Health Policy Exam #3

Fig 3-4 Lack of Ins by Employment Status

- Full-time 15% - Part-time 30% - Unemployed 29%

President

- Has veto power i.e. if a law passes, the president can veto 1 law once - Has power to make treaties with foreign governments - Nominates judges to supreme court

Who can run for office in the U.S.?

- Must be 35 - US citizen by birth - US resident for 14 yrs

Supreme Court

- Review laws to make sure they're constitutional - Interpret laws

Advocacy

- The act of pleading or arguing in favor or against something, such as a cause, policy, or interest

1945-1970: The Provider-Insurer Pact

-During this time period, independent hospitals and small private physician offices populated the U.S. health delivery system -Some large institutions combined hospital and physician care (i.e. Kaiser-Permanente system, Mayo Clinic, and urban medical school complexes), but htese were the exception -Competition among health care providers was minimal because most geographic areas did not have an excess of facilities and personnel. - The health care financing system included hundreds of private insurance companies, joined by the governmental Medicare and Medicaid programs enacted in 1965. -Health care inflated at a rapid rate since reimbursement rules were formulated by physicians, hospitals, and Blue Shield -Medicare and Medicaid programs (enacted in 1965) had the same reimbursement provisions as private patients during this period. -The United States had a relatively dispersed health care industry *BLUE-CROSS SECTION WAS EMPHASIZED FOR EXAM* - A defining feature of the healthcare industry at this time was an alliance between insurers and providers. -The provider-Insurer pact was created when Blue Cross and Blue Shields formed an alliance. ---Blue Cross was formed by the American Hospital Association and Blue Shield was run by the state medical societies affiliated with the American Medical Association. - In the case of the Blues, the provider-insurer relationship was more than a political alliance ----It involved legal control of insurers by providers. -Commercial insurers usually played by the reimbursement rules already formulated by the physicians, hospitals, and Blues, paying for medical services without asking providers to justify their prices or the reasons for the services. - By the 1960s, the power of the provider-insurer pact was so great that the hospitals and Blue Cross virtually wrote the reimbursement provisions of Medicare and Medicaid, guaranteeing that physicians and hospitals would be paid with the same bountiful formulas used for private patients -With relatively open-ended reimbursement policies, the costs of health care inflated at a rapid pace. -The disinterest of the chief organized purchaser (i.e., business) stemmed from two sources: --1) The healthy economy and --2) The tax subsidy for health insurance -From 1945 through 1970, US business controlled domestic and foreign markets with little foreign competition. - Labor unions in certain industries had successfully gained generous wages and fringe benefits, and business could afford these costs because profits were high and world economic growth was robust - The cost of health insurance for employees was a tiny fraction of total business expenses and payments by business for employee health insurance were considered a tax deductible business expense, thereby cushioning any economic drain on business -For these reasons, increasing costs generated by the providers and reimbursed by the insurers were passed on to business, which with few complaints paid higher and higher premiums for employees' health insurance, and thereby underwrote the expanding health care system. -No countervailing forces "put the brakes" on the enthusiasm that united providers and the public in support of a medical industry that strived to translate the proliferation of biomedical breakthroughs into an improvement in people's lives. -RESULTS: ---The development of many independent hospitals and many small private practices ---Many private insurers ---Providers tended to dominate the insurers ---Purchasers had little power ---Reimbursement for providers was generous

Ethical Dilemmas, Old and New

-Ethical dilemmas are situations in which medical/healthcare provider is forced to make a decision that violates one of the four principle of medical ethics (beneficence, nonmaleficence, autonomy or justice) in order to uphold other principles ----Example: Jehovah's witness (Beneficence versus autonomy) - Ethical dilemmas always involve disputes in which both sides have an ethical underpinning to their position. -Financial conflicts of interest on the part of physicians, in contrast, pit ethical behavior against individual gain and are NOT ethical dilemmas. -The principles that take priority in ethical dilemmas depend on each individual case ----i.e. If the pt were a child without sufficient knowledge or reasoning capability to make an informed choice, the physician would not be obligated to withhold transfusions, even if the family so demanded - Although pt autonomy allows the right to refuse treatment, it does not include the right to demand a harmful or ineffectual treatment. -The traditional dilemmas are those that feature beneficence or nonmaleficence in conflict with autonomy. TWO FAMOUS ETHICAL DILEMAS --1) Karen ANN QUINLAN ----Young woman with severe brain damage (persistent vegetative state) asked that physicians discontinue a respirator ----The Quinlan decision promoted the right of patients or their surrogate decision makers to withdraw treatment, even if the treatment is necessary to sustain life. --2) NANCY CRUZAN ----A young woman with severe brain damage (persistent vegetative state) asked that physicians discontinue a feeding tube ----The outcome of the Cruzan case placed limits on autonomy by requiring that life-supporting treatment can only be withdrawn when a patient has stated his or her wishes clearly in advance --Both cases were adjudicated in the courts. TERRO SCHIAVO --Was in a persistent vegetative state for 15 years --In spite of multiple decisions of state and federal courts—up to the Supreme Courts of Florida and the United States—supporting the right of TERRI SCHIAVO'S husband to discontinue her feeding tube, the US Congress, encouraged by President George Bush, passed legislation reopening the option of reinserting the feeding tube. --Eventually, based on the precedents of the Quinlan and Cruzan cases, the courts prevailed and Ms. Schiavo died *Overall, medical ethics has moved in the direction of giving priority to the principle of AUTONOMY OVER BENEFICENCE* NEW GENERATION OF ETHICAL DILEMMAS - Started in the late 20th century -Moved beyond the individual physician-patient relationship to involve the broader society. -These social-ethical problems derive from the new reality that money may not be available to pay for a reasonable level of medical services for all people. -When money and resources are bountiful, the issue of distributive justice refers to equality in medical care access and health outcomes -THIS NEW FISCAL REALITY HAS SPAWNED TWO RELATED DILEMMAS ----1)A conflict between the duty of the physician to follow the principles of beneficence and nonmaleficence and the growing sentiment that physicians should pay attention to issues of distributive justice. ----i.e. In a case of twins who need surgery where one twin has better survival rate than the other, a dr uses the principle of beneficence to perform the surgery even if only one twin will survive RATHER THAN saying the money will be better spent on a pt with a higher chance of survival ----2) The conflict between the individual patient's right to autonomy VS society's claim to distributive justice. -Physicians practice medicine with a recognition that they have a duty to help and not harm their patients. ----i.e. In the above twin scenario, the parents of the twins could have decided that spending $1million of societies money on <1% survival chance would be excessive. But then again, most parent would do the same. - Dr's become dr's with the recognition that they have a duty to help not harm - Individuals claim a right to health care and do not want others to restrict that care. -*Yet the principle of distributive justice (recognizing that resources for health care are limited and should be fairly allocated among the entire population) might lead to physicians denying legitimate services or patients setting aside rightful claims to treatment.* -The BASIS for the principle of justice is the desire shared by many human beings to live in a civilized society, in a state of harmony where each person must balance the concerns of the individual with the needs of the larger community. -*When health resources are scarce, the principle of justice creates ethical dilemmas that touch many people beyond those involved in an individual physician-patient relationship* -The imperatives of cost control have thrust the principle of justice to the forefront of health policy in the debate over rationing.

Who Provides Long-Term Care?

