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PH719: Health Systems, Law and Policy > Final Exam > Flashcards

Final Exam Flashcards

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1
Q

What is insurance for?

A

Manage and redistribute financial risk of unexpected events

Manage trade offs that affect price (e.g. choice of provider, benefit package, cost split between sponsor and member)

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2
Q

History of US Healthcare

A

Out of pocket payment was the most common method, employers started offering insurance as a benefit during WWII

Cost/quality of healthcare skyrocketed as a result–> led to Medicare/Medicaid for people without jobs

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3
Q

Insurance Premium

A

The set amount the individual pays for health insurance every month even if you don’t use services (employer also contributes)

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4
Q

Insurance Deductible

A

The additional amount the individual pays for covered health care services before insurance starts to pay

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5
Q

Insurance Copayment

A

Fixed amount you pay for every health service you receive after you pay your deductible (i.e. $30 to see a dermatologist)

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6
Q

Co-Insurance

A

Percentage of costs you pay for after your deductible (i.e. being responsible for 20% of costs after deductible is met)

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7
Q

Affordable Care Act (ACA)

A

Medicaid coverage for everyone below 138% of the FPL

Health insurance exchanges for everyone above Medicaid eligibility threshold

Federal subsidies between 100-400% of FPL

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8
Q

Employer Sponsored Insurance

A

Federal tax policy subsidizes employer/employee- Used to collect, pool and redistribute money

Larger employers- effectively self-insured, risk pool is employees/dependents
Smaller employers- small carrier-based risk pools=high premiums

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9
Q

What are majority of bankruptcies in US caused by?

A

Inability to pay medical bills

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10
Q

Bronze Level Insurance

A

Lowest premium- highest cost sharing

Protects against catastrophic event, minimal coverage for routine care

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11
Q

Silver Level Insurance

A

Moderate premium- moderate cost sharing, tax credits based on 2nd lowest sliver plan

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12
Q

Gold Level Insurance

A

Lowest cost sharing- better deal for those expecting to use significant amount of care

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13
Q

Platinum Level Insurance

A

Highest premium, lowest cost sharing

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14
Q

Tax Cuts and Jobs Act of 2017

A

Trump’s approach to the ACA- made tax penalty for not having health insurance under the ACA $0

Key parts of the campaign- repeal ACA and replace it with something better (but it never happened)

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15
Q

California v Texas

A

Claimed Tax Cuts and Jobs Act rendered entire ACA unconstitutional

DOJ took many positions, key questions about “severability”, ended litigation for lack of standing

Standing- you have to be an aggrieved party to sue, argue that this doesn’t apply

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16
Q

Medicare

A

Eligibility- 65 and over or under 65 w/ permanent disabilities

2 yr waiting period for Social Security Disability Insurance & Medicare

No waiting period End-stage renal disease (ESRD) or ALS

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17
Q

Benefits of Medicare

A
  1. Providing insurance for people you least want in insurance pools (makes it more expensive for everyone else)
  2. Takes burden off of people would would have to care for family members
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18
Q

History of Medicare

A

AMA- dominant force in preventing major health form (“socialized medicine”)

Old Age and Survivors Insurance (OASI) strategy
1) Focus on elderly- political appeal, needy/deserving
2) Build on existing social security system
3) Restrict scope of benefits- move away from total health system reform and just focus on protecting the elderly

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19
Q

Medicare Part A- Hospital Insurance

A

Includes hospital care, skilled nursing, hospice and some home health care

$400/mo without work history, free if you or your spouse have 10 min years paying into SS from work

Long-term care: all costs out of pocket after day 101, doesn’t cover “unskilled” nursing home residency

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20
Q

Medicare Part B

A

Covers MD visits, preventative care, medical devices, ambulance, outpatient care and some home care (technically optional, most opt in)

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21
Q

Medicare Part C

A

Medicare advantage- private alt. to Parts A/B added later, broader benefits (dental, fitness, eye, prescription drugs)

  • Feds negotiate premium w/ private plan sponsors, individuals still pay part of premium
    -Higher cost for federal gov.
    -Elderly can forgo A &B for Medicare Advantage
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22
Q

Medicare Part D

A

Prescription drugs- Passed during Medicare Modernization Act of 2003

Run by private companies/no public option

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23
Q

Donut Hole

A

Original design of Part D created gap for prescription drug coverage

Catastrophic coverage threshold- Once initial limit is reached, beneficiary pays full cost until out-of-pocket costs reach a certain amount ($4750)

