PH 719 Final

Updated 2025 version. This is based off of Professor Callaghan TA Review session. All the sections should have similar topics for the final. Topics include review on Wk 1-7, insurance basics, Medicare, Medicaid, healthcare financing, healthcare decision making, and population health policy + comparative systemsI Good Luck BUSPH student!

Police Power & The 14th Amendment

• Usually rational basis, unless infringing upon a fundamental right

• Exercised by enacting legislation

• Limited to protecting other people, not protecting individuals from themselves

• Limited by the 14th Amendment Dye Process + Equal Protection Clauses

  • Must limit infringement on personal liberty and enhance autonomy.

  • Federal govt. can rule state law unconstitutional if the 14th amendments is breached

Individual Speech: Content-Based

• What is being said, who is saying it

• Discrimination based on the content/substance of speech

• Strict scrutiny

• Reference: 303 Creative

Individual Speech: Content-Neutral

• When it is being said, where it is being said, how it is being said

• Restrictions on the time palce and/or manner of speech

• The speech itself is not regulated

• Intermediate scrutiny

• McCullen v.Coakley

Central Hudson Test (Intermediate Scruntiny)

1. Does the speech promote illegal activity? Is the speech false or misleading

a. If yes, regulation is upheld. b. If no → upheld only if all below are answered yes

2. Is there substantial government interest

3. Is the ban/restriction on speech directly advancing the govt.’s goal? (What is the really goof evidence of impact?)

4. Is the regulation narrowly tailored? (Or no more burdensome than necessary on speech?)

Zauderer Test (Modified minimum scrutiny)

Commercial speech can be compelled if all are yes:

1. Is the speech without the compelled disclosure deceptive or misleading?

2. Are required disclosures uncontroversial and are fact?

3. Is the law serving a significant governmental purpose?

4. Is what is required by the law reasonably related to the govt.’s goal?

5. Is compliance with the law not unduly burdensome?

Commerce Clause: the three-part test

Commerce has the power to regulate commerce and to make all necessary and proper laws to carry this out as long as at least one (but not limited to) of these is affected:

1. Channels—Use of channels of interstate commerce (interstate highways, rivers, the internet)

2. Instrumentalities—persons, things, vehicles through which interstate (U.S v Lopez)

3. Local activities with substantial effects—interstate activities that have substantial aggregate effect (Wickard v. Filburn)

Spending Clause

Congressional power to levy taxes and to compel states with conditions to achieve federal goals

The Dole Test

Spending power: levying taxes or providing preference (tax breaks)

1. Is the law in pursuit of the general welfare?

2. Are the conditions of the law clear and unambiguous?

3. Are the conditions of the law German (related to the government's purpose)?

4. Are the conditions of the law unbarred by any other provision of the constitution?

If all are yes → law is constitutional, UNLESS the law passes the point where pressure turns into compulsion/coercion.

See: NFIB x. Sebilus

Religious Freedom Restoration Act (RFRA)

Requires strict scrutiny for laws that substantially burden free exercise of religion.

Function of health insurance

• Manage risk of catastrophic cost by pooling funds of many

• redistributes from those who are healthy to those who are sick

• insulates employer and/or government from dealing directly with the individual

Drawback of Insurance: Underinsurance

• Limited coverage with high out-of-pocket costs

• You are underinsured

  • Out-of-pocket medical cost equals 10% of income or more OR

  • Out-of-pocket cost equal 5% of income if below 200% FPL OR

  • The deductible equals 5% or more of income

Drawback of Insurance: Uninsurance

No coverage → entirely out of pocket

Drawbacks of Insurance: Outcomes

• Likely to avoid/delay seeking care

• Worse health outcomes

• Contributes to the majority of bankruptcies in the U.S

Four ways of paying for health care in U.S.

