Based Care) | Central component of Medicare Shared Savings Program under the Affordable Care Act (ACA) |
| Bundled Payments (Episode of Care) | Single comprehensive payment covering all services for an entire clinical episode (e.g., total knee arthroplasty + 90-day rehab) | Encourages interdisciplinary coordination between surgeons, anesthesiologists, and physical therapy to minimize complications | Complications and readmissions eat directly into provider margins |
Federal Healthcare Statutes & Professional Responsibilities
Federal statutes govern emergency access, patient data privacy, and hospital regulatory compliance:
| Statute / Regulation | Core Statutory Requirement | Exceptions & Nuances | Board Exam Clinical Scenario |
|---|---|---|---|
| EMTALA | Hospitals with emergency departments MUST provide an appropriate Medical Screening Exam (MSE) and stabilizing treatment to anyone who presents | Cannot transfer an unstable patient unless patient requests transfer in writing or physician certifies benefits outweigh risks; inability to pay CANNOT delay screening | Uninsured patient arrives in labor; hospital cannot turn them away or demand cash deposit before delivery and maternal stabilization |
| HIPAA Privacy Rule | Protects Individually Identifiable Health Information (PHI) in any form; requires minimum necessary disclosure | Exceptions: Mandatory reporting (abuse, reportable infectious diseases), Tarasoff warnings, treatment/payment operations | Family member calls asking for patient update; without patient authorization, staff cannot confirm or deny patient admission |
| Stark Law (Physician Self-Referral) | Prohibits physicians from referring Medicare/Medicaid patients for designated health services to entities where the physician has a financial interest | Strict liability statute (does not require intent to violate); exceptions include in-office ancillary services | Orthopedic surgeon referring patients exclusively to an MRI facility owned by the surgeon's spouse |
| Physician Impairment Protocol | Professional duty to ensure impaired colleagues (substance use, cognitive decline) do not endanger patients | Immediate danger → remove physician from patient care immediately; Non-acute → report to hospital Physician Health Program (PHP) or state licensing board | Smelling alcohol on a surgical resident's breath prior to entering the operating suite |
Board Traps & Common Distractors
- Under EMTALA, a hospital cannot delay a Medical Screening Examination or stabilizing treatment to inquire about a patient's insurance status or ability to pay.
- If a physician is actively impaired (e.g., intoxicated or acutely cognitively compromised) while responsible for patient care, the observing physician MUST intervene immediately to prevent patient harm; do not wait to report to a committee later.
- Physicians cannot accept gifts, lavish meals, or financial compensation from pharmaceutical companies that could improperly influence prescribing behavior; educational materials of modest value that directly benefit patients are permissible.