-INFORMAL CAREGIVERS --Most people receive long-term care from family and friends --In 2007, about 52 million people served as unpaid family caregivers ----The majority of these caregivers were women ----For men, their wives usually provide care ----For women, usually their daughters provide care ----A growing number of elderly do not have family living close enough to provide "informal care" ----The lack of "informal care" is a common reason for elderly individuals to move to a nursing home ----On average, informal caregivers provide 20 hours per week of care (equivalent to $375 billion in 2007) --37% of informal caregivers to people age 50 and older reported quitting their jobs or reducing their work hours to assist family members --Elderly people with caregivers have: ----Shorter hospital stays ----Fewer hospital readmission's ----Lower inpatient expenses --*Unpaid caregivers are very valuable to the health care system* -COMMUNITY- BASED AND HOME HEALTH SERVICES --It is long term care delivered through a variety of program i.e. ----Home care ----Adult day care ----Assisted living settings ----Home-delivered meals ----Board and care homes ----Hospice care for the terminally ill ----Mental health programs --*What has lead to changes in community-based long-term care?* ----During the 1970s, the independent living movement among disabled people created a strong push away from institutional (hospital and nursing home) care toward community-based and home care that fostered the greatest possible independence (Movement from institutional living to home care from disabled individuals) ----During the 1980s, AIDS activists furthered the development of hospice programs that provide intensive home care services for people with terminal cancer and AIDS; the home is usually a far more therapeutic, comforting environment than the hospital or nursing home (Development of hospice programs for AIDS patients) ----During the 1980-1997, as a product of the intersection of the popular movement toward home care and the DRG-created incentive to reduce Medicare hospital stays, home health services expanded rapidly -------This prompted changes in Medicare payment policies to rein in home care expenditures -------Concerns were voiced about cuts in Medicare program so Medicare instituted a prospective payment system for home care based on the episode-of-illness model --------HOME CARE AGENCIES ARE PAID A LUMP SUM, (which like DRG hosp payments, vary with severity of illness) for 60 days - Many categories of health caregivers function in teams to perform home care including: ----Nurses ----Physical, occupational, speech and respiratory therapists ----Social Workers ----Home Health Aides ----Case Managers ----Drivers delivering meals-on-wheels ---*Home care, designed to help fill the once low-tech niche in the health care system that assists the disabled with ADLs and IADLs, has become increasingly specialized i.e.:* ----I.V. antibiotic infusions ----Morphine pumps ----Indwelling central venous lines ----Home renal dialysis ----Wound care nurses ----Respiratory therapists -These developments are a major advance in shifting medical care from hospital to home, but they have not been matched by growth in the paid personal custodial care needed to allow disabled people to remain safely in their homes. - Similarly, hospice care, while providing excellent nursing services for patients with terminal illnesses, is limited in the ADL support it provides. - Hospice programs may not accept terminal patients without an informal caregiver at home, thus the people who may need home hospice services the most cannot receive them. - Assisted Living ---Provides housing with a graded intensity of services depending on the functional capabilities of its residents ----In 2009, the average annual cost $34,000 (mostly out-of-pocket payments) ----Assisted living too expensive for low to middle income families

Nursing Homes

-Sometimes informal care and home health services are not enough for the elderly/ disabled people -Elderly needing 24-hour around-the-clock care may be placed in a nursing home with care provided by health aides and orderlies under the supervision of nurses. -In 2007, 1.8 million people lived in a nursing home and 67% of nursing home residents are women (who more often outlive spouses) ---- Frequently, after caring for a sick husband at home, women will themselves fall ill and be placed in a nursing home because no one is left to care for them at home -Individuals who are 65 years have a 40% chance of going to a nursing home at some point in their life -76% of nursing home residents have cognitive impairment and 93% have restricted mobility - There are two main differences between the chronically ill inside and outside nursing homes: --1) Nursing home residents have no family able to care for them --2) A larger proportion of nursing home patients suffer from dementia, a condition whose care is extremely difficult to provide at home by family members -EXAM: QUALITY --Varies greatly from one nursing home to another --Omnibus Budget Reconciliation Act of 1987 set standards for nursing home quality and mandated surveys to enforce those standards --In 2005, only 9% of nursing homes had no deficiencies (91% did not meet the standards for nursing homes) --The most frequently cited deficiencies were: ----Inadequate food sanitation ----Quality of care ----Professional standards ----Accident prevention ----Housekeeping ----Infection control ----Pressure sores ----Dignity --Hispanics are more likely to be placed in low-quality facilities --Lower-income individuals often housed in close quarters with several other patients and become totally dependent on an underpaid, inadequately trained staff --Many spend hours lying in bed or sitting in a chair watching TV --While quality of life varies between one nursing home and another, placement in a nursing home almost always thwarts the yearning for some degree of independence of action and for companionship and a sense of futility overwhelms many nursing home residents, and the desire to live often wanes. -Due to cost containment at nursing homes, most care is provided by nursing aides who receive minimal training and are poorly supervised ----The job of the nursing home aide is very difficult, involving bathing, feeding, walking residents, cleaning them when they are incontinent, lifting them, and hearing their complaints. -In 2005, 66% of all nursing homes were under for-profit ownership, many operated by large corporate chains -For-profit ownership has been associated with lower staffing levels and poorer quality of care compared with nonprofit ownership -Offering a humane existence to severely disabled people housed together in close quarters is a nearly impossible task. - One view of nursing home reform holds that only the abolition of most nursing homes and the development of adequately financed home and community-based care can solve the nursing home problem

Florida State Senator

-Upper house of the Florida Legislature -Total of 40 members -Serve 4 year terms

1980s: The Revolt of the Purchasers

BOOK -Late 1980s produced a severe shock: ----The cost of employer-sponsored health plans increased 18.6% in 1988 and 20.4% in 1989 ----Between 1976 and 1988, the percentage of total payroll spent on health benefits almost doubled, from 5% to 9.7% ----Large corporations began to self-insure so rather than paying money to insurance companies to cover their employees, employers increasingly took on the health insurance function themselves and used insurance companies only for claims processing and related administrative tasks. -Self-insurance placed employers at risk for health care expenditures and forced them to pay more attention to the health care issue. -These three developments (i.e., a troubled economy, rising health care costs, and self-insurance) catapulted big business into the center of the health policy debate, with cost control as its rallying cry. -BUSINESS, the major private purchaser of health care, became the motor driving unprecedented change in the health care landscape ----Business threw its clout behind managed care, particularly HMOs, as a cost-control device ----By shifting from feefor-service to capitated reimbursement, managed care could transfer a portion of the health expenditure risk from purchasers and insurers to providers -INDIVIDUAL health care consumers, in their role as purchasers, also showed some clout ----Because employers were shifting health care payments to employees, labor unions began to complain bitterly about health care costs, and major strikes took place over the issue of health care benefits. ----More than 70% of people polled in a 1992 Louis Harris survey favored serious health care cost controls ----The growing tendency of private health insurers to reduce their risks by dramatic premium increases and policy cancellations for policyholders with chronic illnesses created a series of horror stories in the media that turned health insurance companies into highly unpopular institutions. -During the 1980s, the government was facing the tax revolt and budget deficits, and it took measures designed to slow the rising costs of Medicare and Medicaid, with limited success. -The 1983 Medicare Prospective Payment System (diagnosis-related groups [DRGs]) reduced the rate of increase of Medicare hospital costs, but outpatient Medicare costs and costs borne by private purchasers escalated in response. - In 1989, Medicare physician payments were brought under tighter control, resulting in Medicare physician expenditures growing at only 5.3% per year from 1991 to 1993, compared with 11.3% per year from 1984 to 1991 -Numerous states scaled back their Medicaid programs, but because of the economic recession and the growing crisis of uninsurance, the federal government was forced to expand Medicaid eligibility, and Medicaid costs rose faster than ever before. -Governments began to experiment with managed care for Medicare and Medicaid as a cost-control device. -*The most significant development of the 1980s was the growth of selective contracting* ----Purchasers and insurers had usually reimbursed any and all physicians and hospitals, but under selective contracting, purchasers and insurers choose which providers they will pay and which they will not i.e. in 1982 California passed a law bringing selective contracting to the state's Medicaid program and to private health insurance plans. The law was passed because large California corporations formed a political coalition to challenge physician and hospital interests, and because insurers deserted their former provider allies and joined the purchasers (Bergthold, ----The message of selective contracting was: purchasers and insurers will do business only with providers who keep costs down. -----This development, especially when linked with capitation payments that placed providers at risk, changed the entire dynamic within the health care industry. ----For patients, it meant that they had lost free choice of physician because employers could require employees to change health plans and therefore physicians. ----For the health care industry, selective contracting meant fierce competition for contracts and the crumbling of the provider-insurer pact. -*As a result of the PURCHASERS' REVOLT managed care became a burgeoning movement in US health care* -By 1990, 95% of insured employees were enrolled in some form of managed care plan, including fee-for-service plans with utilization management, preferred provider organizations (PPOs), and HMOs. - The growth of managed care plans, especially HMOs, competing against one another for contracts with business and the government, changed the entire political topography of US health care PPT -Reduction in heath costs through: ---Medicare DRGs (1983) ---Fee schedules ---HMOs (Managed care plans become dominant) ---Selective contracting by purchasers and insurers

