383 Health Policy exam 2 Flashcards
1) Explain the “health care pyramid” which is exemplified by “the traditional National Health Service model in the United Kingdom.” As part of your answer, include how that model relates to the distribution of spending on health care. (exemplified?)
- Primary care involves common health problems and prevention measures that account for 80% to 90% of visits to a physician or caregiver. In the NHS the primary care level is virtually the exclusive domain of general practices and is half of all physicians.
- Secondary care involves problems that require more specialized clinical expertise such as hospital care for a patient with acute renal failure. Occupied by physicians in specialties such as general surgery. Provide care to hospitalized patients and usually work in hospital-based clinics and serve as consults for outpatient referrals from GPs.
- Tertiary care, which lies at the apex of the organizational pyramid, involves the management of rare disorders such as pituitary tumors and congenital malformations.
As a result of the pyramid even though in places like the UK where GPs (primary care) provide the majority of ambulatory care, expenditures on their services count for 10% of the NHS budget and its even lower in the US. Almost all industrialized nations devote a dominant share of healthcare resource to secondary and tertiary care. Minority of patients with severe conditions requiring secondary or tertiary care will command a much larger share of healthcare resources per capita than the majority of people with less dramatic healthcare needs. Gps servers as a middleman. Look into further.
- Tertiary care, which lies at the apex of the organizational pyramid, involves the management of rare disorders such as pituitary tumors and congenital malformations.
2) Toth identifies five “dimensions” of integration. Name and briefly explain three. For each, give examples of two countries at different levels of that dimension.
Primary/Secondary Care Integration: concerns the relationship between providers of primary and secondary care. Primary care provides procedures for most common illnesses and problems provided in consulting rooms of GPs. Secondary care is medical care of a specialized nature and is provided primarily in hospitals. In the integrated model is the close coordination that exists between primary and secondary care providers, as GPs and hospital specialists are affiliated with the same organization. vIn a separated model primary/secondary care are largely in disjointed spheres of activity. Primary and hospitals services are managed by different and independent entities. Qualifications for integrated system of care: majority of GPs work for organizations that also provide secondary care. Majority of hospital doctors are affiliated with organizations that also provide primary care.
National examples:
Greece have integrated systems.
Quasi integrated countries: UK, less integrated than Greece but GPs are not employees of public healthcare service and are self employed professionals contracted to the public health service. This creates a long-term bond between physicians and the public service but not comparable to employment relationship.
Gatekeeping mechanisms: relationships between patients, general practitioners, and specialists vary depending on the presence of formalized gatekeeping mechanisms. Gatekeeping is the principle by which access to specialist healthcare is possibly only via referral by general practitioners.
Mandatory Gatekeeping (UK)- GP is the patient’s primary contact with the health system, with an exception made for emergency cases for which citizens can go directly to the emergency room. GP therefore plays a role in sorting and filtering healthcare needs and refers to specialists.
Less Gatekeeping or None (US)- in the US gatekeeping mechanism is only implemented by some insurance plans, like HMOs. However, individuals are free to subscribe or to not subscribe to these insurance plans.
General practitioners: solo versus group practice: Manner in which general practitioners are organized. Two rival models with the first model, GPs practice separately each in their own consulting room which is referred to as solo practice. In the second model, GPS are associated (group practice), sharing common spaces and equipment and expresses a high degree of integration on the structural level. Solo practice is separated, and group is integrated.
The United States practices uses GPs in an associated form, which is most common in OECD countries.
Japan uses solo practitioners making them the minority and famously use this in their 10-minute doctor visits.
Patients Freedom of Choice for Providers:
Feature of the separate model is the ample freedom given to patients to choose the physician and the hospital that will provide healthcare services
In the integrated model- the patient’s freedom of choice is somewhat limited. Physician and hospital are identified and the
3) Toth identifies three main ways to pay physicians. Name and explain each, with some comments about the economic incentives that, according to Toth, they create.
