U.S. Health Care Systems Discussion Questions

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What is the real and perceived performance of the US health care system? Are the views different among patients, providers, payers, policy makers? Why or why not? (Ch. 1)

In the most recent poll, 6% of Americans rated the system excellent, 27% said pretty good, 39% rated it fair and 29% rated it poor. It is theorized that Americans have been "blinded" by the fact that we can afford top notch medical research, some of the most advanced technology in the world and the most modern training and techniques for our clinicians. All these may blind the average American to the issues that are embedded in the health care SYSTEM. No other developed country is so unsatisfied with their own healthcare system. Although more is spent each year on healthcare, dissatisfaction steadily grows. Providers are mostly dissatisfied with the growing population that is being met which a shortage of physicians and facilities which puts much more pressure on them in the future. Policy makers are dissatisfied with the resistance being met with civilians when frustrated with government overreach. However, policy makers are still pushing for health care reform to address obvious systemic issues. Overall, there is a general dissatisfaction with the American health care system. (Ch. 1)

Why does the United States spend so much money on health care? (Ch. 1)

First and foremost, there is a growing population that requires more health care in general. Physicians control a lot of the spending since they are the ones who order for patients to be admitted, what their treatments are and order prescriptions. It has been argued in the book that a change in lifestyle would impact American health the most which would lead to the assumption that more money should be spent on public health and preventative programs. However, 9 times as much money is being spent on medical care for those who are already ill than on public health. Most of the unnecessary spending comes from superfluous physician orders and Americans who are just not interested in being proactive about their health until they are already sick. (Ch. 1)

Why aren't Americans healthier and how might the health system make them so? (Ch. 1)

The book argues that the reallocation of funds toward public health and preventative programs might alleviate the spending on medical costs and help the US focus more on the maintenance of their health rather than the treatment of their illnesses. As stated before, it has become the culture and general attitude of Americans that being proactive about their wellness is just not a top priority. In short... ain't nobody got time for that! (Ch. 1)

What complications does our current health financing system cause for providers of care? (Ch. 3)

The providers of care can be subject to financial disappointment due to payer mix. The low rates given by Medicaid and charity care reduce an organization's viability. The ability to provide good care depends on the financial mix and the organization's ability to negotiate good rates with private insurance companies. (Ch. 3)

What complications does our insurance system cause individual consumers? (Ch. 3)

High individual rates, the lack of freedom of choice, the necessity to utilize gatekeepers, disorganization, lack of streamlined information between PCPs and specialists, etc. (Ch. 3)

What are some of the promising new approaches to changing our health system so that it has incentives to provide more efficient care? (Ch. 3)

Positive reinforcement: Health care insurance availability for all: increasing patient loads yet capitation on payments... only giving fixed rates, forcing health care providers to operate most efficiently.
Negative reinforcement: penalize hospitals for readmits within 30 days. Gives incentive to make sure patient care is efficient and effective during first admission and to make sure the patient is actually ready for discharge. (Ch. 3)

Some people view increases in health care spending as a response to consumer demand, whereas others see these increase as potentially wasteful spending. When other industry sectors assume a rising share of gross domestic product (GDP), it is viewed as a positive development. Should we be concerned about the rising cost of health care and its share of GDP? What types of health care spending might be classified as valuable? Wasteful? (Ch. 3)

We should be concerned with the rising cost of health care and its share of GDP. It is projected in 2019 that health care expenditures will be 19.3% of the GDP of America. The largest portion of that percentage comes from hospital stays. With health care being such a large portion of the GDP, it is important to ask how much of those expenditures are actually aiding the US economy. Health care spending that should be considered valuable would be things like technology, new facilities, supplies, patient education, etc. Health care spending that is wasteful would be things like unnecessary procedures, testing, inefficient care, and unnecessary inflation of costs. (Ch. 3)

What are the strengths and limitations of having multiple payers versus a single payer? (Ch. 4)

A single payer system is more regulated than a system of multiple payers. The single payer system (Bismarck, Beveridge, and National Health Insurance models) all rely on the government to run the healthcare sector. As an employee you are taxed a certain amount commensurate with your salary and that money is pooled into a fund(s) that provides care for the entire population. The US private health insurance system is a multi-payer system where most plans are premium-based, the amount that is set is independent of your income. If you look at the 3 single-payer models they are more government regulated, everything appears to be more streamlined because the government is the single entity controlling the healthcare sector. In the multi-payer system there are multiple entities controlling the various cost-measures and competition drives the market. In a single-payer system they operate with a "no person left behind" mentality meaning, everyone is covered. It's universal health care where you are not charged at the point of delivery. In a multi-payer system it is common for people to fall through the cracks and not be covered. (Ch. 4)

Which health system model would you recommend to low and middle income countries, and why? (Ch. 4)

In a low and middle income country I would recommend a single-payer system. Either the Bismarck or the Beveridge model would suffice. I say that because in the US, many low income people cannot afford insurance and therefore are not covered at all. In countries utilizing a single-payer system everyone is covered regardless of your income. (Ch. 4)

What are the advantages/disadvantages of having strong governmental involvement in (a) health care financing, (b) pooling, (c) provision of health care services? (Ch. 4)

One of the advantages, as listed above, is a more regulated and streamlined healthcare sector. Let's look at each section individually:
(a) Health care financing: The health care system is financed thru taxes or an employee/employer based contribution. The amount that comes out of your check is commensurate with your salary. Everyone's dollar goes to a single entity (the government) and the government allocates funds appropriately. In the US, the insurance, NOT the government sets the price of insurance and then negotiates with each employer regarding a specific plan.

