Health Care Delivery Systems Flashcards
Over the past 30 years, there has been a shift from the illness model of disease treatment to the
wellness model of chronic disease prevention
4 means of healthcare financing
out of pocket, individual private insurance, employer sponsored private insurance, and government
What is the national distribution of health care expenditure?
private insurance> Medicare> Medicaid> out of pocket
Employer-sponsored insurance generally uses principles of__________ to control costs
managed care
Most are either HMO or PPO
An HMO is
a managed care insurance plan where the payer is accountable for both the cost and the quality of care within a closed system
A PPO is
mainly concerned about reducing the cost of care, creates a larger but still restrictive network of physicians who agree to a contracted rate before care delivery
Accountable care organizations (ACOs)
An evolution of HMO and PPO, ACOs are models of managed care that tie payment to cost control and quality of care, theoretically keeping health care providers more accountable for resource use and quality of care
Pharmacy benefit manager
If a healthcare insurer does not manage prescription benefits for its beneficiaries, a pharmacy benefit managers will separately administer the benefits, including formulary development, customer service, and pharmacy contracting
Trends in innovation in health care
growth in retail clinics, expansion of telemedicine and technology, and advances in personalized medicine
From the 1980s onward, the United States healthcare system focus has been
cost and quality
Premiums
The amount of money paid each month by the insured for the plan
Deductibles
Specified amounts of money that the insured must pay before an insurance company will pay a claim
What is the largest payer of healthcare in the United States?
Government-funded
What created Medicare and Medicaid?
When President Lyndon B Johnson signed the Social Security Amendments of 1965 into law
Medicare Part A
Hospital insurance
Helps cover the costs of inpatient hospital care, skilled nursing facility care, hospice, and home health care. For most people who choose part A, part B is required and premiums must be paid for both
Medicare Part B
Medical insurance
Helps cover the costs of doctors services, outpatient care, and some preventative services.
Preventative measures include the flu, hep B, and pneumococcal vaccines, durable medical equipment, diabetes screenings, etc
Medicare Part C
Medicare Advantage Plan
Coverage includes Medicare Parts A and B plus other coverage, which usually includes prescription drug costs
Medicare Part D
Prescription drug coverage
Operated by private insurance companies on behalf of medicare, like Medicare part C
Enrollment is optional
MTM
Individuals enrolled in Part D may qualify for MMS if they meet 3 criteria:
-have multiple chronic diseases
-take multiple drugs
-be likely to incur expenses that exceed a level specified by the Department of Health and Human Services
Only pharmacists and pharmacy interns can provide under part D
Medicaid eligible
Those classified as poor
Children
People with chronic disabilities
People suffering from HIV/AIDS
Managed care
An evolutionary concept reflecting a different approach to provision and reimbursement for healthcare services. It focuses on appropriate use of health care resources. The 2 main configurations of managed care are health maintenance organizations HMOs and preferred provider organizations PPOs.
Affordable Care Act (passed in 2010)
An individual mandate (requiring, under financial penalty, US citizens to purchase some form of health insurance.
Expansion of Medicaid
Creation of insurance exchanges (marketplaces for individuals to buy insurance)
Vertically integrated health systems
One large organization takes responsibility for the delivery of care across all levels of care.
Financed under HMO
Semi-integrated health system model
Health care providers are not employed under the same organization, but still coordinate their services to reduce costs and optimize care.
Physicians in this model join HMOs as part of networks, but will still see patients outside of the HMO
Nonintegrated health system model
Allow broader access to the multitude of physicians.
PPOs
What are the most common measures in pharmacoepidemiological studies?
Incidence and prevalence quantify the rate of disease
Mortality rates quantify the rate of death
Incidence rates
Incidence proportion- does not take into account the different times in which a given population is at risk. It is computed as the number of new cases within a specified period divided by the number of population initially at risk.
Incidence rate controls for the different times during which each population member is at risk. The need to control for the different time at risk exists because the population may lose or gain members
When is an incidence rat more appropriate?
When the time that each individual is at risk differs among the population
Prevalence rates
Prevalence is a measurement of the number of all individuals affected by a certain disease (existing as well as new cases) within a particular period.
