1
Q
Origin of hospitals and insurance plans
A
-• Bellvue farm, first hospital 1811—people pay to die—then abx—seek treatment
-• 1930 many hospitals and medical school like now
o 1932 Depression era—new hospital beds empty
o First insurance plan at Baylor—1500 teachers, pay monthly fee—services
o Set up for steady stream of revenue—then Birth of Blue cross blue shield
• Only sign up healthy people in order to compete with other hospital, less cost
• WWII labor shortage freeze wagebenefit package employer provided health insurance
2
Q
First multi-hospital insurance plan
A
-• 1930 many hospitals and medical school like now
o 1932 Depression era—new hospital beds empty
o First insurance plan at Baylor—1500 teachers, pay monthly fee—services
o Set up for steady stream of revenue—then Birth of Blue cross blue shield
• Only sign up healthy people in order to compete with other hospital, less cost
• WWII labor shortage freeze wagebenefit package employer provided health insurance
3
Q
Employer provided healthcare insurance and WWII
A
-freeze wage, benefit package employer provided
4
Q
Medicare
- part A-D
- financed
- historical
A
-1965
–1972 amendments extended coverage to long term coverage to long term disabled & pts with chronic kidney dz
-financed through SS payroll tax
-A–hospital insurance, skilled nursing
B-supplemental physicians
C- private (1997)
D- private (2003) prescription drug
-funds education; Direct Medical Education (DME) teaching interns, Indirect Medical Education Payments (IME) compensate hospital for inefficiencies
5
Q
Medicaid
A
- 1965
- children or parents of minors
- pregnant
- disabled
- elderly
- long term care
- OB & peds services
- funds education; Direct Medical Education (DME) teaching interns, Indirect Medical Education Payments (IME) compensate hospital for inefficiencies
6
Q
Affordable Care Act
A
- 2010
- expansion of medicaid–elimination of categories
- no preexisting exclsuions
- preventive care
- exchanges
- transparency
- realignment of incentives
7
Q
Identify the key drivers and incentives responsible for increasing heath care costs
A
- payment drives volume, fee for service
- more fragmentation–uncoordinated care
- more variation–in tx not EBP
- no assurance of quality
1. supply–specialists, hospitals, equipments
2. . technology
3. fee for service
4. first dollar payment
5. cost PLUS
6. 3rd party payers
8
Q
Describe the three components of the Triple Aim
A
- health of population
- per capital cost
- experience of care
-safe
effective
pt centered
timely
equitable
9
Q
Understand how new delivery models of care (Patient Centered Medical Home, Accountable Care Organizations) support the goals of improved quality and decreased costs
A
- 4 cornerstones of PCMH—long-term healing relationship
1. primary care
2. pt-centered care - safety & quality
- care is coordinated & integrated
- whole person orientation
- personal physician
- physician directed practice
- enhanced access
- personal physician
- payment for added value
3. new model practice
4. payment reform
10
Q
Recognize the key features of our local health care system landscape
A
- 6 major health systems
- 50+ community centers
11
Q
Define quality
A
- standard measured against other things of similar kind
- meeting the needs and exceeding expectation of people we serve
12
Q
Define quality improvement
A
-systematoc, data guided activities designed to bring about immediate, positive changes in the delivery of health care
13
Q
Define aim statement, SMART aim
A
- a written , measurable, time sensitive statement of the accomplishments a team expects to make from its improvement efforts
- SMART aim
1. specific
2. measurable
3. achievable
4. realistic
5. time bound
14
Q
Define process meaures
A
-meaure if the parts of the system are working as intended
15
Q
Define outcome measures
A
-measure the impact of the system on the patient
16
Q
Define balancing measures
A
-measure if changes designed to improve part of the system are introducing new problems
17
Q
Identify gaps in the safety, effectiveness, and patient-centeredness of the health system
A
-o Diffuse or unstable aim o Measurement unconnected to aims o Gaps in leadership of change o Low investment in system redesign o 19th century information technologies o Toxic financing schemes o Litigation threats o Overregulation for stability o Professional education without a system view
18
Q
Review a scientific model to improve health care
A
-
19
Q
two recent quality improvement projects
A
- handwashing
- asthma
20
Q
PDSA cycle
A
- plan, do, study, act
1. hypotheses
2. procedures
3. data
4. conclusions
21
Q
run chart
A
-raph that displays observed data in a time sequence. Often, the data displayed represent some aspect of the output or performance of a manufacturing or other business process.