(b) Pooling: Again, insurance plans are negotiated are regulated by the government and NOT the insurance companies. For example, France and Germany finance their health care system through voluntary contributions by employers and employees and the risk-pooling occurs at the plan level. However, insurance contributions are a fixed percentage of your income. Also, in most countries (other than US) there is no cost-sharing for services, which means there are no co-payments, co-insurance payments, and/or deductibles.

(c) Provision of Care: The only thing I could really find in the book is that in countries with government involvement, the individual has the freedom to choose any physician they want. Every physician gets paid from the same source: the government. But in America you have to find a physician that is covered by your particular network. I have an employee that has cancer and he needs experimental therapy. The problem is that the doctor that provides this therapy is not covered in our network so if he wants to pursue this opportunity to save his life he'll have to pay a sky-high fee because it's out-of-network. In countries like Germany and England every physician is covered so you can go where you please.
(Ch.4)

Does having a diversified payment system covering different populations automatically mean lack of quality? Explain why or why not? (Ch.4)

According to page 70, "quality has no relation to the health care spending or health care system characteristics." However much a country spends on new technologies or healthcare in general, this still does not change the interaction between physician and patient at the point of delivery. In my opinion, most people judge the quality of care based on how they were treated, timeliness, and outcome. These things are independent of spending (except where a new technology greatly affects an outcome). However, as shown in the US, you can spend trillions of dollars and still have the lowest positive ratings among health care measures. So obviously, spending or a diversified payment system does not equate to quality. (Ch.4)

What are the advantages and disadvantages of collecting health insurance premiums through a payroll deduction compared to financing them through general tax revenues? (Ch.4)

When you finance your insurance through a payroll deduction you are contributing a portion of your pre-tax income, which is then added to a contribution from your employer, to purchase health insurance. The contribution you make varies according to the premium charged to consumers and the proportion of that premium that the employer is willing to pay on your behalf. The amount of the premium is negotiated by insurance companies and employers. The benefit of this program is that large US employers will most likely offer a few different packages. (Ch.4)

What health insurance system might work best for a country with a large percentage of the workforce outside the "formal" economic sector, where employees are paid under-the-table and not subject to payroll taxes? (Ch.4)

For a country where most people are not subject to payroll taxes, the best insurance system might be the United States' model of Private Health Insurance. I say that because the Bismarck, Beveridge, and National Health Insurance models all rely on a single-payer system where the government receives money for healthcare via your taxes. If people aren't subject to taxes then that creates a problem for these systems. Whereas, in the US, even if you work outside the "formal" economic sector you can still receive insurance, you will just pay an arm and a leg for it. (Ch.4)

What are the incentives, advantages, and disadvantages for insurance systems that pay primary care physicians through capitation compared to fee-for-service? (Ch.4)

Fee-for-service is the standard payment system in America. Essentially, the physician receives payment for each service rendered. Capitation is a payment arrangement in which a physician is paid a set amount for each patient assigned to them. The average remuneration is based on the average expected health care utilization of that patient, with greater payment for patients with significant medical history.
Like, DRG, capitation is a fixed amount, but rather than determined by diagnosis, it is determined by the health status of the individual patient. Again, like DRG, this is guaranteed money from the payer. The payer agrees to pay a set amount per individual to each physician. Again, the disadvantage occurs when the true cost of treatment outweighs the fixed amount the insurance paid up front. (Ch.4)

What are the incentives, advantages, and disadvantages for insurance systems that reimburse hospitals through diagnosis related group (DRG) payments, rather than fee-for-service or global budgets? (Ch.4)

A diagnosis related group (DRG) payment is a prospective rate system in which Medicare pays up front a fixed amount for the hospital stay of a patient with a specific diagnosis. For example, if a patient has pneumonia Medicare will pay the hospital up front regardless if the patient is hospitalized for 2 days or 2 weeks. The payment is based on the diagnosis and will always be the same regardless of the length of their stay. However, under recent legislation, hospitals can be penalized if a patient is re-hospitalized too soon after discharge. This provision reduces the hospital's financial incentive to send patients home too quickly, before they are ready.
The advantage is that it's a fixed amount, paid up front by the payer. It is guaranteed money to the hospital. The disadvantage occurs when the true cost of the ailment exceeds the cost of the payment. For example, let's say Medicare pays a hospital $2,000 for a patient with pneumonia, but their length of stay turns into weeks, and the true cost owed to the hospital is $3,000. The hospital now has to eat $1,000 of the cost. (Ch.4)

Why do some refer to the health care system as "the sickness care system"? (Ch. 5)