Prevalence can be viewed as
A snapshot of the population at a point in time which all the members of a population are screened for the disease.
Prevalence rates do not control for
disease duration.
Chronic diseases last longer; thus, more chronic cases will accumulate over time than will acute cases.
Thus, chronic diseases have higher prevalence rates than acute diseases.
When are prevalence and incidence rates useful?
Prevalence is useful in chronic diseases
Incidence is useful in acute diseases
Mortality rate
The number of deaths in a given year, scaled to the size of that population.
Case series
May refer to a study of a single patient (case report) or a small group of patients (case series) who are experiencing a disease.
Purely descriptive and cannot be used to make inferences about the general population.
May lead to hypothesis formation.
Case control studies
Compare rates of exposure to risk factors for a specific condition between subjects who have that condition (cases) and subjects who do not have that condition (controls). The cases and control groups must come from similar populations.
Data is sorted into a 2x2 table and an odds ratio (OR) can be calculated to measure the associated between the exposure factor and the outcome.
OR
The ratio of the 2 odds, reported in case control
OR= (a/c)/ (b/d)
Measures the association between the exposure to a disease risk factor and the disease outcome.
OR >1, OR=1, OR<1
OR=1: No association between the risk factor and disease outcome.
OR >1: Those with the disease are more likely to have been exposed to the risk factors than those without the disease.
OR <1: Those with the disease are less likely to be exposed to the risk factor than those without the disease.
What is faster/more effective, a case control or cohort study??
Case control
What are case control studies best for?
The study of rare diseases because they guarantee a sufficient number of cases with the disease.
What are the issues with case control studies?
They are prone to bias
The main challenge is to identify the appropriate control group.
Cohort studies
Compare the risk of developing a disease between those who are exposed to a risk factor and those who are not exposed. A cohort is a group of people who share a common characteristic within a defined period.
The selection of a cohort is independent of the occurrence of the condition of interest.
Relative risk (RR) and absolute risk reduction (ARR)
Used in cohort studies
RR- a ratio of the risk of getting lung cancer in those who are exposed to smoking versus those who are not exposed.
ARR- the absolute difference in the risk of getting lung cancer in those not exposed to smoking and those who are exposed.
RR values
> 1= Those with the exposure are more likely to have the disease outcome.
=1: No outcome
<1= The exposure is protective against developing the disease.
ARR values
0= no association <0= the exposure indicates an increased risk. >0= exposure indicates an absolute decrease in risk
NNT
the number of patient who need to be treated during a time period to prevent the development of one outcome
2 types of surveillance systems
passive and active
Passive surveillance
Involves health care providers voluntary reporting of unwanted medication effects. Such reports are submitted voluntarily or by contract by pharma companies, consumer organizations, or regulatory authorities.
Active surveillance
Aims to obtain the most complete data possible on drug safety problems. It uses a meticulously planned process to capture comprehensive data on drug safety problems.
Include sentinel sites and registries
Sentinel sites
Type of active surveillance
A limited number of selected reporting sites, from which the information collected may be extended to the general population. Sentinel surveillance systems are useful because a rich source of data collected enables more accurate estimation of a risk than is available from passive surveillance programs
When are sentinel surveillance systems most effective?
For drugs that are used mainly in institutional settings such as hospitals, nursing homes, and hemodialysis centers.
Major weaknesses of sentinel surveillance programs
Selection bias, small numbers of patients, increased cost
Examples of passive surveillance
FAERS
Example of sentinal surveillance
National Poison Data System
What is a disease registry used for?
To estimate prevalence, incidence, and mortality rates for the specific disease population. It can also be used for case control studies.
Mankiw’s 10 principles of economic 3 categories of assumptions
First 4 relate to how people make decisions
Next 3 relate to how the economy works as a whole
Last 3 relate to how people connect.
Externality
An externality exists when an individual unintentionally benefits or is harmed by another individual consuming goods or service.
CDC recommending vaccines is positive externality.
Elasticity
Helps people interpret the percentage change in how pts are likely to respond.