Non-Financial Barriers to Healthcare

LACK OF PROMPT ACCESS -Medical practitioners fail to provide care when needed and has gotten worse with the growing shortage of PCP -31% private insured pts has a delay in obtaining an appointment - *There are more numbers in the book* -Unnecessary ED visits are growing for lack of PCP care -Fewer PCP are taking Medicaid GENDER AND ACCESS TO HEALTH CARE -Women are 50% more than men are more likely to leave a doctor because they are dissatisfied -Women are patient-centered when communicating with MDs - Women twice as likely to report being talked down to or told its all in their head - Female Dr's are more pt centered and spend more time w/ their pts - In a study of patients with insurance coverage for Pap smears and mammograms, the patients of female physicians were almost twice as likely to receive a Pap smear and 1.4 times as likely to have a mammogram than the patients of male physicians -Women more likely than men to have a chronic disease - Physcians are less likely to counsel women than men about cardiac prevention—diet, exercise, and weight reduction. -After having a heart attack, women are less likely than men to receive recommended diagnostic tests and are less likely to be prescribed recommended aspirin and beta-blockers -Women more likely to be Medicaid recipients -Access to abortion clinics limited RACE AND ACCESS TO HEALTH CARE -Latinos and African Americans less likely to have regular care ----Receive fewer services i.e. pain control - Minority groups have higher numbers of uninsured, Medicaid coverage, or are poor and for this, these groups have amplified access problems -African Americans and Latinos in the United States are less likely to have a regular source of care or to have had a physician visit in the past year -There are disparities in quality of care i.e. looking at 38 measures of quality for such conditions as diabetes, asthma, HIV/AIDS, cardiac care, and cancer, African Americans receive poorer quality of care than whites for 66% of these quality measures, American Indians and Alaska Natives and Latinos also have lower quality indicators -Minority neighborhoods have fewer physicians practicing in the area and the dr's that do are usually black or Hispanic -EXPLANATIONS FOR DISPARITIES IN RACIAL/ETHNIC GROUPS ---Cultural differences may exist in patients' beliefs about the value of medical care and attitudes toward seeking treatment for their symptoms. ---Ineffective communication between patients and caregivers of differing races, cultures, and languages. -----African Americans are more likely than whites to report that their dr did not properly explain t -----Communication problems for Latinos big because Spanish is the primary language (but this is not all cases) ---Racism may also contribute to these patterns -----Many hospitals, including institutions in the North, were for much of the 20th century either completely segregated or had segregated wards, with inferior facilities and services available to nonwhites. -----Explicit segregation policies persisted in many hospitals until a few decades ago. -----Racial barriers to entry into the medical profession gave rise to the establishment of black medical schools such as the Howard, Morehouse, and Meharry schools of medicine. -----NOW more insidious and often unconscious forms of discrimination may continue to color the interactions between patients and their caregivers and influence access to care for minorities

CHAPTER 1 POLITICS

*ALL QUESTIONS WILL COME FROM PPT*

Principles of Medical Ethics

*All of these principles are interrelated* Four major ethical principles: -1) Beneficence ----Is the obligation to care for patients to the best of one's ability (this is the principle) ----The obligation of health care providers to help people in need (this is the definition) -2) Nonmaleficence ----Is the duty of healthcare providers "to do no harm" -3) Autonomy ----Is the right of a person to choose and follow his or her own plan of life and action ----Autonomy is founded in the desire of most human beings to control their own destiny, to have choices in life, and to live in a society that places value on individual freedom. ----In medical ethics, autonomy refers to the right of competent adult patients to consent to or refuse treatment. ----While the physician has an obligation to respect the patient's wishes, he or she also has a duty to fully inform the patient of the probable consequences of those wishes ----For children and for adults unable to make medical decisions, a parent, guardian, other family member, or surrogate decision maker named in a legal document becomes the autonomous agent on behalf of the patient -4) Justice ----Treating everyone in a fair manner ----In medical ethics people are treated justly when they receive what they deserve i.e. it is unjust not to grant a medical degree to someone who completes medical school and passes all the necessary examinations. ----Justice refers to universal rights: ------To receive enough to eat, to be afforded shelter, to have access to basic medical care and education, and to be able to speak freely ----Justice connotes equal opportunity: ------All people should have an equal chance to realize their human potential. ---- Justice might be linked to the golden rule: ------Treat others as you would want others to treat you

EXAM: Affordable Care Act (ACA) of 2010 (*KNOW PENALTY FEES*)

*KNOW THIS WHOLE SECTION IN BOOK- ON EXAM!!* FOUR MAIN COMPONENTS TO ITS REFORM ON HEALTH CARE FINANCING: -1) Individual mandate (Beginning in 2014) ---Requires most U.S. citizens and legal residents to have health insurance coverage meeting a federally determined "essential benefits" standards. ---This standard would allow high-deductible plans to qualify, with out-of-pocket cost-sharing capped at $5950 per individual and $11900 per family in 2010 dollars ---EXAM: Those who fail to purchase insurance and do not qualify for public programs (i.e. Medicare, Medicaid, Veterans health care, etc) must pay a tax penalty of $695/ YEAR per individua and up to $2085 per family OR 2.5% of the household income ---Individuals and families <400% poverty level are eligible for income-based sliding scale federal subsidies to help them purchase the required health insurance -2) Employer mandate (Beginning in 2014) ---Employers with 50 or more full-time employees face a penalty if their employees are not enrolled in an employer-based health care plan meeting the "essential benefits" standards and any of their employees apply for federal subsidies for individually purchased insurance ---While this measure does not technically mandate large employers to provide health benefits to full-time employees, it functionally has this effect by penalizing the employers who leave their employees to fend for themselves and comply with individual mandate -3) Medicaid Eligibility Expansion: (effective 2014) ---Under ACA, traditional Medicaid eligibility is eliminated and allows states to make all US citizens and legal residents below 133% of the Federal Poverty Level are eligible for Medicaid. ---In 2011, 133% of the Federal Poverty Line was $14,484 for a single person and $29,726 for a family of 4 ---Under ACA, the Federal Government pays states 100% of the Medicaid costs for beneficiaries under ACA's Medicaid expansion from 2014 to 2016, with states contributing 10% after 2016 ---Benefits are similar to the current Medicaid -4) Insurance market regulation (Implemented 2010) ---ACA imposes new rules on private insurance companies ---Private health plans must allow young adults up to the age of 26 to remain covered under their parents health plans as dependents ---Eliminates caps on total insurance benefits payouts, prohibits denial of coverage based on pre-existing conditions ---Limits the extent of experience rating to max of 3 to 1 ratio between a plan's highest and lowest premium charge for the same benefit package ---Also establishes state-based insurance exchanges to function as a clearing house to assist individuals looking for health insurance coverage to shop for ins plans meeting the standards ---The benefit packages vary depending on what the insurance marketplace offers different types of plans -----Low-premium Bronze plans will have high out of pocket costs -----High premium Platinum will have will have low out of pocket costs -----Intermediate Silver and Gold plans ---These above Mandates were deemed essential for fairness and feasibility