Some refer to the U.S. health care system as the sickness care system because the U.S. system is generally reactive-meaning it responds to abnormality, disease, or injury. (Ch. 5)

Briefly describe the effects of personal health behavior on the individual and population health status and health care costs in the US. (Ch. 7)

See first two pages of this outline. Those pages lay out all the behavioral risk factors and the big statistics from the book. (Ch. 7)

How have health behavior change programs and interventions changed over the past 40 years? (Ch. 7)

o Beginning in the 1970's and well into the 1980's, more research was conducted on behavioral health risks such as the risks of smoking, drinking, unhealthy diets, etc. Education campaigns were, at the time, on an individual level. Physicians were spreading awareness over these newly publicized health risks. Diets didn' really become a fad until the 1990's but the practice of quitting smoking was very strong at first. Then, it seemed the more that was discovered to be "bad for you" the less Americans cared, as if the task of maintaining a healthy lifestyle were practically daunting. It wasn't until the 1980's that prevention campaigns changed from an individual level to population base where entire demographics were being targeted for behavior changes. Stages of Change Model in the 1980s accelerated the shift from individual to population intervention and was a multistage process:
 Precontemplation: not planning to change behavior; behavior is not seen as a problem.
 Contemplation: seriously planning to change behavior within the next 6 months weighing the pros and cons and building supports and confidence.
 Preparation: plans to change are imminent; small initial steps are taken.
 Action: active attempts are made to quit smoking, drink less, become more active or change to a healthier diet and to sustain changes for up to 6 months.
 Maintenance: change is sustained beyond 6 months.
 Relapse: the individual returns to an earlier stage and begins to recycle through the earlier stages.
o Final push for change came in the 1990's with social ecological models. These models integrate behavioral science with clinical and public health approaches. They emphasized that a person's health behavior is affected by multiple levels of influence: interpersonal factors, social factors, organizational and community factors, broader environmental influences and public policies. (Ch. 7)

Most clinical practice guidelines physicians use, in order to achieve effective behavioral interventions, are based on the "5 A's" model. Briefly describe this model, using tobacco cessation as an example. (Ch. 7)

The 5 A's model was developed through a review and meta-analysis of hundreds of controlled studies and has been widely promoted through government approved clinical practical guidelines: Ask, Advise, Agree, Assist and Arrange a follow-up. For example, ask about tobacco use, leading to clear and personal advice to quit for smokers and offer to help. The agree step starts with assessing patient-readiness to quit. Assistance includes a recommended motivational intervention. The final step is to arrange a follow up support and assistance including referral to more intensive or customized help to maintain the behavioral change. (Ch. 7)

Describe the parallel shifts that have taken place in understanding the essential targets need to be for successful interventions to increase patients' adherence to recommended prevention-oriented health behavior and to increase providers' use of recommended clinical preventative behavior change interventions. (Ch. 7)

Individual level interventions aimed at those who possess a behavioral risk factor or suffer from risk-related disease (emphasis on changing rather than preventing risky behavior). Population-level interventions that target defined populations in order to change and/or prevent behavioral risk factors. May involve mediation through important organizational channels or natural environments. State and national public policy/environmental interventions that aim to strengthen socials norms and supports for healthy behavior and redirect unhealthy behavior. (Ch. 7)

With reference to McKinlay's population-based intervention model, outline a possible coordinated downstream, midstream and upstream strategies for curbing binge drinking on a college campus. (Ch. 7)

a. Downstream- offer individual counseling services to students to treat their alcohol abuse problems. Also, make information available to them about other self-help programs.
b. Midstream- being a student organization dedicated to preventing binge drinking on campus and promoting responsible drinking among students.
c. Upstream- instating dry campus policies or state legislature regulating the presence of alcohol on college campuses. (Ch. 7)

Who are the currently uninsured, and what does this tell us about the nature of the problem that national health reform has tried to address in your state and more broadly. (Ch. 8)

The uninsured are often those with low socioeconomic status and certain culture, race, or age groups. It tells us that the problem may not be completely related to opportunities for health care services. It also tells us that the cost of health care makes it difficult for many people to afford insurance. The national health reform has tried to improve preventive care and increase health care access to people within Oklahoma. (Ch. 8)

Even after full implementation of national health reform, there will remain 14 to 16 million uninsured in the United States. Who are these remaining uninsured and what are the financial and other implications of their lack of coverage for your state? (Ch. 8)

These will be people that do not meet Medicaid standards but don't fall under the ACA umbrella, as well as those who choose to pay the fine instead of purchasing health insurance. The implications will be increased premiums, higher co-pays, and higher costs for uncovered services. (Ch. 8)

Who is responsible for reducing noneconomic and quasi-economic barriers to timely and effective health care? What are the different responsibilities of local, state, and federal governments currently and after the full implementation of national health reform? (Ch. 8)

The responsibility falls between local, state, and federal governments to help alleviate these problems, as well as health care providers, insurers, and consumers (patients). State governments have attempted to provide near-universal coverage to its residents. Local governments should work towards smaller, more cost-effective strategies focused on the needs of the smaller populations. The federal government has attempted multiple overhauls, and many smaller incremental changes, and should concentrate on the rights of insurers, hospitals, and patients. After ACA, the federal government will oversee the Medicaid/Medicare payment changes with the states, while ensuring the states are having residents purchase insurance or pay a fine. The federal government should also oversee the possible cost reductions, if any. (Ch. 8)

