HIST 36 midterm 1 textbook flashcards

Four modes of paying for healthcare

1. out of pocket payment

2. individual private insurance

3. employment-based group private insurance

4. government financing 

individual private insurance

A type of insurance where individuals purchase coverage directly from an insurance company; oftentimes there’s a deductible or copay

deductible

out of pocket first portion of one’s health expenses each year before insurance coverage kicks in

ACA impacts on individual private insurance 

provides federal subsidies to obtain individual private insurance through federal/state health insurance companies 

• available to people between 100-400% of fed poverty level

• prohibits companies from denying insurance for preexisting medical conditions'

• requires all us citizens/perm residents to have general coverage health insurance

insurance companies four benefit categories

1. bronze: low premiums, high oop costs

2. silver: high premiums, fewer oop costs

3. gold: high premiums, low oop costs

4. platinum: very high premiums, very low oop costs

government funding

health care financing through direct provision of care, state-operated mental hospitals, and municipal hospitals

created to alleviate two disadvantaged groups:

1. people in low-income brackets

2. older adults

employment-based private insurance

created due to the increasing effectiveness and rising costs of hospital care when few people had individual insurance 

1. employers pay a portion that purchases health insurance for their employees

2. government views employer premium payments as tax-deductible business; employees don’t get taxed on premiums (govt. is essentially subsidizing employer-sponsored health insurance) 

ACA impact on employment-based private insurance

insurers are now severely limited in using experience rating to set premiums

premium variants: family size, geographic location, age, smoking status 

experience rating

a dynamic of health insurance that distributes health care more in accordance with human need rather than exclusively on basis on ability to pay

• less distributive than community rating

community rating 

a dynamic rating of health insurance that helps pay costs of those unable to purchase their own services

two ways:

1. individual group

2. multiple groups

individual group (community rating)

ill people receive excess benefits of their paid premiums; healthy people pay premiums with few/no health benefits 

multiple groups (community rating)

the group using less healthcare than the premium is worth helps pay for the group who uses more healthcare than the premium is worth 

types of medicare plans

part a: hospital care; financed through social security taxes from employers/employees

part b: physician services; paid for by federal taxes and benficiaries’ monthly premiums (80%)

part c: medicare advantage program

part d: prescription drug coverage; financed the same was a part b 

medicare advantage program

a beneficiary can elect to enroll in a private managed care health plan contracting with medicare

• medicare subsidizes premium for private health plan and plan that pays physicians, hospitals, etc; 

medicaid

program jointly administered by federal and state governments

ACA impacts on medicaid

made the only requirement for eligibility income-based; enrollment is optional for the state (ACA intended for all state eligibility)

1. 6/2012: ACA provided states incentive by having federal government pay for medicaid expansion costs

two ways taxpayer can interact with health care consumer

1. social insurance model: only those who pay a certain amount in social security taxes are eligible for medicare A; only those who also pay premiums B-D

2. medicaid public assistance model: eligibility is not linked to an individual’s tax payments

three payment classifications (if it’s worth it or not)

1. progressive: they take a rising % of income as income increases 

2. regressive: they take a falling % of income as income increases

3. proportional: ratio is same for income classes

underinsurance

when an individual’s health insurance coverage has limitations that expose them to large out-of-pocket payments that discourage access to needed service and saddle individuals with large medical bills

criteria:

1. Out-of-pocket costs (excl share of insurance premiums), equal 10% or more of income

2. Out-of-pocket costs (excl premiums), equal 5% or more of income if low income (<200% of poverty)

3. Deductibles equal 5% or more of income  

what does underinsurance include?

1. Low income individuals not living in states in medicaid expansion

2. Individuals opting out of ACA coverage due to too much premiums or deductibles

3. Individuals not enrolling in Medicaid even when eligible

4. Undocumented immigrants remaining ineligible for medicaid/insurance subsidies

Fee-for-service payment

the unit of payment is the visit or procedure; the only form of payment that is based on individual components of health care

1. Physicians have an economic incentive to perform more service → rapid rise in healthcare costs in the us 

2. Insurance companies made fee-for-service payments to private hospitals based on principle of “reasonable cost”, as system under which hospitals had a great deal of influence in determining the level of payment 

Episode-based payment

the physician or hospital is paid one sum for all services during one illness or surgical procedure

1. Surgeons have an economic incentive to limit number of postoperative visits because they do not receive extra payments for extra visits 

hospital diagnosis related group (DRG)

est 1983; medicare pays a lump sum for each hospital admission, with the size of the payment dependent on the patient’s diagnoses