*Eliminated w/ recent policy changes

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24
Q

Medicare Coverage Limitations

A

1) high deductibles & cost sharing
2) no limit of out of pocket spending (A&B)
3) doesn’t cover long term care, dental, eyes, hearing aids

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25
Q

Medigap Insurance

A

Sold by private companies to fill gaps in Medicare coverage

Can pay remaining costs (copayments, coinsurance, deductibles), coverage outside of US, services not included in Medicare

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26
Q

Medicare Trust Fund

A

Hospital insurance trust fund financed through payroll taxes on earnings/income taxes on SS benefits (Part A)

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27
Q

Medicare Drug Provisions of Inflation Reduction Act

A

Feds can negotiate price of certain drugs in Medicare program- pick 10 drugs a year

Change Medicare Part D- get rid of paying 5% on catastrophic cost after $3250

Flaws:
1) Will take a long time to take effect (gives insurance a long time to figure out how to fight this/new president can roll it back)
2) 10 drugs a year is minimal- pharma can increase costs of drugs not picked

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28
Q

Great Social Policy Divide

A

Universal benefits vs particularistic benefits

Universal benefits everyone- inherently popular, seen as earned
Programs benefiting select people aren’t popular- seen as indigent (e.g. Medicaid)

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29
Q

Medicaid

A

Provides health coverage (all kinds of care) for the poor- jointly administered by the states and the federal government (mostly the feds, states cover the rest)

Long term institutional/community care for poor, elderly

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30
Q

Medicaid Eligibility

A

Low income (defined by each state), mostly children, pregnant women and sometimes parents

Low-income elderly/disabled often dual-eligible for things that Medicare won’t cover

Low-income adults w/o dependents in some states (post-ACA)

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31
Q

Federal Medical Assistance Percentage (FMAP)

A

Federal share of Medicaid payment varies by state

Formula relies on state per capita income (poorer states pay for less/richer states pay more), states report Medicaid costs & fed gov matches costs for each state- Lowest federal rate is 50%

Feds pay costs, but states manage as they see fit (while following basic requirements)

Poor southern states are hesitant to accept free $ for Medicaid expansion partly bc they benefit from FMAP

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32
Q

FMAP Requirements

A

Most provide certain benefits to certain populations
Services- physician, hospital, nursing home care
Populations- children and pregnant women

Feds will cover optional services (dental care) for optional groups (poor adults, elderly w/ massive medical costs)

ACA complicates basic requirements

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33
Q

CHIP

A

Medicaid offshoot for children- includes poor children in families that earn too much for Medicaid popular

Comprehensive coverage- free well child visits, copayments for other services

Refunding sometimes an issue, but quickly resolved bc politicians fear retribution

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34
Q

Medicaid Politics

A

Popular but contentious
1) Takes up large portion of state budgets
2) Provides for a group not historically seen as deserving (this is changing)
3) Concern that requirements are too prescriptive- can’t act in best interest of the state
4) Doesn’t pay well- many doctors don’t want to see Medicaid patients

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35
Q

Medicaid Waiver

A

Section 1115 of SS Act allowed federal government to waive provisions of major health programs (e.g. Medicaid)

States apply for them to try projects to improve Medicaid- ideal outcome would be program works and feds could change law nationally to improve Medicaid for everyone

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36
Q

ACA Medicaid Changes

A

Biggest change to Medicaid- mandated that all states expand Medicaid to 138% of FPL

Feds cover 100% of new costs for first 3 years and 90% moving forward

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37
Q

NFIB v Sebelius

A

Holding- most of ACA is constitutional except for Medicaid expansion

Deemed coercive under Dole Test- requiring states to expand or risk losing matching funds for former beneficiaries

Results: some states expanded or opposed expansion for political/economic reasons=coverage gap (people in-between get screwed bc not eligible for either program)

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38
Q

Gresham v Azar

A

Trump HHS pushed a work requirement for Medicaid

  1. Objective of Medicaid must be prioritized
  2. HHS waiver approvals are arbitrary/capricious
  3. Concerns over loss of coverage

Case blocked attempt to roll back Medicaid eligibility- if it leads to less people enrolling, it’s not doing what Medicaid aims to do

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39
Q

Block Grant Argument

A

Conservative states- federal rules are too limiting, want funds as block grants bc they know better how to distribute funds

Would eliminate waste and allow states to innovate

Opposition- what if a recession hits and block grants are too small? Allows states to make programs more meager

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40
Q

Harris v McRae

A

Does the Hyde amendment contradict liberty/equal protection as part of the Due Process Clause of the 5th amendment by denying public funding for abortions?

Should states be required to fund the cost of medically necessary abortions when federal reimbursement is unavailable under Title XIX?

