Health Care in the US Final

Issues with measuring outcomes

"hard", objective, outcomes like death rates are often irrelevant - functional outcomes (good measures for functional outcomes exist, but they are less intuitive to providers) - cost (an outcome, but not a health outcome)m

Externality

"transaction spillover" is a cost or benefit not transmitted through prices that is incurred by a party who did not agree to the action causing the cost or benefit. The cost of an externality is a negative externality, or external cost, while the benefit of an externality is a positive externality or external benefit

The US spends _______ on health care

$3.3 trillion

How much money did the HITECH Act invest in promoting EHR use?

$34 billion

Medicaid expansion was a key goal of the ACA

- 28 parties sued obama administration for abuse of federal power -NFIB - Supreme Court removed tax cuts and jobs act and decided that states could choose whether to expand medicaid

Limits to regulatory power

- 5th amendment, part of the Bill of Rights, 1789 - no person shall be deprived of life, liberty, or property without due process of law -14th amendment, 1868 - forbids states from denying any person - expanded civil rights protections to all Americans - cited more in litigation than any other amendment

Affordable Care Act and women's health

- ACA has helped women gain insurance and improved their ability to get health care - 31 million adult women enrolled in medicaid in 2019

HHS agencies

- CMS, NIH, Agency for Healthcare Research and Quality (AHRQ), food and drug admin (fda), Health resources and services admin (HRSA), centers for disease control and prevention (CDC)

Takeaways

- COVID-19 was viewed as a test federalism by requiring states to manage the pandemic as they saw fit. -federal guidance can serve as a template for state administrations, but varying levels of trust in the former president's - tradeoffs existed between state autonomy and diminished federal oversight

Supply sensitive care

- Care whose frequency of use is not determined by well-articulated medical theory, much less by scientific evidence -supply-sensitive services include physician visits, diagnostic tests, hospitalizations and admissions to intensive care among patients with chronic illnesses - idea that rates of care are driven in part by the supply of providers

History of forced sterilization

- Eugenics movement: sterilization of Black and ethnic minority women and women with disabilities (Buck v. Bell 1927) - practices continued in some states into the 1980s - coerced sterilizations reported in 2020 in immigrant detention centers

Framework

- Future challenges external: increasing complexity of issues faced by the US - Internal: increasing complexity of financing and delivery systems in health care, and serious cost problems - regulatory system flexible, evolving public-private partnership - in some cases we are seeing innovations to provide data to help consumers be "smarter" and thus make markets work better

Burwell v. Hobby Lobby (2014)

- Hobby Lobby sued HHS under religious freedom restoration act, arguing that the contraceptive mandate violated its religious rights - found that HHS had not used the "least restrictive means" in designing the mandate which burdens religious rights (despite its attempts at compromise with religious organizations) - found that closely held corporations can assert religious rights - held that Hobby Lobby (and small corporations like it) can refuse to cover certain contraceptives for employees

FDA history

- Kefauver-Harris Efficacy Amendment - amendment required evidence of efficacy, not just safety -increased/strengthened FDAs control over drug approval process -medical device amendments of 1976 - significant expansion of fda authority - rules for testing and approval of devices that are parallel to those for drugs -drug price competition and patient term restoration act of 1984: hatch waxman act: streamlined rules for testing of generics, required only proof of equal bioavailability

Planned Parenthood v. Casey (1992)

- New standard of review: does the state restriction impose an undue burden on the right to abortion? - the Supreme Court held that: 1. spousal notificiation laws were unduly burdensome. Parental consent laws and laws requiring a 24 hr waiting period and requiring that a patient be given information about fetal development before consenting to an abortion were not unduly burdensome - the court struck a compromise: maintaining the right to abortion under roe, while strengthening states' ability to regulate and restrict it

Walter Stewart at Western Electric

- Stewart introduced idea that any production process, when examined using statistical methods, had a predictable and constant number of errors - error rate is a function of the production process or system (NB: not of the system operators, but of the system itself)

Abortion: roe v. Wade 1973

- Supreme Court held that laws criminalizing abortion violated the right to privacy under the 14th amendment due process clause - court based its interpretation of privacy as fundamental right on Griswold - it weighed the rights of women to self-determination against the potentiality of human life - it used a trimester framework to determine at which points in a pregnancy the state may regulate access to abortion

Dobb's v Jackson women health 2022

- Supreme Court overruled roe and Casey - held that the right to abortion is not a fundamental constitutional right - left it to the state legislatures or congress to determine if abortion should be banned or restricted - changed the standard of review that courts will use to determine if abortion restrictions infringe on women's rights: state must now only show that it has legitimate interest in restricting or banning abortion, not a compelling interest as under roe

How do you ask them?

- Surveys in the office, telephone surveys, mail surveys, internet surveys NB: measures of interpersonal care or patient experience are now often part of quality measurement approaches

Take home messages

- The executive branch has a critical role in implementing the sense of legislation through the development of specific regulations; laws passed by congress are often vague, the executive brach fills in the details; the act is a particularly important example of this because its scope and reach are so great

According to Yong's Atlantic piece, "We're Already Barreling Toward the Next Pandemic", which of the following are TRUE?

- When adjusted for inflation, the Apollo plan will have had a higher governmental budget than the pandemic plan. - The U.S. was low-ranked in terms of pandemic preparedness.

Disparities in Pap test use by sexual behavior and HPV vaccination

- Women with only female sexual partners were less likely to get a Pap test vs. women with only male sexual partners: Disparity completely attenuated by health care factors - Lesbians were less likely to have initiated HPV vaccination vs. heterosexual women: disparity only inly slightly attenuated by health care factors - additional research needed to identify mechanisms of sexual orientation disparities in HPV vaccination.

Summary

- Women's health and well-being is worse in the US than in most other wealthy nations - many policy-related structural issues drive these poor outcomes - recent legal and policy changes threaten to exacerbate poor access to reproductive healthcare and worsen outcomes - women of color and low-income women are most at risk

Unwanted variation

- a more nuanced look (underuse of effective care, overuse of supply sensitive care, misuse of preference sensitive care)

The ACA coverage of contraception

- act requires coverage of essential benefits including preventative services - HHS during Obama admin wrote regulations requiring that most contraceptives be covered by health plans for free - religious organizations argued they should not have to cover contraceptions and Obama admin created opt-out - catholic orgs rejected compromise and continued to fight in court. Supreme Court has sided with religious orgs, saying they are not required to cover contraceptives

Legal basis of regulatory power

- administrative procedures act is a road map for administrative decision making

October 22, 2020: remdesivir

- antiviral medication: US food and drug administration (FDA) Emergency Use Authorization (EUA) - federal program began on May 1, 2020 -reduces illness severity - for hospitalized patients

Take home messages

- as costs rise, issues related to regulation will only become more prominent and complex - government is involved in virtually every domain of regulation but so is the private sector - state governments have responsibility for professional licensing, but they give physicians permission to design and implement the process (Boards of Registration) - state governments have responsibility for hospital and institutional licensing, but JCAHO actually does it (most of the time) - employer based insurance and federal tax expenditures

CDC responsibilities

- broad mandates to address health, safety, and security threats at home and abroad - detect and respond to new and emerging health threats - address leading causes of death and disability - promote healthy communities and best health practices - develop a public health workforce

Through medicare

- certification of participation required: can come through JCAHO certification - EMTALA: hospitals that participate in Medicare must provide appropriate emergency care - Clinical Laboratory Improvement Amendments (CLIA): quality standards for laboratories that bill Medicare

Framework

- complexity - confrontation state-federal balance: Supreme Court decisions on ACA; population vs individual health; acute vs. chronic diseases; public vs. private sector role; compromise

Preference-sensitive care

- comprises treatments that involve significant tradeoffs affecting the patient's quality and/or length of life - decisions about these interventions - whether to have them or not, which ones to have - ought to reflect patients' personal values and preferences, and ought to be made only after patients have enough information to make an informed choice

certificate of need goals

- control health care costs by restricting duplicative services - determine whether establishment or expansion meets a community need

secondary uses EHR

- decision support (development), quality, research, education, public health, regulation

malinformation

- deliberate weaponization of content produced by institutions (headlines, research); deliberate change of context or geniine content, deliberate leaking of genuine content to cause harm

Drugs and healthcare products

- drugs, devices, and other health products are the tools needed for modern care - rapid technological change - key drivers of cost increases - foods, and cosmetics that are consumed in our day-to-day lives

Eligibility/intention

- eligibility for medicaid is determined by the states: working parents 16-206% FPL. Working childless adults 0-211% FPL -ACA intention to decrease the number of uninsured children medicaid: if income under 100% FPL. Insurance marketplace: if income 100-400% FPL

take home messages

- examining variations, and learning how to reduce inappropriate or unnecessary variation

Role of medical documentation

- facilitates diagnosis and treatment - ensures patient safety - reduces medical errors - enables efficient communication between caregivers -fundamental to the care of patients - essentials for secondary uses of information - supporting patient care - legal report of medical actions - supporting research - education - healthcare management and billing

Process vs. Outcome

- goal of health care is to improve health outcomes. it follows that the ultimate goal of quality measurement and quality improvement is to improve health outcomes.