Out of pocket

Individual private insurance

Employer sponsored insurance

Government financed public insurance

Out-of-pocket payment

direct payment to the provider out of the individual's pocket

Individual private insurance

A third party, the insurer, is added to the patient and the health provider

Involves a premium payment from the individual to an insurance plan and a payment from the insurance plan to the provider

Employer sponsored insurance (ESI)

-Came about during WWII

-Often called group health insurance, the employer is responsible for a significant portion of the health insurance premium

-Federal tax policy subsidizes both employer and employee

-Employer-sponsored plans typically are able to include a range of plan options from HMO and PPO plans to additional coverage such as dental, life, and short- and long-term disability.

-Paying ESI premium pre-tax benefits those with highest income

-Same both pre and post-ACA except now there is an employer mandate (for firms >50 people)

Government financed public insurance

• Medicaid is run by the states and funded by federal and state taxes

• Medicare is funded by the federal government only

• Other government insurances

  • Indian Health Services (IHS)

  • Veterans Affairs (VA)

  • Federal Employee Health Benefits (FEHB)

Differences between ESI and individual insurance

Different pools: community rating (individual) v experience rating (ESI)

Different costs due to different pools

Different benefits depending on how much coverage employer offers

Wage trade-off inherent in ESI

Large employers basically self-insure and take on the risk by hiring insurance companies to manage their plans

Community rating

A method for setting premium rates for health insurance plans under which all policyholders are charged the same premium for the same coverage based on the average cost of providing health care.

• Simple terms—population-based insurance pricing; whole communities are pooled together

Experience rating

• Rating system that bases insurance rates on claims history

• Specialized pool based on the individual’s/group’s predicted need for health services

Ex. a group of bank executives might pay a lower premium as a group compared to a group of coal miners because miners have increased health risks as a result of the nature of their occupation and would likely cost more to insure

Current trends in ESI

Employers have shifted some expense to employees

Wage trade-off: we are taking a pay cut to pay for a greater share of our premium (premium wages have risen more dramatically than wages, though)

Direct relationship between premium and deductible (almost dollar for dollar) shifts responsibility significantly

More cost-sharing

ACA Basics

• Community rating

• Individual mandate for insurance (zeroed out)

• Health insurance exchanges

• Mandated essential health benefits (addresses uninsurance)

• Children can stay on parents’ plans until age 26

• Federal subsidies between 100 and 400% of the FPL

• Mandated coverage for all < 138% of the FPL (made optional by NFib v. Sebelius)

• Coverage gap: adults between 38% and 100% of FPL in the states that did not expand do not qualify for Medicaid/Health Exchanges

Describe the federally subsidized individual private insurance marketplace created by the ACA

Original idea was to cover everyone above Medicaid threshold

Subsidies available between 100-400% of poverty level

In the federally subsidized individual private insurance marketplace created by the ACA, money is collected by:

Premium paid by enrollee depending on plan selected

Premium subsidy credited to taxes of enrollee based on income and benchmark plan cost

Deductibles, coinsurance, and co-pays by individual enrollees

Individual private insurance pre- and post-ACA

Pre-ACA: available individual plans often too expensive for low-medium income, old, and sick; plans not always comprehensive

Post-ACA: can purchase on Exchanges/Marketplace for comparison shopping

-Same market reforms as ESI list plus guaranteed issue

ACA plan tiers

Bronze: lowest premium, highest cost-sharing, protects against catastrophic event but minimal coverage for routine care

Silver: moderate premium and moderate cost sharing; tax credits based on 2nd lowest silver plan; most popular

Gold: high premium and lowest cost sharing; may be a better deal for those expecting to use significant amount of care

Platinum: highest premium and lowest cost-sharing

What is cost-sharing

• a situation where insured individuals pay a portion of the healthcare costs, such as deductibles, coinsurance or co-payments

• The burden of splitting the cost of treatment between employee and employer

What is a premium?

The set amount an individual pays for insurance each month even if no health services are used

What is a deductible?

The additional amount an individual pays for covered service before the insurance begin to pay

What is a co-payment?

