US Healthcare System Flashcards

Key Concepts

• Principal/Agent Relationship:
  • Exists when one party (principal) relies on another (agent) to make decisions on their behalf.
  • Physician acts as the agent for the patient.
  • Formed when a principal delegates decision-making authority to an agent due to lacking information.
  • Perfect agent: Makes decisions that are best for the patient.
• Supplier Induced Demand:
  • Healthcare providers use their superior knowledge to influence demand for their services.
  • Doctors can influence the frequency of patient visits and charge more.
• Adverse Event/Medical Misadventures/Iatrogenic injury:
  • Unintended injury or complication resulting in temporary or permanent disability, including increased length of stay.
  • Caused by health management rather than the disease process itself.
• Recissions:
  • Health insurance companies deny claims after providing coverage due to pre-existing conditions or other reasons.
  • HMOs/insurance companies found it preferable to deny claims rather than argue over procedures with doctors.
• Socialized Medicine:
  • The American Medical Association (AMA) linked universal health coverage to the socialization of healthcare, suggesting it would lead to socialist ideology in other areas of life.
  • The AMA successfully associated national health insurance with socialism, making it improbable during rising anti-communist sentiment in the late 1940s and the Korean War.
• No-Preexisting Conditions Exclusions Clause:
  • The Patient Protection and Affordable Care Act (ACA) prohibits denying coverage, increasing premiums, or imposing waiting periods based on pre-existing conditions.

Physician Supply in the U.S.

• Estimation:
  • Easily estimated by the number of currently registered doctors + new graduates + immigrants.
  • Typically shown as the number of doctors per 100,000 population or patients per doctor.
• Optimal Number of Patients per Family Doctor:
  • 1300 to 1500 patients.
• Reason to Care:
  • Supplier-induced demand: too many doctors may lead to unnecessary healthcare usage and increased costs as doctors/provider organizations seek to increase revenue.
• Residency Training:
  • 3-7 years in a recognized specialty accredited by the Accreditation Council for Graduate Medical Education.
  • Approximately 7000 residency programs among ~1500 healthcare organizations.
  • Graduate Medical Education Consortia provide oversight.
• Specialists:
  • Healthcare providers who concentrate primarily on a particular subject or activity, highly skilled in a specific field.
• Number of Specialists:
  • No national policy or master plan to achieve balance.
  • Historical predictions of under- and oversupply of primary MD ratio to specialists fluctuate with little overall change, despite attempts to adjust.
  • Current ratio of 65:35 largely results from individuals’ career choices.

Moral Hazard

• Providers have no incentive to take action to reduce charges; they may charge insurance patients different fees than private patients.
• Result: The 'actual' loss differs from the 'expected' loss, causing the insurance company to lose money.
• Copayments and deductibles reduce moral hazard.

Public Health System

• Defined as all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.

Social Security Trust Fund

• Trust Fund puts away money now to pay for the future.
• Expenses in the future are determined by the number of people receiving Social Security × $amount each person receives.
• Expenses can be predicted because the number of people (life span) can be predicted, and the amount paid out can be controlled (provided they control inflation).
• Conclusion: No major uncertainties, just depends on whether society wants to keep funding it.

Medicare and Medicaid Funding

• Expenses are determined by the number of people receiving Medicare/Medicaid × $amount each person receives.
• Medicare:
  • Can predict the number of people (life span).
  • Cannot predict cost since it depends on health condition, technologies, and inflation in healthcare.
• Medicaid:
  • Cannot predict the number of people (life span).
  • Cannot predict cost.

Charge Master

• Also known as charge description master (CDM), a comprehensive listing of items billable to a hospital patient or a patient's health insurance provider.
• Serves as the starting point for negotiations with patients and health insurance providers concerning the amount to be paid to the hospital.