Types of regulation

- government imposed legal restrictions - self-regulation by a trade organization - social regulation (social norms) - market regulation

take home

- hc systems are very complicated, and there is substantial literature to draw on about cost and quality - total dollars spent = units of price - though there are exceptions, generally in the US units to do explain spending differences. - there is broad agreement that admin costs could be reduced but doing so is difficult

healthcare experiences

- health services research studies research studies show that women report experiencing gender bias, disrespect, and dismissal of symptoms by clinicians - studies on whether gender concordance (when the patient and provide are the same gender) improves care are mixed

women and healthcare costs

- higher share of women forgo health care services due to cost compared to men

Solving this problem is not simple

- if you create incentives to cut costs in high spending on the right things - possible approaches : bundling and ACOs; increase incentives for high value, low cost services -generate and disseminate better data about variations and cost effectiveness -shared decision-making tools

Case Study: Mississippi

- in addition to not expanding medicaid, MI has one of the lowest medicaid eligibility thresholds in the nation at 26% the FPL - consequently, half of Mississippis rural hospitals are at risk of closure because they are overwhelmed by uncompensated care - one of 31 states that has not enacted a minimum wage higher than the federal level of 725 per hour approximately 1/5 of MI receive food stamps through snap, the highest of any state

expansion states medicaid

- in expansion states, higher rates of medicaid coverage and fewer uninsured among postpartum women

Women of color and chronic disease

- indigenous, Latina, and black women have higher rates of: heart disease, stroke, diabetes, cancer - intersectional experiences of discrimination and lower-SES are associated with allostatic load (chronic stress) which are thought to play a larger role in these disparities

Take home messages

- intense focus on quality and disparities, and better and better data - some real progress but many persistent challenges remain - quality improvement does not necessarily mean that disparities are being eliminated -critical trend (using market forces to drive quality improvement) - public reporting and pay for performance who is driving this evolution? - AHRQ: collecting and disseminating data -both private and pub lic payers - new private orgs that have developed to meet the needs of payers often formed by purchasers (employers)

violence and reproductive health

- intimate partner violence often is initiated or increases during pregnancy - homicide is the leading cause of death for pregnant women - access to reproductive healthcare that takes into account a woman's social risk factors is vital to health and safety

Impact of the pandemic of misinformation

- legal mandates that override provider care - regulation of provider speech - lack of trust

COVID-19 vaccines: US FDA EUA

- mRNA vaccines: December 11, 2020 - Pfizer biontech: ages 12 years older / two doses, 21 days apart December 18, 2020 - moderna - ages 18 and older two doses, 28 days adenovirus vaccine - feb 27, 2021 - Johnson ad Johnson ages 18 and older one dose

Disparities by race

- magnitude of sexual orientation disparities in Pap test use differed between black and white women. Disparity completely attenuated by health care factors among white but not black women. - magnitude of sexual orientation disparities in HPV vaccination varied in relation to both sexual orientation and race. Disparities only slightly attenuated by socioeconomic and health care factors. - additional research needed to identify mechanisms of sexual orientation disparities in pap test use among black women and hpv vaccination disparities among sexual orientation and racial subgroups

Disinformation actors create false or misleading content to

- make money (eg driving traffic to their websites so people click on aids, promoting fake covid 19 tests, asking for donations) -for political gain -social or psychological reasons: to connect with a group of people who are just trying to see what they can get away with. eg hoaxing journalists to see if they can turn them to run with wrong information.

Porter paper

- makes the argument against process measures and for outcome measures. - argues that risk adjustment methods are mature and ready for prime time (though debatable) - basic premise: assessing value requires a focus on outcomes (is correct) - debate is about technical problems of measuring risk and adjusting the outcomes

Ways to regulate

- many different types of consequences, or ways to induce behavior change

Measuring technical care

- many processes contribute to any outcome: think of hospitalization for heart attack or treatment of lung cancer; or the cervical cancer screening example - quality of evidence about process-outcome links varies - for any process measure there are practical issues related to the cost, convenience, and validity of the measurement process

Why is regulation necessary?

- markets can "fail" in a variety of ways - development of monopoly or oligopoly power - collective action or public good - inadequate information - unseen externalities

Summary: measuring quality

- measurement science continues to develop, for structure, process, and outcome - science of risk adjustment relatively well developed for some outcomes, but imperfect - drive for standardization of measurement - examples of organizations that review and certify measurement tools (NCQA) NQF

HHS duties

- medicare (health insurance for elderly and disabled Americans) and medicaid (HI for low income people) - medical and social science research -preventing outbreak of infectious disease, including immunization services - assuring food and drug safety - financial assistance and services for low-income families

Preference sensitive case

- misuse of preference-sensitive care refers to situations in which there are significant tradeoffs among the available options. Treatment choices should be based on the patient's own values (such as the choice between mastectomy and lumpectomy for early-stage breast cancer); but often they are not

NIH history

- modern NIH began to take shape just before WWII -1937: National Cancer Institute formed 1940: NIH campus in Bethesda, Maryland opened -WWII: science and technology helped win the war 1944: Public Health Service Act, building on the NCI model, funded private scientists more broadly US research infrastructure is the envy of the world

Take home messages: misuse

- modern medicine and safety problems: Patients: complex, chronic illnesses hospitals: can be dangerous places treatments: often highly effective but with risks - systems are evolving to handle these risks, but there remains lots of room for improvement. Accountability: inpatient, outpatient, across care spectrum

managed care: private regulation

- national committee on quality assurance (NCQA), 1990: private accreditation organization created by the managed care industry to supervise quality

Elements of compromise

- national industry requires some national oversight - state-level regulation - private professional organizations

The argument

- need for these procedures logically can't vary this much by geography -patients' native preferences logically can't vary this much by geography - it has to be the preferences of the physicians practicing in these communities that is driving these variations in rates

technical vs. interpersonal care

- one could argue, at least for the care of chronic diseases, that this is an artificial distinction - high quality interpersonal care, at least for chronic care, is required for good technical care to be implemented - return visits, medication adherence, behavioral changes

block grants

- one large sum of funds - requires budget neutrality - broadly defined provisions - minimal or no rules - greater flexibility for the state ex: subsidies to create a state-run exchange - states can design their policies based on need - encourages innovation

rapid development of therapeutics and vaccines

- operation warp speed 18b sprint for a vaccine

Patient Safety Movement

- origins of errors: human factors, medical complexity, system failures - a new patient safety discipline has developed - role of technology such as eMr and computerized physician order entry - tremendous opportunities in these areas

CDC: covid

- part of White House coronavirus task force/ White House covid response team - developed diagnostic testing for SARS-CoV-2 - guidance and education - mask wearing - isolation and quarantine - schools/restaurants - nationwide vaccine rollout

Primary uses EHR

- patient care: delivery, management, support - billing and reimbursement

Categorical grant example - medicaid

- provides healthcare to certain low-income individuals - open ended matching - match rates are set inverse to fiscal capacity - higher rate/percentage = state with less income - fiscal capacity measured by per capita income