• Has gone one step further than per diem payments in bundling services into one payment

  • Lumps together all services performed during one acute care hospital episode

Per diem payments to hospitals

the hospital is paid for all services delivered to a patient during one day in the hospital

1. Hospital receives lump sum per day patient is in hospital → insurer does utilization review, sending to providers to review patient charts → providers decide if patient is ill/needs to stay in hospital → insurance play may stop paying for additional days (if patient is determined not ill/doesn’t need to stay)

Capitation payment

one payment is made for each patient’s care during a month or year

1. May control costs by providing an alternative to the inflationary tendencies of fee-for-service payment 

   1. Been advocated for its potential beneficial influence on the organization of care 

2. Require patients to register with a physician or group of physicians 

3. Allows for more flexibility at the practice level in how the most effectively and efficiently organize and deliver services

4. Explicitly defines (in advance) the amount of money available to care for an enrolled population of patients, providing better framework for rational allocation of resources and innovation in developing better modes of delivering services

what (2) was created as an attempt to mitigate financial risk associated with capitation?

1. Introducing fee-for-service payments for specified services

   1. Carve-outs: type of services provided but not covered within capitation payment; payment is “carved-out” of the capitation payment and paid separately

2. Risk-adjusted capitation: provides higher monthly payments for older patients, and those with chronic illnesses or other characteristics predicting higher health care needs 

Two-tiered capitation (British)

person freely enrolls with general practitioner → physicians receives monthly payment → patient is required to route all nonemergency medical needs to enrolled doctor → doctor can make referrals if needed

1. the health plan pays the PCP by capitation and pays for referral services through a different payment stream 

Three-tiered capitation (United States)

HMOs do not pay capitation fees directly to individual physicians or small practices, but instead rely on an intermediary administrative

1. The health plan pays a capitation payment to a physician group or independent practice association (IPA), which in turn pays PCP and specialist physicians fee-for-service, capitation, or salary

Global budget

a fixed payment is made for all hospital services for 1 year; every service performed on every patient during 1 year is aggregated into one payment 

1. represent the most extensive bundling of services

managed care plans (origins, forms)

introduced changes in the method by which hospitals and physicians are paid, largely for the purpose of controlling costs

1. Fee-for-service practice with utilization review: traditional type of payment, with addition of third party (insurance/government agency) that does a utilization review; basically approves payment for services deemed necessary

2. PPO: insurers contract with a limited number of physicians and hospitals who agree to care for patients (usually on discounted fee-for-services, or per diem basis with utilization review (hospitals))

   1. Patients pay a much higher share of the cost when using physicians/hospitals outside the “preferred” network

3. HMO: patients are required (except emergencies) to receive their care from physicians and hospitals within that HMO

   1. POS (point of service) have more flexibility in choice of provider

Resource-based relative-value scale (RBVS)

est 1990s by medicare

Fees (vary by area) are set for each service by estimating time, mental effort and judgement, technical skill, physical effort, and stress related to service 

1. Pays surgical at a far higher rate than primary care/cognitive services

Salary payment

aggregates payment for all services delivered during a month or year into one lump sum

1. Physicians in the public sector (municipal, VA/military hospital, state mental hospitals) and in community clinics typically paid by salary

Pay-for-performance

how well physicians and other providers perform in delivering those services

1. Basic mode of payment (small relative to dominant payment mechanisms); bonus payments to physicians and hospitals that achieve a specified high level of performance on certain measures such as preventative care services, diabetes care, patient experience, and cost reduction

Bundled payments

medicare not only bundles payments into more aggregated units using an episode-based rather than fee-for-service method; physician and hospital payments are also bundled together into a single payment 

1. Provides an incentive for the hospital and its medical staff to collaborate to eliminate unnecessary costs, resulting in savings to medicare and higher earnings for the hospital and physicians 

Accountable care organizations (ACOs)

another form of virtual integration; provider organizations contract with a payer “to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population” 

1. Provide an opportunity for physician and hospital organizations to retain a greater share of the upside risk if they are willing to also assume some downside risk 

2. Provides an incentive for physicians, hospitals, and other involved providers to collaborate in eliminating wasteful spending 

Topography of any health care system

the organization of care into primary, secondary, and tertiary levels 

1. Primary care: common health problems and preventative measures that account for 80-90% of visits to a physician/other caregiver 

2. Secondary care: problems that require more specialized clinical expertise (ie hospital care for patient with acute renal failure)

