Health Systems and Policy

Question 1

Health Systems

In various cases, including psychologists’ predictions as to the likelihood of parole violations and a computer’s reading of EKGs to identify heart attacks, which is more accurate, statistical analysis or human analysis?

Answer 1

Statistical analysis every time.

Humans are too swayed by personal histories, recent experiences, improper weighing of certain factors, the order in which we see things, etc.

Question 2

Health Systems

Dr. Gawande cites a Swedish EKG study in which a computer was pitted against a top cardiologist in identifying heart attacks. Who won?

Answer 2

The computer was accurate in 20% more cases than the cardiologist.

Question 3

Health Systems

What thought experiment explains the uncertainty in analyzing patients and the potential failure of relying solely on statistical analysis?

Answer 3

The broken-leg thought experiment

(Statistical analysis can be done to predict whether you will be jogging next Thursday night. But, if I have the information that you have a broken leg, that one piece of random information tells me that you will 100% not be jogging, and so I can beat the machine every time.
Basically, the world is too complex for even statistical analysis to predict everything because even just one missing fact can throw everything off)

Question 4

Health Systems

What is special about the Shouldice hernia clinic in Toronto?

Answer 4

All they do are hernias. They are quick (30-40 minutes instead of 1-1.5 hours). They are efficient (1% of cases have recurrences compared with 10-15% at most clinics). They have no training as general surgeons. They simply overspecialized in one single type of surgery, and so they have achieved a machine-like level of efficiency.

So, the question is, are all the years of medical school and residency really necessary to produce high-quality physicians?

Question 5

Health Systems

Can we have both highly perfected, safe medicine and the ability to train new physicians at the same time?

Answer 5

No, residents need to learn. Mistakes will be made as they follow the learning curve.

In this case, the patients’ well-being falls secondary to society’s need to train capable physicians.

Question 6

Health Systems

How do academic hospitals try to correct for physician error?

Answer 6

Holding legally protected Morbidity and Mortality meetings once a week to recap all the issues and try to correct mistakes for future cases.

Question 7

Health Systems

What is a valid reason to resist the automatization of medicine?

Answer 7

Patients too often feel like just numbers as it is. Making the system more impersonal is a risk we face.

However, medical errors are far more severely damaging than the risk of a patient not feeling loved enough.

Question 8

Health Systems

Are malpractice cases concentrated in a small subset of inept physicians?

Answer 8

No, they follow a bell curve distribution among all physicians.

Question 9

Health Systems

How often does the average physician face malpractice litigation?

Answer 9

Most physicians (especially surgeons) are sued at least once during their careers.

Question 10

Health Systems

Do all mismanaged patients sue?

Are all lawsuits legitimate?

(According to Dr. Troyan Brennan)

Answer 10

Less than 2% of patients that receive substandard care will sue.

Only a small minority of those patients have legitimate claims.

Question 11

Health Systems

What is the principle factor predicting a patient’s likelihood of winning a malpractice case?

Answer 11

How poor their outcomes were

Regardless of whether it was caused by disease or unavoidable risks of care)

Question 12

Health Systems

What did Carl Schneider (Professor of law and medicine at the University of Michigan) find in relation so what patients want from a physician?

Answer 12

Competence and kindness

Question 13

Health Systems

Can the likelihood of what procedure you will be offered vary by city?

Answer 13

Yes.
270% for cholecystectomies
450% for hip replacements
880% for ICU end-of-life care

Question 14

Health Systems

Even though our brains are not wired for long-term statistical analysis, what are our brains geared to do?

Answer 14

Quick pattern recognition

Question 15

Health Systems

In what situations is it appropriate for physicians to take over the decision-making process for a patient.

Answer 15

If asked to do so by the patient.

Patients are often times very ill, despondent, shattered, and scared.
Making the call between two difficult choices brings responsibility and guilt for the outcomes.
Doctors can handle that. Patients won’t always be prepared in that way.

Question 16

Health Systems

Do patients want to make every decision themselves?

Answer 16

No.

64% report of surveyed individuals that if they had cancer, they would make there own choices; however, only 12% of newly diagnosed cancer patients actually want to do so.

Question 17

Health Systems

In studies comparing causes of death during autopsy, were many treatable misdiagnoses found?

Answer 17

Yes. Even after CT, ultrasound, nuclear scanning, and other technologies have become widely available, physicians still miss the following on average (In patients that end up dying of these conditions):

25% of fatal infections
33% of heart attacks
almost 66% of pulmonary emboli

Question 18

Health Systems

How much has the rate of misdiagnoses found during autopsy decreased since 1938?