Caribbean Medical Schools vs. U.S. Medical Schools

• Caribbean Medical Schools:
  • Lower standards of admission.
  • More expensive.
  • Generally 2 years (preclinical); students need to find placements for years 3 and 4.
  • Much higher enrollments.
  • St. George's University School of Medicine and Ross University had more graduates (1,644 and 1,591) than any U.S. university (e.g., UCSF has 180 per year).
• Impact on U.S.:
  • International medical graduates account for 23.8% of the family medicine workforce; one-third attended medical school in the Caribbean.

Federal Public Health Agencies

• The main federal agency is the Department of Health and Human Services (HHS).
• HHS includes programs such as the NIH and CDC.
• Provide funding for surveillance, diagnosis, management, research, evaluation, and training.

Agencies under Department of Health and Human Services

• Administration for Children and Families (ACF):
  • $49 billion budget for 60 programs targeting children, youth, and families.
  • Includes assistance with welfare, child support enforcement, adoption assistance, foster care, childcare, and child abuse.
• Administration for Strategic Preparedness and Response (ASPR):
  • Focuses on preventing, preparing for, and responding to the adverse health effects of public health emergencies and disasters.
  • Includes preparedness planning and response and building federal emergency medical operational capabilities.
  • Provides support to augment state and local capabilities during an emergency or disaster.
• Agency for Healthcare Research and Quality (AHRQ):
  • Enhances the quality, appropriateness, and effectiveness of health care services and access to care by conducting and supporting research, demonstration projects, and evaluations; developing guidelines; and disseminating information on health care services and delivery systems.
  • Basically, the Health Services Research arm of HHS.
• Agency for Toxic Substances and Disease Registry (ATSDR):
  • Focuses on minimizing human health risks associated with exposure to hazardous substances.
  • Works with state and local agencies.
  • ATSDR was created as an advisory, nonregulatory agency by the Superfund legislation and was formally organized in 1985.
• Center for Medi-Care and Medi-Caid Studies (CMS):
  • Works in partnership with state governments to administer Medicaid, the Children's Health Insurance Program (CHIP), and health insurance portability standards.
• Centers for Disease Control and Prevention (CDC):
  • Focuses on disease control and prevention.
  • Includes infectious disease, foodborne pathogens, environmental health, occupational safety and health, health promotion, injury prevention, and educational activities.
  • Also conducts research and provides information on non-infectious diseases, such as obesity and diabetes.

Other Federal Agencies

• Food and Drug Administration (FDA)
• Health Resources and Services Administration (HRSA)
• Indian Health Service (IHS)
• National Institutes of Health (NIH)
• Substance Abuse and Mental Health Services Administration (SAMHSA)

State Public Health Agencies

• California Department of Health Care Services (DHCS): Finances and administers individual health care service delivery programs.
• California Department of Public Health:
  • Part of California HHS.
  • Enforces California health and safety laws.
  • Performs many functions similar to the CDC, but in California.

Local Health Departments

Services typically include:

• Adult health screening.
• HIV/AIDS testing and counseling.
• Communicable and infectious disease control.
• Immunizations; family planning.
• Children's services, including the Child Health and Disability Prevention program, physical exams, medical, nutrition, etc.
• Sexually transmitted diseases.
• Home nursing visits; tuberculosis.
• Women, Infants and Children (WIC) nutritional services; and vital statistics.
• Registration involving birth/death certificates and burial permits.

Mandated Local Health Department (LHD) Activities

• (Health assessment and epidemiology)
  • Processing of vital statistics – birth and death records
  • Receipt, tabulation, and analysis of reportable diseases and conditions
  • Assessment of the morbidity, mortality, and health risks of the population
• (Health prevention)
  • Immunization
  • Communicable disease control/Infectious disease investigation
  • Communicable disease outbreak response and control
  • Sexually transmitted diseases (STD)
  • Occupational health
  • Public health laboratory services
  • Tuberculosis Control
• (Health promotion)
  • Tobacco Education
  • Maternal and Child Health
  • CHDP
  • Public Health Nursing
  • Oral Health
  • Health Education
• (Health protection)
  • Inspection of food facilities (restaurants, kitchens, congregate settings, camps)
  • Environmental Health Inspections
  • Tattoo/Body Art regulation
  • Medical Marijuana
  • Other Controlled Substances
  • Tobacco Control and Prevention