Fee for service (FFS) method- requires each doctor to be paid in proportion to the type and quantity of services provided. Since each service is paid at a certain rate, the most productive or those who provide the services with the most profitable rates will be the ones who earn the most.
Capitation- system assumes that patients are attributed to a particular doctor, or to a group of professionals for a specific period of time. Logic of capitation provides that doctors are reward based on number of patients they care for regardless of how many treatments or type of care a patient receives taking into account age or health conditions of patient. It encourages professionals to buy up patients arriving at treating a huge number of patients. Invites doctors to seek user satisfaction while also preventing incentives to provide unnecessary care.
Fixed Salary- doctors to observe a certain working schedule, for which they are rewarded with a previously agreement amount regardless of both the number of patients and services actually provided. Discourages overproduction of medical services put does not reward productivity of the individual professional. Less attention to patients judgement and treat them wth less kindness/attention as they are not dependent on the number of patients.
4) In Chapter 5 Toth considers types of health care systems. One is Social Health Insurance (SHI) systems. Identify and explain three sources of variation within or among SHI systems, with examples of countries that he says fit the different variants.
Single sickness funds: operate in Hungary, Korea, Poland, and turkey, in these nations multiple funds are tried but later unified into one single fund that is unique for the whole country. Multiple sickness funds: multiple sickness funds exist in the country, in Japan there are more than 3,000 funds and in Germany more than 1000.
Funds: Freedom of Choice: freedom to choose or not choose the sickness fund from which to be assisted. Only exists in multi-fund nations such as in Belgium, Czechia, and Germany.
Risk adjustment mechanisms: in multi-fund countries, the presence or absence of risk compensation mechanism among insures is relevant. In Austria, Belgium, Germany, and Czechia a risk adjustment mechanism redistributes funds.
Occupational, Territorial, and Corporate Funds: only in multi-fund countries, where criteria is according to which workers are assigned to respective sickness funds. Membership of a fund is established on the basis of profession performed or place of residence. France has both professional and terrotirial funds. Czechia has 1 company fund and many employment funds
5) As Democrats sought to come together on a health insurance expansion approach in case they won the presidency in 2008, what was the “public option,” and what were its political advantages and disadvantages?
The Public Option is a government-run program as a voluntary alternative to private insurance. public option would pay hospitals, doctors, and other providers of care at the same low rates Medicare used. This would allow the public option to offer lower premiums than private carriers, which would respond by lowering their prices or giving up their customers to the new government plan. Either way, the end result would be cheaper, more affordable insurance.
Public option appealed to liberals who didn’t like how the Massachusetts-style reforms shunted so public option. Appealed to one other group: the top Democratic candidates, all of whom were eager to secure the backing of prominent liberals. many people into private insurance.
Public option appealed to liberals who didn’t like how the Massachusetts-style reforms shunted so many people into private insurance.
Public option appealed to liberals who didn’t like how the Massachusetts-style reforms shunted so many people into private insurance.
Politically, the public option promised to arouse opposition from industry groups, including not just insurers but also doctors and hospitals who saw a threat to their revenue streams.
Her finding was consistent with other polling, as well as the intuition from the Clinton veterans that threatening employer coverage was a political death wish.
6) Explain the relevant considerations about using “reconciliation” to pass a health care reform bill. What happened at the end?
Senate rules dictate that only certain kinds of fiscal legislation can go through reconciliation and the writer of these rules said healthcare legislation did not qualify. Furthermore, the powerful chair of the finance committee Daniel Moynihan has objections of his own. With both senators, Byrd and Moynihan objecting it failing to get a majority vote the reconciliation attempt was blocked.
Could also mean aca repeal of 2017 and ACA provisions
ITS ABOUT OBAMACARE OF 2010!!!!