The Massachusetts Individual Mandate Plan of 2006

*This was the 1st state w/ universal health coverage* - Almost 20 years after the Heritage Foundation's proposal for an individual mandate, Massachusetts enacted a state-level universal health coverage bill implementing the nation's first legislated individual mandate. - It was enacted under the leadership of Republican Governor Mitt Romney - This Plan mandates that every state resident must have health insurance coverage meeting a min standard set by the state - Individuals are required to provide proof of coverage at the time of filing their their annual tax return, and face a financial penalty for failing to provide evidence of coverage - The state provides subsidies for purchase of private insurance to individuals with income <300% the federal poverty level if they are not covered by the state's Medicaid program or through employment-based insurance. - Like Nixon's employer mandate proposal, this individual mandate does NOT eliminate govt ins plans, but extends the reach of private ins through govt mandate - The state govt would provide an income-adjusted subsidy for individual coverage for people not eligible for employer-based insurance and limits the degree to which private ins can experience- rate their premiums - This plan allows insurers to offer policies wiht large amts of cost-sharing in the form of high deductibles and coinsurance - This plan also includes a weak employer mandate where employers w/ >10 employees will have to contribute to ins coverage or pay into the state fund that underwrites public subsidies for the individual mandate and related programs BENEFIT OUTCOMES: - In 2006, it reduced uninsurance rate among nonelederly adults in Massachusetts from 13% in 2006 to 5%in 2009 NEGATIVE OUTCOMES: - Some people still have trouble affording private insurace even with state subsidy - The high levels of cost sharing allowed under the min benefit standard leave many insured people w/ substantial out of pocket payments --In 2008, 18% of the low income people in Massachusetts reported unmet health needs due to costs(copay, deductible, uncovered services) -20% experienced difficulty in accessing a PCP due to PCP shortage

Milestones in U.S. Healthcare

- 1935: Social Security Act - 1965: Medicare/Medicaid Law - 1986: EMTALA (Emergency Medical Treatment & Active Labor Act) ----Pt cannot be sent away with tx ----If there is a dr on staff, the pt has to be seen regardless of insurance, ethnicity, etc ----The pt also has to be stabilized before transferred to another hospital and the receiving hospital MUST be notified of the transfer i.e. if no psych unit at that hospital, then the pt must be stabilized, receiving hospital notified, and then the pt can be transferred - 1996: HIPAA (Health Insurance Portability and Accountability Act) - 2003: Medicare prescription Drug Act ----Impacts how we regulate meds - 2005: HCAHPS (Health Consumer Assessment of Healthcare Providers & Systems) ----A pt answers surveys and in order for the hospital to "pass", the pt must answer "always" on everything or else the hospital looses reimbursement ----Most of the questions on the survey are R/T nursing

Pluralistic Reform Model: The Patient Protection and Affordable Act of 2010 (*KNOW NUMBERS AND DATES IN THIS SECTION*)

- After a year long debate, in 2010 Democrat-controlled House of Representatives and Senate passed the Affordable Care Act WITHOUT a single Republican vote - Passed on March 23, 2010, and became the most significant health legislation since Medicare/Medicaid in 1965 - ACA was attacked as "socialized medicine" and "govt takeover of health care", but its policy pedigree derives much from Nixon and Romney than from other single-payer national health ins tradition of Democratic Presidents Rooselvelt and Truman -*The pluralistic financing model of ACA includes individual and employer mandates for private insurance and an expansion of publicly financed Medicaid program*

Payment per procedure: Fee-for service

- Before Medicare and Medicaid, drs often discounted fees for elderly or poor patients, and even afterward many physicians have continued to assist uninsured people in this way ---Under this method drs would get paid based on usual, customary, and reasonable (UCR) system -Cost containment changed this and now Medicare moved to a fee schedule determined by a resource-based relative-value scale (RBRVS) ---- With this system, fees (which vary by geographic area) are set for each service by estimating the time, mental effort and judgment, technical skill, physical effort, and stress typically related to that service ----RBRVS tried to take away the bias of physician payment that paid for surgical and other procedures at a far higher rate than primary care and cognitive services. - i.e. Fee for service payment is w/ PPO who pay contracted drs on a discounted fee-for-service basis and require prior authorization for expensive procedures. *With fee-for-service payments, drs have an economic incentive to perform more services because more services bring in more payments and this has contributed to the rapid rise in health care costs*

Payment per Patient: Capitation

- Capitation payments (per capita payments, or payments "by the head") are MONTHLY payments made to a physician for each patient signed up to receive care from that physician—generally a primary care physician (PCP) - There is a shift of financial risk from insurers to providers - Under fee-for-service, pts who require expensive services cost their health plan more than they pay in premiums and the insurer is at risk and loses money while drs and hospitals that provide the care earn more money -Capitation is a 180 degree turn and frees insurers of risk by transferring risk to providers ----An HMO that pays drs via capitation has pays a fixed sum, no matter how many services are provided and the providers earn no additional money, yet spend a great deal of time and incur large office and hospital costs (In the long term, HMOs do want to limit services in order to reduce provider pressure for higher capitation payments.) METHODS TO MITIGATE FINANCIAL RISK - Offer fee for service for certain services and called "carve outs" as their reimbursement is carved out ans paid separately (i.e.Pap smears, immunizations, office ECGs, and minor surgical procedures) - Risk-adjusted capitation will provide higher monthly payments for elderly patients and for those with chronic illnesses PROS -Capitation has potential merits as a way to control costs by providing an alternative to the inflationary tendencies of fee-for-service payment. - Have Beneficial influence on organization of care. - Capitation payments require patients to register with a physician or group of physicians - The clear list of the population of patients in a primary care practice offers advantages for monitoring appropriate use of service and planning for these patients' needs. - It explicitly defines, in advance, the amount of money available to care for an enrolled population of patients, providing better allocation of resources and innovation in developing better modes of delivering services. - For a large group of PCPs size of the capitation payments provides influence and flexibility over how to best arrange ancillary and specialty services

Who are the uninsured in the U.S.?

- Hispanics 32% - Black 21% - Asians 17% - Non-hispanic whites 12% *The two broad categories are: employed uninsured and unemployed uninsured* -Two major categories makeup the uninsured in the U.S: --1) Employed uninsured (because they aren't getting paid enough or they don't offer insurance) ----75% --2)Unemployed uninsured ----25%

Managed Care Plans

- Managed Care Plans offered different methods of payment with the purpose to control costs -Three types of managed care plans: --1) Fee-for-service with utilization review --2) Preferred provider organization (PPOs) --3) Health Maintenance (HMOs)

Payment per Day: Per Diem

- Method to pay the hospitals -Used by private insurance companies & Medicaid plans contracted with hospitals for per diem payments rather than fee for each itemized item used (xray, ecg, room, mri, etc) -Hospitals receives a LUMP SUM FOR EVERYDAY the HMO patient is in the hospital - The insurer may send a utilization review nurse to the hospital and if the nurse decides that a pt is not acutely ill, the HMO may stop paying for additional days. - Bundles all services provided for one pt on a particular day into one payment - Bundling Services ---- With per diem payment, the hospital receives no additional money for expensive procedures as the price is bundled into one (fee for service will charge for each procedure) ----This removes the hospital's financial incentive because it loses, rather than profits, by performing expensive studies. - Insurer at RISK for pt staying in hospital and they have to pay, but hospital also at risk because they don't get extra $$ for extra procedures/tests - Utilization reviews are good for insurer to reduce the number of hospital days and the fiscal concern of how many procedures are done has been transferred to the hospital -Cost containment methods: --Insurer may send a nurse to the hospital to review the patient's chart --If the nurse decides the patient should be discharged, the insurance will not pay for additional days

Methods of Physician Payment

- Payment per procedure: Fee-for service - Payment per Episode of Illness - Payment per Patient: Capitation - Payment per Time: Salary

