Study Guide Test 2 PDF

Smaran Ramidi Study Guide Test 2 Test 2 will be the same format as test 1 with 50 multiple choice, T/F questions. You will have one hour and fifteen minutes. In chapters 5,6, 8,9,10,12, 13 and 15, pay attention to the concepts under each Red bolded headings as they relate to the content covered in...

Smaran Ramidi Study Guide Test 2 Test 2 will be the same format as test 1 with 50 multiple choice, T/F questions. You will have one hour and fifteen minutes. In chapters 5,6, 8,9,10,12, 13 and 15, pay attention to the concepts under each Red bolded headings as they relate to the content covered in class on slides. Ch 5-6 Organization and A&M text Primary, Secondary, Tertiary levels of care-examples-which is most costly - Primary: common health problems that account for 80-90% visits to providers - Ex. immunizations, colds, physicals, ear infections (PCP services) - Secondary: problems that require more specialized clinical expertise - Ex. OB/GYN, ENT, Surgery, Cancer Treatment - Tertiary: rare and complex problems - Ex. Conditions like Cystic fibrosis, Congenital deformities, Organ transplants, rare cancer Regionalized model-dispersed model- features, why dispersed model has grown in the U.S. - Dawson Model of Regionalized Care: highly structured organization beginning with PCPs and moving up specialties as needed - General physician practitioners (GPs) practice exclusively at the primary care level stopping unnecessary meetings - Relies on resources coordinated in a geographic region to allow for people to access higher level care when needed - Similar to HMOs - Dispersed Model: Fluid model to allow patients to go where they wish and tertiary expertise is emphasized - Primary care is spread among specialists - The Dispersed Model has grown in the U.S. - Biomedical Model: Medical training was reformed with an emphasis on Academically oriented training, technology and basic science, specialist training (Flexner Report 1906) - Financial Incentives: - Medicare/Medicaid paid more for procedures rather than general care - Blue Shield Reimbursements: fees remained high for procedures even though physician time for procedures has decreased - Hill Burton Hospital Construction Act of 1946: pushed for hospital expansion - Professionalism of Doctors - Physicians have been sovereign and independent to make decisions with the support of the AMA - System has been weighted toward hospital and specialty care (salary and training) Arguments for and against a dispersed model - Arguments For: Smaran Ramidi - Pluralism enables providers and facilities to be more available - Americans value choice of providers, access to specialists and technology - Arguments Against: - Lack of coordination (no set structure) - Quality of care can be maintained with use of fewer resources - Research shows comparable outcomes for patients treated by GPs and NPs - Not consistent with the health needs of the majority of the population “Common disorders commonly occur and rare ones rarely occur” - Costly - PCPs are more in need than Specialists - Research shows that generalists practice a less resource intensive style of medicine compared to specialists - Costs are lower for patients treated by generalists vs. specialists Supply of U.S. generalist physicians- why this is a problem - Supply of PCPs has been decreasing as less Medical students consider going into PCP training - Income of PCPs is significantly lower than Specialist salary even though they both have the same amount of schooling - PCPs are in very high demand but there are not enough to fill the current positions needed Vertical integration- First generation HMOs- Kaiser - Vertical Integration Model: consolidates all levels of care, staff, and facilities under on organizational ownership - Does not cover an entire population but responsible for delivering all services to its population of enrollees - Physician group practice care to members under a capitated plan - Enables a more population based model of health Virtual integration- Independent Practice Associations (IPAs) and Integrated Medical Groups - Virtual Integration: Hospitals and insurers recruit office based fee for service community physicians into an IPA creating a basis for an HMO and negotiating contracts with the Physicians to provide care - Independent Practice Associations (IPAs) Model: Middle group - Allows insurers to respond to market changes by negotiating contract bargains with providers - Has the advantage of low capital costs because the HMO does not have to own building - Integrated Medical Group (IMG) Model: Physicians do not own their practices but the medical group organization employs them Importance of HMO act 1973 - Under Nixon’s healthcare reform giving federal funds to promote expansion of pre-paid practices and IPAs making medium and large businesses had to offer one HMO plan to employes - IPAs Grew because they were easier to organize than pre-paid practices - Problem: Gatekeepers were used to for cost containment Smaran Ramidi - Problem: Physicians who see patients from several HMOs did not know which hospital or specialist would accept a patient CH 8-9 - Controlling Healthcare Costs Health expenditures as a percent of GDP - Increased from 9.2% GDP in 1980 to 17.9% GDP in 2017 - Total Health Expenditure: sum of public and private health expenditure Health costs and outcomes model - Enables examination of the relationship between healthcare costs and benefits in terms of improved health outcomes - Relevant outcome of interest is the overall health of a population rather than of any one individual Cost control: Painless/painful - Cost = Price x Quanitity - Painless Controls: fees and provider incomes, pharmaceutical prices, administrative costs, medical intervention eliminations, less costly technologies - Quantity: High quantity of service does not correlate with improved outcomes - Challenges to controlling Quantity - Innovation may not decrease quantity of costs (Ex. Laparoscopic Cholecystectomy) - Prevention programs may cost more than treatment (Ex. blood pressure screening) - Prioritization & Analysis of Cost Effectiveness Strategies for cost control: Financing and Reimbursement controls - Financing: flow of money (taxes, premiums) from individuals and employers to health plans - Government regulation of taxes serves as a control over public expenditures for healthcare but increases taxes and requires adequate tax support to avoid deficits - Competitive Strategies: health insurance plans compete on basis of price and market forces to restrain premium prices and costs - Primary U.S. model but has not been successful in controlling cost and quality of care - Cost of premium is shared between employees and eomployers - Price Sensitive Purchasing: businesses aggressively negotiate with insurers over premium costs Smaran Ramidi - - Managed Competition: a method to make employees more cost aware by companies offering a fixed amount of premium subsidy and the employees paying the rest of cost Reimbursement: flow of money out of health plans to providers - Price Controls: - Competitive bidding for contracts/services was initially effective but insurers shift cost to other payers and some populations were no longer covered - Quantity Controls: - Changing Unit of Payment: move to more aggregated units of payment to counter cost inflation due to provider pressure to increase quantity (DRGs), risk is shifted to provider - Patient Cost Sharing: U.S. has one of the highest levels of cost sharing of any nation and also the highest overall costs - Point of Purchase = premium payments - Point of Service = utilization - Utilization Management: Insurers examine physician behavior and use of services as a micromanagement approach - Payment is denied for services deemed unnecessary - Administration is expensive and reviewers decisions may be inconsistent - Supply Limits: controls are put on the number of providers and material resources - Supplier induced demand is affected by quantity which varies across locations - Supply limits can be painless by requiring physicians to prioritize services based on the appropriateness and urgency of patient need - Controlling Type of Supply - Generalists vs Specialists and the needs for them What cost containment policies should focus on - Macro-management issues of capacity and budgets - Global Cost Containment tools - Paying by capitation or aggregated method - Limiting size and specialty mix of providers - Concentrating high tech services regionally Ch 10 - Quality of Healthcare in the United States Primary reasons why quality is lacking in the U.S. - Lack of Access to care - Practice Variations Practice defects requiring change - Overuse: higher volumes or more costly than are appropriate - Underuse of Effective Care: underuse of generic drugs and controller medications - Misuse and Errors: Adverse events, inappropriate and contraindicated prescriptions, failure of communication, equipment and system failure - Inefficiency and Waste: waits and delays, operating through throughput, postoperative intubation time, medical record availability Smaran Ramidi Donabedian’s quality assessment model: Process, structure, outcomes Healthcare Effectiveness Data and Information Set (HEDIS) Methods to achieve malpractice reform Proposals to improve quality Pay for Performance Ch 12- Long Term Care Characteristics, who would qualify for care, benefits, Hospital care, Rehabilitation Facility, Skilled Nursing Facilities, Nursing Home- custodial only, Hospice Home care - In Hospital Care: comprehensive medical management for acute conditions or exacerbation of chronic conditions - Rehabilitation Facility: provides complex medical management and/or intensive rehabilitation services. - Must be able to tolerate and benefit from a minimum of 3 hours of therapy per day to qualify under insurance and medicare - Skilled Nursing Facility (SNF): provides skilled nursing and rehabilitative services - Medicare and insurance pays for short term skilled care (Up to 100 days) - Skilled: patient has a rehab and nursing need but doesn’t qualify for a Rehab center - Nursing Home: homes that provide only custodial care - Patients might receive a functional maintenance program carried out by certified nursing aids - Not covered under Medicare, Medicaid, or private insurance - Custodial Care = Maintenance Care = Unskilled care: activities of daily living that the patient needs help with and is unable to go home - Hospice: care for patients that are terminally ill - Medicare covers if a doctor