Quality Assurance Approach

- quality assurance is the concept of inspection or culling, throw out defective products or "bad apples" - focus on the "tail" of a distribution that does not meet standards - find the individual that is the source of the mistake

underuse

- random sample of adults in 12 communities - phone call followed by request to review medical records - review of the medical records for adherence to standards of care for multiple conditions

Categorical grants

- recipient matches a portion of funding: allocates federal money to states according to a specific formula depending on fiscal capacity - narrowly defined purpose and populations - includes administrative and reporting requirements - seeks to ensure both financial and program accountability

Evidence Based Medicine

- refers to a set of methods, developed in the last 20 years, that are used to evaluate and summarize the information in the published literature; ranking the quality and generalizability of evidence

Legal basis of regulatory power

- regulatory power has a unique role in US system of laws -agencies require specialized knowledge, expertise, and resources: legislation doesn't try to address/resolve technical issues, but creates mechanisms to do so - while leadership positions at federal agencies are federal appointees, staff remains in place

Managed care: state regulation

- remember: HMOs have both financing and delivery system feature - the insurance (financing) features of "fully insured" private/commercial insurance are regulated by states - RI has an office of the health insurance commissioner

Sexual orientation and cervical cancer

- sexual minority women are at risk of acquiring HIV (bisexual > heterosexual> lesbian) - SMW are at risk of developing cervical cancer: SMW who acquire HPV may be at higher risk of cervical cancer vs. non-SMW - Health insurance, access to health care, smoking

social and structural drivers of women's health

- single parenthood - poor nutrition - housing instability and poor quality - intersectional discrimination for low-income women (racial, ethnic) - stress

advantages of measuring technical processes

- some measures can be relatively simple, which makes comparisons relatively simple. Most accepted quality measures of technical processes

Hospitals: state regulation

- state licensure, in theory, is primary oversight mechanism for hospitals and other health organization - joint commission on the accreditation of healthcare organizations (JCAHO) - JCAHO certification can satisfy requirement for state licensure: 80% of hospitals choose this root - the other 20% choose state mechanisms

Marketplace types

- state-based marketplace (SBM): states responsible for performing all marketplace functions consumers purchase their health plan on state exchange - state-based marketplace federal platform - states rely on he federally-facilitated marketplace IT platform. Consumers purchase their health plan on healthcare.gov state0-artnership marketplace: states conduct plan management and may administer in person consumer assistance. HHS performs the remaining marketplace functions. Consumers purchase their health plan on healthcare.gov Federally-facilitated marketplace: HHS performs all marketplace functions consumers purchase their health plan on healthcare.gov

Pros and cons of federalism in COVID

- states have autonomy to tailor containment efforts to their specific populations and communities - states can exercise agency if they disagree with federal policy or pandemic response cons - patchwork response to epidemic - sub-optimal federal leadership can affect local leadership - states may not receive adequate funding to accomplish the policies they deem appropriate - state-specific inequities can be exacerbated

Federal/state interplay

- states/local authorities are the enforcers of federal orders and handle other measures beyond federal authority - states can ignore federal guidelines or can go beyond - states would have to consent to being put under federal direction - jurisdictional boundaries are strictly maintained in part to preserve limited budgets - states may want to follow federal guidance but may be hamstrung by limited resources.

Supports for new parents

- the federal Family and Medical Leave Act of 1993 provides the right to unpaid leave - no federal paid family leave - no federal paid sick leave - 11 states including rI have some form of paid family and medical leave

take home messages

- theory: independence of regulators and regulated - practice: interdependence " the most knowledgeable people are also the most conflicted" - ib health care in the US, regulation and oversight can have federal, state, and private components - think about regulation as necessarily fluid, responsive to many forces

After congress passes laws

- there is a complicated process to put law into practice - laws often do not include al details to explain how to follow the law or how to make the law work - congress authorizes government agencies in executive branch to create regulations to implement laws - agencies are authorized to take executive, legislative, and judicial types of actions in the course of implementation (policies are modified and uptake varies)

Funding for abortion

- they Hyde amendment: federal funding may not be used for abortion services - states may prohibit Medicaid programs from funding abortion -courts have rejected lawsuits challenging funding restrictions, saying that they did not burden access or violate roe or Casey

those who spread misinformation do so because

- they like to feel that they have new information that others don't know - they want to protect the people they care about - they may be seeking explanations or wanting to share information that helps them make sense of events - they want to feel connected to others

Cervical cancer in trans masculine people

- trans masculine people are at risk of acquiring HPV: sexual partners of various genders and sexual violence -transmasculine people are at risk of developing cervical cancer: health insurance, access to care, smoking

Conspiracy theories take advantage of

- trusted spaces to push their own content in comments and replies

Summary comments on overuse

- variations can be seen in all dimensions of care: diagnosis and treating - seen more often in when there is lack of consensus about what is appropriate - in general, areas in which spending is higher do not show higher quality care, better patient outcomes, or more satisfied patients

- medical records

- what you can find in medical records - medical records can be incomplete and if not electronic can be difficult to review - expensive and time consuming, even if they are electronic

Measuring interpersonal care

- you have to ask the patient - ask about things they are uniquely qualified to answer - what do you ask them about: service quality, communication quality, more complex concepts (satisfaction)

economic regulation: hospital supply and rates

-Hill-Burton construction funding; goal was expansion - Certificate of need (CON) programs; hospitals had to get permission to build or expand - goal was contraction - federal legislation requiring CONs lapsed in 1986 - today 36 states require CONs: federal program has reverted to some states

Supply Sensitive Care

-Overuse of supply-sensitive care is particularly apparent in the management of chronic illness (such as admitting patients with chronic conditions such as diabetes to the hospital, rather than treating them as outpatients) - the cause is an over dependence on the acute care sector and a lack of the infrastructure necessary to support the management of chronically ill patients in other settings

Breyer, Sotomayor, Kagan dissent

-court has decided that from the moment of fertilization, a woman has no rights. Rejected roe's balance of interests for state and women; removed right to bodily autonomy and is jeopardizing health, especially for low-income women

NCQA

-private regulatory entity - created by plans to regulate plans - has become a trusted entity - taking a leadership role in quality measurement and reporting - producing information so that markets can work

How to decide what processes to assess

-strong evidence of process-outcome linkage

Take home messages

-there are many forms that regulation can take; all markets need regulation of some kind; heath care markets -as you know well by now - are particularly complex, and therefore require regulation; regulation focuses on cost, access, and quality; but particularly on cost; the triple aim is slightly different: better care, better health, lower cost

According to Tobin-Tyler's book, Essentials of Health Justice, approximately how many women will have an abortion in their lifetime?

1 in 4

According to the article by Roszko et al., "Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm Related Injury," firearm-related injuries are the second-leading cause of death overall among what US age group?

14-24 years

According to Claire Wardle's article, "Misinformation has created a new world disorder", what proportion of journalists are trained on how to responsibly report misinformation?

15%

FDA History

1848 Drug Importation Act US dumping ground poor quality drugs that were unmarketable in Europe Soldiers of the Mexican-American War facing high casualties that were attributed to the administration of weak and adulterated drugs Banned food and drug adulteration Imported drugs had to meet the standards for strength and purity Pure Food and Drug Act of 1906 - prohibitions against "adulteration and misbranding of foods and drugs in interstate commerce" - required food ingredients be listed on packages - for drugs, required that dangerous ingredients such as alcohol, heroin and cocaine be listed

CMS History

1965: Medicare and medicaid enacted 1972: medicare extended to those with ErSD 1973: HMO Act passed 1980: medical (a private plan) brought under federal oversight 1982: quality oversight expanded to include peer review organizations (PROs), which in 1992 became quality improvement organizations (QIOs) 1986: EMTALA 1997: Balanced Budget Act of 1997 - SCHIP 2003: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA), created part d (medicare drug coverage) and created Medicare Advantage 2010: ACA - cost savings through MA, prescriptions drugs, preventive services, expanding access, cost-containment

History of AHRQ

1989: created as part of the Omnibus Budget Reconciliation Act of 1989, called the Agency for Health Care Policy and Research (AHCPR) Part of charge: clinical guideline development - 1993-1995: conflicted with drug and device industries, and with surgeons, who disagreed with evidence about the lack of effect of back surgery for low back pain 1994: Republican control of House and Senate (Gingrich "Contract with America") 1995: budgetary battles and near elimination of the agency 1997: Dr. John Eisenberg became director reframing, new directions for agency 1999: reauthorizing legislation changed name to the Agency for Healthcare Research and Quality (AHRQ), dropped guidelines focus

HRSA History

1990: Ryan White Comprehensive AIDS resource emergency (care) act begins providing support for ppl with HIV/AIDS 2010: ACA increases funding to community health centers (11b)

Publication of To Err is Human

1999 - 44k-98 preventable deaths in the US annually due to errors in hospital care - 7000 due to medication errors -similar efforts to quantify adverse events all over the world - system focus

According to The New Yorker article, "Why Physicians Hate Their Computers", for every hour spent face to face with a patient, physicians spend ______ doing work

2 hours

According to the IOM 2010 report, what percentage of healthcare spending goes to waste?