Rationing with One Health Progrm: The Oregon Health Plan

- Rationing medical care nationwide presumes a mechanism that redirects savings from interventions not performed toward more cost-effective services (This does NOT exist nationwide) - Only in specific medical care programs do we find a decision-making apparatus for allocating expenditures i.e. The Oregon Health Plan -In 1994, Oregon added 100,000 poor uninsured Oregonians to its Medicaid program and to control costs, a prioritized list of services was developed, and the state legislature decided how many services would be covered. -The PRIORITIZED LIST was based on how much improvement in quantity and quality of life the treatment was likely to produce. ---The final list contained 745 condition-treatment pairs, and the State of Oregon paid for items above line 574 on the list, while conditions below that line were not covered ETHICAL IMPLICATIONS OF THIS PLAN: --1) The plan was more than a rationing proposal and its chief feature was to extend health care coverage to 100,000 more people. ----That aspect promotes the PRINCIPLE OF JUSTICE --2) Another positive feature of the plan was its attempt to prioritize medical care services on the basis of effectiveness, which, if rationing is needed, is a reasonable method for deciding which services to eliminate NEAGTIVE IMPACT OF THE PLAN ON DISTRIBUTIVE JUSTICE OR EQUAL ACCESS TO CARE W/OUT ABILITY TO PAY --1) In 1996, 12% of beneficiaries reported being denied services because they were below the line on the priority list and of those, 78% reported that the denial had worsened their health ----Medical services were rationed for Oregon's poor but not for anyone else. --2) The plan targeted beneficial medical services in a state with considerable medical waste. ----In 1988, many areas of Oregon had average hospital occupancy rates below 50%. ----The closing of unneeded hospital beds could have saved $50 million per year, enough to pay for some of the treatments eliminated in the plan ---- Oregon DID NOT exhaust its options for painless cost control before proceeding to potentially painful rationing. -By 2004, the Oregon Health Plan had unraveled and the state entered a period of budgetary woes, new premiums and copays were instituted, and Oregon Health Plan enrollees responded by dropping out of the program. -The rate of uninsurance climbed from 11% to 17%, but the bold experiment in rational rationing remains alive in the minds of health care policymakers.

How a Bill becomes Law

- Starts as an idea - Contact local congressman - Congressman introduces idea to congress - If congress agrees, it becomes a bill - Bill goes to committee in capitol hill where congress discuss whether or not to make the bill a law - If congress agree, the bill goes to the house of representatives and they vote on the bill - If house of representatives vote Yes, the bill goes to the senate to get voted on - If voted yes from the senate, it goes to the white house for the president to sign off on ----President can veto this law in which case the bill goes back to congress and the process starts all over again

The Effects of Underinsurance

- The famous RAND HEALTH Insurance Experiment compared non-elderly individuals who had health insurance plans with no outof-pocket costs and those who had plans with varying amounts of pt cost sharing (deductibles or copayments). -The study found that cost sharing reduces the rate of ambulatory care use, especially among the poor, and that patients with cost-sharing plans demonstrate a reduction in both appropriate and inappropriate medical visits. -For low-income adults, the cost-sharing groups received Pap smears 65% as often as the freecare group. -Hypertensive adults in the cost-sharing groups had higher diastolic pressures, and children had higher rates of anemia and lower rates of immunization - In 2003, underinsured adults aged 19 to 64 with health problems were much more likely than well-insured adults to skip recommended tests or follow-up, forego seeing a physician when they felt sick, and fail to fill a prescription on account of cost - In 2006, 20% of Medicare beneficiaries Part D coverage did not fill or delayed filling RX due to costs *Lack of comprehensive insurance reduces access to health care services and may contribute to poorer health outcomes*

What is Rationing?

- The general public and the media often view rationing as a limitation of medical care such that "not all care expected to be beneficial is provided to all patients" (Aaron and Schwartz, 1984) COMMODITY SCARCITY EXAMPLES R/Y RATIONING *Specific items are limited in supply* --i.e.Lack of intensive care beds -More precisely,rationing means a conscious policy of equitably distributing needed resources that are in limited supply -- i.e. During World War II, insufficient gasoline was available to both power the military machine and satisfy the demands of automobile owners in the United States, so the government rationed gasoline, giving priority to the military, yet allowing each civilian to obtain a limited amount of fuel. --i.e. In a rural area, there may be a shortage of health care providers and in an overcrowded urban public hospital, there may be an insufficient number of beds in the transplant arena, donor organs are truly in short supply. --The US has adequate supply of hospital beds and physicians in most communities BUT a scarcity in in health care i.e. PCP a --A different kind of health resource is becoming scarce, and that is MONEY (BUT THIS IS CONDIDRED FISCAL SCARCITY) *Rationing in medical care means the limitation of resources, INCLUDING money, going to medical care such that not all care expected to be beneficial is provided to all patients, and the fair distribution of these limited resources*

Medicare

-1950s ----Less than 15% of the elderly population in the United States had health insurance -1965 ----Medicare enacted -Eligibility ----Individuals 65 years and older -Financed ----Social security contributions, federal income taxes and individual premiums -What is it? ----A social security program ----Individuals have to make social security contribution before they retire to receive benefits.

Governor

-Can serve up to two consecutive 4 year terms -No lifetime limits - i.e. After their two consecutive 4 year terms, they can't run for the next 4 years, but can run again after that

1970s - Tensions Develop

-Conflict between providers and insurers -Purchasers (especially government) concerned about costs of health care -In early 1970s, the U.S. fell from it position of postwar economic dominance. -Western Europe and Japan start to gain ground in the world markets. U.S. industrial production dropped from 60% in the 1950s to 30% in 1980. -Insurers begin to question generous reimbursements to providers -Result: ---Federal government established a network of health planning agencies to slow growth of hospitals. ---Peer and Utilization reviews were established to monitor appropriateness of MD services under Medicare and the glut of unused hospital beds and reduce length of stay. ---State governments started to regulate hospital construction and hospital rate regulation. ---Insurers demanded that services be provided at lower costs. ---Blue Cross legally separated from the American Hospital Association in 1972

The New Millennium: Provider Power Reemerges

-Consolidation in the Health Care Market (Insurers, MDs, Hospitals) -Growing Power of Specialists and Specialty for profit service centers -Increasing Physician-Hospital tensions (MDs taking business away) -For profit- a threat to traditional professionalism and community service ( economic motivation clash with the professional commitment to patient welfare.)

Florida Legislature

-Convenes the first Tuesday after the first Monday in March each year -Regular sessions of the Legislature are not to exceed 60 days unless an extension is approved by a 3/5 vote in each house. - EXTENSION is called a "special session" and it is for ONE topic

Proposals for Improving Long-Term Care

-Developing social insurance to finance long-term care -Shifting from nursing home to community-based care by improved financing of community-based care -Training and supporting family members as caregivers -Expanding the number of comprehensive acute and long-term care organizations ----Example: On Lok Senior Health Services (San Francisco, CA) reduce costs by keeping elderly out of the hospital as much as possible

Distributive Justice

-Distributive justice is the realm of ethical thinking that is concerned about the allocation of benefits and burdens in the society i.e. ----Who receives what amount of wealth? -----Who pays what amount of taxes? -Justice is linked to the idea of fairness, but in distributive justice, no agreement exists on what formula for allocating benefits and costs is fair ----Should each person get equal share? ----Should those who work harder receive more? ----Should those that greater wealth pay more? -Most societies construct a mixture of the above questions/ allocation formulas. ----i.e. Unemployment benefits consider effort (having had a job) and need (having lost the job) ----i.e. Welfare benefits are primarily based on need. ----i.e. Job promotions may be based on merit. - Many goods are distributed according to ability to pay. -Primary education in theory (but not always in practice) is founded on the belief that everyone should receive an equal share