3. Tertiary care: management of rare disorders (ie congenital malformations, pulmonary tumors)

Approaches used to organize a health care system around these levels of care

1. Dawson model: based on the concept of regionalization; the organization and coordination of all health resources and services within a defined area 

   1. Emphasizes the primary care base and a population-oriented framework for health planning

2. Free-flowing model: more fluid roles for caregivers, more free-flowing movement of patients across all levels of care

   1. Tends to place a higher value on services at the tertiary care apex than at primary care base

primary care

 “the provision of integrated, accessible health services by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnerships with patients, and practicing in the context of family and community”

key tasks of primary care

first contact care, continuity, comprehensiveness, coordination 

1. First contact care: performing the initial evaluations when symptoms of illness develop

2. Continuity: sustaining a patient-caregiver relationship over time

3. Comprehensiveness: the ability to manage a wide range of health care need

   1. Contrast with specialty care, which focuses on a particular organ system/procedural service

4. Coordination: builds upon longitudinally

what is the “triple aim” of health system improvement that PCP are aiming to achieve?

1. Better patient experiences

2. Better patient outcomes

3. Lower costs

medical home (history/origins)

PCP is dying because they don’t get paid as well as other specialties and severely overworked due to understaffing → using medical home principles help PCPs and its reform efforts

est. 1967; the notion of a primary care practice that would coordinate care for children with complex needs

1. Principles built upon in PCP to call for greater attention to patient-centeredness, implementation of innovative practice model, and changed in physician payment 

2. ACA promoted reform efforts ie medicare comprehensive primary care initiative 

Two factors of growth of dispersed mode of healthcare delivery

1. Preeminence of the biomedical model among medical educators

   1. The belief that every illness had a discrete, ultimately knowable cause and that medication can be crafted to eradicate these sources of disease 

   2. Caused the consolidation of medical training in med school 

2. Financial incentive for physician specialization and hospital expansion; results played out in various ways:

   1. Insurance benefits first offered by Blue Cross covered hospital costs, but not physician visits and other outpatient services 

   2. Growing differential in payment between generalists and specialists 

   3. Federal involvement in health care financing → expansion of hospital care and specialization

      1. Medicare encouraged this through its policy of extra payments to hospital to cover costs associated with residency training 

multispecialty group practices

attempted to promote a collaborative style of care in which colleagues shared responsibility for the care of patients; formally integrating physicians into a single clinic structure

community healthcare center model (origins, impacts)

revived in 1965 by federal Office of Economic Opportunity’s “War on Poverty”: 

1. combining comprehensive medical care and public health to improve the health status of defined low-income communities

2. Building of multidisciplinary teams to provide health services

3. Participation in the governance of the health centers by community members

   1. Improving ambulatory care of low-income patients → centers reduced hospitalization and ED visits by their patients 

   2. Have had some success in improving community health status

prepaid group practice

HMOs before HMOs were HMOs

meld financing and delivery of care into a single organizational structure

1. Patients could pay in advance to directly purchase health services from a particular system of care

2. Care is delivered a large group of practitioners working under a common administrative structure

   1. Renamed HMOs in 1970s; more emphasis on preventative care than had the traditional medical model 

vertical integration

consolidating under one organizational roof and common ownership all levels of care, from primary to tertiary care, and the facilities and staff necessary to provide this full spectrum of care

horizontal integration

consolidation of health care units providing the same type service 

1. Allows hospitals to regionalize tertiary care services at a select number of specialized centers

Network HMO

insurance plan only pays for services provided by those physicians and hospitals that participate in the HMO plan (“narrow network” of providers); provided are not owned or employed by a single organized health delivery system 

1. Consists of contractual links between HMO health insurance and individual physicians, IPAs, multispecialty med groups, hospital, and other provider units 

2. Hospitals and physicians have contractual relationships with many different insurance plan

categories of underinsurance

1. uncovered services

   1. long term care under medicine

   2. durable medical equipment under some insurance plans

   3. caps on coverage (ie limited physical therapy visits)

   4. restricted benefits from “limited benefits”; insurance plans exempted from ACA requirements

2. insurance deductibles and copays 

two dimensions of social ranking (that physicians were trying to rise to)

1. differences in wealth and income (objective access to scarce resources)

   1. corresponds with the concept of class

2. differences in honor, deference, and prestige (favorable or unfavorable social evaluations)

   1. corresponds with status 

medical sects

were like religious ones as they set themselves a part for having a certain belief and lifestyles, seeing themselves/ higher ups as apostles of truth;; differed as they had a set of definite ideas as requirements of members and medical ones were only focused of career concerns not necessarily the entire way of life