How will ACA change noneconomic and quasi-economic barriers to access? In what ways will health reform increase and decrease these barriers? (Ch. 8)

Health reform does little to address directly the noneconomic barriers to care. There are provisions for enhanced federal collection and reporting of data on race, ethnicity, sex, primary language, and disability status, and the Secretary of Health and Human Services is required to analyze and monitor these data to document trends in disparities. In another limitation, the current health reform does not significantly change incentive around prevention and health promotion for providers, patients, or insurers. Although it expands federal support for preventive services within Medicare, adds coverage for Medicaid enrollees' immunizations, and permits employers to offer rewards to employees who participate in their insurer's wellness programs, it does not attempt to significantly move the health care system from its current orientation toward treatment. Finally, large numbers of children and adults are eligible but not enrolled in existing CHIP and Medicaid programs. ACA will make even more Americans eligible for publicly supported health care, especially under Medicaid. Overcoming barriers to enrollment- excess paperwork, frequent reenrollment requirements, language problems, limited outreach efforts, etc.- will be essential in order to achieve the expected benefits of expanded coverage. (Ch. 8)

What are the costs of barriers to access, and who bears these costs? (Ch. 8)

The barriers are economic, noneconomic, and quasi-economic. Economic barriers are barriers related to cost of obtaining insurance or obtaining health care. Noneconomic barriers are barriers related to race, ethnicity, language, culture, etc. Quasi-economic barriers are related to education and resource availability/performance. Those who bear the cost are ultimately the consumer, due to increased charges incurred due to lost revenues from health care providers, thereby increasing charges for those able to pay. (Ch. 8)

Explain how each of the following factors influences the patient-physician relationship: (Ch. 9)

a. Insurance - health insurance is linked to employment and individuals are responsible for obtaining their own insurance. In turn, health insurance may be too multifaceted for some too understand, which may lead to the termination of the patient-physician relationship.
b. Medical knowledge - as this knowledge has become more comprehensive and detailed, the medical field has witnessed a proliferation of treatment choices and protocols.
c. Technology - electronic health records are becoming more abundant due to the fact that they are readily available and can be shared very easily.
d. Accreditation - the joint commission and the national committee for quality assurance. If a physicians practice, clinic, or hospital is accredited it may influence patients to go to that provider knowing the fact that they will received quality care.
(Ch. 9)

What are the main sources of complexity in the U.S. medical care field? What factors contribute to its diversification? In what ways is the field fragmented? How is it stratified? How do each of these characteristics - complexity, diversification, fragmentation, stratification - influence patient care and health? (Ch. 9)

a. Sources of complexity - medical knowledge (too much to know), insurance plans, prescription drugs, and chronic conditions.
b. Diversification - specialist vs. general practitioners, superspecialization, new types of provider organizations (dialysis clinics), and insurance plans and reimbursement strategies.
c. Fragmentation - physician silos (info is kept to small group rather than shared), underdeveloped health information technology, lack of care coordination, lack of incentives to coordinate care, and focus on acute care.
d. Stratification - uninsured Americans and uncompensated care. (Ch. 9)

How have other Western countries addressed issues of fragmentation and stratification? How do their strategies influence patient care and health? (Ch. 9)

They provide a universal health care system and every citizen is insured. (Ch. 9)

Summarize the main similarities and differences between the four pathways to better care. (Ch. 9)

a. Chronic care model - propose an overall health system should be organized to be proactive and focused on keeping people as healthy as possible, instead of just reacting when people are injured or sick.
b. Patient-centered medical home - is a physician-directed medical practice with a team of providers in which each patient has an ongoing relationship with a personal physician. Coordinates preventive, acute, chronic, and end of life care.
c. Accountable care organizations- ACO & HMO.
d. Bundled payments - pay providers for an individual's episode of care instead of the individual treatments provided.
(Ch. 9)

What factors prevent the U.S. medical care field from becoming more coordinated and less stratified? (Ch. 9)

It is a disease management industry and not a preventive industry. Physicians are not trained in a "team" like way. High fee for service charges discourage med students from entering primary care. Must be legally allowed to share patient info. IT must be increases.Patients must be involved and informed. (Ch. 9)

Imagine you are a Washington lobbyist. (Ch. 9)

Simply, provide a universal health care system where everyone is covered. (Ch. 9)

Choose three critical issues facing the U.S. health care system and rank order them in terms of their impact on patient health. (Ch. 9)

a. Stratification
b. Diversification
c. Fragmentation
(Ch. 9)

Choose three critical issues facing the U.S. health care system and rank order them in terms of the availability of solutions. (Ch. 9)

a. Stratification
b. Diversification
c. Fragmentation
(Ch. 9)