Ten Essential Public Health Services

• Assess and monitor population health status, factors that influence health, and community needs and assets.
• Investigate, diagnose, and address health problems and hazards affecting the population.
• Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it.
• Strengthen, support, and mobilize communities and partnerships to improve health.
• Create, champion, and implement policies, plans, and laws that impact health.
• Utilize legal and regulatory actions designed to improve and protect the public’s health.
• Assure an effective system that enables equitable access to the individual services and care needed to be healthy.
• Build and support a diverse and skilled public health workforce.
• Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement.
• Build and maintain a strong organizational infrastructure for public health.

Factors Influencing Waiting Times

• Health of the population (sicker people mean more need for healthcare).
• Doctor/patient ratio (waiting times can actually be less in rural areas).
• Alternative treatments (e.g., hernia surgery vs. cancer treatments).
• Inefficiencies in the system.

Sectors of the Indian Healthcare System

• Public sector (Primary health centers, Subcenters, Community health centers, District hospitals and Medical colleges and hospitals)
• Private sector (Clinics and hospitals)
• Indigenous medicine (Ayurveda, Unani and Homeopathy)

Healthcare Statistics: U.S. vs. India

• Life expectancy in India is 67.24 years compared to 76.33 years in the U.S. (World Bank 2021).
• India is ranked 47th on the World Healthcare Index, while the U.S. is ranked 38th (World Healthcare Index 2024).
• Fertility rate in India is 2.03 births per woman, while in the U.S., it is 1.66 births per woman.
• Infant Mortality rate in India is 27.7 deaths per 1000 live births in 2022, while in the U.S., it is 5.6 deaths per 1000 live births in 2022.

Healthcare Expenditure: U.S. vs. India

• Healthcare spending per capita is $57 in India compared to $13,493 in the U.S.
• India spends 2.7% of its GDP on public health-related expenditure compared to almost 18% in the U.S.
• The size of the healthcare market in India is $370 billion in 2022, and in the U.S., it is $808 billion in 2022.

Healthcare Workforce: U.S. vs. India

• India has over 1.2 million doctors registered with the Indian Medical Council in 2021, compared to 1.06 million in the U.S.
• India has 1.34 physicians per 1000 population.
• The U.S. has 2.58 physicians per 1000 population.
• India has 1.7 nurses per 1000 people, which falls below the recommended level of 3 nurses per 1000 people.
• The U.S. has 11.7 nurses per 1000 people.

Challenges for the Indian Healthcare System

• Lack of reliability and accuracy of the electronic Health Management System for reporting of communicable diseases.
• Optional implementation of National Health Policy goals by states led to wide variations in the availability of healthcare services across the country.
• Poor government oversight of for-profit healthcare facilities in the implementation of government policies.
• Misuse of funds allocated for treating low-income patients at private hospitals through the Arogyasri Yojana.
• Falsification of records to claim government funds for providing coverage to low-income individuals by private medical insurance companies.
• Limited availability of accredited national laboratories that can carry out testing for complex and novel diseases.
• Affordability: Less than 40% of the population is covered by any type of health insurance arrangement.
• Only one-fifth of healthcare spending is covered by the government; the majority of costs are borne by the patient.
• Accessibility: 80% of healthcare experts reside in metropolitan regions. Rural residents have only 13% access to primary health centers, 33% to subcenters, and 9.6% to hospitals.
• Social norms: Perceptions of disease and care seeking affected by diverse beliefs and religious practice. Women often confined to home and dependent on male family members to access care.
• Fragmented healthcare system: Lack of care coordination between public and private healthcare providers. There is limited regulatory oversight over private healthcare providers.