• serves as a competing “reference group” for its members, allowing them to seek status and prestige on more favorable terms than available in wider society 

homeopathy and its appeal

started by the dutch guy, believed this was a route to public favor 

homeopathy’s appeal:

1. Encouraged good doctor/patient relationship

2. Insisted symptoms were only perceptible aspect of disease, needed to be learned from uninterrupted report between doctor/patient 

3. Provided alternative to the pharmacological excesses of orthodox physicians

4. Due to experimental and philosophical nature, it seemed to people to be less scientific than orthodox medicine. 

medical school reform and med schools involved with it

reform caused tightening of education required to being a doctor and raised doctor prestige 

1. Harvard: requiring students to pass all their courses, take tests to get in; and change their fee system to yearly with endowments

2. Johns Hopkins emphasized research alongside medical education; causing a surge in the field of academic medicine 

FLEXNER REPORT

Jacksonian vs progressive eras

1. Jacksonian: saw science as knowledge to be widely and easily spread; professional monopolies 

2. Progressive: science should be complex and inaccessible to the general public; Reforms and radicals held political authority 

As hospital care turned profitable, how did doctors use hospitals professionally without becoming a cog in the machine? 

1. Using interns and residents in hospitals

2. Encouragement of a kind of responsible professionalism among higher ranks of subordinate health workers

3. NURSING: the employment of professionally trained, mainly women workers that would not challenge the authority or economic position of the doctor

What were the three common reactions to the introduction of new medical technology, as exemplified by the stethoscope in the 19th century?

The three common reactions were reluctance from older physicians to adopt new methods, the fact that technology still needed interpretation by human senses which could be flawed, and overzealous enthusiasm that claimed the invention did more than it could, leading to disappointment and disposal when expectations were not met.

Describe the core philosophy of "heroic treatment," a dominant medical approach before the rise of therapeutic skepticism.

Heroic treatment was based on the idea that every part of the body is linked and that illness resulted from an imbalance. It advocated for aggressive, "do something" interventions, such as venisection (massive bloodletting) and purging with laxatives, to restore the body's equilibrium.

Explain the central theory of Homeopathy and describe why it posed a significant economic threat to "regular" physicians.

Homeopathy was based on the theory of "like cures like," meaning a patient could be healed by taking a minuscule dose of a substance that produces similar symptoms in a healthy person. It was an economic threat because regular, educated doctors began to embrace this new idea, taking their fee-paying patients with them to homeopathic practices and hospitals.

What was the Flexner Report of 1910, and what was its most dramatic impact on the landscape of American medical education?

The Flexner Report was a critical review of all American medical schools, funded by the Carnegie Foundation, that exposed their inadequate standards. Its impact was a dramatic consolidation and reform of medical education, causing numerous schools to close, standardizing a four-year curriculum based on science, and leading to a significant decrease in the number of medical graduates.

How did the development of chemical anesthesia revolutionize surgery, and what was its immediate, ironic downside?

Chemical anesthesia solved the problem of pain, making surgery more possible and accessible than ever before. The ironic downside was that it also made surgery more deadly, as an increased number of operations were performed without any understanding of germs or hygiene, leading to a rise in fatal post-surgical infections.

What is "hospitalism," and what were the two primary concerns patients had about entering hospitals in the 19th century that contributed to this phenomenon?

"Hospitalism" was a term for hospital-borne infections and the general phenomenon of patients getting sicker after entering a hospital. The two main concerns that fueled this were the high risk of contracting a deadly infection within the hospital and the fear of being experimented on by physicians who used hospital patients, particularly the poor, for practice and research.

According to the source materials, what is the difference between primary, secondary, and tertiary levels of care in a health care system?

Primary care addresses common health problems and preventative measures, accounting for 80-90% of visits. Secondary care involves problems requiring more specialized expertise, such as hospital care for acute renal failure. Tertiary care is the management of rare and complex disorders like congenital malformations or pituitary tumors.

Why did the American Medical Association (AMA) historically champion the slogan "No third parties"?

The AMA's slogan "No third parties" reflected its core belief that nothing should interfere with the doctor-patient relationship, particularly its economic aspects. The AMA sought to prevent any outside entity, specifically insurance companies or the government, from getting in the way of how a physician was paid by a patient.

Describe J. Marion Sims's breakthrough in curing vesico-vaginal fistula, including the key material he used and the subjects of his experiments.

J. Marion Sims developed a cure for vesico-vaginal fistula through years of experimental surgeries on enslaved women, primarily Anarcha, Lucy, and Betsey. His breakthrough came after dozens of failures when he theorized that the suture material was the problem and successfully used a fine suture made from pure silver to close the fistula.

