Final Exam Review PT 8351 PDF

Final Exam Review PT 8351  Format Similar to midterm Ethics Multiple Choice Genomics/Precision Medicine Short Answer Professional Boundaries Re...

Final Exam Review PT 8351  Format Similar to midterm Ethics Multiple Choice Genomics/Precision Medicine Short Answer Professional Boundaries Respondus Lockdown EBP Payment 50ish questions Dr. Ward’s lectures and Whitman-Walker Health not testable Assessed by Implicit Bias VoiceThread Reflections  Types of ethical challenges Dilemma -Two courses of action could be taken Case Example Ethical -Right vs. Right Challenge ? Distress -You know the right choice of action but are not 1. A new wheelchair company tries to give you tickets to empowered to perform it an NFL game hoping that you will recommend their -There may be financial or institutional barriers wheelchairs, even though they cost more than other -Two morally correct courses of action are possible, but comparable chairs. they cannot both be followed Temptation -You may stand to benefit from the wrong decision 2. At a weekly meeting, the boss tells everyone that they -Right vs. wrong need to bill one more unit of time to the insurance company so that the payment will be increased. Raises will Silence No one is speaking about the challenge to values ( this be considered to all that comply. No one has the nerve to say anything. may be the course taken when someone is in moral distress) 3. A 16 year old patient tells you a “secret” and does not want you to tell her parents. But, you feel the parents should know. 4. A medical student overhears a conversation while watching TKR surgery. The hospital is using a cheaper implant on most patients so that they have a greater profit on each case. The surgical resident comments that he is worried about the life span of the implant compared to others. Portions adapted from Dr. Rhea Cohn 3 Key Clinical Ethics Concerns Autonomy The capacity to act on your own decisions freely and independently Respect a patient’s dignity/right to make decisions (What is adequate Informed Consent to genetic testing?) Justice Treating patients fairly and equitably (Access to research and clinical care; confronting history of exploitation and abuse) Beneficence/Non-maleficence First do no harm Risk/Benefit Analysis (How do we balance the costs and challenges with the potential benefits?) Privacy/Confidentiality Maintaining patient secrets; not sharing patient communications (What are the limits to these duties?) Author: Joe Heller (2000) Autonomy The patient has the ability to exercise their own freedom in a given situation. The patient has self-determination or personal “agency” A guiding principle in the practice of “medicine” as we know it. Evidence suggests that patients are more likely to get better if they feel a sense of control and can exercise their autonomy. Questions: 1. Do you believe this? 2. Do you think all patients believe this? 3. How can we foster a patient feeling a sense of control? Portions adapted from Dr. Rhea Cohn 5 What is “informed consent” Informed consent is the process by which a treating health care provider discloses appropriate information to a competent person so that he/she may make a voluntary choice to accept or refuse treatment.* It should include: Nature of decision/procedure Reasonable alternatives to the proposed intervention Relevant risks, benefits, and uncertainties related to the alternatives Assessment of patient understanding Acceptance of the intervention by the patient Costs of the intervention and timeframes Possible treatment alternatives This is at the “core” of autonomy! *Adapted from: https://depts.washington.edu/bioethx/topics/consent.html 6 Three considerations: Competency: Patient or his/her surrogate must be competent. Coercion: Patient must be participatory in the decision rather than just signing a form. Comprehension: Patient must understand the information that is presented in layperson’s language. 7 Tips for Practice Informed consent laws differ by state. Refer to the state statutes and regulations. Include in documentation: You provided information regarding the proposed treatment (POC). The patient demonstrated they understood the information. The patient gave consent to the proposed treatment (POC). 8 What is “confidentiality” https://www.cdc.gov/aging/emergency/legal/privacy.htm Federal Law: The right to privacy granted by HIPAA (1996) gives legal standing to this ethical principle. Balances protections for the individual with what is needed for appropriate care. Protected health information (PHI) is oral, electronic, or paper-based. Question: Do you see the principle of “autonomy” here? https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html 9  A provider is permitted to share patient information with someone if the information has relevance to that person’s role in the care of the patient. Use the “Need to Know” test. Do No HARM! Use the “minimum necessary” rule: A covered entity must make reasonable efforts to use, disclose, and request only the minimum amount of protected health information needed to accomplish the intended purpose of the use, disclosure, or request TIP: Don’t get caught divulging your own personal information! 