1990s: The Breakup of the Provider-Insurer Pact

-During the 1990s, many areas in the US experienced upheavals of their medical care landscape. -Independent hospitals began to merge into hospital systems. - In the most mature managed care markets, three or four health care networks were competing for those patients with private insurance, Medicare, or Medicaid. -Selective contracting allowed purchasers and insurers to set reimbursement rates to health care providers. ---HMOs that demanded higher premiums from employers did not get contracts and lost their enrollees. ----Providers who demanded higher payment from HMOs were cut out of HMO contracts and lost many of their patients. ----Selective contracting tended to disorganize rather than organize medical care patterns i.e. physicians were forced to admit patients from one HMO to one hospital and those from another HMO to a different hospital; i.e. Laboratory, x-ray, and specialist services close to a primary care physician's office were sometimes not covered under contracts with that physician's patients' HMO, forcing referrals to be made across town. -The 1990s was a period of purchaser dominance over health care. -The federal government stopped Medicare inflation in its tracks through the tough provisions of the Balanced Budget Act of 1997. - The average annual growth in Medicare expenditures declined from 12% in the early 1990s to zero in 1999 and 2000. - On the private side, employers bargained hard with HMOs, causing insurance premium annual growth to drop from 13% in 1990 to 3% in 1995 and 1996. In California, employer purchasers consolidated into coalitions to negotiate with HMOs. ----Pacific Business Group on Health (negotiating for 400,000 employees) and California Public Employee Retirement System (CalPERS, representing a million public employees) forced HMO premiums to go down during the 1990s -Enrollment in HMOs grew rapidly in the 1990s, expanding from 40 million enrollees in 1990 to 80 million in 1999

Medicaid

-Enacted in 1965 -What is it? ----Public assistance or welfare model of government insurance ----In the United States, it covers a portion of the low-income population ----Individuals do not have to make contributions in order to receive benefits. -Financed ----Federal and state taxes

Improving Long-Term Care

-Financing Long-Term Care -Providing Long-Term Care

Providing Long-Term Care

-First step is to move care from an institutional setting to a more comprehensive community-based or home long-term care services -Ideal long-term caregivers --Patient's family and friends --If family is not available, innovative long-term care programs like On Lok in San Francisco, CA (started in Chinatown) can be implemented with success ----On Lok means peaceful, happy abode in Chinese ----On Lok merges adult day services, in-home care, home-delivered meals, housing assistance, comprehensive medical care, respite care for caregivers, hospital care and skilled nursing care -United States does not have a social insurance program for long-term care - In 1995, Germany implemented a near-universal social insurance for long-term care

The Role of Government in National Health Insurance Plans

-Funds are collected by the government of a quasi-government fund which pays: ---Hospitals ---Physicians ---Health Maintenance Organizations (HMOs) ---Other healthcare providers

Florida Legislature Consists of

-Governor -Florida House of Representatives -Florida State Senator -Florida Legislature

Medicare & Medicaid

-Guaranteed health coverage for two groups (poor and elderly) was achieved through the passage of Medicare and Medicaid in 1965. -Affordable Care Act of 2010 ---Expanded health insurance to over 30 million uninsured Americans -National health insurance means: ---The guarantee of health insurance for all the nation's residents

The Provider Counter-Revolution

-HMOs enrollments dropped from 32% to 19% of insured employees. -Instead, PPO (preferred provider organization) enrollment grew from 30% to 60% of insured employees. -Hospitals consolidate into hospital "systems" and demand more money from insurers. -Physicians balked at tight managed care contracts -Negotiation between health care providers and insurers became hostile

Underinsurance (Medicare Coverage and Limitations)

-Having insurance does not guarantee financial access to care - Many people are UNDERINSURED meaning that their health insurance coverage has limitations that restrict access to needed services -Underinsured = health insurance coverage is limited ----Coverage limitation impacts access to care- 20% of adults ages 19 to 64 were underinsured (2007) CATEGORIES OF UNDERINSURED IN US: -Limits to insurance coverage - Insurance deductibles and copayments - Gaps in Medicare coverage - Lack of coverage for long-term care LIMITS TO INSURANCE COVERAGE - In 2007, 71% of privately insured people with low incomesand substantial medical expenses were underinsured - In 2007, 62% of bankruptcies were caused by inability to pay medical bills (Healthcare is the #1 reason for filing bankruptcy) and 75% of these people had health ins at the beginning of their illness INSURANCE DEDUCTIBLES AND COPAYMENTS Just because you have ins, doesn't mean that you are covered 100% -From 2006-2010 the deductible of $1000 or more for SINGLE coverage increased from 10% to 27% of individuals -In 2010 average insurance deductibles for FAMILIES was $3500 plus cost of premiums and copayment GAPS IN MEDICARE COVERAGE - You have ins, but it may not cover what you need -Underinsured and more likely to skip recommended tests or follow-up visits (because of $$) ----Fail to fill prescriptions -Medicare covers about 48% of healthcare expenses in 2006 -In 2004, for 5% of medicare beneficiaries with the poorest health, average uncovered costs was $7646 (up 48% from 1992) - Medicare Part D donut hole- these pts pay a lot out of pocket for meds (it was expected to improve w/ ACA) LACK OF COVERAGE FOR LONG-TERM CARE - Medicare paid only 20% of the elderly's nursing home bills in 2009, and private insurance policies picked up only an additional 8% - Many elderly families spend their life savings on long-term care, qualifying for Medicaid only after becoming impoverished

Impact of ACA

-If ACA is implemented to its fullest extent: ---32 million of the 51 million uninsured Americans will be covered under ACA ---An estimated 16 million will be covered through Medicaid expansion ---Another 16 million would be covered through the individual mandate -None of ACA's coverage would benefit undocumented immigrants (they will not be eligible under federal premium subsidies from individual mandate nor Medicaid except for emergency care) -ACA is expected to cost $938 billion over 10 years, with most of its costs expected associated w/ Medicaid expansion and individual mandate subsidies -ACA FINANCED BY: ---ACA is financed through new taxes and fees and also by cost savings in the Medicare and Medicaid programs ---Individuals w/ earnings > $200,000 and married couples with earnings > %250,000 would pay more for Medicare Part A --- Health Insurance companies, pharmaceutical firms, and medical device manufacturers would pay yearly fees --- Medicare advantage insurance plans and hospitals would receive less payment from Medicare programs - The Congressional Budget Office estimated that the new laws would reduce federal deficit by $124 billion in 10 years, though CBO progression not universally accepted. - ACA has come under political and judicial threats since enacted ---One of the first acts passed by the House when Republicans gained majority again was to repeal ACA -----This attempt was not successful because the Senate, with Democratic majority did not vote to repeal ---Republican Governors and Attorney generals in many states filed suits against ACA challenging the constitutionality of requiring purchase of health insurance and in June 2012, the Supreme Court upheld the constitutionality of the individual mandate, but ruled that state participation in Medicaid expansion must be on a voluntary basis -----*Because many states are not planning on implementing Medicaid expansion, more Americans will remain uninsured than initially projected*

Individual-Mandate Model of National Health Insurance

-In 1989, an individual mandate came about, which was a new species of national health insurance appeared, sponsored by the conservative Heritage Foundation: a -Just as many states require motor vehicle drivers to purchase automobile insurance, the Heritage plan called for the federal government to require (or mandate) all US residents to purchase individual health insurance policies. - Tax credits would be made available on a sliding scale to individuals and families too poor to afford health insurance premiums - Under the most ambitious versions of universal individual insurance proposals, neither employer-sponsored group insurance nor government-administered insurance would continue to play a role in financing health care. ----These existing financial models would be dismantled and replaced by individual mandate programs - Ironically, the individual insurance mandate shares at least one feature with the single-payer, government- financed approach to universal coverage: Both would sever the connection between employment and health insurance, allowing portability and continuity of coverage as workers moved from one employer to another or became self-employed. -With individual mandate health insurance, the tax credits may vary widely in their amount depending on characteristics such as household income and how much of a subsidy the architects of individual mandate proposals build into the plan. - In a generous case, a family might receive a $10,000 tax credit, subsidizing much of its health insurance premium. - If the family's tax liability is less than the value of the tax credit, the government would pay the family the difference between the family's tax liability and $10,000. - A related version individual mandate is a VOUCHER SYSTEM ---Instead of a tax credit, the govt will issue a voucher for a fixed dollar amt that could be used toward the purchase of health insurance ----A tax-financed voucher system would completely replace existing insurance program directly administered by govt as well as employer-sponsorship of private insurance -Another version of health insurance expansion is that proposed by the President George W. Bush ---Individuals would not be required to purchase individual insurance, but would receive a tax credit if they choose to purchase insurance *The level of tax credits in the Bush plan and similar proposals have been small compared to the cost of most health insurance policies, with the result that these voluntary approaches if enacted would have induced very few uninsured people to purchase coverage.*

Who Needs Long-Term Care?