Specialty Drugs

• high-cost, high complexity and/or high touch drugs
• Often biologics —"drugs derived from living cells“ - that are injectable or infused (although some are oral medications)
• Used to treat complex or rare chronic conditions such as cancer, rheumatoid arthritis, hemophilia, H.I.V., psoriasis, inflammatory bowel disease and hepatitis C.
• In 1990 there were 10 specialty drugs on the market, around five years later nearly 30, by 2008 200, and by 2015 300.
• Drugs can be defined as specialty because of their high price.
  • Medicare defines any drug with a negotiated price of $670 per month or more as a specialty drug.
  • Require a higher patient cost sharing

Specialty Drug Pricing

• Low volume, meaning that no other manufacturer is likely to produce it
• High need: While there may not be many people who need it, they have to have it
• Result: Opportunity for investors to buy up drug, jack up the price, and then make massive profits until either someone makes the drug or they are regulated

Opioid Crisis

• OxyContin [Purdue Pharma] initially marketed as a non-addictive pain reliever
• Was only approved by FDA for supposed “chronic pain if safer alternatives are not feasible” (on label) but was marketed to doctors as being good for all pain (off label)
• Became very common, widely prescribed for things like lower back pain (not on-label)
• Shipments soared, with pharmacies (CVS, RiteAid, etc.) having huge amounts of OxyContin moving through their pharmacies
• By early 2000’s it became apparent that
  • OxyContin was highly addictive
  • It was being overprescribed
  • Purdue Pharma had information to suggest that it was a problem but continued to market it
• Reaction:
  • Significant pressure to reduce use of OxyContin, but by then many people were addicted
  • Question: What do people do when they are addicted to a drug (OxyContin) that they can no longer get?
  • Answer: Turn to a similar drug – Heroin
• Fentanyl
  • 50 to 100 times more potent than morphine
  • Often mixed into heroin or cocaine to increase potency at a low cost
  • Change in racial composition of overdoses
  • Black Americans tend to consume cocaine more frequently than heroin or other prescription opioids compared to white populations
  • Increase in deaths is linked to the greater prevalence of fentanyl-laced cocaine.
  • Fentanyl and other simulants
  • Increase has primarily been observed in male populations from non-Hispanic American Indian, non-Hispanic Black, and non-Hispanic White populations

Stages of Drug Development

• Stages to drug development
  • Development of compounds
  • Randomized Controlled Clinical trials
    • Stage 1 – Safety
      • Often conducted with healthy volunteers
      • Single dose, small numbers, highly controlled
    • Stage 2 – Efficacy
      • Conducted with patients
      • Very controlled
      • Ideal circumstances
    • Stage 3 – Effectiveness
      • Use in real world settings
• Stage 4 – Cost effectiveness
• Brand drug price
  • Cost of drug manufacture + cost of development + marketing
• Generic drug price/ marginal price
  • Cost of drug manufacture
• Average drug price
  • Cost of drug manufacture + cost of development

On Patent Drugs

• 20-year patents for the drug during which the drug company can recover its costs
• After 20 years, any company can offer a ‘generic’

On Patent vs Off Patent Drugs

• When the drug is ‘on patent’:
  • Price charged = Average Cost (at least…might be more)
• When a drug is ‘off patent’ and facing generic drugs:
  • Price charged = Marginal Cost

Direct-to-Consumer Advertising (DTCA)

• Direct to consumer advertising is marketing of drugs aimed directly at the consumer rather than at the doctor
• Only the US (and New Zealand) permit such advertising
• Direct to consumer - 15% of total drug marketing budget

Pros and Cons of DTCA

• Pros: Encourages patients in poor health to talk to their doctors; physicians are not perfect agents
• Cons: Can lead to unnecessary spending on drugs

Direct-to-Doctor Advertising (DTDA)