certifies that a patient is terminally ill and if the care is provided by a Medicare-participating hospice - Provides services at home and at facilities - Covered Care - Intermittent nursing, PT, OT, SP - Doctor’s Services - Drugs, including outpatient drugs for pain relief - Home health aide and homemaker - Medical Social services - Medical Supplies - Short-term inpatient care - Counseling - Gaps in Coverage: many patients need 24 hr. care but only intermittent care is provided with the patient needing to pay more for additional care - Home Health: medical care given at the home of the patient - Medicare coverage has 3 conditions - Patient needs intermittent skilled nursing, PT, OT, or SP - Patient is Homebound: leaving home requires major effort and leaving is infrequent - Physician certifies that there is a reasonable expectation that significant functional improvement will result from treatment - Home Health agencies provide short term care Smaran Ramidi - - Part time or intermittent skilled nursing care - PT, OT, SP - Medical Social Services - Medical Supplies - some durable medical equipment Medicare reimbursement is based on episode of illness model-agency paid lump sum for 60 days of care and then out of pocket for the patient Budget Reconciliation Act- What is it, what reforms it included - Omnibus Reconciliation Act of 1987: set standards and an enforcing system for nursing homes - Required 24 hour care - Quality of care varies widely - Average age of resident is in the 80s - 65% of residents have a cognitive impairment and 93% of residents have restricted mobility Who pays for long term care (LTC) - Medicare has no coverage for custodial care - Medicaid will cover nursing homes but not 24 hr custodial home care - Private Long-term Care Insurance: people who need it most cannot afford it or are rejected due to chronic illnesses, policies have high deductibles, or they do not cover a person's needs How can long term care be improved? - Develop Social Insurance - Shift to Community Based Care - Train and support family members as caregivers - Expand comprehensive acute and LTC organizations modeled on On Lok Social insurance - Social Insurance: principle of making small payments when you are well and earning money against sickness, unemployment, and retirement - Pepper Commission in 1990 recommended Medicare expansion - Funding is a major issue - Would maintain the quality of life and personal independence by supporting services to keep people at home On Lok program - Community Based Comprehensive Care Model starting in the 1970s now called Program of All inclusive care for elderly (PACE) - Financed by capitations by blending Medicare and Medicaid payments - Provides comprehensive cost effective care to people 55+ who qualify for nursing home care - Minimizes costs through fewer acute care hospitalizations for residents - Elders have many situations: multiple medical conditions, areas of dependency, daily living activities, and cognitive impairments Smaran Ramidi ACA reforms for LTC - Community First Choice Option: assists states with the costs of in-home programs for people who would otherwise be institutionalized - Balancing Incentive Program: increases federal matching Medicaid funds in states with less coverage for home and community services Money Follows the Person - Money Follows the Person (MFP) Rebalancing Demonstration Grant - Assists states in rebalancing their medicaid long-term care systems - Has allowed 31,000 institualized people to transition back to the community - Allows people to get long-term-care services in the setting of their choice Medical Homes - Medical Homes: designed to manage chronic care by introducing incentives to keep older adults at home through access to multiple doctors Ch 13: Medical & Clinical Ethics Table 13-1 Four principles of medical ethics - Beneficence: the obligation of health care providers to help people in need - Nonmaleficence: the duty of health care providers to do no harm - Autonomy: the right of patients to make choices regarding their health care - Justice: the concept of treating everyone in a fair matter Table 13-3 Rationing and Cost control - Not all cost control is rationing - Painless cost control is not rationing, because no limitation is placed on medical care expected to be beneficial - Painful cost control may require rationing because limits are placed on medical care expected to be beneficial Clinical Decision Making Models-Four-Box model- Why we should try to stay above the double line - Medical Indications: the goals of medicine, what is felt to be clinically important and efficacious taking into account the medical history, accurate diagnosis, accurate prognosis and all treatment options Rationing by medical effectiveness - The providing or withholding of care is ideally determined by the probability that the treatment will maximize benefits and minimize harm, that is by the criterion of medical effectiveness - The cost of interventions are not considered, rather which is more medically effective Concept- distributive justice Smaran Ramidi - Distributive Justice: requires all people to equally receive a reasonable level of medical services based on medical need without regard to ability to pay Patient Self-Determination Act- All