Why do you think U.S. insurance companies do not reimburse practitioners for time spent coordination patients' care (e.g., calling other practitioners, answering e-mail, etc.)? (Ch. 9)

a. Because insurance companies only pay practitioners for direct rendered services to the patient.
b. Second, it takes very little time to make consulting phone calls or simply answer a patient's email. In turn, it is not a worthy to pay a practitioner for time spent coordinated patients' care because there may be times when they do not follow up on their end. (Ch. 9)

The current U.S. medical care field has an acute care focus. Could current structures of the field sustain a focus on chronic and preventive care? If so, how? If not, what aspects of the field would need to change in order to accommodate this changed focus? (Ch. 9)

a. No, current structures do not allow a focus on chronic and preventive care. Reason being, policies would have to be implemented to increase community health promotion. Why? Because, prevention is key in regards to bypassing certain illnesses and diseases.
b. Changes would include adding health promotion departments to medical facilities. Certified health education specialists would be available to ascertain diet, exercise, and other health promotion topics for the betterment of patients.
(Ch. 9)

What challenges do we face in developing consistent and comprehensive process and outcome measures for doctors and health care institutions? (Ch. 11)

a. Mixed attitudes toward measurement- When we ask people to measure things they are not interested in or which they feel will be used against them, they are resistant
b. Unlike the car industry, performance measures are complicated
i. First, inputs to the healthcare system (patients, physiological traits, health problems) all vary. Patients in the same category (62 year old white male) are all quite different so measurement of the performance, reliability, etc. and predicting their future are two separate matters
ii. Considerable variation in the theories and processes that drive the delivery of care. Clinicians have different theories, hospitals/clinics have different processes & procedures, different departments have different steps in delivering care
(Ch. 11)

Explain the differences between proportions, percentages, and rates. (Ch. 11)

a. Proportion: A proportion is a measure in which the numerator is included in the denominator often not converted to a percentage so you would just say 5 out of 100 patients fell
b. Percentage/proportion: a percentage is a yes or no answer, so for example: while this patient was with us did he/she fall once or more? 5 patients fell /100 total patients = 5%
c. Rate: A rate usually shows a "change" over time, so 3.2 falls per 1000 patient days
i. some event, disease, or condition occurring in members of a population divided by total number in that population (crude: whole population is denominator, specific: demographic characteristics define denominator)
(Ch. 11)

Describe the key issues that need to be resolved before you start to collect data. (Ch. 11)

a. How often and for how long will you collect the data?
b. Will you employ sampling? Determine sampling design as well as probability or nonprobability type
c. Will you conduct a pilot study before collecting on large scale?
d. How will you collect the data? (manual v. automated, who will collect if manual)
e. Will the collection effort have any negative impact on patients, staff, or families? IRB approval needed?
f. How will the data be coded, edited, verified, and analyzed?
g. How will the data be used and who will have access to the raw data and results?
(Ch. 11)

Why is using statistical process control methods (SPC) the preferred approach to analyzing data for quality improvement? Name the two primary SPC tools and describe the key elements of each (Ch. 11)

a. SPC is preferred because it allows the researcher to determine whether the process reflects what are classified as controlled and uncontrolled variation in order to decide whether the data demonstrate significant change. SPC methods provide the foundation for the analysis of QI data.
i. Controlled (common cause)- regular, natural, or ordinary fluctuations in data
1. Affects all outcomes of a process, referred to as stable variation
ii. Uncontrolled (Special Cause)- arises from irregular or unnatural causes
1. Affects some, but not necessarily all of a process's outcomes, referred to as unstable variation
(Ch. 11)

Describe the sequence for improvement (i.e. testing, implementing, and diffusing) and why it is so important to link any quality-related measurement effort to these improvement strategies? (Ch. 11)

a. Develop a change (after theory and prediction), test a change (test under a variety of conditions), implement a change (make part of routine operations), sustain and spread the change to other locations
b. The primary objective of the sequence is to start with small tests of new ideas, build on the success and failures of these tests, and move to testing under different conditions to determine how robust and reliable the new ideas are. (Ch. 11)

Is it ethical to limit access to patients covered by poorly paying insurers? As an administrator, how would you approach a situation where you needed to limit losses created by treating patients with no insurance or poorly paying insurance who arrive in your emergency room? (Ch. 12)

It is unethical to limit health care access to patients who have poorly paying insurers, or who can't afford to pay. At the same time, health care is a business. A facility can't operate without money. Cost shifting has long been effective, but it has become less feasible. Providers can limit the volume of Medicare/Medicaid patients and indirectly limit access by limiting the size of the ER or eliminating certain services to decrease costs. (Ch. 12)

Does every facility need to have a surgical robot? Does it benefit the supplier to limit the number of robots sold, in order to maximize utilization per robot? Would the market benefit if the supply of surgical robots were restricted? (Ch. 12)

Not every facility needs a surgical robot. Group purchasing by several facilities and narrowing the number of similar products used by clinicians allows facilities to negotiate lower prices from vendors and reduces the cost of supplies, or in this case, the robot. (Ch. 12)

As an employer, how would you establish co-pays and deductibles to encourage more efficient use of health care services? What other actions could you envision that would encourage employees to improve their use of health care services? (Ch. 12)