(The number was about 40%)

Answer 18

It hasn’t. We still misdiagnose causes of death just as often.

Question 19

Health Systems

Why do physicians misdiagnose?

Answer 19

They fail to include the correct diagnosis in their differential.

Question 20

Health Systems

What did Gorovitz and MacIntyre (philosophers) say are the two main sources of our human fallibility?

Answer 20

1. Ignorance (lack of knowledge)
2. Ineptitude (failure to apply knowledge correctly)

Question 21

Health Systems

What is likely the main reason doctors still fail in cases where they have all the requisite knowledge to succeed?

(Why do cases of ineptitude occur?)

Answer 21

The sheer complexity of medicine and volume of available scientific knowledge is overwhelming

Question 22

Health Systems

Respectively, what percentage of patients with the following conditions receive inadequate or incomplete care consistent with how current medical knowledge has stated they should be treated?

Stroke
Asthma
Heart attack
Pneumonia

Answer 22

30%
45%
50%
60%

Question 23

Health Systems

Approximately how many WHO-recognized diseases, syndromes, and injuries are there?

How many drugs do physicians have access to today?

Answer 23

13,000

6,000

Question 24

Health Systems

What are examples of simple, complicated, and complex problems?

Which of these best exemplifies the mistakes made in medicine?

Answer 24

• *Simple** - baking a cake
• *Complicated** - sending a rocket to the moon
• *Complex** - raising a child

Medicine has elements of each level of complexity, but the mistakes made in medicine are often simple ones (e.g. forgetting to wash hands or consider a certain diagnosis in the differential)

Question 25

Health Systems

What are two simple measures that can greatly improve surgical outcomes and surgical teamwork with very little cost in time or resources?

Answer 25

Make sure everyone knows each other’s name;

pause for a minute or two before the surgery to discuss the case, potential complications, etc. (make sure every team member contributes)

Question 26

Health Systems

What is the common Public Health allegory relating downstream and upstream care?

Answer 26

3 friends come upon a river where children have become caught in its current and are being swept to their deaths.

1 friend starts pulling kids out downstream.
1 friend begins building a net midstream to catch more kids.
1 friend swims upstream to find ou why kids are falling in to the water.

All 3 friends have very important jobs.

Question 27

Health Systems

What do we call health providers that seek to treat individuals at the root social determinants of health?

Answer 27

Upstreamists

Question 28

Health Systems

What is one method by which physicians can gain much more information about patients without using much more time?

Answer 28

Medical assistants asking questions about the patients living/working/socioeconomic conditions.

These questions should be tailored to the needs of the specific community. Information regarding disease concentrations and clusters in the community can be found using GIS. Cultural needs should also be taken into account.

Question 29

Health Systems

To whom can an upstreamist refer his patients in need of environmental justice and aid in modifying their living conditions?

Answer 29

Tenants’ rights advocates
Community health workers
GED tutoring
Job training
Rehabilitation
Psychiatric care

Question 30

Health Systems

If a pregnant mother is stressed and abused during the pregnancy, what is the effect on the child?

Answer 30

Increased sensitivity to stress hormones

Question 31

Health Systems

What proportion of physicians think social problems are as important as physical health problems?

What proportion feel capable in addressing social needs?

(According to a 2011 RWJF study)

Answer 31

4/5

1/5

Question 32

Health Systems

What are the side effects of our fee-for-service system?

Answer 32

Overcharging
Over-service
An abundance of highly paid specialists
Procedure-heavy practices
A lack of focus on social aspects
An increase in lucrative tests, high-tech diagnostics, and brand name medications

Question 33

Health Systems

For what percentage of U.S. deaths do the top two leading causes (CVD and cancer) account?

Answer 33

48%

(CDC 2014)

Question 34

Health Systems

What percentage of U.S. health care spending goes towards chronic disease expenditures?

Answer 34

75%

(AHRQ 2010)

Question 35

Health Systems

What phrase is sometimes given as a counterpoint to overuse of Occam’s razor in medicine (e.g. by physicians assuming their is a single cause for all of a particular patient’s many S/Sy)?

Answer 35

‘A man can have as many diseases as he damn well pleases.’

(Hickam’s dictum)

Question 36

What are the two broadest categories of healthcare delivery modality?

What defines each?