healthcare facilities receiving Medicare and Medicaid reimbursement are required to ask patients if they possess formal advance directives - Facilities must provide patient education regarding their rights in relation to advanced directives Decision making capacity- competence - Competence: assumed in adults unless proven otherwise in a court of law (a global description) - DMC: criterion applied clinically to assess a patient’s ability to make authentic, self-determining decisions (task specific) - Can comprehend the clinical information being presented regarding his/her condition - Can understand each of the treatment or non-treatment options and their consequences - Has the ability to make and communicate a choice - Can demonstrate a rational thought process in weighing the risks and benefits in relation to his/her personal, authentic values Advance directives- 2 types used most: Living will, Durable power of attorney, Informal advance directives - Advanced Directive: a legal document that allows an individual to state his/her wishes for future medical decisions under certain qualifying conditions - Living Will: written request to forego life-sustaining treatments in the event of a terminal condition when the patient lacks DMC - Durable Power of Attorney for Health Care (DPAHC): allows an individual to name a proxy or surrogate decision-maker who can speak for him/her should he or she become unable to participate in medical decision-making - Informal Advanced Directives: statements a person has made regarding certain healthcare situations and treatments, or a physician documentation of a discussion of the patient’s wishes regarding future health care Surrogate decision-makers, Substitute judgment, Best interest standard - Surrogate (Proxy) Decision Maker: One who has the moral and legal authority to make decisions for an individual who cannot make decisions for him/herself. - The proxy can be assigned through an advanced directive or informally in certain circumstances - Substitute Judgment: making decisions the patient would have, based on his/her values and preferences - Best Interest Standard: in the absence of knowledge of what decision the patient would have made, making a decision that is felt to be in a patient’s best interest Assent - Informal agreement obtained from a person who is unable to fully participate in the informed consent process, but who can provide a preference related to medical care Informed consent Smaran Ramidi - A formal process undergone between the patient and the health care provider during which the patient is informed of the risks and benefits of a proposed diagnostic procedure or treatment - May or may not include the signing of a formal document, but should always involve a discussion between the patient and the professional responsible for administering the procedure Refusal of treatment - Adults who possess DMC have the right to refuse medical treatment, even life-sustaining treatment - A surrogate decision-maker has the right to refuse medical treatment for a non-capacitant individual avoided the decision is made based on the patient’s values, expressed wishes, or on what is considered to be in the patient’s “best interest” Meaningful language = Withholding treatment, withdrawing treatment - Withholding and withdrawal are viewed equal under the law and within the principles of healthcare ethics - But they feel different from a psychological perspective for those involved Health Care in the Community - Dr. Ian Huntington- Slides and your own lecture notes National Health Reform- Slides and Ch 15 text 4 main components of reform under the ACA- Individual mandate, employer mandate, expansion of Medicaid eligibility, Insurance market regulations - Individual Mandate: requires virtually all Americans to have health insurance (Revoked in 2018) - Employer Mandate: Companies with >50 employees must provide their employees insurance - Expansion of Medicaid: children, pregnant women, parents, and adults without dependent children up to 133% of the Federal Poverty Level are now covered - Insurance Market Regulations: Federal government established a high risk pool to provider coverage to people with pre-existing conditions along with no rescinding of insurance Key coverage measures- Table 15-3 - High-risk health insurance pools for individuals with no insurance due to preexisting conditions - Expansion of dependent coverage for young adults up to age 26 - Elimination of provisions that allow health insureres to cap lifetime benefits or deny coverage to children based on preexisting conditions - Reductions of the coverage gap for prescription medications under medicare Part D - Expansion of Medicaid to individuals below 133% of the federal poverty level - Individual Health insurance Mandate - Subsidized health insurance exchanges for the uninsured to purchase insurance - Elimination of provisions that allow health insureres to deny coverage based on pre-existing conditions - Requirement for employers with >50 employees to provide health coverage or pay a penalty Employer “pay or play” requirements - Employers with more than 50 employees now have approximately a $2000/employee penalty excluding the first 30 employees if they don’t offer an employer sponsored plan to at least 95% of