22
Q
FDA’s definitions of drugs and medical devices
A
Drugs
- chemical mechanism of action
- center for drug evaluation & research (CDER)
- cost more than 1 billion
- timeline 8-10 yrs from time of discovery to approval
Device
- mechanical (nonchem or metabolic)
- Center for devices & radiological health (CDRH)
- cost less than 100 million
- timeline several months to 10yrs
23
Q
describe the commercialization pathways of: a) drugs; b) medical devices; c) medical apps
-define medical device
A
digital health 1. device/app-->class I-III-->require FDA clearance 2. nondevice/app-->regulated FCC/OCR -med device is product that reach pts through market commercialization 1. completed design 2. pre verification & validaiton 3. design freeze 4. IDE & 510K 5. verification & validation 6. launch
24
Q
describe the most productive first step after coming up with a novel solution/invention
A
-clinical needs & validation
25
-define invention & innovation
| describe at least 4 roles of physicians in medical product innovation
- invention is an idea that has been reduced to practice; it must be novel, useful, non-obvious to an expert
- innovation is invention + implementation
26
Regulation
- provisional patient application
- utility patent application
- patent
- freedom to operate
27
Claims
-define exactly what you actually own
28
Describe the major historical landmarks that led to the development of our current health care payment system
-1940 men overseas because of war, lure employees offered health insurance benefit package. Healthy help pay for the sick
-1940s strength of union gave worker more bargaining power—tax free employer sponsor health care program
-1950—new medicine, abx for infection, w/o employer healthcare, pay out of pocket or not have health care at all
-1960---companies offered plans for the increase in cost of healthcare and procedures. Medicare & Medicaid were implemented—elderly & poor
-1980s & 90s—health costs rose rapidly most employer healthcare plan change from more expensive pay as needed plan to plan that allow third party to set up and manage cost
-mid 90s—most common type is manage care---Today PPO plan—but losing popularity as consumer driven plans are introduced, employer sponsored still around
If self-employed or not working---three options
--no coverage, pay full price, purchases your own on the market
1. employer, government, individual on the market
• By 2020 we will be over 20% of our GDP
29
3 reasons of increasing health care costs
1. absolute expenditures $2.8 trillion (2012)
2. overwhelming wage gains
3. cost growing faster than economy
- 5% GDP 1960-->18% 2012-->20% 2021
30
six items of wasted health care spending
1. unnecessary services
2. missed prevention opportunities
3. fraud
4. excess administrative costs
5. prices too high
6. inefficiently delivered services
31
6 domains of the IOM
1. safe
2. effective
3. patient-centered
4. timely
5. equitable
6. efficient
32
Cost PLUS
- creating incentives
- hospital reimbursed on % of their cost PLUS a % of working & equity capital
- allowed physicians to be reimbursed according to reasonable and customary
33
3 cost cutting efforts?
1. prospective payment system
2. resource based relative value scale (RBRVS)
3. relative value scale update committee (RUC)
34
gaps (8) in healthcare
1. access
2. financial
3. socioeconomic
4. transitions in care
5. cultural
6. literacy
7. fragmentation
8. partialists
35
4 areas of health measures
1. behaviors
2. community & environment
3. public & health policies
4. clinical care
36
1. CMMI
2. CPCI
3. PCMH
4. HB
5. NCQA
6. AAAHC
7. JC
1. center for medicare & medicaid innovation
2. comprehensive primary care initiative
3. pt-ctr medical home
4. house bill
5. national committee for quality assurance
6. Accreditation Association for Ambulatory Health Care
7. joint commission
37
blended reimbursement
1. care coordination
2. fee for service
3. pay for value
38
payment reform realignment incentive
| -3 insurance companies
1. humana
2. united
3. anthem
39
1. CDRH
2. CBER
3. CDER
1. center for devices and radiological health
2. center for biologics evaluation and research
3. center for drug evaluation and research
40
1. FCC
2. FDA
3. OCR
1. federal communication commission
2. food & drug administration
3. office for civil rights
41
4 main ideas in which the code of professional ethic
-autonomy, justice, beneficence, and non-maleficence
42
the 9 basic principles of medical professionalism from the AMA
- 1847, development of code--self regulation paramount to practice of good medicine
- set of principles describe standards of conduct & honorable behavior
1. provide medical care w/ compassion, respect for human dignity & rights
2. professionalism interactions, report physician deficient character/competence, engage in fraud/deception
3. respect law, recognize responsibility to seek changes which are contrary to pt's best interest
4. respect rights of pts, colleaugues, other health professionals, safeguard pt confidences, privacy within the law
5. continue study, apply, advance knowledge--commitment to med edu, make relevant info available to pts, colleagues, public, obtain consultation, use other talents when indicated
6. except emergencies, be free to choose whom to serve, whom to associate, environment to practice
7. participate in activities to improve community, better public health
8. regard responsibility to pt as paramount
9. support access to medical care for all people
43
ethical values and legal principles
-ethical principles are not laws but standards of conduct basis for code of medical ethics
-
44
medical ethics to cases that pertain to medical students
-
45
autonomy
- t rational individuals have the right to self-determination
