What are the main roles of the government?
Maintain law and order, provide public goods, deal with market failures, and distribute income
How does the government provide public goods?
Direct production of services, financing of services, or regulation of the private market to produce services
What is public health?
Prevention focused, population centric method of preventing disease and promoting health through systems and policy
What is the largest health related department of the government?
Dept of health and human services (includes FDA, NIH, etc)
What does the Center for Medicare and Medicaid Services do?
CMS administers medicare, medicaid, state children's health insurance, and monitors HIPAA compliance
What is the role of the FDA?
Assure safety, efficacy, and security of human and veterinary drugs, medical devices, food supply, cosmetics, and radioactive substances. Regulates tobacco products, supports research, and supplies science-based info to the public
What is the role of the Agency for Healthcare Research and Quality?
Support research to improve health care quality and outcomes, reduce cost, reduce error, and broaden access. Responsible for guidelines
What is the role of the CDC?
Prevent and control disease, injury, and disability through investigation of problems, research, prevention implementation, and protection from biochemical terrorism
Which uses more of the HHS budget, Medicare or Medicaid?
Medicare (52%) uses more than Medicaid (33%) as of 2010
What are the main techniques of managed care?
Integrated delivery with selected providers, emphasis on preventative care, and financial incentives to encourage enrollees to use care efficiently
What is capitation?
System where healthcare service providers are paid a set amount for each enrolled person assigned to that physician or group, regardless of whether or not that person seeks care.
What is an HMO?
Coordinated delivery system that combines both the financing and delivery of health care. HMO's specify a list of benefits to all members, charge all members the same monthly premium, and are non-profit
What was the first form of managed care?
HMO's, brought about by the Health Maintenance Organization Act of 1973
What did the HMO Act of 1973 do?
Require employers with 25 or more employees to offer federally certified HMO options if they offered traditional health insurance
What was the major shift that came with the HMO era?
Transition from open economy of choice and personal expense to less choice and more benefits
What is the principle of supply sensitive care?
The greater the supply of health care resources, the greater the frequency of use of the care without regard to scientific evidence or medical theory
What is the principle of preference-sensitive care?
Choices of treatments based upon a patient's (or provider's) personal values and preferences
What is the Dartmouth model of rationing?
Based on supply-sensitive principle, if the US insured more people but did not increase supply of health care resources, cost of care would decrease (per person) while outcomes remain the same.
Based on the Dartmouth rationing model, what is the reason for current problems with lack of access?
The reason for lack of access right now is not lack of supply, but disorganization of care.
What is the death with dignity act?
Allows physicians to assist terminally ill patients with suicide and offers immunity from prosecution for the physicians
What is the essential measure for allocation of care under the NICE policy in the UK?
Quality adjusted life years
What is missing from healthcare "rationing" in the US right now?
Efficacy, outcome, evidence, long term cost of care
What is PPACA?
Patient protection and affordable care act is the Obamacare package that includes expansion of Medicaid, prohibition of denial of coverage, and establishment of exchanges
What was the original plan for the public option?
Subsidized public option for those making 133-300% poverty line and unsubsidized public option for those making more than 300% of the poverty line. Designed to compete with private insurers. Killed in HR 3962
What is the concept of "death panels"?
Informed end of life decision making through discussion of advanced directives with patients. Basically, Sarah Palin is a mindless dipshit and should burn in a grease fire
Does PPACA provide coverage for undocumented immigrants?
No, because undocumented immigrants are just figments of your imagination and are not real people
What were the primary focal points of the Meidcare debate?
Whehter or not the aged needed help with medical bills and what mechanism should be employed to cope with the problem. The argument was never whether or not the aged had a right to care (this was always accepted by all sides)
What were the three alternative approaches considered to cover the elderly?
Government subsidies for private insurers, direct government payments to low income elderly to use on healthcare, or health insurance as a part of social security (eventually Medicare)
What was the AMA's stance on government encroachment into healthcare?
Opposition based on Jeffersonian philosophy that government involvement in private affairs is unnecessary, unwelcome, and, only if deemed necessary, a last resort. Yay Jefferson!
When were the Medicare and Medicaid programs established?
With amendments to the Social Security Act in 1965 (Title 18)
What was the King-Anderson Bill?
The first foray into providing Medicare-like benefits to the elderly. Viciously opposed by the AMA
What was the Kerr-Mills Bill?
AMA supported alternative to the King-Anderson bill where federal funds were spent to serve the needs of medically indigent elderly people (not well-provided enough to fund their own care)
What was the AMA's biggest gripe with the King-Anderson bill?