30%

According to the Kellerman and Rivara article in Jama, "Silencing the Silence on Gun Research," approximately how many US residents die each year from firearms?

30,000

In "Avoiding Overuse - The Next Quality Frontier," Berwick states that approximately how many total knee replacements in the US are inappropriate per year?

34%

Current status of state medicaid expansion decision

40 states including DC have adopted Medicaid expansion and 11 have not SD voters approved ballot measures that add medicaid expansion to their state constitutions. Expansion coverage set to begin on or before 7/1/23

According to the KFF health tracker, a pregnancy resulting in a cesarean section bears an average total cost that is __ than vaginal deliveries

77% greater

According to the Gawande 2018 article, about what percentage of hospitals have been computerized within the last decade?

90%

Employer-provided health insurance benefits arose in the mid-20th century as a result of A. A Supreme Court ruling that health insurance could be included in the collective bargaining process B. Unions and employee-rights groups demanding access to health insurance C. An executive order requiring employers to provide health insurance to employees. D. The passing of the Social Security Act of 1965

A Supreme Court ruling that health insurance could be included in the collective bargaining process

Which of the following is true according to "What are Health Disparities and health equity? We need to be clear"?

A social disadvantage may be due to income, race, ethnicity, or sexual orientation

what is an "all-payer system" (such as that seen in Maryland)?

A system where all insurers and public programs pay the same amount for healthcare

What is one major benefit of having multiple competing interests in the regulation of health care according to Robert Field? A. It ensures that no one regulatory power becomes too powerful. B. It drives dow the price of delivering healthcare C. It stimulates compromise between physician and patient D. all of the above

A. It ensures that no one regulatory power becomes too powerful

According to Robert Field, what is the primary reason health care regulation is so complex? A. There are a variety of regulatory bodies with competing interests. B. The lobbying power of the AMA is too strong C. Many practicing doctors are not training in America and medical procedures are not standardized. D. The average patient is becoming more and more knowledgeable

A. There are a variety of regulatory bodies with competing interests.

States, ACA, and health insurance exchange

ACA allowed states to decide whether to create their own health exchange states could apply for a waiver to fund the creation of an exchange if a state did not create their exchange, then they automatically used the fede4ral exchange - states opposed to the ACA often refuse to create their own exchange

State legislation in response to COVID-19

AL: HB448 - extends postpartum coverage period for pregnant women sC: SB 1161 - requires all individual and group health insurance plans, health maintenance organizations and the state health plans to waive cost sharing requirements associated with testing for COVID-19

What was the direct result of Dobbs v. Jackson Women's Health Organization (2022)?

Abortion's legality was left up to the states to decide

CMS responsibilities

Administer Medicare CMS contracts with private companies (Fiscal Intermediaries under part A and Carriers under Part B) to process and pay claims Administer Medicaid and CHIP This duty is assigned to state agencies who receive funding support from the Federal Gov Regulate all laboratory testing on humans

According to Tufekci's article, "The Unvaccinated May Not Be Who You Think," which demographic group has the lowest rates of vaccination rates in New York City as tracked by the city?

African-Americans

According to "Will 2020 Be the Year that Medicine Was Saved?" the pandemic led to:

An acceleration in the shift from hospitalizations to clinic and at-home care

Intersectionality

An interdisciplinary analytic tool rooted in black feminist theory and practice that allows us to more accurately capture the complexity in the world which are shaped by multiple social inequalities and power relations that act in diverse and mutually influencing ways.

What does API stand for?

Application Programming Interface

What is the purpose of the Public Health Service Act (PHSA)?

Authorizes the HHS secretary to prevent spread of communicable disease regardless of emergency declarations

Which of the following has been a historic reason against changes in the financing and delivery of health care?

Beliefs and values

In the 2021 KFF Women's Health Survey, for which of the group(s) is extending postpartum health coverage for a full year after childbirth a top priority for the majority of the group?

Black women, women with incomes below 200% of the federal poverty level

What were the first prepayments plans in America during the Great Depression?

Blue Cross and Blue Shield

First National Academy of Sciences report

Built on To Err is Human - 8 goals for effecting progress on diagnostic error and improving patient outcomes

Federal vs. state Govs in promoting public health

CDC health departments, vital statistics, water supply

Federal and State regulation of facilities

Certificate of need: state law for establishing or expanding health care facilities and services in a given area; evidence of need (Early CON programs typically regulated capital expenditures greater than 100k facilities expanding their bed capacity and facilities establishing or expanding health care services)

what services did Title X of the Public Health Service Act provide?

Contraception and HIV treatment

Delayed health care

Coronavirus caused more than 10 million adults to lose health insurance

What is one major downside of having multiple competing interests in the regulation of health care according to Robert Field? A. Healthcare policy is enacted hastily and without much thought B. Compromises between competing factions are rarely made. C.Medical schools are struggling to teach future doctors about all of the rules they must follow D. Some regulatory bodies do not have an interest in protecting the public

D. Some regulatory bodies do not have an interest in protecting the public

Which is not one of the reasons for rising health care expenditures as articulated by Shi and Singh? A. Growth of technology B. increase in the elderly population C. cost-insensitive consumers D. increase in the population of foreign-born physicians

D. increase in the population of foreign-born physicians

According to Austin Frakt in his NYT article, "Value of Care was a Big Goal. How Did it Work Out?" which of the following is true about current value-based programs?

Despite promising early analyses, the Hospital Readmissions Reduction Program has not had much of an impact on spending or quality

Main idea Walter Shewart

Don't over react to individual defects, analyze and fix the production system that created them; shift the whole curve (in this case upward, toward higher % on time)

Take home points

Each element of the triple aim remains a big challenge: improving the individual experience of care, improving the health of populations, reducing the per capita costs of care for populations

Monoclonal antibodies: November 2020

Eli Lilly, regeneron FDA EUA - federal program, 300k doses of each -reduces hospitalization risk for 65 years of age and older or medically at risk

What was the name of the medical software used by Gawande in his 2018 article "Why Physicians Hate Their Computers"?

Epic

What was the outcome of Buck v. Bell (1927)?

Eugenic sterilization became legally sanctioned.

Which of the following branches of government is a supplier of policy?

Executive, legislative, judicial

The 21st Century Cures Act requires that

Existing certified EHR products must allow health information to be assessed and exchanged across different formats

What is a recent NIH-funded initiative on prevention of firearm injuries, mentioned in the NEJM article, "#ThisIsOurLane: Firearm Safety as Health Care's Highway"?

FACTS

True or False: Most private insurers incentivize use of a standard open API in EHR use within their provider networks?

False

True or False: Research about healthcare disparities and structural racism is now frequently published in major medical journals according to Bailey's NEJM article.

False

True or False: providers and payers use a standardized set of outcome measures and definitions of healthcare quality.

False

True or False: the existence of so many specialty areas gives physicians greater power in health care policy?

False

True or false: According to Tobin-Tyler's book, Essentials of Health Justice, heart attacks in women are overdiagnosed because women are often perceived as being overly sensitive.