I have no idea how to answer the first part. The only thing I can think of is lowering the co-pay and deductible so people are more likely to use health services if it is a lower out of pocket expense. For the second part: A health risk assessment allows employees to ID personal health risks and decide whether to pursue wellness, disease management, or other programs. (This section is on page 265 if you want to answer the question with your own opinion) (Ch. 12)

Since health care tends to be local, as a policy maker what would you do to encourage the large community (retailers, restaurants, employers, schools, etc) to improve the health of the community? For these initiatives should the government play a role or should they be sponsored by other entities? (Ch. 12)

You could probably offer some type of incentive to businesses that encourage healthy behaviors. These incentives should be community lead. I'm much more likely to do something if someone that I know locally encourages me to do it. Most small town communities perceive the government to be way off in Washington with no concern for small communities. Even state governments can seem to be out of touch. Future government involvement could be possible, but it should start locally. (Ch. 12)

What are the benefits and costs of comparative effectiveness knowledge for a society? (Ch. 13)

Benefits - Quality Improvement and Cost Savings
Costs - May curb progress of technological innovations (Ch. 13)

Do the benefits of using a comparative effectiveness approach outweigh the costs of withholding health services from certain members of the population? (Ch. 13)

Depends on who you ask, but I would think so. (Ch. 13)

Does a comparative effectiveness program actually save money for the health care system? (Ch. 13)

All health systems seem to function better with some sort of comparative effectiveness program. But the trend of these systems in Europe is that costs are steadily increasing. Cost savings are unproven in public CER programs, but private programs may fair better. (Ch. 13)

Why has the U.S. health care system not yet implemented a comparative effectiveness effort? (Ch. 13)

Public Opinion is preventing any sort of system from being implemented. The public does not trust government/boards to make decisions regarding their health care. (Ch. 13)

What parties stand to gain or lose from the introduction of comparative effectiveness in the United States? (Ch. 13)

Gain - The public. There will be a greater control of quality and costs for patients.
Lose - Health care professionals. Reduction of ineffective treatments and redundancy in tests will cause a decrease in physician pay. Competiveness and innovation of different companies will also decrease. (Ch. 13)

Are the countries that have already implemented comparative effectiveness programs benefiting from their decisions and, if so, in what ways? (Ch. 13)

U.K., France, Germany, and Australia all have different C.E. programs with pros and cons. Look at above outline for details... (Ch. 13)

Which agencies should evaluate the comparative effectiveness of different health care services and in what ways? (Ch. 13)

The U.S. has created the AHRQ and NIH for a reason. They should be empowered to conduct their research and evaluate therapies. U.S. needs a central system/governing body that will help reduce costs and control quality across the states/systems. (Ch. 13)

Who should distribute findings of comparative effectiveness research and in what ways? (Ch. 13)

U.S. should have a governmental agency that is reported to by the various programs that do research. The effectiveness of the treatments and the costs should be evaluated against one another and reported. Hospitals/organizations can look at these reports and determine which treatments are actually unnecessary/ineffective. (Ch. 13)

What products or treatments should be subject to comparative effectiveness evaluations? (Ch. 13)

Many countries use their programs to evaluate the effectiveness of drugs mostly. They research or use outside research to determine the benefits of a drug and compare these benefits to the costs of the drug. This would take a hit to the pharmaceutical industry, but should be done. The public of Europe agrees with such evaluations. (Ch. 13)

Who should fund a national comparative effectiveness program? (Ch. 13)

For the U.S., the public would most likely support a program that a quasi-governmental aspect. Part of the funding would come from the government. The other portion would come from corporate taxes to help supplement the funding already provided the government. (Ch. 13)

What are some of the ways to measure performance of HCOs? (Ch. 14)

The organization must have transparent, measurable objectives that are shared with key stakeholders and progress toward them must be regularly reported. To establish these objectives, many HCOs use their mission statement or examine their influence on the community. They must monitor quality standards and changes in patient satisfaction and care. (Ch. 14)

What are the advantages and disadvantages of the different forms of ownership of HCOs-public, nonprofit, and for-profit? (Ch. 14)

Nonprofit: aren't accountable to outside body, board members aren't paid, good job security. Public: accountable to elected officials, job security. For-profit: accountable to shareholders, full time board members, goal is return on investment (easy to measure), low job security----probably more but this chapter is very vague. (Ch. 14)

What skills and experience are required to own and manage HCOs? (Ch. 14)

Managers and owners only need skills and experience related to their organizations goals. Important skills include "people skills" and emotional intelligence (self-awareness, self-regulation (think before acting), motivation, empathy, and social skills.) experiences and skills vary widely across management positions. (Ch. 14)

Who should be in charge of HCOs and how should they be trained? (Ch. 14)

Boards are generally in in ultimate control. These are appointed by the owners and are usually not employees of the HCO or even familiar with important HCO decisions. Managers of HCOs can be formally trained with an MBA< MD, etc or not trained at all. They should go through a formal orientation into the organization and go through formal education programs. (Ch. 14)

What mechanisms of accountability are most effective for nonprofit HCOs? (Ch. 14)