-In 2010 in the United States, approximately 10 million people needed some type of long-term care --3.6 million or 37% were under the age of 65 --6 million were over the age of 65 --It is estimated that at least 70% of people turning age 65 will need long-term care -Factors that increase the likelihood that a person will need long-term care: ----Age ----Gender ----Disability ----Health Status ----Living Arrangement AGE -The older one gets the higher the probability that they will need long-term care GENDER -Since women outlive men. -They are more likely to need help since they live by themselves DISABILITY -Accidents or chronic diseases increase the likelihood of needing long-term care -Chronic conditions (diabetes, high blood pressure and family history may increase your chances of needing long-term care LIVING ARRANGEMENTS -Individuals that live alone are more likely to need care than individuals that are married or living with someone

Who Pays for Long-Term Care?

-In the United States in 2009: --$205 billion spent on long-term care services --22% of patients and their families financed long-term care through out-of-pocket payments --Typically, a family becomes eligible for Medicaid long-term care after they spend a portion of their life savings on long-term care --Medicaid pays for 34% of U.S. long-term care -In 2006, one year of nursing care at home cost an average of $76,000 -INDIVIDUALS -FAMILIES -MEDICARE --Does not cover assistance with ADLs that are considered custodial services --*Medicare only covers or pays for only "skilled care"* ----i.e. Registered nurses in a hospital facility, nursing home, or home care services --RNs provide a wide variety of services i.e. changing wound dressings, taking blood pressures, assessing heart and lung sounds, reviewing patient compliance with medications and providing patient education (diabetes, hypertension and heart failure). --Usually covers services after an "acute" hospitalization --Does not cover care for "chronic conditions" -MEDICAID --Generally does not pay for around the clock (24 hour) home care of people that cannot take care of themselves --In 2005, Medicaid spent 35% of long-term care budget on home and community-based care --Qualifying for Medicaid - Nursing Home Coverage ----Families may be forced to spend their life savings to low levels to qualify for Medicaid benefits --Increase in Medicaid Coverage of Home Health Services ----As a result of home and community-based care 1915 (c) waivers --1915 (c) waivers ----Attempts to prevent nursing home admissions by allowing Medicaid recipients to receive more home care services -PRIVATE LONG-TERM CARE INSURANCE --Plays a minor role in long-term care financing --Only 8% of long-term costs are covered by private insurance policies --Usually have a large deductible --EXAM:Experience-Rated Insurance ----Results in high premiums for the elderly population because they are at a considerable risk of requiring long-term services --In 2009, the median income of people age 65 and older was $31,000.00 and due to the median income of people aged 70 to 74 years of age, only 17% of households could afford long-term insurance policies

What is Long-Term Care?

-Individuals that need help with ADLs & IADLs require long-term care. *EXAM: Know difference between ADL and IADL* --Activities of Daily Living (ADLs) ----Bathing ----Dressing ----Using the bathroom ----Transferring from one area to another ----Bed to living room, chair to sofa, etc ----Eating -Assistance with everyday tasks or Instrumental Activities of Daily Living (IADLs) ----Housework ----Managing money ----Taking medication ----Shopping for groceries ----Caring for pets

Health Maintenance Organization (HMO)

-Individuals with a HMO are expected to receive their care from providers within the HMO network with the exception of emergency care - Some HMO's pay drs and hospitals via bundled units of payment --Per diem --Capitation --Salary

Consolidation in the Health Care Market

-Intense copmetition stimulated consolidation among insurers and providers to improve bargaining power -Large HMOs bought smaller ones -In most states, three (Wellpoint, United Healthcare & Aetna)large insurance companies dominated more than 60% of the market -Providers also consolidated -By 2001, 65% of hospitals were members of multi-hospital systems or networks -Hospital prices often rose after consolidation -Specialists increasingly joined single-specialty groups -Private primary care and specialty practices were being acquired by hospital systems to increase their market clout -Consolidation went hand-in-hand with organizations converting from non-profit to for-profit status -For -profit hospitals provide less charity care, treat fewer Medicaid patients, lower quality, and higher administrative costs due to being investor owned. -Non-profit community hospitals are competing too- these hospitals are creating "specialty service lines" to attract specialist physicians and well-insured patients

Kennedy Bill & Single Payer Plan

-Legislation introduced by Senator Edward Kennedy & Representative Martha Griffiths ---Legislation attempted to cover the entire population through a national health insurance program ---Bill called for one single federally operated health insurance system that would replace all public and private insurance plans -Opposed by the American Medical Association

Preferred Provider Organization (PPO)

-Loose knit organization in which insurers contract with a limited amount of hospitals and physicians -In turn, hospitals and physicians are paid an agreed upon discounted fee-for-service with utilization review

Florida House of Representative

-Lower house of the Florida Legislature -Total of 120 members -Serve 2 year terms -SPEAKER OF THE HOUSE ----If a speaker of the house doesn't want to hear a bill, they do not have to read it ----Elected by House members ----Serves for 2 years ----Can appoint members to committees ----Can influence bills on the calendar

Allocation of Resources

-Macro-allocation ----Refers to the amount and distribution of resources within a society ----This type of decision may be more significant than micro-allocation and affect thousands or millions of people -Micro-allocation ----Refers to resource constraints at the level of an individual physician or institution ----These types of decisions can be more acute -Example: respirator in ICU/medical effectiveness

Congress

-Make laws - Divided into 435 members of House of representative (that number can change) AND 100 members of the senate (that number DOES NOT change)

Allocation of Health Care Resources

-Medical commons --A portion of the U.S. economic resources dedicated exclusively to healthcare. --United States, medical commons area is considered "open range" ----The quantity and price of medical visits, hospital days, surgeries, diagnostic studies, drugs and other medical interventions determine the total cost of medical care --Other nations around the world ----Government budgets set a clear limit on the quantity of resources available

Organ Transplant

-National waiting list ---16,000 (1988) to 111,000 (2010) -Pool of organ donors ---Estimated at 14,500 ---In the U.S., 19 patients die each day waiting for an organ ---Insufficient supply to meet demand -Explicit Rationing ---System that determines who gets organs and who does not is inevitable

Making the Call

-Physicians cannot serve two masters: ---1) Society's needs ---2) Patient's needs -If physicians refuse to serve two masters, who will make the decisions? --Currently, those decisions are made by: ----Medical Directors of private insurance companies ----Leaders of the Medicare and Medicaid programs ----Decisions vary from plan to plan and similar patients -If physicians decide to serve to masters (society and individual patients): ---Rules are needed to assist physicians to make the right decisions ---These rules should operate at the population and individual level. ---Population level -----Society should decide which treatments should be paid through a universal health insurance ---Individual level -----Rules are needed to guide decisions about prioritization of resources for specific patients -----Example: Organ allocation model (UNOS)

Nursing and Policy

-Policy and politics are the ways and means that nurses can use to influence the quality, safety, and accessibility of patient care. -Nurses need to be key change agents since nursing is concerned with health issues that are subject to frequent policy changes at all levels. Therefore every action and decision that influences health and the health system should be important to nurses. -Understanding the policymaking process permits nurses to determine when and how to intervene to shape a policy to benefit a patient.