>1- elastic
<1= inelastic (the consumers behavior is not responsive to change in price)
Rx drugs are relatively inelastic
Direct medical costs
lab tests, medications, ED visits, surgery
Indirect medical costs
lost productivity, lost wages, costs of premature death
Direct nonmedical costs
home health care, transportation, food, family care
Intangible costs
pain, suffering, lost leisure time, inconvenience
4 P’s of marketing
Product, price, promotion, place
Admissible
A term used to describe evidence that may be heard by a jury and considered by a judge or a jury in civil and criminal cases
Appeal
A request, usually made after a trial, asking another court to decide whether the trial court proceeding was conducted properly
Bail
The release of a person charged with an offense prior to trial date under specified financial or nonfinancial conditions designed to ensure the persons appearance in court when required
Bill
A draft version of a potential law presented to a legislature for consideration of amendments and enactment
Bond
A written agreement by which a person agrees to perform a certain act or abstain from performing an act that typically requires a sum of money to be held with the condition that failure to fulfill the obligation will result in the forfeiture of the money; the amount of money put up to guarantee the bond
Code
A collection of compendium of laws adopted by a state or nation; also referred to as code of law or legal code. For example, the US Code consolidates and codifies the general and permanent laws of the US by categories of subject matter.
Indictment
An official written statement charging a person with a crime, primarily for a felony
Interrogatories
A form of discovery where written questions are to be answered in writing and under oath. Interrogatories are submitted to a party in the case by the party seeking discovery.
Redress
A means of obtaining a remedy; compensation (as damages) for a wrong or loss
Tort
A wrongful act causing injury to the person, property, or reputation for which relief may be obtained in the form of damage. A tort is also a violation of a duty imposed by law, but it is not a crime and is tried in a civil court
The federal government regulates pharmacy and healthcare products through which 2 federal laws?
The Food, Drug, and Cosmetic Act (FDCA)- regulated by the FDA
Controlled Substance Act (CSA)- regulated by the DEA
6 types of law
statutory, case, civil, criminal, substantive, and procedural
Statutory law
Established by enactments of lawmaking bodies. Five principle types of statutory law are shown in descending order of authority (constitution, treaty or international agreement, statute, regulation, ordinance)
What is the highest level of law?
Constitution
Ordinances
Laws enacted by local lawmaking bodies such as city council or county commission.
Case law
Created by judicial decisions or rulings that provide ongoing contributions to the common law. A significant principle of case law is the doctrine known as stare decisis (to abide by decided cases)
A negligence based lawsuit requires the plaintiff to prove what 4 elements?
The pharmacist owed a duty to the patient
The act (error), or failure to act (omission), on the pharmacist breached the duty owed
The act (error), or failure to act (omission), but the pharmacist was the cause of the injury
The patient suffered actual injury or harm
Central tendency measures
mean, median, mode
A test result can be evaluated using which 4 measures of probability estimates?
sensitivity, specificity, predictive value positive, predictive value negative
For each parameter of interest, the investigator can compute 2 estimates:
the point estimate and an interval estimate
Null hypothesis
hypothesis to be tested. The null hypothesis is a statement presumed to be true in the study population.
Regression analysis
focuses on the assessment of the nature of the relationships with an ultimate objective of predicting or estimating the value of one variable given the value of another variable
Correlation analysis
Related to the strength of the relationships between two variables
Coefficient of determination
One way to evaluate a regression equation.
Describes the relative magnitude of the scatter of data points about the regression line. The coefficient of determination ranges from 0 to 1
Correlation coefficient
Sample estimate and population parameter designated as r.
Ranges from -1 to 1
Chi-square test
Most frequently used test when an investigator is working with frequency or count data and when the values are categorical
Nonparametric tests apply when
the data are merely rankings or classifications
Class intervals
A set of contiguous, nonoverlapping intervals used so that each observation in the data set belongs to one and only one interval. A commonly used rule of thumb is that one should have between 6 and 15 class intervals.
Variance
The variance measures the scatter of the observations about their mean. When computing the variance of a sample, one subtracts the mean from each observation in the set, squares the differences obtained, sums all squared differences, and divides the total by the number of values in the set minus 1.
Standard deviation
The unit for variance is squared. If the investigator wishes to use the same concept as the variance but express it in the original unit, a measure called standard deviation can be used. Standard deviation equals the square root of the variance.