One of the big GOP complaints about the Affordable Care Act had always been about the process. Republicans loved to say that Democrats had jammed it through Congress without due time for consideration and that the final vote on amendments took place under reconciliation rules, which required just fifty votes in the Senate. But the original Senate bill, which constituted the bulk of the final statute, had passed with sixty votes through regular order. Early versions of legislation were public for weeks before committee hearings, and no votes took place without formal, full CBO assessments. Lawmakers from both parties, as well as independent, outside analysts, had plenty of time to sort through the language and figure out what it actually meant.
The House would pass a reconciliation bill that left in place some of the law’s key elements, including funding for the Medicaid expansion. Over in the Senate, that was fine with McConnell but not with his own increasingly antsy conservative wing. At the insistence of Cruz, Rubio, and several allies, who were threatening to withhold their votes, the Senate amended its bill so that it would wipe out every dollar that had gone to helping people get health insurance. The House went along with the new, more ambitious version and sent it to the president.9
Obama vetoed the bill, as expected, but the exercise of passing the bill gave Republicans a template for future action, because it required rulings from the Senate parliamentarian over what was permissible under the rules of reconciliation.
7) Briefly explain three of the deals that were cut with individual senators to gain their support for the bill that passed the Senate.
Cornhusker kickback- Ben Nelson the most conservative democrat, former insurance lawyer, and last holdout was causing issues in the passage in the senate. Reid devised a deal where only Nebraska would be let off the hook for any new Medicaid expenses by having the federal government pick up the entire cost.
Louisiana Purchase- Louisiana Medicaid supplement by specifying that it would apply only to states in which every single county had been declared a federal disaster area in recent years. (Louisiana, because of Katrina, was the only state that met that criterion.) Mary Landrieu, of Louisiana, wanted more Medicaid funding for her state and blocked the bill until this happened.
Senator Bernie Sanders- Sanders’s big ask was for $10 billion in new funding for community health clinics, which cared for people who couldn’t afford to pay on their own. The $10 billion for clinics was still $10 billion Reid would not have for other uses, like subsidies. But it was $10 billion going directly to providers of care for people who needed it and not, for example, the medical device firms that Evan Bayh was so determined to protect. Reid signed off, and Sanders pledged his vote, with just one other condition—that he get a chance to introduce a single-payer amendment on the floor.
8) Explain, as best you can, the controversy over President Obama’s claim that, “if you like your health care plan, you’ll be able to keep your health care plan.” An explanation includes why he would say that, how it was and wasn’t true after the ACA passed, why the law wouldn’t simply guarantee that, and why nobody could have reliably promised that anyway.
Why Obama said this: Democrats wanted to distinguish the new plan from the 1993/94 effort by showing it would leave employer-sponsored coverage largely in place. “You can draw a straight line from the nervousness about losing your current insurance during the Clinton health debate to President Obama’s promise that you could keep your plans,”
Truth: The law had one other provision to protect people who already had insurance from paying more under the new system. Under a grandfather clause, insurers could keep policies that were already in place in March 2010, when the Affordable Care Act became law. They couldn’t sell the plans to new customers, but they could maintain them for existing customers who wanted to stick with them.
Not the truth: But reform was always going to have more profound effects on insurance for the small minority of people buying on their own, or what policy professionals call the “non-group” market. In fact, changing that insurance was one of reform’s major goals. It was here that insurers were charging higher premiums or denying coverage to people with preexisting conditions. And it was here that insurers sold policies with massive gaps that were difficult for consumers to spot until they were sick or injured, went to get care, and discovered their policies came up short.
Why it was likely impossible: But the non-group market was notoriously volatile. Lots of people buying insurance on their own did so for only a year or two, or just a few months. Then they would sign up for an employer policy, Medicaid, or some other type of insurance. Insurers, for their part, were constantly dropping and adding policies and making changes to the ones they had. “Turnover is so significant in the ordinary course of business,” law professor Timothy Jost noted in 2010, “that relatively few policies will remain grandfathered for any significant period of time. But they couldn’t make significant pricing changes, and they couldn’t take away benefits, either—which, given how frequently insurers modified those policies, meant that as many as two-thirds of plans would lose grandfather protection every year, according to the government’s own estimate.