Ruling: violates liberty interest, financial need isn’t a suspect class

Essentially gov doesn’t need to remove obstacles to freedom of choice that it didn’t create ) :

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41
Q

Hyde Amendment

A

Restricts abortion funding under other health programs (Medicaid) funded through HHS

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42
Q

Health Care Provider Examples

A

1) Hospitals and outpatient centers (e.g. Academic medical centers, community hospitals, safety net providers)
2) Physicians (e.g. primary care, specialists)
3) Other providers (e.g. nurses, PAs, home health aids)

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43
Q

Health Care Purchaser Examples

A

1) Employers- choose which insurance plans to offer their employees
2) Patients- choose private plans, eligible for public plans, or uninsured

44
Q

HMO v PPO

A

Health Maintenance Organization (HMO)- lower cost, less flexibility

Preferred Provider Organization (PPO)- higher cost, higher flexibility

45
Q

How is money spent to deliver care?

A

1) By governments and insurers
-directly to providers on behalf of patients/for facility fees, indirectly through taxes
-to intermediaries enrolling members/negotiating with providers
-to individuals paying out of pocket and need reimbursements

2) By individuals
-Deductibles, copayments, coinsurance, out of pocket to providers
-Premiums to insurers

46
Q

Fee for Service (FFS)

A

Payer pays provider for each individual service provided to payer’s member based on negotiated price for each service (Or has fee schedule under Medicare)

47
Q

Alternative Payment Methodologies (APMs)

A

Alternative payment structure agreed upon through payer-provider contract that financially incentivizes efficiency

(e.g. global/capitation risk budgets, bundled or episode-based payments, pay for performance)

48
Q

What factors contribute to medical spending?

A

Medical spending=price x utilization

1) Prices- spending goes up if prices increase
2) Utilization- spending does up if patients use more services
3) Service mix- spending goes up if patients use more $$ services (e.g. Surgery vs PT, MRI vs X-Ray)
4) Provider mix- spending goes up if patients choose more $$ hospital over less $$ hospital

49
Q

Major Hospital Ownership Changes

A

1) Governed by Board or Board of free-standing leaders instead of free-standing independent
2) Doctors in private practice
3) Multi-hospital systems employing physicians in community settings, owning/operating dispersed outpatient or imaging facilities

50
Q

Key Payment Terms: Charge

A

Amount set by hospital, not usually what they get paid

51
Q

Key Payment Terms: Price/Reimbursement

A

Payer- what they pay the hospital, own negotiated rate varies
Patient- what it costs them out of pocket

52
Q

Key Payment Terms: Cost

A

Resources needed to provide a service, inputs, fixed and variable
(consumers and hospitals often have no idea, not a constant)

53
Q

Hospital Consolidation Pros

A

1) Costs can do down- purchasing power
2) Quality will improve- tech improvements, coordinated care
3) Access- long term stability, patient trust due to name recognition

54
Q

Hospital Consolidation Cons

A

1) Lower cost- more likely to close, smaller/weaker/non teaching hospitals, risk of price hikes
2) Quality could go down- improvements aren’t guaranteed/clear cut
3) Access- rural/inner city more likely to close

55
Q

Pay for Performance

A

Based on bonuses and penalties- hospital is evaluated for each program using hospital data compared to what would be expected for a hospital with a similar patient-mix

56
Q

How is the ACA changing hospital payment?

A

-Medicare: P4P for readmissions/value/complications, some hospitals in ACOs, bundled payments
-Loss of funding for uninsured/vulnerable populations due to Medicaid shift
-Medicaid expansion increased % of insured people
-Exchange plans may not cover all hospitals

57
Q

No Surprises Act of 2020

A

Patients pay what they would have if care had been performed in network (other than ambulances)

Situation 1) emergencies
Situation 2) Non-emergencies where patients are treated at in-network hospitals but receive care for out of network ancillary providers

58
Q

Ambulatory/Outpatient Care Structure

A

1) Physician offices
2) Hospital outpatient/ambulatory centers (diagnostic, therapy, surgery)
3) Free standing centers (CHCs, retail mini-minute clinics, surgical centers, imaging centers)

59
Q

Community Health Centers

A

Safety-net centers for low-income, uninsured patients, sliding scale payment based on income

Comprehensive medical, dental, support

60
Q

Patient Centered Medical Home

A

Team based delivery model- providing continuous medical care to meet patient needs

Patient-centered, coordinated care, accessible service, quality, safety

61
Q

Non-Medicare ACA Changes to Primary Care

A

1) Increase workforce (increased training slots, increased national health service corps, loan forgiveness

