Insurance, etc. Flashcards
Objectification/Dehumanizations
Using pt as teaching tool in teaching hospital in direct view of pt, discussing case w/ colleagues in listening range of pt
Allostatic Overload
The wear and tear on the body and brain caused by chronically increased allostasis
*McEwen, 1998
Payment per patient (capitation)
Unit of payment = sum of pt’s tx (monthly or yearly)
- pt registers w/ physician group
- emphasis on primary care
- fixed sum of $ per pt, regardless of # of services provided
Age/Gender Effects
Be aware of gender differences in communication styles
Transference
Relationship schemas
Beliefs, expectations, perceptions from the past informing the present
Who pays most healthcare financing in the US?
Government (46%)
Hospital payment per episode of hospitalization
Unit of payment = diagnosis-related groups (DRGs)
- single (bundling) of payment of all services for 1 pt for entire stay
- lump sum depends on pt dx
- started in 1983 for Medicare pt’s
Physician Impairment
75% of cases are drug/ETOH related, 20% involve mental health
Fee-for-service
Unit of payment = procedure (inpt or output)
- private insurance (UCR) gave way to payer determined fee schedules
- Medicare (RBRVS) vary by geographic area
- managed care PPOs: discounted fees
- incentive for medical inflation
Hospital payment per institution
Unit of payment = global budget
- complete (bundling) of services: hospitals receive fixed budget per yr
- staff =-model HMOs w/ integrated hospitals
- some public sector hospitals
Healthcare in Canada
Single-payer model, Canada Health Act (1984) - comprehensive, accessible, portable, universal, publicly administered
*paid by “fee for service” and fees are negotiated
Allostatic load types
- Repeated “hits” from multiple stressors (e.g. - child abuse @ same time every day, etc.)
- Lack of adaptation
- Prolonged response due to delayed shut down
- Inadequate response that leads to compensatory hyperactivity of other mediators
Countertransference
Physician’s relationship schemas
Boundary Crossings
Deviation from therapeutic activity that is harmless, non-exploitative, possibly supportive of therapy, slippery slope to boundary violation
E.g. - hug, excessive personal disclosure
Healthcare in Japan
Social insurance which is mandated
- large employers: mandated to operate their own plans
- smaller firms: employees enrolled in gov-managed insurance
- community-based insurance: self-employed and retirees known as “national health insurance” administered by municipal gov
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Job loss, still have the right to continue under group coverage up to 18mo after, must continue to pay premium
*1985
4 parts of Medicare
A: hospitAl insurance
B: Basic medical Bills
C: (parts A + B) delivered by private Companies
D: rx Drugs (the “donut hole”)
UK Health System
National Health Service (NHS) - primary/secondary/tertiary care triangle structure, general practitioner (GP) as “gate-keeper” is essential component, “pay for performance” has increased GP incomes
State Children’s Health Program (SCHIP)
Created in 1997 to provide fed funds to states for child health, Medicaid expansion, provides coverage to children @ or below 200% poverty level
Cognitive impairment
Provide written instructions for memory impaired pt’s, determine pt competency to understand and comply with tx rec’s, refer for eval if needed
Reporting Misconduct
AMA mandates that you must report in accordance w/ legal requirements in each state
Payment per episode of illness
Unit of payment = global surgical and other fees for an illness or episode
- single (bundling) of payments for multiple services
- shifts financial RISK from payer to provider
Affect (MSE)
The observable emotional state of the pt, short time scale (as opposed to mood which is longer)
Preferred Provider Organization (PPOs)
PPO payer receives monthly premiums from subscribers and employers, pt req to select dr/hospital approved (“preferred”) by payer
Race Effects
Understand how a long h/o racism in countries like US have led to racial disparities in tx and minority distrust of healthcare professionals
2 Tier Capitation
Health plan must pay fee to referral service to register w/ the physician group your health plan then pays the physician by means of capitation
Report to who?
