PHMS Exam 1

Understand the basic nature of the U.S. health care system.

No central agency, partial access, imperfect market

Multiple payers

Premium cost sharing- employer and employee pay into ins

Quad function model- financing, insurance, delivery, payment

what are the main objectives of a healthcare delivery system

Provide access to care

Meet standards of care

Care is reasonably efficient (costs)

what are the 4 elements of the quad function model

financing, insurance, delivery, payment

DFIP

The key functional components of the U.S. health care delivery system. Which role does each play in the delivery of health care?

Quad function model:

financing (employers, inds, govt)- provide funds to pay for health services (or purchase ins)

insurance (companies, self, BCBS)- protects insured against financial risks, defines package of services someone can receive (covered)

delivery (provider, supplier)- ie specialized care, preventative services

payment (ins, BCBS, third party claims- multiple payers)- reimburse providers, big admin costs bc of multiple payer system

Employer contracts with managed care org MCO- have provider network

A general overview of the Affordable Care Act. What is its main goal?

Main goal: expand insurance coverage - have less uninsured people

Covered by parent's ins until 26 y/o

Employers must offer ins, citizens/residents must be covered

Easier to qualify for medicaid (tho this didn't achieve universal coverage)

What are the main objectives of public health?

prevent disease

promote health- encourage behaviors/enviros for wellbeing

prolong life- manage health risks across pop

PH PPPs

public health preventions

Primary prevention- reduce disease probability in future (vaccines)

Secondary prevention- early detection/treatment of disease (screenings)

Tertiary prevention- interventions in ppl w chronic conditions (turning pts to prevent pressure sores)

what are the blum model key determinants of health

enviro, lifestyle, heredity, medical care

HELM

blum model determinants of health and their implications for health care delivery

Enviro: wider income gaps → worse pop health status. This is even true for ppl in countries w national health ins. Income inequality = less available primary care

Lifestyle (behavioral risk factors): diet → heart disease, diabetes, stroke, cancer etc

Heredity: genetic predisposition to certain diseases

medical care: (least important- us focuses a lot on med r&d)

elements of the epidemiology triangle of disease occurrence

Host, agent, environment → disease

Host- organism (human)- genetic makeup, level of immunity, fitness, personal behaviors

Agent- ie bacillus- presence of agent doesn't ensure that disease will occur

Enviro- physical/social/cultural/econ aspects (ie sanitation, pollution, cultural beliefs, equity, social norms, econ status)

explain the concepts of market justice and social justice.

Market: individual responsibility, private solutions to social probs of health

healthcare = econ good, assumes free market conditions, focuses on ability to pay

Social: collective responsibility, govt solutions to social probs of health

healthcare=social resource, govt involvement, central planning, equal acces=basic right

how do market and social justice complement each other, and how do they conflict?

complement:

US uses hybrid approach!!

market justice for private ins market, social justice w medicare/medicaid, private employers contract w MCOs (use market-based networks to provide care)

conflicts:

market justice leaves people who can't pay stranded

US individualism

ACA focuses on social justice goals in a market justice system

How is health care is rationed in the market justice and social justice systems?

Market = demand side rationing (rationing by ability to pay)

Prices + ability to pay discourage/prevent ppl without money to get care

Utilization limited by what someone can afford (premiums, deductibles, copays)

Social = supply side rationing (planned/explicit rationing)

Govt limits ability of certain health care services to control costs (ie limit expensive tech or number of specialties)

Access managed w waitlists or gatekeeping by pcp, prioritizing ppl w need rather than money

Main historical developments that have shaped the U.S. health care delivery.

Pre industrial era <1800s

No health ins, medicine was a trade (not profession), fee for service

almshouse/pesthouse/dispensary/asylum

Post industrial >1800s - professional dominance

Private practice, tech advanced for insured pts, organized medicine profession, gained power/prestige/wealth

Urbanization, tech, institutionalization, licensing, educational reform

Corporate era (late 1900s+) - corporate dominance

Growth of managed care, consolidation of health care orgs

Health care reform (2000s) - ACA

How World War II period lent support to employer-based health insurance in the United States.

To control inflation in WWII, congress froze wages. Employers offered health ins instead of raises to keep workers

1948 supreme court said benefits were a legit part of union negotiations

1954 congress made employer-based coverage nontaxable (= tax-free salary increase)

Emergence of general hospitals

Tech development required competence → specialized training

Science based medicine → demand for services communities couldn't provide

Advanced treatments req pooling resources → hospitals = core of delivery

As hospitals expanded, more dependent on drs keeping beds full (they decided where to hospitalize their pts), so hospitals had to keep drs satisfied

Historical perspective on the Affordable care Act.

Passed 2010 when dems held presidency and both houses

Included medicaid expansion (tho states could choose to join, and abt half did) and an individual mandate with fines

Expanded coverage for ppl w pre-existing conditions and young adults up to age 26

Faced criticism for rising premiums and limited provider participation

Super contentious/polarizing politically - 2017 Trump tried to appeal

Mostly people agree on coverage for pre-existing conditions and incentives for preventive health behaviors

define principles of management PoM theory. what are its components?

