Week 2 Flashcards
Used as proxies for SES
Race
Education
Income
Percentage of wealth blacks have as much as whites
8%
Avg. Black income compared to whites
62%
Reasons why blacks have higher mortality rates than whites
Heart disease
Diabetes
Cancer
Homocide
People within different zip codes of a city can have as much as 20 yrs. in life expectancy differences
“Zip code is Destiny”
Divergent outcomes
We can see improvements for disease rates in whites but not in blacks. Probably has to do with access and quality of care.
Reason to be cuatious of rewarding hospitals based on quality ratings
States with the largest percentage of white residents have the highest Medicare quality rankings.
All cancer mortality relative risk
Black men in general have much higher rate of prostate cancer death than whites. Has to do with access to quality care and aggressiveness of disease
Unability to provide quality care
Primary care physicians visited chiefly by black patients were more likely to report they were unable to provide high-quality care to all their patients than those visited primarily by white patients.
Mortality after heart attack
Mortality after heart attacks is higher in hospitals with more admissions of black patients than in those with no admissions of blacks.
Myocardial infarctions
Blacks with myocardial infarctions experience longer door-to-balloon times than all other groups
Pneumococcal vaccination
Minorities are less likely to have ever received a pneumococcal vaccination than whites
Psychiatric hospitals
Black and Hispanic youths are more likely to be restrained upon admission to a psychiatric hospital than white youths.
Hospitalizations due to preventable conditions
Blacks are two to four times more likely than whites and Hispanics to be hospitalized for potentially preventable conditions.
Emergency Department
Blacks are more likely than whites or Hispanics to visit the emergency department for conditions that could have been treated by a primary care provider.
Two reasons for health inequities observed by race
1) SES differences (most important)
2) Other manifestations of racism
Mechanisms of segregation
1) Zoning
2) Public Housing
3) Restrictive Covenants
4) Contract Loans
5) Redlining
6) Blockbusting and Neighborhood Violence
7) Discriminatory Taxation and Rule Enforcement
Symbolic Racism
When people say I’m not racist, but why change the way things are?
White fragility
Desperate desire not to be called “racist.” Racism without Racists.
Black high school drop outs who will be incarcerated in their lifetimes
1 in 3
Mind-body medicine
You can address body and brain pathology by either preventing it or treating it through the patient’s mind
Stress response affects 2 mechanisms
- Intentional (behavior)
2) Reflexive Effect
Stressor
An environmental exposure, real or imagined, that can be appraised as threatening or benign depending on an organism’s perceived capacity to cope with it.
Stress response
The combined cognitive, emotional, behavioral, and physiologic changes associated with that exposure. These changes can be adaptive or maladaptive.
Distress
Is the unpleasant emotional impact of an adaptive or maladaptive stress response.
Relaxation response
The combined cognitive, emotional, behavioral and physiologic changes that mitigate or prevent the stress response.
Smoke detector effect of stress
We have been left we a system that produces false alarms, because it was advantageous to be hypervigilant.
Fill out stress diagram
[Diagram]
4 most important systems for chronic stress
1) Cardiovascular
2) Neurologic
3) Immunologic
4) Endocrine
Main components of Stress Physiology
1) Pre frontal cortex
2) Amygdala (limbic system)
3) Hippocampus (limbic system)
2 pathways of stress physiology
1) Lupus serulus (brain stem)
2) Pitituary-CRH-ADH hormones to produce epinephrine
Fight of Flight Response
Sympathy-Adrenomedulary System
Long-Term Stress Response
HPA Axis
May help organism adapt to stress, but can end up eventually harming the organism
Maladaptive stress responses
Homeostasis
Dynamic regulatory process in which physiologic microsystems throughout the organism are maintained in a balanced state; parameters are preset and do not accommodate wide variation
Allostasis
A dynamic regulatory process in which homeostasis is maintained by physiologic and behavioral adaptation to environmental challenges; parameters may vary widely according to the demands on the organism
Allostatic load
Consequences of allostatic regulatory wear and tear on brain and body leading to multisystem dysregulation and ill health; represents the cost of adaptation
Placebo Effect
iImprovement in a patient’s illness attributable to the symbolic
significance or meaning of an intervention
Nocebo Effect
Worsening of a patient’s illness attributable to the symbolic
significance or meaning of an intervention
Placebos in Controlled Trials
1) Specifically designed to eliminate non-
specific psychobiologic effects through blinding; the more inert the better
2) A placebo response is above and beyond
other non-specific changes that may affect all groups*
3) The rate of placebo responses in randomized groups cannot be predicted
4) No effort is made to mirror the clinical environment
5) Nocebo responses uncommon
Open-Hidden Design
One group of patients knows when they treatment is administered and the other does not.
Placebos in Clinical Practice
1) Since blinding is irrelevant, clinical
placebos may take any form
2) Placebo response may account for all, part or none of any observed outcome
3) Occurrence of a placebo response in an
individual patient is largely unpredictable
4) The probability and intensity of placebo responses can be manipulated
5) Nocebo responses variable
When a resource is scarce, we tunnel our attention to preserving the resource
Scarcity
It is not enough to give people enough. A little bit of extra [..]