Med student? Dean of med school
Resident? Residency director
Physician? Division/hospital chief
If conduct violates state licensing laws? Report to state licensing board
If conduct violates criminal statutes? Report to law enforcement
Yerkes-Dodson Law
- performance and adaptive learning are optimal under moderate levels of stress
- learning new/difficult tasks is optimal with low/moderate arousal levels
- performance of well-learned tasks is optimal w/ moderate/high arousal levels
Sexual Violations
Sexual contact or inapprop sexual behavior in the room w/ a pt, etc
Pt Self-Determnination Act
Est that pt’s must be given written info about their health care decision making rights and the institutional policy on advanced directives
*1991
MedicaiD
Is for the Destitute
- public assistance program jointly administered by fed gov and states
- eligible if “low income”, have young children, pregnant, or disabled
EMTALA
All hospitals receiving fed payments must screen and stabilize ER pt’s, to prevent hospitals from dumping indigent pt’s
*1986
Payment per time
Unit of payment = salary of physician
- payment per # of hrs
- staff model HMO
- public sector physicians, community clinic staff
Boundary Violations
Behavior that transgresses the limits of the professional relationship and has potential to cause harm
E.g. - should not treat self, loved ones, not accept gifts from pt’s, avoid relationships w/ pt or pt family, etc
Hospital payment per diem
Unit of payment = daily costs of pt
- single (bundling) of payment of services for 1 pt for 1 day
- usually includes utilization reviews on behalf of insurer
First-gen HMOs
Full-time salaried (“staff model”)
- vertical integration, consolidated model, salaried physicians, global budget hospitals
Accountable Care Organizations (ACOs)
Authorized by ACA, bring together physician practices, labs, etc.; create budget targets
Language and Cultural Differences
Enlist interpreters/translators, be receptive to cultural beliefs, explanations and prohibitions
MedicarE
Is for the Elderly
- Americans 65+ are eligible, covers spouse as well one they turn 65, also covers Americans w/ permanent disability
- individuals pay into Social Security until age 65
Pt’s Bill of Rights
Right to receive complete info, to refuse tx, and to know about hospital’s financial conflicts of interest
*1972
Dysregulation of HPA axis
Abnml cortisol levels found in:
- anxiety disorders (high levels)
- depression (high levels)
- PTSD (high and low levels)
- h/o child abuse (high levels)
- professional burnout (high levels)
Healthcare in Germany
Social insurance (Bismarck model), "Sickness Funds" which every citizen must join, 90% are mandatory and 10% are voluntary - "Concerted Action" to control costs
Sexual Harassment
Unwanted and repeated verbal or physical advances, derogatory statements or sexually explicit remarks, or sexually discriminatory comments made by someone in the workplace
Sexual Impropriety
Performing intimate exam w/ no explanation, using the dr-pt relationship to solicit a date, discussing personal sexual experiences, prefs or fantasies
Dispersed model (US health care)
Multiple access points (pt choice or dr referral), more fluid roles for providers, less distinction in hospital care, higher value on tertiary care
ASEPTIC (for MSE)
Appearance Stream of mental activity Emotion Psych sx Thought Insight Cognition
Mental Health in physicians
Depression/anxiety elevated in medical students, suicide in physicians elevated compared to general public
Cost of healthcare in US per capita?
$7000, 2X as much as other developed/rich countries
Allostasis
Process of maintaining stability (homeostasis)
*Sterling and Eyer, 1988
Hospital payment per procedure
Unit of payment = fee for a procedure
- traditional model (Blue Cross)
- (reasonable cost) formula
- itemized bill for procedures and charges: heavy administrative costs
Independent Practice Associations (IPAs)
Loose collection of private dr’s who work in their own practices, contracts w/ HMO on behalf of the dr’s
- receives capitation payment from HMO and pays through capitation or fee-for-service
Capitation
Pt registers w/ physician group, fixed sum of $ per pt regardless of # of services provided
Sensory Impairment
Be prepared to utilize sign language interpreter or written materials
Protocol for conveying bad news to pt’s
SPIKES: Setting up interview Perception of pt Invitation Knowledge Emotions/Empathy Strategy/Summary
Second-gen HMOs
Virtual integration, group model (prepaid group practice, contracts w/ IPAs), network model (mix of IPAs, home health agencies, pharmacies, etc.)