9) Explain three of Cohn’s points about the lessons, or legacies, of his story.
- One of the Affordable Care Act’s legacies is the political one, which Republicans made clear in 2018 and 2020 every time they swore to protect people with preexisting conditions. Taking benefits away from people once they have them turns out to be nearly impossible, just as Bill Kristol predicted in his famous 1993 memo. Universal coverage does not yet exist in the U.S., but some of its principles now have wide acceptance. The boundaries of acceptable political conversation have changed, quite possibly forever.
- The Affordable Care Act’s other legacy is the human one. And it is not ambiguous at this point. One major literature review from 2020, taking into account some of the most important studies on the topic, concluded that “the Affordable Care Act generated substantial, widespread improvements in protecting Americans against the financial risks of illness.” That included fewer people racking up credit card debt or missing house payments; more people getting cancer screenings and maintenance care for their diabetes; and ultimately fewer people getting medical problems they could avoid. There’s evidence of other benefits too, like more freedom to start businesses or take part-time jobs because insurance no longer depends on having a big, generous employer. Not everybody is better off, and certainly not everybody feels better off. But the improvements are tangible and significant.
- Lesson: But some things about American politics haven’t changed and one of them is the ambivalent, conflicted feelings of the public. Americans have a strong bias toward the status quo, even when they don’t like it. On health care, they are wary of promises of new and better health insurance alternatives, especially when those come from a government that they still do not trust the way they did in the 1950s and 1960s. That reticence limited what Obama and his allies could accomplish, and it will surely limit the next generation of reformers, as well, quite possibly forcing them to make the very same kinds of compromises.
10) According to the Clancy and Fraser article, what are the three ways that public reports “have the potential to improve quality?” And what are three reasons why some of this alleged potential may not be so real? (Note: you do not need to mention one reason for each of the “ways”)
To Improve:
1. Public reports theoretically enable consumers to comparison shop for health, as they do for other products, selecting those with higher quality and/or lower cost.
2. Employers, health plans, and others who contract with providers of care can favor high-according organizations when creating networks of care and can educate their employees or plan members about the quality differences.
3. Public reports enable heath care providers to compare their performance with the performance of their peers. For reasons both professional and business related, providers do not want to be received poorly
Not so Real-
1. Consumers often are not in a position to choose between 2 providers. Their employer may offer only 1 health plan or their may restrict their choice of hospital/medical group.
2. Circumstances may not permit a choice. A patient suffering a heart attack cannot do research
3. Patients often rely on physicians for referrals are not accustomed to seeking information from public reports
or
The Measures- most information in public reports has not been developed in response to expressed consumer interest, but in response to what measure developers and report producers think should interest in consumers/patients
Competing reports: With policy interest in transparency growing and public reports on quality proliferating, confusion reigns regarding scores. The number of competing reports resulted in discrepancies.
Information overload: Consumers prefer to start with simple summary measures and icons and then drill down in accordance with their interests.
Clunky format: increasingly, consumers rely upon websites/social media for information. These venues support and link to sophisticated search engines where consumers can prioritize their own preferences. public reports lag behind the internet in essence.
12) Briefly explain why Studdert et al. conclude that their study of medical malpractice litigation contradicts claims that “frivolous litigation… is common and costly.”
Claims that lack evidence of error are not uncommon, but most are denied compen-
sation. The vast majority of expenditures go toward litigation over errors and payment of them. The overhead costs of malpractice litigation are exorbitant. One is that portraits of a malpractice system that is stricken with frivolous litigation are overblown. Although one third of the claims we examined did not involve errors, most of these went unpaid. The costs of defending against the were not trivial. Nevertheless, eliminating the claims that did not involve errors would have decreased the direct system costs by no more than 13 percent (excluding close calls) to 16 percent (including close calls). In other words, disputing and paying for errors account for the lion’s share of malpractice costs. A second conclusion is that the malpractice system performs reasonably well in its function of separating claims without merit from those with merit and compensating the latter. In a sense, our findings lend support to this view: three-quarters of the litigation outcomes were concordant with the merits of the claim
13) Christine Cassell and colleagues in 2014 identified two main problems with performance
measurement. Explain and give examples for each.