• Direct to doctor – called “detailing” coming from drug rep visits to doctors, accounts for 85%
• Reason to focus on doctors? Principle agent relationship

Reasons for Advertising Drugs

• Information
  • Pro: Provides patients with information on the potential treatment for a condition that bothers them
  • Anti: You might not know a) what your problem is and b) whether this drug is what you need
  • Changing tastes
  • Pro: People may not be aware that a condition (such as bad breath) is something that others care about
  • Anti: Can make people care about problems that they would not have normally cared about
  • Exclude potential entrants
  • Pro: If Bayer is clearly better, then other companies will know that and thus not waste the time and money competing
  • Anti: Creates a monopoly, such as FaceBook buying up all competitors

Medicalization

• “Medicalisation is a process by which non-medical problems become defined and treated as medical problems, usually in terms of illness and disorders”
• The larger the population that is targeted, the more lucrative an advertising campaign will be
• In 1998, during an ad campaign for baldness (Propecia), a visit to US doctors increased by 79%

Medicalization vs. Lifestyle Drugs

• “Lifestyle drug”
  • took off in the 1990s with Prozac and Viagra
  • Drugs aimed at real conditions
• Medicalization
  • Drugs aimed at problems for which there are “acceptable” lifestyle alternative (Weight gain)
  • Drugs aimed at conditions that were not previously seen as health problems (E.g., menopause in older women, Hair loss for men)

How Patients Can Lower Their Doctor’s Bills

The patient should ask the following questions:

• Is the practice owned by a hospital or licensed as a surgical center? – Hospitals buy outpatient centers, and then charge hospital prices
• Will you refer me only to other physicians in my insurance network, or explain in advance why you can’t? – Out of network doctors are much more expense
• If I need blood work or radiology testing, can you send me to an in-network lab?
• Will there be charges for phone advice or filling out forms? Is there any annual practice fee?
• If I am hospitalized, will you be seeing me in the hospital? What is your coverage on weekends?
• How much will this test/surgery/exam cost?
• How will this test/surgery/exam change my treatment?
• Which blood tests are you ordering? Why an X-ray?
• Are their cheaper alternatives that are equally good, or nearly so?
• Where will this test/surgery/exam be performed – at the hospital, at a surgery center, or in the office? How does the place impact my prices?
• Who else will be involved in my treatment? Will I be getting a separate bill from another provider? Can you recommend someone in my insurance network?

How Patients Can Lower Their Hospital Bills

• Question why you have a private room – Many hospitals have an oversupply of rooms, and so will try to charge you for a private room
• “As long as the providers are in my network…”
  • In the documents you sign, see if there is one that says that you are willing to accept financial responsibility
  • If there is, write in this clause
• Are you being admitted or under ‘observational status’? – Admission is much more expensive, and hospitals can keep you for three days under observational status
• Ask identify of every unfamiliar person who appears at your bedside, what he/she is doing, and who sent them – Doctors who ‘stop by’ can charge you $100’s of dollars for a ‘consultation’
• If the hospital tries to send you home with equipment you don’t need, refuse it
• If you receive an outrageous bill from a hospital, don’t wait – negotiate
• When a hospital bill arrives, request complete itemization
• Check the bill against notes you made while you were in the hospital
• Protest bills in writing to create a record
• Argue against surprise out-of-network bills