2) Increased % insured and removing cost sharing for preventative care

3) More $$ to Federally Funded Community Health Center (CHC)

4) Increased Medicaid reimbursement for PC visits

62
Q

Patients v Consumers

A

Patients:
-Goal- prevent hard, protect health
-Assumes unequal knowledge and skill
-Fiduciary duty on providers
-Resource use based on need

Consumers
-Goal: permit voluntary choices
-Assume equal bargaining positions
-No fiduciary duty of seller to buyer
-Entitlement to goods

63
Q

Patient Rights

A
  1. Reasonable care by providers
  2. Informed, voluntary choice of medical care
  3. Medical care
  4. Right to refuse treatment (Jacobson v MA)
64
Q

Tort Liability

A

Includes:
1) Allocation: Responsibility for injury
2) Compensation to injured party
3) Prevention of harm (deterrence, incentive to prevent risks/improve quality)

65
Q

Battery

A

Intention and offensive touching without consent (e.g. operating on wrong part of the body, adding a surgical procedure not previously agreed to)

66
Q

Negligence

A

Failure to perform duty of care- causing harm to the person receiving services

67
Q

Types of Negligence

A

Ordinary negligence- informed consent
Professional negligence- malpractice
Breach of confidentiality

68
Q

Plaintiff must provide which 4 points when proving negligence?

A

1) Defendant had a duty of care to the plaintiff to act reasonably (Duty)
Duty of reasonable care for malpractice, duty of disclosure for informed consent

2) Defendant breached that duty by not acting with reasonable care (Breach)

3) Plaintiff suffered actual injury (Harm/injury)

4) Defendant’s breath of duty was the proximate cause the plaintiff’s injury (Causation)

69
Q

What is the goal of informed consent?

A

Give patients opportunity to make autonomous choices

Creates minimum conditions for making a medical choice possible

70
Q

Health Care Practitioner’s Duty and Standard of Care

A

1) Duty to exercise same degree of knowledge/skill that a competent practitioner would exercise in similar circumstances
2) Duty of care is a legal principle
3) Standard of care- duty of care is constant, but standard of care varies based on case/circumstances

71
Q

Malpractice Examples

A

Failure in:
Diagnosis- failure, delayed or incorrect diagnosis

Treatment recommendation- incorrect recommendation, failure to refer

Performance- incorrect performance of prescribed therapy

Follow-Up- failure to monitor, follow-up, incorrect follow up

72
Q

Cobbs v Grant

A

Ulcer surgery leads to many other medical problems (spleen injury, subsequent ulcer, hospitalization, etc.)

Charged with medical malpractice

Jury reversed judgement to focus on negligence and not battery- requirement to share potential risks and complications

73
Q

Scope of Duty to Disclose

A

1) Full and complete disclosure
2) What doctors in good standing would disclose
3) Information for the decision the patient has to make (patient-centered decision)
4) What the doctor determines should be disclosed at that time

74
Q

What must be disclosed?

A

1) Patient’s medical condition/risks of going w/o treatment

2) Recommended treatments
a) Potential benefits and probability of success
b) Risks/Complications
c) potential benefits/risks of alternative
treatments

IN LAY TERMS

75
Q

Sine v Vega

A

Implied consent in emergency situations where patient/family member can’t consent

Competent patient’s refusal to consent can’t be overridden just bc the patient is in a life-threatening position

76
Q

4 C’s of Competent

A

1) Conscious
2) Comprehends relevant info (medical condition, treatment options)
3) Chooses- capable of making an affirmative decision
4) Communicates a decision

77
Q

Children Patient Rights

A

Parents have duty to provide necessary medical care to patients

Some minors can consent to their own medical care- emancipated minors, mature minors

78
Q

Rights for Incompetent Adults

A

Same rights as competent adults, just exercised by rep.
-Informal- knowledgeable family member
-Formal- health care proxy, legally appointed guardian

“Substituted judgement”- be voice of the patients and make decision the patient would want

79
Q

Cruzan v Director, Missouri Dept. of Health

A

Car crash, parents wanted life-sustaining treatment withdrawn
No clear and convincing evidence about withdrawal of treatment in a life or death situation

Court ruling- MO has a clear interest in keeping its residents alive

80
Q

Washington v Glucksberg

A

Is Washington’s prohibition against causing/aiding a suicide a violation of the 14th amendment?