The most effective way of providing accountability is electing a board that will focus strongly on the HCOs mission. They must be accountable to their owners as well. The public opinion of a nonprofit organization affects their accountability also. (Ch. 14)

How do we know when we have too many or too few doctors, nurses, or other health professionals? (Ch. 15)

An optimal supply of health workers that combines the concepts of need and market would say it is the number needed to deliver the care necessary to maximize the health of a population, given the resources spent in the health care industry. (Ch. 15)

What determines the supply of doctors and nurses? (Ch. 15)

An optimal supply of health workers that combines the concepts of need and market would say it is the number needed to deliver the care necessary to maximize the health of a population, given the resources spent in the health care industry. (Ch. 15)

How will health reform impact the health care workforce? (Ch. 15)

Health care reform increases the amount of people in the U.S. that will be covered by health insurance. With this increase, there is also an increase in people who will now demand health care services. A higher demand in services means there will be a higher demand in supply of health care workers, especially in the primary care sector. (Ch. 15)

Why is primary care so important? (Ch. 15)

1) Primary care is ideally the first point of access to the health care system and, again ideally, the primary care physician or nurse practitioner coordinates the advice and treatment plans of various specialists
2) Increasing number of primary care will not only improve access to care and quality of care, but will also reduce its costs
3) Primary care vital in achieving better quality of care
(Ch. 15)

With the global shortage of doctors, especially in less developed countries, is relying on international medical graduates an ethical solution to U.S. primary care shortages? (Ch. 15)

This can be a very ethical problem depending on your view. The ethical issue is that we are reducing the amount of physicians in other (probably less developed) countries for our own country's health. These physicians could be more effective in improving the health conditions of their own country. Perhaps a more ethical solution for our country's problem is by improving our own health care system and incentivizing our own students to enter primary care. (Ch. 15)

To what extent can nurses substitute for doctors? (Ch. 15)

75% of primary care services performed by doctors can be performed by nurse practitioners with the same quality. Unfortunately there are many restrictions that are still in place that prevent NPs from practicing independently from physicians. (Ch. 15)

Why are incomes of primary care doctors lower than incomes for specialists? (Ch. 15)

Health care pay is estimated on various criteria. Primary care services can include counseling, health education, and coordination of care which is undervalued by current system. Although these services are actually very important to patient health, the system does not deem it as important for some reason. (Ch. 15)

How can reimbursement policy improve the supply of primary care? (Ch. 15)

Nurse practitioner reimbursement guidelines can be examined and fixed so that NPs can be value. Currently, many NPs are not independent from physicians and so also cannot be reimbursed directly for their services. Reimbursement for services from primary care physicians is also predetermined from preexisting contracts. This gives very little room to adjust for nurse involvement. (Ch. 15)

Why do you think the health care industry has invested less in information technology than the banking industry? (Ch. 16)

The health care industry has invested less in IT because of the cost of implementing an electronic medical records system and philosophical differences concerning access to information. HIT competes with technologies for diagnosis and treatment- technologies that are both expensive and constantly emerging. Some health care providers believe that patients should not have full access to their medical records because they will interpret the information wrong without a physician's guidance. (Ch. 16)

Who do you think should pay for improvements in HIT? (Ch. 16)

I think the Federal government should pay for improvements in HIT. The Federal government mandated hospitals and physician offices to have EHR systems by 2015 so they should pay for HIT improvements. (Ch. 16)

What role should the federal government play in stimulating the adoption of information technology? (Ch. 16)

I think the Federal government should play a major role in stimulating the adoption of IT because they mandated that physician offices and hospitals to adopt an EHR system. It is their job to explain the benefits of an electronic medical records system. Referencing the VA health systems many successes with HIT, the increase in the quality of care, a potential for increase in revenue, and the incentives the federal government is giving out for implementing an EHR system are all good points. (Ch. 16)

What role should insurance companies and employers play in increasing the use of information technology in health care? Should they contribute financially? (Ch. 16)

Insurance companies and employers could also convert to an electronic system to store information. If an insurance company has gone completely paperless, they can only send information electronically. If a physician's office does not have an EHR system then they have no way of viewing that information and storing the information securely. The physician's office would be more likely to implement an EHR system to make communication and the transfer of information between insurance company and the physician's office easier.

I don't think insurance companies and employers should have to contribute to the cost of HIT. Increased cost for insurance companies and employers means an increase in insurance premiums for the customer or employee. (Ch. 16)

Name one or two technologies that can both improve the quality of care and increase patient satisfaction?
(Ch. 16)

Web based databases can increase patient satisfaction because they would be able to schedule appointments and look up lab results online. It increases the quality of care because the physician does not have to wait for the results to be faxed and the patient would not have to be placed on hold on the telephone to get their lab results. Also, there is less of a chance that the results will get lost or mixed up because everything is electronic. (Ch. 16)

Should patients be allowed to control who sees their medical information? How should this be accomplished? (Ch. 16)

Patients should be allowed to control who sees their medical information.
If web based databases are created for patients, they would be able to log on to their profile to view who has accessed their medical profile. (Ch. 16)

What can be done to insure the privacy and security of patient information? (Ch. 16)

First of all doctors, nurses, and other medical staff need to be careful not to share passwords or pull up a patient's profile in the presence of unauthorized individuals.
EHR systems can limit information to certain individuals, so that they do not see more information than necessary.
Along with a username and password, systems can be setup to also require authentication either by sliding a special card with a metal strip, by fingerprint, or by iris scan.
(Ch. 16)

What are the causes of physician resistance to CPOE? What can hospitals do to reduce it? (Ch. 16)

Physicians believe that it will affect their independence, by advising them on what care to provide. They believe using CPOE technology will take time and reduce efficiency.