Impact of Different Factors on the Future Demand for Doctors

• Supplier induced demand: Do physician reduce their services when payments go down?
  • Study in California found that physicians increased the intensity and quantity of services to Medicare beneficiaries in response to a freeze in program payment rates
  • However, other studies have found contrary results
• Do physicians families use less services than everyone else?
  • Their families use more
• Compare physician’s desired income with actual income
  • Results: The more below their desired level, the more they charged patients
• Health of the population:
  • Ageing population (increase)
  • Obesity rates (increase)
  • Rise in chronic illnesses (increase)
  • Things that kill people quickly (decrease) – COVID – Opioids
• Income/ health insurance coverage:
  • Increase - As a country gets wealthier, they use more healthcare
  • Neutral – The cost of medical care has risen faster than regular inflation, but most people only see this increase through premiums
  • Increase - ACA has means that more people have insurance and having insurance means you use more healthcare
• Advances in medical technology:
  • Diagnostic (increase)
  • Illness management (increase)
  • Curative interventions (increase)
  • Prevention (decrease)
  • System management (decrease)
  • Facilities and clinical management (decrease)
  • Organizational delivery structure (decrease)
• Changes in practice patterns
  • Allow to prescribe medications….?
    • Pharmacists?
    • Traditional healers?
    • Nurses?
    • People? (more over the counter)
  • Changes to the way practice is conducted…
    • More reliance on telehealth?
    • More drop in clinics?
    • Better on-line diagnostics and technology that people can use at home?
  • Reducing demand for going to the doctor… More use of promotores and other community health workers
• Job satisfaction
  • Burnout (decrease)
• Willingness for people to become and stay doctors? High
• Likelihood of increasing the supply for doctors via bigger medical schools? Low
• Likelihood of increasing the supply for doctors via more foreign trained doctors? Zero
• Likelihood of significant changes to the practice? High

Changes in Public Health Over Time

• ACA cuts meant initial large reductions in
  • Clinics
  • Since everyone would have insurance, don’t need clinics anymore
• Role of PH would be to direct people to FQHC

Instead: More ‘grant work’

• Prior to cuts: Counties would decide their priorities
• Example: Merced “Eye, Limb, and Life”
• After the cuts: More funding through specific grants
• Example: CDC puts out a call for PH departments to provide diabetes prevention

Pay Differences Between U.S. and Other Doctors

• United States – $316,000.
• Germany – $183,000.
• United Kingdom – $138,000.
• France – $98,000.
• Italy – $70,000.
• Spain – $57,000.
• Brazil – $47,000.
• Mexico – $12,000.

Reasons for Pay Differences

• US trained doctors debt from Medical School
  • Public schools - $167K$
  • Private schools - $190K$
• But…
  • Caribbean schools - $348,601$
  • Completion rate – 59%

Malpractice Claims

• Time to resolve claims – 4 to 5 years
• Cost of malpractice insurance to insurers
  • $6.5$ billion
    • $4.4$ billion in claims
    • $1.4$ billion in legal defense
    • $700$ billion in administration
    • .46% of all health spending
• Average of $11,150$ per doctor
• Healthcare is a ‘luxury’ good, so expect to pay more as your income goes up
  • But suggests:
    • Nurses nearly $8,000$ more
    • Physicians nearly $30,000$ more trend line
    • Specialists nearly $50,000$ more
• More expenses than other countries (medical schools and malpractice)
  • France and UK – Education is free
• Not the most significant contributor to health costs
  • Doctors salaries only 10% of all healthcare costs
  • Reduce all salaries by 10% would save you $26$ billion
  • Not much compared to overall healthcare costs
• Other areas are equally as important
• In readings, arguments for why Dr.’s aren’t paid too much. Includes
  • “Everyone in US gets paid more” = Dr.’s get more relative to everyone else
  • “Cost more to be a doctor” = True, but not THAT much more
  • “Risks” = Doctors can go to jail for cheating…but they monitor themselves
  • “Fewer doctors per capita” = True, but they work to keep it this way (barring foreign doctors”
  • “More specialists” = True…but that is because specialists make more!
  • “More rural doctors” = Just reflects the fact that places have to pay doctors more to live in rural areas
  • “US doctors work more” = True, but when you are paid on a fee for service (as opposed to salary) “more work” = “more money”

Key Terms

Deficit

• Deficit = Tax receipts – Federal Spending

Debt

• Debt = Accumulation of deficits from previous years + deficit from this year

Community Health Needs Assessment (CHNA)