PoM- how organizations are led, organized, and operated to achieve goals efficiently- focus on optimizing resources, improving productivity, and establishing clear structures

planning, organizing, leading, controlling

POLC

define efficient econ market EEM theory. what are its components?

EEM- perfect competition- assumes self-regulating market with perfect competition w maximum efficiency → prices reflect true marginal cost of production

perfect information, many buyers/sellers, homogenous products, free entry/exit, zero transaction costs

(many perfect homos r free... zero)

Define and explain the Principles of Management theory, its components, and application to understanding the healthcare system.

PoM- how organizations are led, organized, and operated to achieve goals efficiently- focus on optimizing resources, improving productivity, and establishing clear structures

Planning- est long term goals/policies, mission statements, etc to improve pt outcomes (incl budgeting, resource allocation, risk management)

Organizing- efficient depts/workflows- define clear job roles/responsibilities

Leading- apply behavioral theories- use team dynamics, motivation, and leadership to foster a positive work culture - recruit/train/retain professionals

Controlling- use data to track performance, reduce med errors, comply w regulations- ie using studies to improve efficiency, quality control for pt satisfaction

applied in healthcare to improve patient care, operational efficiency, and financial sustainability

Define and explain the Efficient Economic Market theory, its components, and application to understanding the healthcare system.

EEM- perfect competition- assumes self-regulating market with perfect competition w maximum efficiency → prices reflect true marginal cost of production

Perfect info- participants know prices, quality, tech → no info asymmetry

Many buyers/sellers- so many participants that no one can influence market price

Homogenous products- identical across all sellers → no brand loyalty

Free entry and exit- firms can leave during losses without significant legal/tech/financial barriers → firms produce at lowest possible cost

Zero transaction costs

Healthcare is imperfectly competitive- info asymmetry, barriers to entry, non homo products, consolidation of power, barriers to entry, significant admin costs

Understand various types of health services professionals and their training, practice requirements, and practice settings.

All of these need state licensing

DO (osteopathic) - holistic approach, emphasize musculoskeletal system/prevention

MD (allopathic) - active intervention to neutralize disease

Hospitalist - dr specializing in care of hospitalized pts to increase efficiency and reduce costs

Dentists - most work in private business, some VA hospitals and ph clinics

Pharmacists- dispense meds, provide pharm care - consultation on drug selection/misuse

Nurses

RN- associate ADN or bachelors BSN + NCLEX

LPN- 1 year certificate

Other doctorals: optometrist (OD 4 yr degree) (opthalmologist is eye MD), podiatrist (DPM), chiropractor (DC 4 yr degree)

Differentiate between primary care and specialty care.

Primary: gatekeepers, longitudinal, whole person, generalist

Specialty: referral based, episodic/intense, specific organ/disease, specialized → residency + board exam

Roles of midlevel providers in the delivery of health care?

Physician assistance PA - diagnose/histories/physical exams - prescribe in most states

Certified nurse-midwives CNM

Nurse practitioners NP - health promo/disease prevention (often PCP) - prescribe in some states

Similar function to doctors without MD/DO

Understand the role of allied health professionals in health care delivery- technicians and assistants

req supervision, focus on following treatment plans

Pharm tech

Dental hygienist

Med assistant

Understand the role of allied health professionals in health care delivery- therapists and technologists

evaluate pts, diagnose probs, develop treatment plans

PT- help pts with movement dysfunction

OT- help w mentally/physically/emotionally disabilities

Medical dietitians

xray tech

Med lab tech

sonographer

Understand the meaning and role of medical technology in health care delivery.

Meaning: practical application of science to improve health, create delivery efficiencies

Role: Transformed urban hospitals into high-tech med centers, allowed for growth in alternative settings like home health and outpatient surgery

The main provisions of HIPAA with regard to the protection of personal health information

protect personal health info PHI by restricting legal use to: Healthcare delivery, operations, reimbursement

Also grants pts the right to inspect and get copies of their med records

Which provisions were added to HIPAA under the HITECH Act?

2009- stricter rules for PHI protection- increased civil money penalties for violations, req that any breach of unsecured PHI be reported to the person, the govt, and sometimes the media

Main components of a fully developed electronic health record (EHR) system.

Clinical info systems- process/store/retrieve clinical data

Admin info systems- manage financial/personnel/materials data - ie payroll

Decision support systems- analytical tools to support managerial/clinical decision making (forecasting, clinical alerts ie about drug interactions, automatic pt history summaries)

Info exchange- enable sharing of pt data across healthcare orgs/providers

CADI

The roles of efficacy, safety, and cost-effectiveness in the context of health technology assessment.

Efficacy- health benefit -how well it works under ideal conditions- efficacious if it produces a better health outcome

Safety- protect pts from unnecessary harm during use

Cost effectiveness- clinical benefits vs monetary cost

Why is it important to achieve a balance between clinical efficacy and economic worth (cost-effectiveness) of medical treatments?

Balance crucial because while technology improves care, it is a primary driver of rising healthcare costs; health tech assessment (HTA) tries to find the point where max benefit is achieved without exceeding value- helps determine if the benefit justifies the expense.