Holding- banning physician-assisted suicide doesn’t violate Due Process Clause of the 14th amendment

81
Q

Justifications for Research on Human Subjects

A

-Some scientific questions can’t be answered w/o testing in humans
-Study design is scientifically sound
-Subject selection is based on justice and relevant to research question
-Risk to subjects is reasonable/minimized
-Subjects participate w/ voluntary, informed consent

82
Q

Info Necessary for Informed Consent Research

A

-Study purpose, design, and procedures
-Interventions, standards of care
-Nature of investigational intervention
-Anticipated benefits/risks
-Subjects can withdraw at any time
-Care/compensation in case of injury

83
Q

Researchers v Physicians

A

Duty: properly conduct research v quasi-fiduciary duty to patient

Confidentiality: No duty v active duty

Intervention: Prescribed by research protocol v patient need

Consent: Must obtain in writing v not required

Goal: Obtain valid results v successful treatment chosen by patient

84
Q

International Bill of Rights

A
  1. Universal Declaration of Human Rights
  2. International Covenant on Economic, Social and Cultural Rights
  3. International Covenant on Civil and Political Rights

*US hasn’t signed and ratified all of them

85
Q

Universal Declaration of Human Rights

A

All human beings are born free and equal to dignity and rights….

-No cruel treatment
-No arbitrary interference
-Right to standard of living adequate for health (food, clothing, shelter)

86
Q

International Covenant on Economic, Social and Cultural Rights

A

Equal gender rights, right to work, fair wages, right to SS, right to education, etc.

87
Q

Factors Impacting Health Systems

A

-Form of gov
-Population demographic, homogeneity
-Geography (large v small country)
-History
-Ideology
-Culture
-Economic prosperity
-Local burden of disease

88
Q

Goals Across Health Systems

A

Access and quality of care, sustainable costs

89
Q

4 Methods of Health Care Finance

A

1) Out of pocket
2) Individual private health insurance plans
3) Employer sponsored health insurance
4) Public insurance- gov pays for insurance

90
Q

2 Methods of Care Delivery

A

Private providers- Canada, Germany, Japan
Public providers- UK

91
Q

GINI Index

A

Measures degree of inequality in the distribution of family income in country
Scale of 0 (perfect equality)-100 (perfect inequality)

92
Q

Beveridge Model

A

National Health Service- Care provided to all citizens through tax payments (Socialized medicine), gov. controls all aspects of the system

E.g. UK, Cuba

93
Q

Bismark Model

A

Social insurance w/ competing plans- jointly financed by employers and employees, doctors/hospitals tend to be private

E.g. Germany, Japan

94
Q

National Health Insurance

A

Publicly funded, privately delivered

E.g. Canada, Medicare in the US, India

95
Q

Germany- Health Care History

A

Health and other benefits tied to employment- people pay for insurance through taxes in addition to companies

Public coverage covers everything including those not working

Health insurance is mandatory

96
Q

Canada- Health Care History

A

Path of voluntary employment-based health insurance, universal coverage is recent

Canada Health Act- care will be universal, comprehensive, accessible, publicly administered, portable

Long wait times, drugs/eyeglasses covered by private insurance

97
Q

UK- Health Care History

A

Socialized medicine
Pros: Costs are low, happy people, better health outcomes
Cons: Doctors not paid as well, less nice hospitals, longer wait times

98
Q

Prevention

A

Aimed at reducing incidence of disease/disability or slowing the progression and exacerbation of illnesses

99
Q

Primary Level Prevention

A

Focus on preventing disease, promoting better standard of living (and save $$)

E.g. immunizations, physical activity, better wages, seatbelts, fluoridated water

100
Q

Secondary Level Prevention

A

Focus on identify/reduce incidence of illness in population, focus on high risk individuals

E.g. hypertension screening/treatment, smoking cessation programs

Rarely cost saving, maybe cost effective

101
Q

Tertiary Level Prevention

A

Focus on maintaining function/soften impact of ongoing illness

E.g. long term disease management, rehabilitation (mode of transport for trauma patients)

102
Q

Cost Saving

A

Cost of prevention is less than cost of treatment

103
Q

Cost effective

A

Doesn’t save $ in medical treatment, but there is significant benefit to population or individual for cost of prevention

104
Q

4 Categories of ACA Mandated Coverage for Preventative Services

A

1) Evidence-based screenings and counseling
2) Routine immunizations
3) Childhood preventative services (e.g. autism screening, blood screenings)
4) Preventative services for women (e.g. birth control, STD screening)

105
Q

Braidwood Management Inc v Becerra

A

Christian owned businesses and individuals argue that USPSTF is unconstitutional, requirements to cover PrEP violates RFRA

Argued that USPSTF officers not nominated my president

Being appealed to 5th Circuit Court of Appeals

PH719: Health Systems, Law and Policy (1 decks)

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