False

True or false: growth in healthcare spending can be accounted for by aging Americans and increasing population size

False

Takeaways federalism

Federalism is the way the federal and state governments share power responsibility states have an important role in regulating health, particularly regulating insurance and health care facilities states have different levels of federal funding depending on their fiscal capacity waivers are used for innovative ways to experiment in providing health care to a state's residents block grants have the potential to allow states to provide care more efficiently, but may exacerbate differences between states

Based on "How Decades of Racist Housing Policy Left Neighborhoods Sweltering," all of the following are true EXCEPT:

Formerly blue-lined neighborhoods have more paved surfaces that absorb more heat

educate and train health workforce

Funds medical schools, grants and loans for medical training License physicians and other health professions, operate state medical schools

What does the Consumer Price Index measure?:

General inflation

What is the problem with germ theory as Ed Yong puts it in his Atlantic article

Germ Theory undermines social causes of disease

Which of the following statements were made in the article by Goldstein et al., "Behavioral Health Care and Firearm Suicide"?

Greater behavioral health treatment capacity may have a modest protective effect on firearm suicide; clinicians can play an important role in reducing firearm suicide

Legal restrictions on Access to Contraception

Griswold v. Connecticut (1965): Supreme Court found law criminalizing distribution of contraception unconstitutional under the 14th amendment. First case to interpret a right to privacy based on language in 14th amendment.

In the NEJM article by Ranney et al. "#ThisIsOurLane -- Firearm Safety as Health Care's Highway," what does the hashtag, #ThisIsOurLane, refer to?

Gun violence is an appropriate issue for all healthcare professions

Take home messages

HHS agencies have diverse missions in support of public health; relative size of his agencies vary widely; regulation is not static; the federal bureaucracy is constantly in evolution as the problems that face the country change; federal power and authority has grown over time, creating conflict

regulate health insurance and pharmaceuticals

HHS, FDA license insurance plans

Which of the following describes the trend in federal health grants

Health grants to states and local governments have significantly increased over time

How does the Prospective Payment System for Medicare work?

Hospitals are paid a predetermined fee per patient for a hospital admission

How does the Prospective Payment System work

Hospitals are paid a predetermined fee per patient for a hospital admission

Which is a recommendation made by Adler and Mistein for improving health IT from the patient's perspective?

Improve patient's access to data created at the point of care; enable patient participation and contribution to care delivery and health management; more readily engage patients in research

In the Gawande 2009 article, Doctors Hospital at Renaissance is known for

Incentivizing physicians to send their patients there for procedures and tests which are probably unnecessary

"How Decades of Racist Housing Policy Left Neighborhoods Sweltering," states that the difference in life expectancy between Gilpin and Westover Hills may be due to

Increased air pollution due to highway proximity; old electric wiring cannot handle the air-conditioners provided by the city; lack of proximity to grocery stores, public transportation, and primary care physicians; increased incidents of chronic conditions, such as asthma, diabetes, and high blood pressure

Which of the following are principles mentioned by the JAMA article, "Presidential Powers and Response to COVID-19", key to achieving a careful balance between public health and individual rights?

Interventions should be evidence-based, without political considerations; coercive measures should be proportionate to the threat faced; health officials should make individualized risk assessments

According to Fuchs in "Is US Medical Care Inefficient?" the fact that life expectancy is lower in the US compared to other high-income countries

Is not sufficient proof that the U.S healthcare system is inefficient

In Gawande's 2009 article, the town of McAllen in Texas is distinctive because

It is the town with the highest health care expenditure in the nation

Disinformation is not designed to change minds

It's designed to sow chaos and confusion over time so no one knows who to trust anymore

TQM/CQI in US Health care

Joint Commission for Accreditation of Healthcare Organizations (JCAHO) has used QI approproaches for 20 years - practice improvement module in American Board of Internal Medicine (ABIM) recertification process. - medical schools and house staff training increasingly teaching principles of teamwork, root cause analysis

Hospitals: private quality oversight

Joint Commission on Accreditation of Healthcare Organizations (JCAHO); - Surveys each organization every 3 years - formerly very process oriented: look at many things including completeness of medical records, minutes of medical staff committees, quality assurance and improvement processes, operating room procedures - last 10-20 years: focus on outcomes and quality improvement - JCAHO surveys not considered "friendly visits" by most hospitals

According to the article by Roszko et al., "Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm Related Injury," which of the following factors appear to reduce the frequency of physicians screening for firearm access or providing injury prevention counseling?

Lack of formal training; feeling that suicide was not preventable; believing that patients were unlikely to follow their advice

Tufekci's article, "The Unvaccinated May Not Be Who You Think," mentions research done by the KFF on the uninsured. What was the most powerful predictor of who remained unvaccinated according to this research?

Lack of health insurance

Which of the following is true about travel restrictions, according to the JAMA article "Presidential Powers and Response to COVID-19"?

Large-scale domestic travel bans are legally problematic since judicial precedents suggest this is a constitutional right

The JAMA article, "Presidential Powers and Response to COVID-19" says that: Group of answer choices

Large-scale domestic travel bans are legally problematic, since judicial precedents suggesting it is a constitutional right

In the US Surgeon General's Advisory about health misinformation, what actions are recommended for individuals, families, and communities to take?

Learn how to identify and avoid sharing health misinformation; provide alternative explanations and sources of information for those who may hold some misperceptions

Compared to the US, physicians in other high-income countries are _______ likely to prescribe newer, more expensive versions of drugs when equally effective versions are available

Less

Which of the following is the responsibility of state governments? A. Funding medicare B. licensing C. collecting health statistics D. B and C

Licensing and collecting health statistics (D)

Which of the following groups benefited the most from health insurance coverage due to Medicaid expansion under the Affordable Care Act?

Low-income adults

States and the origin of the ACA

MA launched its health reform initiative in 2006 based on the principle of shared responsibility among Indivs, gov, and business building on the existing system , the state expanded its medicaid program, created a new subsidized program through a health insurance exchange, instituted insurance market reforms to make insurance more available and affordable. Required individuals who could afford it to purchase insurance.

Which act of congress delegated authority to the states to regulate insurance

McCarran-Ferguson Act

What is the effect of implementing medical homes on health care expenditures?

Medical homes have little to no effect on health care expenditures, except when providing care to chronically ill patients

The Centers for Medicare and medicaid services administer

Medicare and Medicaid, CHIP

History of federalism in health care

Minimalist period: local and federal government were separate in providing health care emergent period: Increasing state and federal; presence Growth period: 1965 - medicare and medicaid post reform - present 2010 - the Affordable care act

What is the likely explanation for macro-level inefficiencies in the US hc system according to Fuchs?

Misallocation of resources; fragmented financing of health care; excessive technology use

Which of the following statements is/are true according to Claire Wardle's article, "Misinformation has created a new world disorder"?

Misinformation is caused by confusion; malformation and disinformation are deliberate

According to the article by Roszko et al., "Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm Related Injury," which of the following was a major finding about patient attitudes regarding firearm screening and safety interventions?

Most patient groups reported that discussing firearm safety with their physician was a lower priority when compared with other preventative health topics

Takeaways:

Much of the ACA was based on a set of 2006 health insurance reforms in MA medicaid operates as a state-federal partnership decisions to expand medicaid and create a state-run exchange exacerbated differences in insurance rates between states

How to effectively address intersectional disparities

Multilevel interventions tailored to the specific needs of SGM people of color are needed to effectively address intersectional disparities.

Claims databases

NB: all FFS reimbursement requires that claims be filed - also called administrative data - if no bill for this, there is no record - poor recording of things like race/ethnicity - "errors" such as family history of diabetes being confused with history of diabetes

Regulation of managed care

NCQA: what do they measure? - structural features of HMOs: how providers selected, size of provider network - patient satisfaction type measure : ease of enrollment, responsiveness to enrollee inquiries - Health Employer Data information set: Clinical performance (preventative care, screening, measures of disease management)

Legislative Action

Patient safety and quality improvement act (2005) - development of national safety reporting system -provided legal protections for reporting of data about safety-related events -allowed reporting of anonymous, aggregated data - authorized the creation and maintenance of National Patient Safety Databases (NPSDs) - processes for certification of patient safety organizations - regular reporting of national data

The NYT article "As coronavirus deepens inequality, inequality worsens its spread" states that:

Poor workplace protections and employees still going into work while sick may have prolonged the H1N1 pandemic

According to Koller's editorial, "Provider Payment Reform: Right Course, Wrong Students?" recent research has found that:

Practices with higher shares of PCPs had lower costs and higher quality of care

According to the NEJM article by Ranney et al. "#ThisIsOurLane -- Firearm Safety as Health Care's Highway," what did the Dickey Amendment (1996) do?