- parallel with Kantian idea individual have worth not a means to presumed higher goal
- free to make own choices, deception & coercion avoided
- may be compromised by circumstance
- max range of choices, min choices for least priviledge as acceptable level of autonomy
- degree of separation btw rich & poor
- equality & needs vs. effort & contribution
- requires informed consent--risks & benefits of options
- patient capacity to make decisions
46
distributive justice
-non-comparative and comparative that need to be addressed considering equality, need, contribution, and effort
1. noncomparative justice--rights to ppl to receive that to which they are entitled
2. comparative justice--distribution of burdens & benefits
-what is a right vs. privilege
Munson 4 prinicples on societal resources distribution
1. equality
2. need
3. contribution
4. effort
Joel Feinberg: basic needs met first then effort & contribution considered
47
beneficence
- always act in ways that promote the welfare of other people
- resonable sacrifices on behalf of pts
48
non-maleficence
- admonishes us to do no needless harm through carelessness, malice, inadvertence, or avoidable ignorance
- optimize benefits but reconize potential bad outcome
49
CEJA
council on ethical and judicial affairs
- steward of code of medical ethics
- 17 physicians, 1 resident, 1 medical student
- interpret 9 basic principles of medical ethics
50
steps of an ethical work-up in a clinical situation
i. When is it appropriate
ii. How to obtain the information
iii. What to expect
iv. How to apply the ethical principles to real life patient cases
51
Identify and name the four quadrants in in the paradigm for clinical ethical decision making
-
52
major ethical theories: utilitarian
- utilitarianism--Jeremy bentham & John Stuart Mills--ends rather than the means
- maximize happiness greatest # people, equal importance
- expand definition: promote knowledge, beauty, love, friendship, liberty, health
- good outcome rather than achieving outcome
- higher values than max happines for most
- lack justice that protects the rights of minority
53
major ethical theories: Kantian ethics
- consequences of action are irrelevant
- universal laws or categorical imperatives--implement w/o reference to outcome
- means > ends; motivation>outcome
- always act so as to tx ppl as an end in themselves and not as a means to another end
- rational ppl=autonomous, self-regulating=value & worth
- goodwill=sense of duty to others not sake of results
- honor pt autonomy & self determination
- not lie for outcome
- pt can refuse tx if he is rational
- Kantian address need for standard of justice
- Questionable on absolute categorical imperatives--relative to situation?
- define autonomous self regulating? who is rational?
54
Ross's ethics
- both utilitarian & kantian
- 2 fundamental moral properties: rightness, goodness
- know the facts before act upon
- conscience/intuition not absolute
- "prima facie=apparent duties & actual duties
- which has higher priority?
- duties are relative
- knowledge of facts needed to make ethical decisions
- rely on own judgement not equation to make decision
- end does not justify means--no absolute imperatives
- major prima facie duties: fidelity (truth telling), reparation, gratitude, justice, beneficence, self-improvement, nonmaleficence
- ability of right/wrong left to individual--moral relativism--can be objectionable
55
natural law & roman catholicism
-counterbalance to relativism, reason is inherent in nauture to determine rightness of actions rather than social norms/individual values
-reason dictates what is good/right
-ordained by GOd, eternal, unchangeable
1.principle of double effect--good & bad; bad must be unintended/indirect consequence
2. principle of totatlity---right to dispose organs/destroy function to extent well being of whole body demands it--rule out vasectomies, cosmetic surgery, sterilization of mentally ill
-critize: assume nature & life have purpose
questions the divine as moral compass
56
clinical research
- trial is an expt on human being carried out in order to evaluate one or more potentially beneficial therapies
- investigator have control over therapies evaluated and pt population
57
what makes research ethical
1. social/scientific value
2. scientific validity
3. fair subject selection
4. favorable risk benefit ratio
5. independent review
6. informed consent
7. respect for potential and enrolled subjects
58
risk/benefit measure
Risk:
-probability of occurrence of harm to human health
-severity of harm that may occur
-studies include: no risk/min/max
Benefits
-degree to which participant derive personal direct/indirect gain from participation
-may be direct tangible (relief symptoms/cure)
-indirect tangible (contribute to knowledge, benefit society)
59
conflict of interest
- btw clinical & research missions
- per capita payment for conducting research
- non-pecuniary rewards
60
PHS
| NMA
public health service
| national medical association
61
• Biomedical model
-
62
• Biopsychosocial model
-
63
• Reductionistic approach
-
64
• Holistic approach
-
65
1. Identify the differences between a reductionistic and a holistic approach to medical
-
66
2. Recognize when a reductionistic approach is more appropriate, and when a holistic approach is more appropriate
-
67
3. Appreciate how a patient’s personality and psychosocial factors can influence the course and outcome of an illness.
-
68
4. Differentiate between stress and strain
-
69
5. Differentiate between illness and disease
-
70
6. Describe common coping mechanisms
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Physician & Society
flashcards
Decks in class (2)
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