The fixed amount ($) paid for every service after the deductible

What is co-insurance?

The % of cost the individual is responsible for after paying the deductible

3 key elements to ACA marketplace

Guaranteed issue: plans have to cover everyone regardless of pre-existing conditions

Individual mandate: everyone needs to buy insurance or pay a tax necessary to cover very sick people

Tax subsidies: government pays if your income is up to 400% of the federal poverty level to help you buy your plan

Key changes after ACA repeal

-Individual mandate penalty set to $0

-CSR payments removed, potentially destabilizing individual market

-Lawsuit to strike down ACA based on individual mandate

Under the health care law, insurance companies can account for only 5 things when setting premiums

Age: Premiums can be up to 3 times higher for older people than for younger ones.

Location: Where you live has a big effect on your premiums. Differences in competition, state and local rules, and cost of living account for this.

Tobacco use: Insurers can charge tobacco users up to 50% more than those who don't use tobacco.

Individual vs. family enrollment: Insurers can charge more for a plan that also covers a spouse and/or dependents.

Plan category: There are five plan categories - Bronze, Silver, Gold, Platinum, and Catastrophic.

Ways private insurance pays physicians

Fee for Service/Discounted FFS

Bundled Payments - Payment per Episode of Illness - Physician DRGs (RBRVS unique to Medicare)

Capitation- Payment per Patient

Two-tiered Capitation

Salary - Payment for Time

Ways private insurance pays hospitals

Fee for Service

Per-Diem (bundle services removes the hospitals incentives from doing more expenses services. Moves risk, insurer is at risk for how many days, whereas hospital is on the line for services within the day)

Payment per Episode of Illness - DRG

Capitation - Payment per Patient

Global Budget

Major goal of ACA

Universal Coverage - originally planned that Medicaid would cover everyone up to a certain poverty threshold would be covered

ACA market reforms/changes in ESI

-No upper limits on coverage

-Young adult coverage

-Mandatory benefits

Efforts to change ACA under Trump

• Tax penalty repeal to counteract individual mandate/universal coverage

• Medicaid waivers/work requirements to counteract Medicaid expansion/universal coverage

The info below may not be relevant:

CSR nonpayment to counteract cost sharing reductions/risk corridor payments/universal coverage

HHS 4 year plan revoked to counteract universal coverage/ women's contraceptive coverage/ section 1557 anti-discrimination rule

Medicare Basics

Eligibility:

• Everyone 65+

Under 65 with a permanent disability

• End-stage renal disease

• Amyotrophic lateral sclerosis (ALS)

• eligible for social security disability insurance (SSDI) and Medicare after a two-year waiting period

Payment:

• Set fee schedule, value-based payments, prospective payments based on diagnosis-related groups (DRGs)

No long-term care coverage

• 100 days of skilled nursing coverage

Medicare A

• Covers hospital care, skilled nursing, hospice, some home care

• Auto-enrollment is guaranteed if you have 10+ years of paying into social security

  • If not → $400/month

• No premium, yes deductible

• Benefit period

  • Begins when admitted, ends at 60 days

  • Co-insurance starts after

• Long-term care:

  • Skilled nursing < 100 days

  • No unskilled

  • Intended for rehabilitation only

Medicare Part B

Covers: Physician services, outpatient care, lab services, home care (not associated with hospital stay)

Eligibility: technically optional—no penalty for not enrolling

Cost:

• $175/month if income is <$103k

• $500+/month if > $103k

• $240 deductible

• 20% coinsurance

• No limit on out-of-pocket spending

Financed: General Revenues Income and Federal Taxes, Premiums; Pooled at National level

Medicare Part C- Medicare Advantage

• THe private alternative

• Medicare Advantage programs combining parts A and B

• No premium, yes deductible

• May cover vision, dental, and/or hearing

• Federally negotiated premiums using Part A Trust Fund

• Medigap insurance—push to have part C cover what isn’t covered in the other part of Medicare.