Hospitals can educate physicians on the benefits of the technology. That it has reduced the incidence of serious medication errors by 55%. That an electronic system that writes prescriptions is seven times less likely to make errors than those writing prescriptions by hand. (Ch. 16)

Why is it difficult to forecast the impact of trends on the future of health care delivery in the United States? (Ch. 17)

It is difficult to forecast the impact of trends because it is not quantitative. There are so many different factors that affect health care such as: the economy, the government leaders, and prevalence/incidence of diseases. (Ch. 17)

What are some of the common forecasting methods used? (Ch. 17)

a. Economist approach to forecasting is to analyze past data to predict future economic events.
i. Collect time series data on a set of economic variables, then develop theories about how each variable influences the others, then test these theories with data from the past, and finally estimate how the variables will change events in the future, based on the estimated relationships established.
b. Delphi method, a more qualitative approach to forecasting, systematically obtains expert opinions, with an end goal of achieving consensus.
i. Delphi administrators poll experts about their forecasts in three or four rounds of questionnaires. After each round, results are tabulated and circulated to the group. The Delphi is completed when the group reaches a convergence of opinion.
c. The third approach is a less scientific approach to forecasting. It relies on nationally recognized leaders in a field to apply their experience about the past and dynamics of the present to make predictions about the future.
(Ch. 17)

What forces do the chapter authors believe will be the principle drivers of changes in health care delivery in the next 5 years? (Ch. 17)

• The circumstances of health form implementation
• The path of the current economic challenges
• The ability of the health system to improve quality and slow expenditure growth
• The obesity epidemic and other behavior-related health conditions
(Ch. 17)

What major trends affecting health care delivery will be important in the next 5 years? (Ch. 17)

• That the Federal government would act to expand health insurance if more middle class Americans began to fear losing coverage
• That cost containment efforts would begin more intensively
• That health care providers would focus more on managing chronic diseases
• That providers would become more customer friendly, transparent, and accountable
(Ch. 17)

What examples of public health and prevention can you identify in your daily life? (CH 6)

One would be the availability to get a flu shot. Another would be clean water. A third would be decreasing carbon emissions. These take part in my daily life.

What is the difference between individual- and population-based prevention efforts? For population-based prevention what is the difference between universal and targeted strategies? (CH 6)

Individual prevention efforts have to do with a single person making changes that will benefit his/her health outcomes. Population prevention efforts work towards improving a group of people a health outcome. Universal refers to all health outcomes, while targeted would be something like decreased smoking, reducing obesity, etc.

What does a population focus take, in terms of planning, consensus building, and resources for implementation? In the case of auto safety belts? (CH 6)

It would require tracking population health outcomes, incidence, etc. The planning would be considerable and the consensus building would be required to determine what health outcome to target. The resources would be people, time, money, etc. For safety belts, it would require who would work on policy, how to work with state/local governments, and how to raise money to accomplish the goal.

Why can't public health do more to achieve its goals? Name some of the political, legal, logistic, and resource challenges. (CH 6)

Public health cannot do more due to the population being less receptive to changing lifestyle habits. The political problems would be policies restricting implementation, legal would be something like HIPAA, logistic would be reaching certain demographics; resource would be lack of money.

What should be left to the public sector to do, in order to achieve public health goals? (CH 6)

They should be left to change lifestyle habits. Things like stopping smoking, exercising, and using preventive care would be beneficial to the public. But, public health should illustrate these things are important, so it is a dual effort.

Give some examples of the constituencies that public health will have to reach in order to implement its goals in environmental goals and HIV/AIDS. (CH 6)

Groups for environmental goals would be groups like the auto industry, oil companies, and political groups. HIV/AIDS would be the general public, young constituencies, third-world countries, and the economically disadvantaged.

Why do some public health problems pose "flashpoints" for conflict? What could be done about them? Give examples in the case of HIV and other problems. (CH 6)

Some create flashpoints because they are "hot-button" issues that are not well understood. AIDS/HIV was like this because it created a view of homosexuals that was not true because of misinformation. Also, some issues are viewed as moral problems as opposed to health problems. HIV was misunderstood and those who were affected by it were demonized for it until the disease was better understood.

How would you personally balance individual liberty, the common good, and social justice in public health? What would have to change to achieve this balance? (CH 6)

I would balance personally liberty first, with the common good and social justice next. I think it is important to have them all be relevant, but individual liberty is the most difficult to change and also difficult for populations to change. Exercising and eating healthy foods is a lifestyle choice, and public health needs to be conscious of trying to change lifestyles. I would work on incremental steps to help the transition be more effective.

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