- Many observers fear that a proliferation of measures is leading to measurement fatigue without commensurate results. An analysis of 48 states and regional measure sets found that they included more than 500 different measures, with only 20% of which were used by more than 1 program, and similarly, measures overlapped little with measures used by public problems. Health care organizations are therefore devoting substantial resources to reporting their performance to regulators and payers. Too many measures
- Concern that programs are not using the correct measures. Some metrics capture health outcomes or process to have major effects on overall health but others focus on activities that may have minimal effects.
14) Explain the meaning and reasons for what White (citing others) calls “the demise of the
useful medical note.
The original purpose of a physician’s notes was to document to herself, for her own memory and reflection, what she needed to know about the patient. A note might report some test results, but a good note was a narrative that told the story of the patient’s illness. Now the physician is entering dozens or hundreds of clicks about topics that have been standardized either for purposes of billing (“we did this so you should pay us for it”), or “quality assurance” (“I asked if the patient feels safe at home, and I told them smoking is bad for them, which shows I’m providing quality care”), or to make the record something that can be used by everybody in the system (for “interoperability” and “integration”).
Much of this “note bloat” is because physicians, required to provide “complete” documentation but with limited time to enter it, “copy and paste” language from previous reports into the boxes. This is very helpful for physicians entering the data: “clinicians in the top quartile of copy and paste use were significantly less likely to report burnout.” Unfortunately, “copy and paste often leads to longer, less useful notes and potentially dangerous errors or miscommunication” – and is “independently associated with increased stress and burnout” among physicians who have to read the notes, “suggesting that a decrease in burnout for the note writer may be offset by an increase in the note reader. “the note as a means of communicating how the patient is doing has all but been destroyed” It should be obvious that increased communication of unhelpful information is not progress.
16) Explain the reasoning and likely importance of two of Warner’s “lessons from the antismoking campaign for controlling obesity.”
A principal implication is that education, exhortation, and the theme of individual responsibility cannot do it all, as they could not with tobacco. In particular, they are likely to have the least impact on those most burdened- the impoverished. More assertive public policy interventions will be needed, many possibly of a regulatory nature. Public health forces will need to develop multipronged and comprehensive strategies and remain for the long haul. In this battle, victories are tallied by a reduction in damage not by final conquest.
Some lessons from the clean indoor air movement do apply to the obesity epidemic. One can imagine a junk-food-free environmental by removing junk food from school.
Excise taxes can also be included here, junk food taxes coupled with a food program to encourage healthy eating (SNAPs for health food).
1) Lucie Michel tells a story about donuts and croissants. What is the story and what is the point?
In France, we are well known for our love of croissants and our long coffee breaks.
In each unit I visited, the break room was open to everybody. It was customary to sit
down to have coffee together—doctors, nurses, and other staff. Even if time is very limited, this is a setting where nurses’ assistants, secretaries, nurses, residents, and sometimes the attending physicians and fellows stop by to take a little break with each other. It is during these breaks that (for instance) a nurse in long term care liked to “take the temperature” of what happened the previous day while she was off. It is where the resident in
medicine comes to inquire about the family history of a lonely patient, and where nurse managers give informal feedback about the last institutional meeting. Those clinical professionals and their coworkers can share a place in which to laugh, chat, and express themselves freely. It is, I believe, a valuable resource for communication and team building. In the United States, I have yet to see anything like it. Of course, you sometimes find a big
bag of donuts a physician has offered to the team. But everyone tends ake the donuts and eat them in front of their screens, looking at Facebook while drinking a huge, very un-French coffee.