Eligibility: Have to enroll in Parts A and B first before you can enroll in C

Medicare Part D: Prescription Drugs

• Prescription drug coverage

  • 10 high-cost drugs ar a negotiated price

  • Insulin price cap

• Out-od-pocket max

• Administered through private insurance

• Penalties on manufacturers

• Drug cost inflation

  • Pharmaceutical industry lawsuits

    • Dole

    • Commerce

    • 5th and 1st

    • Due process

Note: Donut hole - over time, the ACA wants to narrow this

Eligibility: Voluntary Enrollment - premium penalty minimum of 1% per month if do not enroll in first 6 months after becoming eligible, unless have equal or better coverage

Medicaid Basics

Eligibility

• Low-income children, pregnant women and in some states adults (defined by state with federal limits)

• Low-income elderly and disabled

• Medically needed coverage (not as expansive as categorically needed)

• Jointly administered by states and federal government

• Children’s Health Insurance Program (CHIP)

  • fills in the gap for kids whose families don’t qualify for medicaid

  • Same copayments

  • Comprehensive

Medicaid Basics

Benefits

• All categories of care

  • May vary by state

• Long-term care fo the poor, elderly, and frail

• Jointly administered by state government

• Financing

  • Federal medical assistance percentage (FMAP)

  • Relies on states’ per capita income reporter per quarter

  • Lowest fed.rate → 50%

• Requirements:

  • Care for key services (MD, hospital) and key populations (kids, mothers)

  • Federal govt. covers optional services

  • Medicaid covers nearly 2/3 of all long-term care in the U.S

Describe joint state/federal nature of Medicaid

-Subject to federal standards, states administer Medicaid programs and have flexibility to determine covered populations, covered services, health care delivery models, and methods for paying physicians and hospitals

-States can also obtain Section 1115 waivers to test and implement approaches that differ from what is required by federal statute if they are determined to advance program objectives

Variations in Medicaid eligibility by state

-Wealthier states (MA, NY, etc) get 50 percent of Medicaid expenses reimbursed.

-Poorer states get more reimbursement.

-States that walked away from Medicaid expansion walked away from big reimbursement

Medicaid waiver: Social Security Act Section 1115

• The federal government (the DHHS) can waive provision of major health programs

• Allows states to pilot programs; states as laboratories of policy

• Should these programs succeed, they can theoretically be applied nationwide

• Anything affecting benefit, cost sharing, enrollement or other requirements

Section 1115 in practice: work requirements

• Trump administration policy, approved via section 1115

• Began in AK, KY → current job/training/volunteer position required to qualify for Medicaid

  • Requirements made extremely complex/difficult to navigate on purpose. You have to submit paperwork frequently in order to keep insurance coverage

  • Means you have to have some type of job/position for medicaid

• Support from the public is 50/50

• courts have largely ruled this as unconstitutional.

  • rolled back by the Biden administration

  • Reinstituted by second Trump administration

Medicaid waivers: Social Security Act Section 1915

• Home and Community-Based Service Wavier

• Allows states to fund these services for specific populations

• Usually long-term care/support

Medicaid Block grants

• A fixed amount of money that the federal government gives to a state for a specific purpose.

• If Medicaid was turned into a block grant, the federal government would set each state's Medicaid spending amount in advance.

• Conservative solution to the argument that “federal rules are too limiting”

  • Basically saying that medicaid is an entilitement program and anybody who has it really need it

  • Approved dor Tennessee in 2021; reversed by Biden

• Medicaid funds granted as block grants

  • “States know best about how to manage their own distribution.”

• Opposition

  • What happens in a recession? → Excuse for states to make programs meager, race to the bottom.