Slack
US health data is organized by
Race
Types of racism
- Interpersonal racism (discrimination)
- Implicit bias
- Institutional racism
- Structural racism
Results in chronic diseases
Maladaptive Stress Responses
Behaviors with greatest effect on stress
1) Exercise
2) Social interaction
Training people to manage their emotions
Cognitive Behavioral Therapy
Affects degree to which organism reacts to stressor
Perception and appraisal
Four Features of A Productive Clinical Encounter
- A patient in distress
- A clinician who is perceived as an expert in dealing with the
patient’s distress - An explanation of the patient’s condition and a treatment plan
acceptable to both the patient and clinician - Some sort of healing ritual conducted by the clinician that
serves to instill positive expectations in the patient
2 Pathways of clinical encounter to Health outcome
- Non-specific, psychobiologic changes resulting from the clinical encounter
- Specific physiologic changes directly resulting from a medical intervention
Pure Placebos
Interventions lacking any known specific physiologic activity
Impure Placebos
Interventions with a non-zero but extremely low probability of producing a specific physiologic effect, or that have known clinical value for some conditions but lack specific physiologic effects for the presumptive diagnosis
Open Label Placebos
Pure or impure placebos given to patients with full disclosure
When you take a topic area and think ethically about the problems that arise in that field and work out particular answers to them
Applied Ethics
Ethical theories that guide actions, and guide the way you should be. More general advice
Normative Ethics
John Stuart Mill (theory and primary focus)
Consequentialism: Primary focus is action. The Greatest Happiness Principle
Immanuel Kant (theory and primary focus)
Deontology. Primary focus is action. Decision procedure and the Categorical Imperative.
Aristotle
Primary focus is character. Decision procedure: What would a virtuous person do?
Metaethics
Tris to investigate very nature of ethics.
Greatest Happiness Principle
actions are right in proportion as they tend to promote happiness; wrong as they produce the reverse of happiness.
Mill’s influence on bioethics
End of life decisions.
Categorical Imperative
Act in such a way that you treat humanity, whether in your own person or in that of another, always at the same time as an end and never simply as a means.
Autonomy
A person’s capacity to use reason to figure out the best thing to do. Basis for human dignity
Kant’s Influence On Bioethics
1) Informed Consent
2) Positive and negative duties regarding autonomy
3) Deontological approaches to the ethics of killing
Negative duty
Don’t interfere with patient’s freedom
Positive duty
Provide active support to help your patient’s make good decisions
Firm and stable disposition to feel and act in certain ways
Character (Aristotle)
Aristotle’s Advice For Bioethics
Downplay strict rules for ethical decisions. Instead, develop skills to navigate the rich moral landscape. Learn from the wise among us. Be guided by the purpose of your profession
Three elements of End of Life Decisions
1) Active vs. Passive
2) Prognosis
3) Patient Preferences
Nancy Cruzan case
Supreme Court ruled that withdrawing and withholding LST is permissible. However, States have wide latitude in establishing procedural safeguards.
Doctrine of Double Effect (DDE)
It is permissible, under certain conditions, to perform an action that has a bad effect, including the effect of shortening life.
Conditions for the Doctrine of Double Effect
The action is not intrinsically wrong
▪ The action has both good and bad effects, but you intend only the good effect (though you may foresee the bad effect)
▪ The good effect of the action is more weighty than the bad effect
▪ There is no way to achieve the good effect except by an action that also produces the bad effect
▪ The good effect is not achieved via a causal chain that includes the bad effect
Palliative sedation to unconsciousness may be considered when
(1) the patient is terminally ill and close to death,
(2) the patient is experiencing significant physical pain and discomfort that is refractory to other methods of pain control
(3) the patient and/or patient’s decision making representative have been informed and consent to the option
Good prognosis
Return to an acceptable baseline of health. Or return to good quality of Function life.
Substituted Judgment
Determine what the patient would have wanted were they able to understand relevant information and make a choice.
Best interest standard
What would the average person want in this situation? (It’s a last resort).
Elements of Informed Consent
- Decision making capacity
- Voluntariness of the action
- Disclosure of information, including diagnosis, prognosis, treatment
options and the risks, benefits and burdens of each option - Practitioner recommendation (if appropriate)
- Assessment of understanding (using the teach back method)
- Reflection and choice
- Legal authorization (oral or written, documented as appropriate)
Shared Decision Making
An approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences
Capacity
Medical determination
Competence
Judicial determination
Conditions for decisional capacity:
1) the ability to communicate choices;
2) the ability to understand relevant information;
3) the ability to rationally manipulate information; and
4) the ability to appreciate the situation and its consequences.
Order of persons who make decision for patients who lack capacity
In order of priority:
- Power of attorney (unless revoked)
- Court appointed guardian
- Family member acting as surrogate.