Answer 36

Inpatient (patient stays ≥ 2 midnights);

outpatient (patient doesn’t stay overnight)

Question 37

Describe what percentages of U.S. hospitals are not-for-profit, for-profit, public, etc.

Answer 37

Question 38

What are the two main types of hospital according to function?

Answer 38

General (teaching hospitals are in this category);

specialty (e.g. children’s, psychiatric, cardiology, etc.)

Question 39

If a health system performs many different types of services (e.g. insurer, hospital owner, outpatient clinic owner, employer of physician), what type of network is it?

If a health system performs only one type of services (e.g. a system only owns a number of pediatric hospitals), what type of network is it?

Answer 39

A vertical network (e.g. Kaiser Permanente);

a horizontal network (e.g. Shriners hospitals)

Question 40

A higher primary care : specialist ratio will lead to what effects?

Answer 40

More preventative medicine, better health outcomes, fewer hospital administrations, less overall cost

Question 41

True/False.

There is a current (and worsening) shortage of both primary care providers and nurses in the U.S.

Answer 41

True.

Question 42

What type of insurance plan involves strict regulation of which providers can be seen and which procedures are pre-authorized?

What type of insurance plan involves making deals for discounted rates with certain providers that cost the insuree less to see?

Answer 42

Health maintenance organizations (HMOs);

preferred provider organizations (PPOs)

Question 43

What are the three main types of insurance plan offered by employers?

Answer 43

Preferred provider organizations (56%);

consumer-driven (e.g. health savings accounts) (20%);

health maintenance organizations (14%)

Question 44

What percentage of U.S. citizens accounts for 50% of all healthcare spending?

What healthier 50% of U.S. citizens accounts for what percentage of all healthcare spending?

Answer 44

The sickest 5%;

3%

Question 45

Describe where most Americans get their insurance.

Answer 45

Question 46

What percentage of Americans get their insurance through either Medicare, Medicaid, CHIP, Tricare, or the VA?

Answer 46

31%

Question 47

Describe Medicare Parts A - D.

Answer 47

A - inpatient costs

B - outpatient costs

C - medicare advantage plans

D - drugs

Question 48

The Medicaid expansion includes what people?

Answer 48

Any U.S. citizen at ≤ 138% of the FPL

Question 49

If not a fee-for-service system, what are the three criteria for how physicians can be paid?

(I.e. if not paid per service, a physician can be paid per ________)

Answer 49

1. Paid per diagnosis (episode of illness)
2. Paid per patient (capitation)
3. Paid per year (salary)

Question 50

What is the difficulty of pay-for-performance health systems?

Answer 50

Quality of care is difficult to measure;

different systems serve different populations (with different baseline health levels)

Question 51

What system does Medicare use to keep inpatient costs down in relation to a new diagnosis?

How does it work?

Answer 51

Diagnosis-Related Groups (DRGs);

a flat fee is paid for the management of a new diagnosis

(the hospital gets to keep whatever isn’t used in managing the disorder)

Question 52

What system does Medicare use to keep outpatient costs down in relation to a new diagnosis?

How does it work?

Answer 52

Relative Value Units (RVU);

each procedure is given a certain number of ‘points’ based on required labor, costs to the physician, and malpractice insurance

(E.g. a diagnostic colonoscopy is worth about 6 RVUs, while surgically removing part of the colon is ~40 RVUs)

Question 53

What percentage of the U.S. GDP goes towards healthcare?

What are U.S. per capita healthcare expenditures?

What is this total (not per capita)?

Answer 53

17.2%

$9,000

$2.8 trillion

Question 54

What percentage of Medicare spending goes towards the last year of life?

Answer 54

25%

Question 55

Describe health lobbying in terms of main players.

Answer 55

Question 56

Expanding Medicaid access so anyone could enroll (while also leaving private insurance as an option) would be an example of what type of healthcare reform?

Answer 56

Public option

Question 57

Under the ACA, all insurance plans must cover which essential benefits?

Answer 57

Ambulatory, emergency, hospitalization, maternity and newborn, mental health and substance abuse, prescription drugs, laboratory, prevention and wellness, chronic disease management, rehabilitation and devices, and pediatric services

Question 58

In his article ‘The Cost Conundrum,’ what does Atul Gawande argue is the cause of the exorbitantly high medical costs in the U.S.?

Answer 58

Overmedicalization (too many tests, too many procedures, too many medications, too many hospitalizations)