  • Most block grant proposals start with significant cuts in federal Medicaid support (would shift quite a bit of risk to the state)

  • States will have to find ways to cut back on optional eligibility and benefits to provide Medicaid for people in need

  • The idea that whatever funds aren’t used in the block grant can be used for other parts of the government (like the police)

Current proposals to reform Medicaid

-Block grants: federal government give large block grants to states, but this tends to be more expensive because it's a lump sum

-Work Requirements: all able-bodied, non-elderly adults receiving Medicaid would need to meet work requirements unless they fell within an exemption

-Per capita caps: the federal government would put a ceiling (or cap) on the amount of federal money that can be spent per Medicaid enrollee in that state

NFIB v.Sebelius

• Individual insurance mandate → ruled constitutional

  • Later zeroed out

• Mandated Medicaid expansion → ruled unconstitutional

  • The decision to expand is decided by the state

  • Contributes to coverage hap between states

  • In non-expanded states, Medicaid is reserved for the poorest of the poor

    • Those that are poor but do not qualify are uninsured

• Election Referendums

  • Method to expand Medicaid through public support despite conservative opposition

  • Not possible everywhere (i.e., ballot obstacles) (voted fo in Maine, vetoed by gov.)

  • Achieved in Maine, Missouri, Oklahoma, Nebraska, Idaho, and Utah

  • It's important that this view is popular. There are efforts to make these referendums more difficult to pass. Ex. in South Dakota they said everything has to be put on one page so the public made their bill on a large piece of paper

Harris v.McRae: The Hyde Amendment

Summary

• No federal funds may be used for to perform abortions unless the mother’s life would be endangered

• Yes, they can. The feds do not have to contribute funding to abortions

• Requires states to use their own funds

• Poverty → not a suspect class

Detailed explanation:

Is it constitutional?

1. Title 19 (Medicaid) requires states participating in Medicaid programs to provide for different categories of medical services (including family planning services), BUT Title XIX does not obligate a participating State to pay for those medical services for which federal reimbursement is unavailable

2. 5th Am. substantive due process clause (liberty right): Federal governments fa’s failure to pay for abortions in state Medicaid programs is a violation of due process similar to in Roe v Wade

-Court concludes due process liberty was NOT infringed upon because it does not interfere with freedom of choice

3. Equal protection under fifth amendment: the only requirement of equal protection is that congressional action be rationally related to a legitimate governmental interest. The Hyde Amendment satisfies that standard

Describe the major players in the U.S. healthcare delivery system

Providers:

• Hospitals—academia/research, community care, sfety net

• Physicians—PCPs, Specialists, DOs

• Others—nurses, PAs, Home Health Aides, PT, OT, etc

Purchasers:

• Employers—HMO, PPO plans

• Patients - private, employee-sponsored insurance, exchanges

• Uninsured—out-of-pocket payments

What is Fee-for Service (FFS)?

• paid a set rate for service delivered

• prioritize volume over efficiency/efficacy

What is capitation?

preset amount ($) per patient regardless of use of services, also known as prospective payment system

What is episode of care (bundled)?

preset amount ($) per patient for an episode of care; definition of episode vague

What is a global budget

hospital given an overall budget that must be maintained within regardless of patients seen or services provided

What is pay-for-performance

pay based on quality of service; rewards quality care, peanalizes poor care

What is a charge ?

fee set by hospital

What is price/ reimbursement?

to the payer: what is paid to the hospital

to the patient: the out-of-pocket cost

What is the cost?

The actual financial resources needed to provide a service are largely opaque

Hospital consolidation

Horizontal

• hospital merge to increase market share, reduce competition

• similar services merging together

• example: two cancer hospitals joining together to reduce competition/expand their patient pools

Vertical:

• expansion to control more parts of the supply chain

• example": a novel proton therapy clinic being acquired by a cancer hospital to expand its available treatment option

Cross-market Mergers

• mergers that occur across different geographic markets

Hospital consolidation Pros and Cons

Pros:

• Cost reduction

• Increase in purchasing powers as a larger group

• Increases in care coordination and quality

• Better economic stability. More hospitals mean more money

• Brand recognition → patient trust

Cons

• Reduced competition.