All elderly people, even those who neither needed nor wanted assistance, were to receive it. This would put a drain on the system.
What was Eldercare?
A progression of the Kerr-Mills Bill that was proposed by the AMA instead of the King-Anderson proposal
What was the Byrnes Bill?
Republican-endorsed bill that, like Eldercare, called for coverage of both hospital and physician services for the aged through private insurance. Administration was to be federal, not by states
What was the final product of the debates over all these bills?
Medicare ended up as a fusion of the King-Anderson, Kerr-Mills, Byrnes, and Eldercare bills
What is Medicare Part A?
Similar to the King-Anderson Bill, includes hospital care for retirees financed by Social Security. No monthly premium but there is an annual deductible ($1,100 per hospitalization)
What is Medicare Part B?
Similar to the Byrnes Bill, provides supplemental, voluntary insurance covering physician services. Enrollees must pay a premium (income-based) which is matched by the government
How many people are currently covered by Medicare?
Almost 50 million Americans over 65 or under 65 with permanent disabilities
What is Medicare Part C?
Also called "Medicare Advantage," allows beneficiaries to enroll in a private plan (such as HMO) as an alternative to traditional fee-for-service. Members pay the same monthly premium as Part B but can also have an additional premium due to their HMO
What is Medicare Part D?
Outpatient prescription drug benefit delivered through private plans that contract with medicare. Enrollees pay a monthly premium with really poor people getting assistance
What are examples of things that Medicare does NOT cover?
Dental care, vision care, hearing exams/hearing aids, and custodial long term care at nursing homes or assisted living facilities
Does Medicare have a stop loss benefit?
No, there is no maximum out-of-pocket figure that beneficiaries are limited to. Many beneficiaries face significant out of pocket costs for premiums and beyond.
What is the "doughnut hole"?
The coverage gap in Medicare Part D between $2830 of total drug costs and $6440 of total drug costs. If you need $6439 worth of drugs, you're screwed!
How much of total federal spending in 2010 goes toward Medicaid/Childrens' Health Insurance Program?
How is spending in Medicare distributed (FFS vs. other)
10% of total Medicare beneficiaries on FFS account for 60% of Medicare spending (as of 2006). This further shows why FFS is unsustainable
According to the current trend, can Medicare Part A stay solvent?
No, at the current rate, Medicare Part A will be depleted of funds in 2017 (F our lives). However, changes made in healthcare reform should decrease spending and extend this projection (probably still F our lives, though)
What is the goal of Part D Medicare reform?
To gradually eliminate the doughnut hole by 2020. This involves requiring pharm companies to slash prices on prescriptions for those in the coverage gap
What is the most important goal of Medicare by 2014?
Require Medicare Advantage plans to have medical loss ratios no lower than 85% (this could put lots of for-profits out of business and pave the way for backdoor entry of another public option)
What is contributory negligence?
The idea that it's okay if you messed up but were honestly trying your best to help the patient. (Died in the 60's and 70's)
Why was the idea of "loser pays fees" destined to fail?
1. Local judges awarded huge fees to local paintiff's attorneys
2. Most plaintiffs are busto. When they lose, they are unable to pay.
As per the Medical Malpractice Reform Act of 1985, how much in insurance do physicians have to be covered for?
What two factors constitute liability?
Breach (fault) + Causation = Liability. Breach and causation must be established by expert testimony (opens the door to professional/phony "experts")
What is the False Claims Act?
Disallows billing for services not rendered, not medically necessary, or rendered by intern or resident.
What is one found liable for false claims responsible for?
Civil penalty of $5-10k plus treble damages
What constitutes violation of the False Claims Act?
Person who knowingly presents a fraudulent claim or knowingly presents a false record to get a claim paid
What does the whistleblower get in a false claims case?
15-25% if the gov't intervenes and 25-30% if the gov't declines
What is the main point of the anti-kickback statute?
Prohibits the offer or receipt of remuneration in return for referrals or purchase of supplies and services reimbursable under government health care programs
What is Greber Rule?
Part of anti-kick back statute; if even one purpose of payment is to induce referral, statute is violated
What is the punishment for violating the anti-kickback statute?
Exclusion from Medicare/Medicaid for a minimum of 5 years and further action from state medical board
What are safe harbors?
Regulatory or statutory criteria (such as risk sharing arrangements) that guarantees legality; if not within safe harbor, actions can still be legal but are at risk (except for Stark Law, where outside of safe harbors = definitely illegal)
What is the point of Stark Law?
Prohibits physician self referrals (referrals to a facility in which the physician has financial interest)
What is the big exception in all of the Stark Law safe harbors?
Compensation can NOT be based on volume/value of referrals