- Others who know the patient
Accuracy of Surrogates
68%
Societal costs
Per capita health care expenditures
Societal affordability
Health care expenditures as % of GDP.
Consumer costs
Premiums and out-of-pocket health care expenditures
Consumer affordability
Health care expenditures as a % of total income.
Decade US started to diverge in healthcare spending from other countries
1980s
Significant Contributors to Health Care Cost Growth in the U.S (8)
- We pay providers for doing more.
- We are growing older, sicker and more obese.
- We want new drugs, technologies, services and
procedures. - Litigious society- difficult to measure impact.
- Increasing levels of health insurance coverage.
- No transparency in price and quality information.
- Consolidation of providers and insurers.
8.High administrative costs- due to complex, multi-payer
system.
US Spends more than other countries in these services:
Outpatient care, Governance and administration (among others)
Specialties that who practice defensive medicine, and it impacts its costs (increases and decreases)
Increases:
1) Primary Care
2) Emergency Medicine
3) Cardiology
Decreases:
OB-GYN
Orthopedic Surgery
Healthcare costs formula
price x volume
How are prices determined (public vs private sector)
Public: complicated formula
Private: Separate negotiations between insurers and providers
Drivers of price variation in Commercial Market
Quality of provider (clinical Quality/perceived quality)
Hospital characteristics
Medicare/aid/Uninsured share
Provider and Insurer market
Four target areas of cost reduction
- Pharmaceuticals
- High Volume, High-Margin Procedures
- Imaging
- Administrative Waste
Which costs are we trying to contain?
- Overall health care spending in the United State
- Public sector spending
- Out-of-pocket spending for consumers/patients
- Health care spending within a state (often Medicaid
Supply-Side Approaches to Cost Containment
Change the way resources/providers are deployed in the health care system
Demand-Side Approaches to Cost Containment
Change the way patients seek health care services
A functioning market would require: (4)
- Large number of buyers
- Full information about quality of services
- Full information about prices of services
- Enough providers/suppliers to avoid monopoly power
Economic Stabilization Program (ESP)
Nixon Program (1970s). Froze wages and prices
Managed Care
1990s. Capitation, HMO.
Delivery System and Payment Reform
(2010s). Shifting away from fee-for-service, toward value-based payments.
- Creating new provider organizations to align with new payment models.
- Emphasis on coordination, integration, team-based care
• Drive consumers to high-value health care through value-based
insurance design and cost-sharing arrangements
Single Payer Financing through Taxation
Shift the U.S. system to one that is financed through taxation,
rather than a combination of employer, employee, government, and consumer payments
Global Budget
Budget often set at the level of federal or state government, within which total health care spending must be contained
Prescription Drug Volume Purchasing
Entities (e.g., states) can create multistate purchasing agreements
All-Payer Rate Setting
Payment for a specific service is the same for ALL patients receiving that treatment, procedure, or service from the same provider. Rates may be set by provider or by regulatory authority at state or federal level
Global Payments
A fixed prospective payment made to a provider entity (e.g., group of
providers, health care system, Accountable Care Organization) to cover cost of ALL care provided to a population of patients.
Episode-Based Payment
A single prospective payment for all the care related to a specific illness, condition, or medical episode for a defined period of time
Accountable Care Organization
A provider-led organization that is accountable to a payer
for the total costs and quality of a defined population for a defined period of time
Patient-Centered Medical Home
Primary care model that emphasizes team-based care,
care coordination, population health management, chronic condition management, and coordinated referrals
High-Cost, High-Need Patients
An array of care delivery approaches that target high-
cost, high-need patients to manage illnesses, and prevent more expensive utilization of services
Principles for Addressing Patients Who are High Cost and High Need
- Identify patient subgroups with similar need
- Shift care delivery to home and community, out of institutions
- Address social, behavioral, and medical needs (need more capacity to do this)
- Help make coordination happen – patients, caregivers, and professionals
- Set goals collaboratively, with patients, caregivers, and providers and align care delivery with these goals
- Allocate resources based on the potential for improving quality of life of patients and caregivers
Administrative Simplification
An array of strategies to streamline administrative functions in the health care system
Service Coverage Changes
Removing specific benefits from coverage as a means to reduce cost
Cost Effectiveness Determinations
Use cost effectiveness analysis to determine what is covered and what is not covered and/or what is available
Price Transparency
Require publication of prices for health care services, procedures, or drugs
Generics vs. Brand Name
Requiring purchase of generic prescription drugs rather than brand name
Government Rate Setting
Government sets rates for procedures, services, drugs
Require Shared-Decision Making for Preference -Sensitive Services
Require that providers document that patients were
engaged in shared-decision making prior to electing a specific procedure that is determined to be preference sensitive. (:Preference sensitive:: where legitimate treatment options exist that may have quality of life or length of life trade-offs)
Reference Pricing
Amount of co-insurance for a patient depends both on the price of the drug/service as well as the price for an alternative approach/less costly service location
Value-Based Insurance Design
Design of health insurance plan has tiers that reflect cost and quality of provider networks