• Access issues: closures of small, rural hospitals

• Smaller, weaker, non-teaching hospitals at most risk

• Risk of price hikes as hospitals increase market share

• Only a marginal improvement to quality

• Less competition means there is less incentive to provide quality care or continue improving their quality care

Payment Reforms

ACA Reforms

• Medicare → bundled, valued-based

  • Penalties for readmittance, hospital-acquired illness

• Medicaid → state -led expandsions toincrease insured population. more funding means more eligibility and more benefits

2020 No Surprise Act

• Protection from surprise out-of-network bills in emergency/ancillary services

• For example, if you are getting surgery and your anesthesiologist is out of network, you will not be charged extra for that.

Patient Rights

Patients are entitled to Reasonable

• REsonable care by providers

• Informed, voluntary choice of medical care

  • Medical care includes diagnostic, preventive, curative, surgical , pharmaceutical, radiological, rehabilitative, palliative

• The right to refuse treatment

• Patients vs Consumers

  • PAtients as recipients rather than buyers

  • Assumes unequal positionality

  • Imposed fiduciary responsibility:

    • the legal duty to act in someone's best interest rather than one’s own

  • Acknowledges seeking health care as a need-based act

What is a tort?

• An act/omission that gives rise to injury or harm to another and amounts to a civil wrong

• Use to allocate (responsibility for personal injury), to compensate (the injured party), and to prevent harm (through deterrence)

Examples:

• Intentional - battery, assault, invasion of privacy, defamation

• Mixed—confidentiality breach, infliction of emotional distres

• Nonintentional - product liability, negligence

Battery in a healthcare context

• Intentional, offensive touching without consent

• Limited public health/medical application

Examples

• Operating on the wrong body part

• Adding a non-consented procedure

Negligence in a healthcare context

• More common in public health/medicine

• Failure to perform a duty of care, which causes harm to the person to whom the duty is owed

Causes of action

• Ordinary negligence

  • informed consent

• Professional negligence

  • Malpractice

• Breach of confidentiality

General Rule of Negligence

The plaintiff must prove all:

1. The defendant had a duty of care to the plaintiff to act reasonably.

2. The defendant breached that duty by not acting with reasonable care

3. The plaintiff suffered actual injury

4. The defendant’s breach of duty was the proximate cause of the plaintiff’s injury

a. The harm was a direct, foreseeable and natural consequence of the action

Informed Consent

Giving patients the opportunity to make fully informed, voluntary and competent autonomous decisions

The Four Cs of competence

• Conscious

• Comprehends- relevant information

• Chooses—capable of making an affirmative decision

• Communicates - a decision

Epidemiological Revolutions

First Revolution (infections)

• Sanitation, hygiene, nutrition

• Infrastructure, pasteurization, vaccines

• Think of John Snow on Broad St in London.

Second Revolution (risk factors)

• Individual behaviors

• Prevention (education, screenings)

Managed care

A system of healthcare in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company

6 factors that influence type of insurance someone has

Age

Employment Status

Parent vs not

Income

Location

Gender

Disability

How access to care exists through government-funded providers like community health centers

Community health centers rely on a combination of Medicaid payments, grant revenues, and other private and public funding sources to fund their operations

total cost = units of service * price per unit

-Formula that highlights how difficult it is to constrain health spending

-If you constrain units of service, price per unit increases, and vice versa.

-One thing we can do, is to set a budget/limit for total health expenditure

Who is left without insurance-based access to medical care?

-People who are not poor enough to qualify for Medicaid and not wealthy enough to buy it on their own

-Males that are not married and don't have kids in states that didn't vote to expand Medicare.