What were Blue Cross and Blue Shield, and how did they represent a uniquely American, private-sector solution to financing health care during the Great Depression?

Blue Cross was a private hospital insurance plan, originating with an employment-based plan at Baylor, that provided coverage for hospital costs. Blue Shield was a parallel plan created and run by physicians to cover physician services. Together, they formed a voluntary, private insurance system that became the dominant American model, in contrast to the government-run systems in Europe.

AMA (American Medical Association)

A professional society and governing body for organized medicine, formed to maintain ethical, intellectual, and professional standards. It also acted to restrict the practice of medicine, initially viewing homeopathic doctors as its main enemy.

Antisepsis

The practice of using chemical agents, like carbolic acid, to sterilize a surgical field and prevent infection.

Auscultation

The act of listening to the internal sounds of the body. "Immediate auscultation" involved placing an ear directly on the patient's chest, a practice superseded by the stethoscope.

Cellular Pathology

A theory, developed in Germany by Rudolph Virchow, stating that disease originates at the cellular level, not in the whole body or a specific organ. This shifted medical focus to the microscopic level.

Chiropractic

A medical sect created by D.D. Palmer, based on the idea that the key to health is proper alignment of the spine, which is achieved through manual manipulation.

Eclectic Medicine

A medical sect founded by Wooster Beach that took "a little bit of everything" from other theories. It primarily used condensed botanical medicines, which made it popular with physicians on the American frontier.

Flexner Report (1910)

A landmark critical review of American medical schools that exposed poor standards and led to widespread reform, including the closure of many schools, the standardization of a four-year curriculum, and higher admission requirements.

Germ Theory

The scientific theory that many diseases are caused by microorganisms. Its acceptance revolutionized medicine, leading to practices like antisepsis and the development of antibiotics.

Heroic Treatment

An aggressive medical philosophy, championed by figures like Benjamin Rush, that involved drastic interventions such as bloodletting and purging to restore the body's supposed equilibrium.

Hospitalism

A 19th-century term for hospital-borne infections and the general poor outcomes associated with hospital stays.

Humoral Theory

An ancient Greek medical theory which held that the body contained four humors (blood, phlegm, black bile, yellow bile) and that health depended on these being in perfect equilibrium.

Legitimate Complexity

The idea that medicine required a high level of specialized expertise that was inaccessible to the general public. This concept, which emerged in the late 19th century, reversed the democratic, "do-it-yourself" impulse and restored authority to physicians.

Listerism

The practice of sterilization in surgery, named after Joseph Lister, who pioneered the use of carbolic acid to clean surgical fields.

Osteopathy

A medical system founded by A.T. Still, based on the theory that the brain produces all necessary healing substances but that a malformed skeleton (bones) can block their delivery. Treatment involves skeletal manipulation to restore flow.

Paris Clinical School

A center of medical education in the early 19th century that revolutionized medicine by associating a patient's symptoms with specific organ pathology, discovered through autopsy. This marked a shift away from whole-body theories like the humoral theory.

Sectarianism

The proliferation of competing alternative theories of medicine in the 19th century, such as Thomsonianism and Homeopathy, which challenged the authority of "regular" physicians.

Sphygmomanometer

A medical instrument used to measure blood pressure, which standardized a key diagnostic indicator and further removed the patient's subjective words from the diagnostic process.

Stethoscope

Invented by René Laennec, a tool used to listen to the internal sounds of the heart and lungs. It was one of the first technologies that allowed physicians to diagnose based on evidence from inside the body, increasing the physician's diagnostic power and distance from the patient.

Therapeutic Skepticism

A medical philosophy that emerged in the 19th century, advocating for letting the body's natural course heal an illness rather than resorting to the harsh and often deadly interventions of heroic medicine.

Thomsonianism

A medical sect founded by Samuel Thomson, who believed the root of all health problems was being "too cold." His treatments involved heating up patients with steam baths, hot peppers, and other methods.

UCR (Usual, Customary, and Reasonable)

An early method by which insurance companies determined payment prices for medical services, which contributed to escalating costs.

Vesico-vaginal fistula

A tear between the bladder and the vagina, causing uncontrollable leakage of urine. J. Marion Sims pioneered the first reliable surgical cure for this condition.

X-ray

A diagnostic technology that uses cathode rays to see through human tissue and visualize skeletal structures. It captured the public imagination and became a powerful diagnostic tool, increasing collegiality among physicians who could collaborate over the images.