Prohibited use of CDC funds for advocacy or promotion of gun control.

Which of the following is a health policy challenge faced by state governments?

Protecting public health; subsidizing the costs of caring for the uninsured; financing health services for the poor

Frakt's NYT article, "Value of Care was a Big Goal. How Did it Work Out?" states that bundled payments:

Provide a set amount of money to cover a certain condition in a certain time period; have been found to save money without reducing quality of care; are meant to encourage hospitals to treat their patients in the most efficient way.

What did the Hill-Burton Act do?

Provided federal grants to states for the construction of hospitals

Which of the following is the most reported issue faced by the newly insured under the ACA?

Provider capacity

The JAMA article, "Presidential Powers and Response to COVID-19" says that:

Public health interventions must be evidence-based and not political; the cdc had not used its Federal quarantine powers in past 50 years except to quarantine single cases of a disease

The JAMA article, "Presidential Powers and Response to COVID-19" says that:

Public health interventions must be evidence-based and not political; the cdc had not used its federal quarantine powers in past 50 years except to quarantine single cases of a disease

According to the Kellerman article in Jama, "Silencing the Silence on Gun Research," in what ways has the Congress reduced support for firearm injury research?

Reduced funding for the CDC's National Center for Injury Prevention; extended restrictive language used with the CDC to all HHS agencies

TQM/CQI observations

Shewart's observations ignored in US, implemented in industry in Japan after WWII, re-imported to the US in industry gradually starting in the 1960s.

What has been identified as one of the main reasons for the shortage of physicians who are trained in geriatrics

Shortage of faculty in colleges and universities

Compared to other high-income countries, the US government plays a _______ role in healthcare

Smaller

In an ideal health IT world, providers should be able to:

Spend minimal amounts of time on documentation

What is the goal of ICHOM?

Standardize risk factors and outcome measures for disease on a global scale.

States as laboratories of democracy

States can try social and economic experiments without risk Successful experiments can be scaled up horizontally (in other states) or vertically (on the federal level)

Creating regulation

Step 1: Federal agency proposes regulation Proposed regulation listed in the Federal Register for public comment Step 2: Federal agency considers comments and issues final rule Comments considered and regulation is revised File rule issued and published in the Federal Register Step 3: Regulation codified in the Code of Federal Regulations(CFR) CFR is the official record of all regulations created by the federal government

Donabedian's Model

Structure: physical and organization resources contributing to healthcare delivery Process: activities that constitute care delivery Outcome: results of care processes; recovery, restoration of function, survival

Which of the following is referred to as "an American epidemic" in the article by Goldstein et al., "Behavioral Health Care and Firearm Suicide"?

Suicide

alternative: tqm/cqi

TQM: total quality management cqi: continuous quality improvement

Which amendment to the constitution outlines the concept of federalism?

Tenth Amendment

Based on the NEJM article "How structural racism works," all of the following are true except: - incarcerated people face a higher risk of death after release - our current policing system has roots to slave patrols used to capture runaways - The "War on Drugs" and the "War on Crime" disproportionately impacted black Americans - The Civil Rights Act of 1964 led to a dramatic decrease in lynching and convict-leasing system - Police violence indirectly harms mental health for communities due to constant surveillance and threats of violence

The Civil Rights Act of 1964 led to a dramatic decrease in lynching and convict-leasing system

Which federal agency is the most important for the provision of health services

The Department of Health and Human Services

Which government program significantly increased the use of informatics tools across health care settings?

The EHR incentive program (otherwise known as Meaningful Use)

Which government division under the Department of Health and Human Services helps to regulate the health workforce?

The Health Resource and Services Administration (HRSA)

Which of the following issues does Porter raise in discussing the measurement of health care quality?

The US medical system overemphasizes process measures which has limited effect on quality; outcome measurements are mainly performed among specialists and specialty societies; outcome measurements traditionally focus on clinical status rather than functional status.

In "Professionalism, Performance, and the Future of Physician incentives," Khuller argues for

The banning of physician incentives due to their ability to corrupt the profession

A service is cost efficient when:

The benefit received is greater than the cost incurred to provide the service.

Which of the following statements about vaccine hesitancy were established in Tufekci's "The Unvaccinated May Not Be Who You Think"?

The minority of the unvaccinated believe that they would not benefit from a vaccine

According to Bailey's article "How Structural Racism Works," what is an example of unequal health care?

The perception that the pain of black patients is less severe than the pain of white patients; performing experimental operations without informed consent or anesthesia.

According to Bernick in his Lancet Editorial, "Avoiding Overuse - The Next Quality Frontier," which of the following is a reason that overuse of ineffective care has become a problem?

The public tends to view more care as better; asymmetry of knowledge between providers and patients

What is likely to be the biggest obstacle to the delivery of cost-efficient care, according to Shi & Singh?

The public's attitudes

Misinformation

The sharing of false or misleading content because of a belief that it will help - by people who did not check the veracity or by people who believe deeply that the information is true

The National Health Planning and Resources Development Act of 1974 is notable for which of the following

The shift from improvement of access to cost containment as the principal theme in federal health policy

According to Robert Field, which level of government has the most power to regulate health care?

The state level

On average, over the course of their pregnancies, pregnant women enrolled in large employer health plans pay almost 3,000 in additional health costs than similar women who are not pregnant. Why must this be an underestimation?

The study does not take into account out-of-pocket spending on prenatal vitamins or over the counter drugs that pregnant women may use; high-cost births may reach their out-of-pocket maximum

Which of the following would be an example of the mission of the Agency for Healthcare Research and Quality? A. The cost of generic prescription drug increases due to r and d costs B. The cost of health insurance premiums has increased to offset the law that protects patients from being denied coverage C. The use of urinary catheters in hospitals has significantly decreased because evidence has shown they cause more harm than good D. Community health centers are reserved for use by underprivileged populations

The use of urinary catheters in hospitals has significantly decreased because evidence has shown that they cause more harm than good

According to Robert Field, what is the primary reason health care regulation is so complex?

There are a variety of regulatory bodies with competing interests.

Which of the following is a reason that no specific programs exist to serve the health needs of minority populations in the United States?

There is little consensus among policy makers on what can or should be done to design professional education, sensitivity to special needs, and services in appropriate areas

How did the Mayo Clinic control health care costs according to Gawande in the 2009 article?

They paid all doctors a salary

Why is ERISA important?

This act gives the federal government power to regulate health plans of large employers

Patient activation is lowest among which of the following people

Those enrolled in medicaid

Access to contraception for low-income people

Title X provides federal funding to clinics serving uninsured and low-income people for family planning and reproductive health care services. Funding has been political football: some administrations (republican) have cut or withheld title x funding to programs that provide abortion services while democratic ones have expanded funding without restrictions. (will take at least two years to rebuild the title x network)

What is the primary purpose of certificate-of-need statuses

To control capital expenditures by health facilities

What is the health care function of the judicial branch?

To handle disputes arising from the provision of health services

According to Claire Wardle's article, "Misinformation Has Created a New World Disorder", which of the following techniques would be effective in reducing the spread of misinformation?

Training people to develop skepticism for information consumption

True or False: The Center for Medicare and Medicaid Innovation is housed under the Centers for Medicare and Medicaid Services

True

True or False: since 1975, the rates of change in medical inflation have remained consistently and continuously above the rates of change in the Consumer Price Index.

True

True or false: state governments play a significant role in the development and implementation of health policies

True

True or false: the center for Medicare and Medicaid Services houses more than 16 different offices and centers

True

The NEJM article, "The End of roe v. Wade", argues that overturning Roe v. Wade will do what to patient-clinician relationships?