full time employees Smaran Ramidi - Employers with fewer than 50 employees are exempt Small business tax credits - Employers with fewer than 25 employees with an average yearly wage less than $50K can purchase employee health insurance with a tax credit up to 35% of the employer’s contribution Financing reform- taxing people without coverage, Increase Medicare tax on wages and unearned income, excise tax on insurers that provide costly health plans, pharm industry fees, insurance co. fees, medical device fees - People without coverage will be taxed - Wealthy people will pay more into Medicare: tax rate on wages and on unearned income will increase - Insurers of employer-sponsored health plans that exceed $10,200 for individual and $27,500 for family plans will pay an excise tax - Annual Feeds on Pharmaceutical industry, Health insurance companies, and medical device-excise tax Health Insurance exchanges- what are they - Health Insurance Marketplace Exchanges: a portal where people can shop for individual health insurance - Percent cost coverage varies from Bronze → Silver → Gold → Platinum with increasing premiums - Out of pocket limits are reduced for individuals from 100% to 400% of the FPL Efforts that will contain costs - Centers for Medicare and Medicaid Services created an innovation center - Medicare payments are reduced to sophitals for excess admissions and hospital acquired infections, movement towards bundles and DRGs - FDA is approving more generic drugs - Waste, fraud, and abuse will be monitored more vigorously Efforts to improve prevention efforts - Establishment of a National Council for Prevention/Wellness - Expanding program funding - Developing grant programs to support delivery of evidence-based and community-based services - Eliminates cost-sharing for preventive Medicare services 4 ways people can get insurance under the individual mandate of the ACA - Employment based - Medicare - Medicaid - Health Marketplace Exchanges Video is a good review of the ACA. http://kff.org/health-reform/video/youtoons-obamacare-video/ Ch 14 Health Care in Four Nations and the film Critical Care: America vs. the World Smaran Ramidi United kingdom How is the NHS funded? How do doctors and hospitals get paid? - NHS is a Single Payer system funded by taxes - Government through the NHS pays doctors and hospitals The NHS covers almost all costs of health care Who has access to the NHS system? - Anyone who pays taxes to the government How does the cost of care and the outcomes compare to the United States? - Cost of care is significantly less compared to the U.S. - Better outcomes and less chronic illness What is a weakness of the NHS? - Incredibly long wait times for elective surgeries - More than 10% buy supplemental insurance to avoid long waits or decide to go abroad for care - National Institute for Health and Care Excellence: determines cost control mechanisms by setting price of services within NHS Switzerland On average what percentage of income is spent on health insurance? - 16% of their income on premiums Are co-payments higher or lower in Switzerland than the United States? - Higher copayments but better coverage for care Is health insurance tied to your employment? - Health insurance is separate so you are always covered regardless of employment status What role does the Swiss government play in insurance? - The government regulates private insurance but not too much because they still have the ability to grow - There are 60 private insurance companies - If you don’t buy private insurance, the government will provide it through wage deductions - The government caps the yearly out of pocket amount that someone can pay Who is required to have health insurance? - Everyone is required and will receive assistance - No coinsurance but rather all copay Australia What is Australia’s public health insurance plan called? How is it funded? Who is it available to? - Medicare - Funded by taxes paid by citizens and provided to all citizens Why would Australians choose to buy private health insurance? - You can’t choose a specialist on medicare so private health insurance can provide for choice - Private health insurance can provide shorter wait times and “nicer facilities” Who sets prices for prescription drugs and treatments? - The government What is causing a strain on the health insurance system? Smaran Ramidi - Many younger people are not buying private health insurance as much as previous generations increasing the pressure on the Medicare system - Public insurance companies have older populations that are spending money and not enough young people contributing money to the insurance pool Canada What type of health care system does Canada have? - Universal healthcare system - Single Payer system What were the strengths of Canada's universal health care system during the pandemic?’ - COVID treatment was completely paid for by the health system - All hospitals were working together allowing for better communication and resource allocation across the regional health systems What are the gaps in coverage in the Canadian health care system? - Main gap is in coverage of drugs - Many people go to the U.S. to buy drugs because their coverage is low in Canada - Drugs through the hospital are covered but not outside