10  Summary for confidentiality: Protect yourself and your patient 1. Confirm the patient’s identity at the first encounter. 2. Never discuss the patient’s case with anyone without the patient’s permission (including family and friends) other than necessary providers. 3. Never leave records, computer screens, where unauthorized persons may access them. 4. Use only secure (e.g encrypted) routes to send patient information. Be careful about apps! If it is unencrypted, make sure you have patient permission in writing. 5. When using a qualified interpreter, attempt to ensure that he/she understands the importance of patient confidentiality. 6. Track changes in telehealth, both the technology as well as the jurisdiction regulations. 11 Key Trend: Going Beyond Genetics/Genomics Precision Medicine The right treatment to the right patient at the right time Precision Medicine Initiative President Calls for $215 Million in 2015 to support the Precision Medicine Initiative (Congress approved 200 Million) “Precision medicine gives us the chance to marry what’s unique about America — our spirit of innovation, our courage to take risks, our collaborative instincts – with what’s unique about Americans – every individual’s distinctive genetic makeup, lifestyles, and health needs. In doing so, we can keep ourselves, our families, and our nation healthier for generations to come.” President Obama, 7/7/16, Boston Globe Your potential concerns School/company policies for storage, processing and sharing data? Discrimination/stigmatization Social Institutional (university) Insurance (life) Privacy Ownership Control Should counseling be mandatory? Do you feel capable to make this decision alone without family members? Is the information accurate? Evolving understanding of genetic markers + rapid pace of research and discovery = difficult for anyone to interpret.  Genetic Information Non-Discrimination Act (GINA) 2008 Protects against discrimination by employers and health insurance companies only Employers may not request, require or purchase genetic information related to employees and candidates. ✓ Includes athlete employees ✓ Work study students Diversity & Inclusion 96% of participants in genome-wide association studies of European descent (2009) Participants of Asian ancestry increased to 20% African American and Latino participation under 4% Population descriptors 'black cases' and 'sub-Saharan African', were often used to describe people of African ancestry. More often “geographically specific and informative descriptions were those used for samples of European origin...” Sexual Harassment is…. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when: Submission to such conduct is made either explicitly or implicitly as a term or condition of an individual's employment, or Submission to or rejection of such conduct by an individual is used as a basis for employment decisions affecting such individual, or Such conduct has the purpose or effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile, or offensive working environment. Civil Rights Act, 1964 (Title VII) [employers > 15 employees]  Successful strategies Unsuccessful strategies Distraction Ignoring the Avoidance problem Direct confrontation Making jokes, giggling, laughing Behavioral contracts Being indirect in Transfer of care your use of Use of chaperones language Has a “hostile” environment been created? Open discussions within earshot of other employees or patients. Promotion of an employee over another because of a sexual favor. A patient keeps asking his therapist for a date. Another employee downloads pornography onto an office computer or posts photos in the office. Supervisors or managers do nothing to change the behaviors. Dirty jokes are acceptable. Sexual slang is tolerated. Review of Part 1 Key Terms PPO—more choice, incentivized to use in-network HMO—closed network, lower copays HDHP—cost shift to employee https://www.apta.org/your-practice/payment Copay—patient cost per visit (fixed) Deductible—patient out of pocket cost prior to insurance paying Prospective Payment—predetermined payment system In-network/Out of Network Fee for Service—a la carte; fixed fee for each service provided Payment Implications on PT Practice Health Insurance Terms and Definitions Premium: The amount the beneficiary pays each month for health care insurance. No premium for Medicare Part A and Part B or Medicaid. Benefits: The health care services that are covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan’s coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules. Health Insurance Terms and Definitions Deductible: The amount of money the patient must pay out-of- pocket during the benefit period (typically one year) before a payer (insurer) reimburses for covered services. Plans may have individual and family deductibles. Deductible may be different for in- network and out-of-network providers. Health Insurance Terms and Definitions Co-pay: the fixed financial liability a patient has for each visit to a specialist or primary care physician. Providers cannot waive co-pays. Co-Insurance: the insured pays a percentage of the payment, after the deductible is met, in addition to the co-pay. Fee-for-service: payers reimburse providers a fixed fee for each service they provide from an approved list. This model gives incentives for providers to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Health Insurance Terms and Definitions Secondary Insurance: Coverage bought separately from a medical plan that helps cover care that your primary medical plan may not. Examples: Vision plan, dental plan, accidental injury plan. Supplemental Health Insurance: Added medical coverage that can be purchased to contribute to paying the costs not covered by the primary health insurance plan, such as co-insurance, co-pays, and deductibles. With a supplemental Medicare insurance, Medicare pays 80%, Supplemental pays 20% Health Insurance Terms and Definitions PPO: Preferred Provider Organization: health plan models that allow patients to choose their own providers, however, there is a financial incentive to utilize the payer’s in-network providers and reduced coverage for out of network providers HMO: Health Maintenance Organization- health plan models that have a closed network of providers and lower copays compared to Preferred Provider Organizations (PPOs); limits coverage to in- network providers Managing Financial Risk Employers Increase employee premium cost, increase deductible Limited network of providers/plan types Require more co-pays Employees Use In-network providers High vs. Low-deductible Co-pays Payers Limit covered services Limit visits PT Clinic Documentation Deliver great outcomes—quality care, patient-centered, great experience Value Based Payment Models Pay for Performance: Under this model, physicians receive financial bonuses for achieving specific care-quality and cost targets. However, this model is typically deployed as an overlay to fee-for-service payments, which can incentivize the provision of costly, and sometimes unnecessary care. Also, bonuses have often proven insufficient to reward or enable the necessary changes in provider practice. Bundled Payments: An alternative to fee-for-service payments, providers working under this model are reimbursed a fixed, predetermined fee to perform all the services associated with a given procedure (e.g., knee replacement surgery), rather than an individual fee for each. So, providers benefit financially when they perform procedures most cost-efficiently and effectively, avoiding unnecessary procedures while prioritizing care for preventable complications. Reduces fragmentation and incentivizes good outcomes. Capitation: Providers working within capitation models take full financial responsibility for the health of a defined patient population. Members pay a fixed, usually annual, premium, and those premiums are pooled together to fund care for the entire population. Unlike fee-for-service, this model enables providers to spend funds however they think best to maximize the health of their covered population. And the more successful they are at doing this, the more of the premium funds they can apply to the bottom line, rather than to direct care costs. So, capitation rewards delivery of high-quality and cost-effective care, rather than overutilization. Shared Savings: This model entails payers setting a budget for care-delivery costs, such that providers whose total costs fall below the budget share in the savings. Shared savings is not itself a payment model, but can be used in conjunction with a number of models, from fee-for-service to value-based models. Shared Risk: A step beyond Shared Savings, providers working under this model still share in any recognized savings but are also expected to pay for any care delivery costs exceeding the payer-set budget. https://www.christenseninstitute.org/blog/what-is-value-based-payment-and-what-does-it-mean-for-healthcare/ EBP Definitions and Steps of EBP Hierarchy of Evidence Types and Format for clinical questions Intervention vs Diagnosis vs Prognosis Foreground vs Background Searching for evidence, websites/databases Reference citation formats AMA vs APA Good Luck! You got this! Congratulations on making it through your first semester! We are pulling for you!