Turn clinicians into perceived opponents of patients

Doing comparisons using outcomes

Unlike many process measures, risk adjustment is necessary and can be challenging

What is Dr. Tufekci's MAIN argument in her NYT opinion piece, "American Dysfunction is the Biggest Barrier to Fighting Covid"?

We need to increase vaccine outreach and enact clearer public health guidelines

Take home messages: underuse

We underuse many diagnostic and treatment modalities that have a strong evidence base evidence suggests that on balance underuse may be a more important as a threat to patient safety than overuse

According to the NYT article "How Decades of Racist Housing Policy Left Neighborhoods Sweltering" neighborhoods that were redlined:

Were deemed "hazardous" for mortgage loans and investments; were most often Black neighborhoods

What is information asymmetry?

When doctors know more about the value of a medical treatment than their patients

Impact on hospitals

Wuhan hospitals; surgeon general advises hospitals to cancel elective surgeries; economic impact on hospitals (federal support healthcare and hospitals)

According to the article by Goldstein et al., "Behavioral Health Care and Firearm Suicide," which state had the highest rate of firearm suicides in 2015?

Wyoming

Every dollar of cost saved for hc payers is

a dollar of revenue lost to some health care provider

Definitions of quality

abstract, multi-faceted concept that relates to the improvement of patient health outcomes. Perspectives vary between patient, payer, and provider

additional aims

address health and care inequalities, increase the well being and engagement of the workforce

US healthcare spending

administrative costs account for 1/4 to 1/3 hc spending. Far greater than other countries and exceeds estimates of the amount necessary to perform the functions of healthcare administration. 3 ways administrative savings 1.) claims submission and adjudication 2.) prior authorization determinations 3.) quality measurement and reporting. Need for data exchange among payers and providers. Could save 50b annually

Balance of payments

amount of federal spending distributed in a state (expenditures) minus the amount paid to the federal government by a state's residents and businesses (receipts)

Developing healthcare system that can learn

assess quality, develop informatics approaches to improve quality, assess costs, develop informatics approaches to reduce costs (provide better care at less cost)

4 in 10 adults reported

avoiding medical care because of concern related to COVID 19

Evidence-based medicine proposes to incorporate ______ into medical care

best practices

The impact on health care workers

burnout and mental health impact

What treatment did doctors provide for Gawande's mother when she fainted in a grocery store?

cardiac cauterization

Pros of block grants

cater to the needs of the local population allows regional governments to experiment (subsidies for state run exchanges state flexibility

According to the executive summary, "Under the Surface", which of the following were NOT among the top topics of online conversation surrounding vaccine discourse?

common misconceptions

Conspiracy content and meme content

continue to increase. Misinformation and hate speech continue to intersect. People are taking advantage of existing racial divisions and xenophobia. Closed messaging apps are increasingly spaces where misinformation is spreading. The news media are a fundamental part of amplifying first person experiences in ways that can dominate search engine results.

According to the Gawande 2015 article, what happened to care costs and overutilization in McAllen, TX in the years following the publication of his 2009 article? They:

declined

Health care expenditure growth has been

decreasing

According to Shi and Singh, what was the key factor contributing to the passage of the ACA?

democratic control of congress

Fuchs article

efficiency: comparing inputs and outputs - complicated -no two countries are alike -outputs: length vs quality of life - exogenous morbidity: idea of degree of difficulty, things that are outside of the healthcare system but impact health care and health (social conditions, personal behaviors)

All of the following are principle features of US health policy except: A. Dominant role of the private sector B. Emphasis on public health services C. highly influential interest groups D. incremental and fragmented policies

emphasis on public health services

Original triple aim

enhance experience of care; improve the health and well-being of the population; reduce per capita cost of health care and improve productivity

Medicaid waivers are an example of

executive federalism

Which are steps that the 2022 Commonwealth Fund Issue recommended to US policymakers to take to substantially improve health and wellness for some of reproductive age?

extend affordable and comprehensive primary care to all women by expanding on the ACA's reforms; subsidize medical education to incentivize medical students to opt for primary care practice

Disinformation

fabricated or deliberately manipulated audio/visual content - intentionally created conspiracy theories or rumors

T or F; Currently, the state's role in health policy is limited mostly to basic public health functions

false

T or F; Historically, presidents have not had a substantial impact on national health policy

false

True or False: In Gawande's 2009 article, health care costs in McAllen, Texas are high because the population is extremely unhealthy

false

True or False: The CDC has been tracking breakthrough Delta variant cases diligently because it has been shown to be more infectious.

false

True or False: The US constitution clearly outlines the functions of federal and state governments in healthcare

false

True or False: US physicians have no issue with accessing prior data about their patients

false

True or False: according to Tufekci's article, "The Unvaccinated May Not Be Who You Think," most of the unvaccinated population in the U.S. is resistant to vaccines.

false

True or False: according to ed song's Atlantic article, the US is spending a larger proportion of each medical dollar on public health

false

True or false: managed care increased the rate of growth in health spending between 1993 and 2000?

false

The ______ provides health care to veterans, Native Americans, and military personnel

federal government

In "Accountable Care at the Frontlines" by Ganguli and Ferris, challenges to implementing ACOs include:

financial sustainability of ACOs due to conflicting financial incentives; inconsistent quality metrics from commercial and public payers

Measuring technical care

find process measures in claims databases, medical records: electronic health records (hers) paper medical records (charts)

Which incentive does the federal government use to encourage states to address population health problems

grants

Which of the following is NOT a recommendation Emmanuel and Navathe provide in their article, "Will 2020 Be the Year That Medicine Was Saved?" - have hospitals offer an at-home care option for all patients - reimbursing physicians at the same rate for both in-person and telehealh visits - accelerating medicare payments to independent providers to prevent further healthcare consolidation - provide site-neutral reimbursement for services - requiring medicare to reassess payments for elective procedures

have hospitals offer an at-home care option for all patients

Uwe Reinhardt attributes America's exorbitant spending on health care to

high prices

US women have the

highest rate of avoidable deaths: women's health in the US is not particularly good - maternal mortality is an American health crisis - chronic disease prevalence higher for women

Health care workforce impact

hopital staffing shortages

healthcare worker deaths

increase during pandemic

Since WWII, government oversight of medicine and public health services has

increased

Tension between principles

intervene, do something/ be patient, knowing that most interventions have risks

Why is HB 155, the bill passed by Florida's legislature, so controversial?

it undermines the sanctity of the patient-physician relationship; it allows government to put the interests of lobbyists above the safety of Americans; physicians can lose their licenses for trying to educate patients about gun safety

According to Bailey's NEJM article, "How structural racism works" the effects of redlining:

led to a disinvestment in infrastructure, such as transport and schools, in formerly redlined neighborhoods

rulemaking process

legislation: congress passes a law proposed rule: agency publishes the proposed regulatory language, including justification and analysis public comment: public invited to submit comments to federal agency (minimum number of days for public comment varies by agency final rule: agency publishes final regulatory language along with a response to all issues raised during the public comment period

According to the Kellerman and Rivara article in Jama, "Silencing the Silence on Gun Research," compared to understanding why some people commit violence against themselves or others, substantially ______ research has been devoted to understand how easy access to firearms affects both the likelihood and consequences of these acts:

less

The disadvantages of digitized medicine, as articulated by Gawande in "Why Physicians hate their computers" include

less face-to-face time with patients; additional after-hours work for physicians; physician burnout

CA legislation to combat measles outbreak

measles outbreak at Disneyland CA: SB277 that prevents exemptions due to personal and/or religious beliefs to excuse their children from immunizations

Risk adjustment = fair comparisons / case mix

medical care is, if anything, more complex than educational achievement. Outcome measurement, to be fair, should take account of or adjust for patient characteristics related to their baseline risks for the outcome in question. Comparing apples to apples, all other things being equal. risk adjustment can be technically complex and expensive. Critical in public reporting and pay for performance

Nation's third biggest killer

medical errors in 2013

Which occupational group has developed to assist physicians with computer-regulated tasks?

medical scribes

TQM/CQI in US HC

medicare - peer review organization, created in 1982 to review outlier cases in Medicare program - Quality Improvement Organizations, created in 1992 to improve care of all patients in Medicare program; Malcolm Baldridge National Quality Award mid 1987; expanded to health and education sectors in 1998