-Undocumented immigrants

-Procedure in ACA says if premium you are required to pay is above some portion of your income then you don't have to pay it (not eligible for Medicaid but can't afford the premium on the exchange and the subsidy isn't enough to make up for it)

Major changes underway in ownership of hospitals (MAYBE DELETE)

From free standing independent, governed by Board of community leaders; doctors in private practice

To multi-hospital systems employing physicians in community settings; owning and operating dispersed outpatient and imaging facilities

How alternative methods of payment shift financial risk

-Incentive to provide more or fewer services based on payment method

-Ex. Fee for service vs. capitation: Will perform more services in FFS vs. Capitation

-When you move from FFS to Global budget: More aggregated, more of the risk is shifted from the insurer to the provider.

-Pay for performance: more risk shifted to provider.

Biggest penalties we are seeing are placed on hospitals that are treating very poor patients because they tend to have more complicated health problems.

Scope of practice

What providers are allowed to do in each state

State licensure limitations on providers

Different states have different licensing requirements, licensing boards are made up of professionals with a vested interest in maintaining exclusivity within the profession.

Safety-net providers

Providers who accept everyone regardless of insurance

Role of community health centers in access to ambulatory care

Provide primary care services at little to no cost to people living in federally designated rural or inner-city underserved areas

Requirements of the informed consent doctrine

-full disclosure of the nature of the research and the participant's involvement,

-adequate comprehension on the part of the potential participant, and

-the participant's voluntary choice to participate.

-Must be in lay terms

What must be disclosed to individuals to enable informed decision-making

-Description of procedure

-Risks and benefits

-Description of alternatives

-Results of no treatment

-Probability of success

-Major problems in recuperation/time of recuperation

-Any other "materially relevant" information.

Presumption of legal competence and requirements for overcoming the presumption

• Adults are presumed competent by law, and the burden of proving they are not is on the person who wants to "declare" the patient incompetent.

• If a patient is incompetent, the personal advocate, nearest relative, or health care agent can usually make medical decisions for the patient

• The physician cannot make medical decisions for the patient.

• Missouri requires that evidence of the incompetent's wishes as to the withdrawal of treatment be proved by clear and convincing evidence

Parens patriae power

Literally means "parent of the country"

Refers to the state's duty to protect those citizens who cannot care for themselves.

Difference between medical treatment and research

-Physicians treat patients with a treatment known to be safe and effective that the physician believes in in the patient's best interest and with informed consent.

-Researchers follow a scientifically protocol to test a hypothesis, which is followed whether the intervention is working or not.

-Medical treatment benefits you, whereas research may not benefit you.

Reasons for requiring consent to medical care and to research.

Primary means of protecting the legal rights of patients and guiding the ethical practice of medicine.

It may be used for different purposes in different contexts: legal, ethical, or administrative

Primary prevention

• Prevent onset of disease

• Disease status: susceptible

• Effects: reduced disease (incidence)

-Avoiding disease and promoting good health practices, includes social and behavioral determinants of health.

Secondary prevention

• screening/early detection, prevent progression

• Disease status: asymptomatic

• Effects: reduced prevalence consequence

• Health promotion directed at people who are at high risk for contracting diseases but may not be sick.

Tertiary prevention

• Maintain health status, improve function

• Disease status: symptomatic. Disease has already happened

• Effects: reduced complications/disability

Cost-saving

cost of prevention is less than the cost of treatment

Cost-effective

May not save money in treatment but maintain significant benefit

The U.S Preventive Services Task Force (USPSTF)

• A panel of independent experts that make graded recommendation on what preventative measure should be covered by insurance

  • A (recommended) → B → C → D (not recommended) → I (insufficient evidence)

• REcommendations do not need to be cost-saving.

Levels of Change

Top Increasing population impact

• Counseling and education,

  • driver’s ed

  • SNAP

  • EPA clean air act

• Clinical interventions

  • antibiotics

  • cancer care

• Long-lasting protective interventions

  • Vaccinations

  • dental sealants

• Changing the context to make individuals' default decisions healthy

  • Calorie counts

  • cigarette warning labels

  • soda ban or tax

• Socioeconomic factor

  • universal basic income

  • housing subsidies

Bottom Increasing the individual effort needed