• “a systematic process involving the community to identify and analyze community health needs”
• “process provides a way for communities to prioritize health needs, and to plan and act upon unmet community health needs”

Community Health Improvement Plan (CHIP)

• “outlines how to address community health needs and safety in a specific area”
• Process aims to help community members and health officials work together to set priorities, develop programs, and direct resources
• Note: Also a SHIP (State Health Improvement Plan)

Total cost

• The total amount that is spent on a service

Average cost

• The total expenditure divided by the number of people receiving the service

Marginal cost

• Cost of providing the service to an additional person

Opportunity cost

• “the loss of potential gain from other alternatives when one alternative is chosen”
• “the value of the next-highest-valued alternative use of that resource”
• Note:
  • Not a ‘cost’ as we have been using it, but rather a ‘forgone benefit’

Overhead costs

• Overhead costs are recurring expenses that a business incurs to operate but are not directly tied to producing goods or services. They are also known as indirect costs and include things like rent, utilities, insurance, and administrative salaries. These costs are necessary for a business to function but don't directly contribute to the manufacturing or service delivery process.

Micro/Resource Based Costing

• Information required on Economic Impact Statements
  • Public Health Agency only:
    • Total cost of a program = Developing and operating the program or regulation
  • Direct impact on providers
    • Cost to providers as a result of the program or regulation
    • Can be done when estimating the cost of a new program (scoping) or when evaluating an existing project (evaluation)

Defensive medicine

• Practice of recommending a diagnostic test or medical treatment that is not necessarily the best option for the patient, but an option that mainly serves the function to protect the physician against the patient as potential plaintiff.
• Doctors are afraid that they will get sued, so they order multiple tests even when they are certain they know what the diagnosis is.
• Estimate of $650$ billion annually from defensive medicine.

Malpractice

• It refers to not just ‘making a mistake” by a healthcare professional. There must be…:
  • Existence of a legal duty.
  • Breach of that duty.
  • Causal connection between the breach and injury.
  • Measurable harm from the injury.

Most Common Reasons for Malpractice:

• Misdiagnosis or delayed diagnosis
• Childbirth
• Failing to solicit a complete patient history indicative of possible complications
• Failing to apprise the patient of necessary preoperative procedures like not eating (to avoid aspiration)
• Neglecting vital signs
• Use of excessive anesthesia
• Using defective equipment
• Failed endotracheal intubation
• Lack of informed consent
• Doctors doing something without getting patient’s explicit permission
• Infection with superbugs like methicillin-resistant Staphylococcus aureus
• Medication errors
• Surgical errors

General Damages

• General damages are designed to compensate for the patient’s cost that they suffered. Common examples are:
  • loss of enjoyment of life caused by the medical defect
  • physical and mental pain and suffering
  • loss of future earning capacity because of the medical defect

Special Damages

• Special damages are designed to cover the patients’ expenses that they incurred because of medical malpractice. These can be past medical expenses, future medical bills and expenses

Punitive Damages

• In some cases, a patient may recover punitive damages if the doctor’s act was willful and malicious or the doctor knew or should have known that an injury will result. Punitive damages vary from state to state

Medical Misadventure

• Also known as Adverse events' or Iatrogenic injury
• Unintended injury or complication that results in temporary or permanent disability, including increased length of stay, caused by health management rather than the disease process

Efficacy

• How well a treatment works in the best circumstances (clinical trials)

Effectiveness

• How well it works in practice
• “Degree to which improvements in health now attainable are attained (Donabedian)
• Produced by healthcare, measured by improvements in health

Evidence Based Healthcare

• Focuses on the use of best practice (efficacy) and effectiveness (what works) to inform patient decisions

Quality Gap

• Difference between how well it should work and how well it actually works

Two Approaches to Looking at Errors

• The person approach: Focuses on the errors and violations of individuals. Remedial efforts directed at people at the ‘sharp end’.
• The system approach