Provide and finance health services

medicare/medicaid, VA, IHS medicaid

micro vs macro inefficiencies

micro - how well we implement something c/w another country. Not a big problem for US macro- what we do; idea of misallocation of resources, likely considerable

_________ is the erroneous diagnosis of a disease while __________ is the correct diagnosis of a disease that will not bother you in your lifetime.

misdiagnosis; over diagnosis

3 kinds of quality problems

misuse, underuse, overuse and variations

Patient safety

misusing both appropriate and inappropriate (necessary and unnecessary care) care can produce safety problems

Take home points

modern theories and practice of quality improvement have come to medicine - understand the difference between quality assurance and quality improvement - relatedly, understand the difference between a focus on systems and a focus on individuals working in systems - understand some examples of how QI has come to health car4e

Potential impact of expansion

non elderly uninsured adults in non-expansion states who would be eligible for medicaid if their states expanded, 2019

According to the 2022 Commonwealth Fund Issue Brief, the maternal mortality rate is highest in ___, and disproportionately high in _____.

none of the above

According to the article by Goldstein et al., "Behavioral Health Care and Firearm Suicide," which subgroup is most at risk of firearm suicide?

older white males

Which of the following difficulties brought by the pandemic and faced by public health are mentioned in "Why Public Health Faces a Crisis Across the U.S."?

only three of the above (find them)

In Gawande's 2009 article, what does he point to as the cause of high health care costs in McAllen, Texas?

over utilization

According to The New Yorker article, "Why Physicians Hate Their Computers", the fastest growing consumers of electronic health records are

patients

Components of a health care system

patients, providers, and payers - government oversight for safety, quality, and fraud congress passes laws which often are modified and occasionally repealed; courts: rule on civil, criminal, and occasionally constitutional matters related to health care - executive branch is responsible for most of the implementation and regulation of health care.

Which of the following is TRUE based on the NYT article, "As Coronavirus Deepens Inequality, Inequality Worsens Its Spread"?

people in lower socioeconomic strata are more likely to COVID-19; people with lower incomes on average tend to develop chronic conditions earlier and are more likely to have one; small businesses will struggle more than larger ones to keep paying employees beyond already allotted sick days; the threshold for a drastically greater risk of dying from COVID-19 lowers to 55 from 70 individuals with low SES and chronic conditions

Which of the following is found more in neighborhoods that were originally marked green or blue based on "How Decades of Racist Housing Policy left Neighborhoods Sweltering"?

playgrounds with shade and vegetation

Enumerated powers

powers specifically given to congress, primarily found in Article I section VIII of the constitution (tenth amendment says powers not delegated to the US by constitution nor prohibited to the states are reserved for the states

COVID-19 as cause of death

pre-covid-19 (not disease): covid-19 is the #3 cause of death in the US thus far in 2022

Which of the following could be classified as being the highest health care cost and is continuing to increase?

prescription drugs

According to Shi and Singh, which of the following will be a focus to further health care reform?

preventative services

Studies point to one reason why the US spends more on hc than other countries

prices, not the amount of care. But, lowering prices would upset a lot of people in the healthcare industry

The American Medical Association is a ____ regulator of healthcare

private

shift from _______ to ____________ during pandemic

private insurance; medicaid

Legal basis of regulatory power

process of regulation - rules issued by agencies are similar to statutes (acts) even though they are not issued by legislatures - adjudications have force similar to court rulings even though they aren't issued by judges or courts

According to the NEJM article by Ranney et al. "#ThisIsOurLane -- Firearm Safety as Health Care's Highway," what did the Dickey Amendment (1996) do?

prohibited use of CDC funds for advocacy or promotion of gun control

Pros and cons of state-run exchanges

pros: flexibility to tailor to state specific needs; regulation flexibility and the ability to extend open enrollment periods beyond federal enrollment period cons: expensive; if it does not work properly, political repercussions and puts residents at risk. Could signal that you r state is supportive of the ACA

Based on "What are health disparities and health equity? We need to be clear," achieving health equity involves

protecting and promoting human rights; working to eliminate social and economic factors that contribute to disparities

More catheterizations

provided no additional clinical benefit in mortality or quality of life

According to the KFF Women's Health Survey, which policy had the greatest difference in prioritization between men and women?

providing more public funding to support access to family planning services and birth control

According to Berwick in "Avoiding Overuse - The Next Quality Frontier," what objectives have the WHO and other organizations pursued in order to improve care?

reduce inappropriate uses of antibiotics

In "Professionalism, Performance, and the Future of Physician Incentives", all of the following are suggested as alternatives to pay-for-performance incentives except: - performance reviews of supervisors/peers - team-based rewards - using targets developed with the input of local clinicians - scholarships

scholarships

Managed care: federal regulation

self-insured companies, often with employees in many states, come under the aegis of ERISA, * which means these companies are regulated by the federal government - remember the HMO act of 1973 that stimulated the growth of managed care entities - medicare and ma

What is federalism

shared powers (constitution declared) between states and government

When the year-end costs of an ACO is set below a set risk-adjusted benchmark, they profit from

shared savings

Understanding the causes

state maternal mortality review committees

Regulation in the US

state, federal, and private

Section 1115 demonstration waivers

states can apply for and obtain to operate medicaid without fully compliance with federal rules - historically used for: expanding eligibility or services, innovate service delivery

What is the next step in promoting interoperability between APIs?

substitutable apps

2020 AHRQ report

summarizes evidence for 47 different patient safety practices addressing 17 different harm area (eg healthcare associated infections, medication management, and diagnostic safety)

Who can help combat health misinformation?

teachers, nurses, journalists, researchers

The ACA gave ________ more power to regulate healthcare

the federal government

Which of the following are recommendations to counter COVID-19 misinformation, according to "Under the Surface"?

track problematic vaccine narratives; don't create an oversupply of information

According to the article by Roszko et al., "Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm Related Injury," is this statement true or false? "Multiple studies have reported that there is a large disparity between the percentage of clinicians believing that firearm screening and interventions were important and the percentage of clinicians who reported actually using evidence-based screening or intervention practices."

true

T or F; government spending for health care in the United States has largely been confined to filling the gaps left by the private sector

true

True or False: According to Clair Wardle's Article, "Misinformation has created a new world disorder", bad actors creating misinformative content are attempting to confuse consumers.

true

True or False: According to Dr. Tufekci's NYT article, "American Dysfunction is the Biggest Barrier to Fighting Covid", despite much of the elderly population being Republican and consumers of misinformation, most of them have been vaccinated.

true

True or False: In the 2009 Gawande article, he notes that more patients die from complications in surgery than from car crashes in America

true

True or False: In the Gawande 2009 article, he makes the argument that physician decision-making is highly dependent on what city the physician works in.

true

True or False: Local public health is less equipped to confront a pandemic now as compared to the beginning of 2020.

true

True or False: the elements of the Donabedian model include outcomes, structure and process?

true

True or false: Most thyroid microcarcinomas are not life threatening

true

True or false: Women are more likely than men to live in poverty.

true

True or False: states continue to have the right to decide to expand their Medicaid programs through the ACA

true; as of 1/4/2019, 37 states (including DC) have adopted the Medicaid expansion and 14 states have not adopted the expansion

Which of the following is NOT a reason public health officials are facing burnout, as mentioned in the NYT article, "Why Public Health Faces a Crisis Across the U.S."? - state and local legislative restrictions on health mandates - being left out of conversations over changes to public health laws - threats and personal attacks - vaccine hesitancy

vaccine hesitancy

emergency use authorizations and approvals

vaccines, therapeutics

cons block grants

variation could lead to disparities and decreased access to care enrollment caps could decrease intended effects of program

The US is moving from a ________ health care system to a _______ health care system.

volume-based; value-based

Outright falsehoods

we're seeing far less outright falsehoods and more content that just skirts content moderation policies

What is grant targeting?

when federal grants target states with higher need

According to Tobin-Tyler's book, Essentials of health Justice, how was differential treatment of men and women typically premised under the law?

women are more vulnerable and require protection