Point estimate
A single value estimated to represent the corresponding population parameter`
Interval estimate
A range of values defined by two numerical values
Confidence interval for the population mean
Estimate 90, 95, and 99% CI
For example, in a study of patients’ punctuality for their appointments, a sample of 35 patients was found to be on average 17.2 minutes late for appointments with a standard deviation of 8 minutes. The 90% confidence interval for the population mean is calculated as [15, 19.4]. This confidence interval can be interpreted using the following practical interpretation: the investigators are 90% confident that the interval [15, 19.4] contains the population mean.
Type I error
When the null hypothesis is true but the statistical decision is to reject the null hypothesis
Type II error
When the null hypothesis is not true and the investigator accepts it as true
Scientific validity of trial designs
Systematic reviews and meta-analyses > RCT > Cohort > Case-control > Case series > Case report
4 principles of bioethics
autonomy, beneficence, nonmaleficence, justice
Autonomy
grounded in the fundamental duty of respect for persons. The foundation for the principle of autonomy is the ability of each person to make choices for him or herself.
Beneficence
the obligation to promote well-being of others
Nonmaleficence
Do no harm
Justice
Maintains that benefits, burdens, and resources should be distributed fairly and equitably
5 virtues of biomedical ethics
compassion, discernment, trustworthiness, integrity, and conscientiousness
Discernment
The ability to reach appropriate decisions without being unduly influenced or distracted by peripheral considerations, fears, personal preferences, or outside pressures.
Conscientious objection
the refusal to perform a service or provide a product on the grounds that doing so would violate ones moral integrity
What are the 3 prime questions in pt counseling?
What did the doctor tell you this medicine is for?
How did the doctor tell you to take this medicine?
What did the doctor tell you to expect?
Fogging
Acknowledging possible truth from someone while ignoring any implied judgments about oneself:
Patient: “$90! That’s outrageous! You’re trying to rip me off.”
Pharmacist: “Yes, this is an expensive medication. If you would like, I can call your doctor and discuss some less expensive alternatives.”
Being a broken record
Using calm repetition:
Patient: “The doctor wrote this; you have to fill it!”
Pharmacist: “I cannot fill this prescription as it is written.” (Repeated over and over.)
Using negative inquiry
Using negative inquiry: Actively prompting feedback to use the information while prompting the critic to be more assertive and less dependent on manipulative ploys:
Patient: “That is impossible! I can’t give myself an insulin shot.”
Pharmacist: “What is it about giving yourself an insulin shot that bothers you?”
Ethnocentrism
The belief that ones own culture is superior while expressing contempt for another culture
Stages in the transtheoretical model of change
Stage 1: Precontemplation Stage 2: Contemplation Stage 3: Preparation Stage 4: Action Stage 5: Maintenance
Primary, secondary, tertiary prevention
Primary- action before disease occurs
Secondary- action in early stages of disease
Tertiary- focuses on minimizing complications after an individual has been diagnosed and trying to maximize QOL
Medication possession ratio (MPR)
The most common metric used to measure medication adherence.
Determined by dividing the number of days for which a patient has medication and dividing this number by the total number of days the patient is being observed.
A value of >80% is considered good adherence
Dimensions of patient-centeredness
Biosychosocial perspective Patient-as-person dimension Sharing of power and responsibility Therapeutic alliance Doctor-as-person dimension
Strategies to facilitate openness
Listen
Acknowledge
Wonder
Collaborative working relationships model
Stage 0- professional awareness
Stage 1- professional recognition
Stage 2- exploration and trial
Stage 3- professional relationship expansion
Stage 4- commitment to collaborative working relationships
Theories of leadership
Trait theory
Behavioral theory
Situational theory
3 categories of tamper resistance required on medicaid hard copies
Copy resistant
Erasure or modification resistant
Counterfeit resistance
Med recs can ensure what “five rights”?
Right patient Right med Right route Right time Right dose
PDSA cycle
Plan
Do
Study
Act
Failure mode effect analysis
Establish severity
Establish an occurrence score
Establish a detection score
When these are established a risk priority number (RPN) can be established and can determine the effect of changes
Root cause analysis
Retrospective analysis of an undesirable event with the purpose of developing an action plan to prevent it from recurring.
