Barry R Furrow

This reflection article examines the trajectory of health law — using scholarly work by George Annas, Wendy Mariner, and Fran Miller as a platform.1 These three health law scholars have been analyzing the complications of health law in the U.S. economy for decades, and each of them has been prescient in anticipating what the future of health care delivery will look like and how we might improve it.

This article proposes ethical - and legal - accountability for lawyers representing clients such as private equity (PE) firms who create ownership structures for nursing home systems. Using PE ownership as a case study, I will show that nursing home residents are often harmed and Medicaid costs inflated. I propose private law provides tools to compel such accountability, through (1) aiding and abetting doctrines and (2) fiduciary doctrines that require that the fiduciary be responsible for its vulnerable beneficiaries, not just ethically but for damages and equitable relief. I further propose that the teaching of Professional Responsibility needs to be changed to force law students to consider the effect of legal practice on third parties in situations like health care financing.

Treatment of mental illness in the United States is woefully inadequate. One-third of adults report having a mental health condition or substance use disorder, but less than half receive treatment for their condition.Access is the problem. The U.S. is short on mental health professionals: more psychiatrists are needed and psychologists and social workers are overextended. Proposed solutions are to (1) increase reimbursement rates for psychiatrists and other mental health practitioners, and (2) use a wider range of providers, including nurses and family support specialists-all good ideas. My focus however is on two other forces that are moving into the behavioral health area, offering both financing and technologies to extend the reach of mental health services-private equity and telemental health.First, private equity firms see high demand in this market. Behavioral health is desperately needed but is highly fragmented and lacking in innovation. Private equity is attracted to outpatient programs that target specific conditions that have evidence-based clinical models-programs aimed at addiction, eating disorders, and autism; these areas require less capital. Federal and state reimbursement is available, some regulations have been relaxed to allow remote prescribing of medicine; and innovative telehealth tools can be used. The problem is that private equity has a poor track record in both nursing home care and behavioral care for teens. The private equity model and its financial incentives are at odds with good care.Second, telemental health tools, already in use because of the need during the pandemic, appear attractive. These tools require less capital to treat a higher volume of patients and promise much improved access to mental health treatment for populations that could not get such care because of travel distance, costs, and time limitations. The problem is that the telemental health tools have yet to be subjected to evidence-based testing.My goal in this article is to test whether these two developments - private equity and telemental health -can improve access for patients at an acceptable level of quality. I conclude that both have substantial problems and I offer a range of regulatory approaches to control patient abuses and poor quality.

This chapter presents a comparison of liability/compensation systems across countries, which can be challenging because of substantial differences in tort doctrine, judicial systems, and administrative compensation mechanisms. It approaches the problem of patient injury in a healthcare system from the dual (and dueling) perspectives of system responsibility and provider culpability. The basic question that the chapter asks is this: Who should bear the economic costs of medical adverse events? The US system remains solidly anchored in the tort liability system, with its emphasis on negligence-based culpability in medical malpractice cases—but with timid moves toward enterprise liability and statutory communication and resolution programs. By contrast, the Scandinavian systems have publicly funded patient compensation funds.

This chapter examines the processes of litigation arising from medical malpractice liability, changes in tort doctrine, and judicial responses to medical injuries. It first considers physician liability, with emphasis on evidentiary requirements for proving the medical standard of care and how expert testimony on the standard of care has increasingly relied on practice guidelines that articulate the parameters of the standards of care. It then turns to the Affordable Care Act with its emphasis on “best practices” and “practice guidelines,” along with defenses that are available against a malpractice suit. The chapter also looks at the importance of informed consent in promoting patient sovereignty in medical decision-making and alternative dispute resolution as a tool for reducing the risks of malpractice litigation and jury trials. Finally, it discusses the liability of hospitals, taking into account the agency doctrine and corporate negligence as well as nonhospital system liability and nonphysician liability.