Policymaking and Nursing

-Policy making is a complex, multidimensional, dynamic process; ....it encompasses the choices that a society or organization makes regarding its goals and priorities and the ways it allocates its resources to attain those goals. - Politics simply means the process of influencing the allocation of scarce resources ($). Politics is often associated with "conflicting values". -Nurses can improve the health of people by developing influence in four interconnected spheres: the workplace, government, professional organizations, and community.

Employer-Mandate Model of National Health Insurance

-President Nixon ----Responded to Democratic Senator Kennedy's legislation by proposing the nation's first employment-based, privately administered national health insurance ----Under Nixon's proposal, the federal government would require (mandate) employers to purchase private insurance for their employees. ----Moved national health insurance debate to private sector

Medical Benefits

-Private insurance health plans (i.e. Cigna, United Healthcare, AvMed, Blue Cross -Blue Shields, Aetna, Humana, etc) ---Also affect the distribution of medical care Insured largest number of individuals in the United States ---Private insurance companies may also determine what kind of medical care patients received by covering some types of medical care and excluding others ---Private insurance health plans may be experience rated, which means that premiums may cost more for individuals with a chronic disease or for individuals that are at higher risk -----This may impact individuals ability to pay or attain private health insurance -----Does this practice violate the justice principle? -----How should people that smoke, eat unhealthy and abuse alcohol be treated?

Private Long-Term Care Insurance

-Private insurance plays a minor role in long-term care financing, with only 8% of long-term care costs covered by private policies (Table 12-2). -EXAM: Experience rating has had a profound effect on the dynamics of private long-term care insurance. -The largest market for this type of insurance is the elderly population. - Under experience-rated insurance, the elderly are charged high premiums because they are at considerable risk of requiring long-term care services. -The 2009 median income of people over 65 was $31,000 -Only 17% of households with the head of the household aged 70 to 74 years could afford the average long-term care insurance policy -The major attractive market for long-term care insurers is the younger employed population, but only a tiny fraction of this group is interested in long-term care insurance because the prospects of needing such care are so remote. -People purchasing long-term care insurance may find it to be a poor investment. -Some private policies specify that a policyholder must be dependent in three or more ADLs before receiving benefits for home health services, yet many people with fewer than three ADL impairments need long-term care services ----For these people, their insurance may pay nothing. -Long-term care policies usually have a large deductible (measured in nursing home days) for nursing home care, and most policies pay a fixed daily fee rather than reimbursing actual charges. - A typical policy might provide $150 per day after a 90-day deductible. The 2006 average daily nursing home charge was $220, meaning that $70 would be the patient's responsibility. ----Thus a year's stay would require out-of-pocket expenditures totaling $39,050 (90 days x $220 = $19,800 plus 275 days x $70 = $19,250) over and above payment of the insurance premium. - Most policies limit their coverage to a few years, which places a cap on how much the insurance will pay

Types of Policy

-Public Policy ---Formed by governmental bodies (ie. Legislation passed by Congress such as the ACA). -Social Policy ---Pertains to policy decisions that promote welfare of the public (ie. A local age limit ordinance). -Health Policy ---Decisions made to promote the health of individual citizens (ie. gov't paid smoking cessation program) -Institutional Policies ---Those that govern workplaces such as hospitals. ---Magnet hospitals have nurses involved in decision making policies at all levels of the institution. -Organizational Policies ---Positions taken by organizations such as the ANA, or NLN.

Cost Containment versus Rationing

-Rationing ----Limitation of resources including money going to medical care such that that all care expected to be beneficial is provided to all patients ----Example: Denial of bone marrow transplants -Cost Containment ----Limitation of money going to medical care, not all cost containment reduces beneficial care to patients ----Example: Closing 2 of 3 MRI scanners

Florida Nurses in State Legislature

-Rep. Denise Grimsley, RN (District 77) Florida State Legislature 402 South Monroe Street Tallahassee, FL 32399-1300 Tel: 850.488.3457 [email protected] -Rep. Yolly Roberson (District 104) Florida State Legislature 402 South Monroe Street Tallahassee, FL 32399-1300 Tel: 850.488.7088 [email protected]

Payment per Episode of Hospitalization: Diagnosis-Related Groups (DRGs)

-Started in 1983 -Method of payment for Medicare patients -Instead of fee for service, Medicare pays a lump sum for each hospital admission and amt of $$ is based on patient's diagnosis - Get paid a lump sum???? (Question on the exam?) - DRG reimbursement lumps together all services performed during one hospital episode (per diem was per day) ---- The term episode under the DRG system refers only to the portion of the illness actually spent in the acute care hospital (i.e. transfers or outpts will be considered separate) Risks: -Medicare at risk for number of admissions -Hospital at risk for length of stay and resources ----Hospitals conduct internal utilization review to reduce the costs incurred by Medicare patients from long stays

Payment per Episode of Illness

-Surgeons usually receive a single payment for several services (the surgery itself and postoperative care) that have been grouped together, and obstetricians are paid in a similar manner for a delivery plus pre- and postnatal care - Get paid a lump sum???? (Question on the exam?) - With payment by episode, surgeons have an economic incentive to limit the number of postoperative visits because they do not receive extra payment for extra visits, but have the incentive to perform more surgeries just like fee for service - Under this system, one fee would be paid for one episode of illness, no matter how many times the patient visited the physician - Concept of RISK comes into play and refers to the potential to lose money,earn less money, or spend more time without additional payment on a reimbursement transaction. - Fee for service, the party paying the bill absorbs all the risk, but with this bundling of service, a portion of the risk from the payer to the physician ----The more services bundled into one payment,the larger the share of financial risk that is shifted from payer to provider ------PAYER: refers to whomever pays the bill

Government-Financed National Health Insurance

-The American Association for Labor Legislation Plan -The Wagner-Murray-Dingell Bill -Medicare & Medicaid -1970 Kennedy Bill & the Single-Payer Plan of the 1990s -Can be divided into 2 categories: ---1) Social Insurance Model -----Only those that pay into the program usually through social security contributions are eligible ---2) Public Assistance (Welfare) Model -----Eligibility is based on a means test where individuals below a certain income may receive benefits

Politics

-The art or science of government -The art or science concerned with guiding or influencing governmental policy

Long Term Care (Chapter Introduction)

-The crisis of long-term care is twofold: --1) Thousands of families each year lose their savings to pay for the chronic illness of a family member --2) Long-term care often takes place in dehumanizing institutions that rob their occupants of their last remaining vestiges of independence. - EXAM: Long-term care includes those health, social, housing, transportation, and other supportive services needed by persons with physical, mental, or cognitive limitations sufficient to compromise independent living. -The need for long-term care services is usually determined by evaluating a person's impairment of activities of daily living (ADLs; e.g., eating, dressing, bathing, toileting, and getting in or out of bed or a chair) and in instrumental activities of daily living (IADLs; e.g., laundry, housework, meal preparation, grocery shopping, transportation, financial management, taking medications, and telephoning) (Table 12-1). - 12 million people in the United States require assistance with one or more ADLs or IADLs, and can therefore be considered as needing long-term care services. - Projections of growth for the elderly population in the United States are: ----In 2000, the population 65 years of age and older numbered 35 million and this figure is expected to reach 72 million by the year 2030. ----The number of people 85 years and older will nearly double from 4.2 million in 2000 to 7.3 million in 2020. ----Those 80 years and older are most likely to need long-term care because 57% have severe disability -As more and more people need long-term care, the answers to two questions become increasingly urgent: How shall the nation finance long-term care? Should most long-term care be delivered through institutions or in people's homes and communities?

Healthcare & Distributive Justice

-Throughout history, the problem has been healthcare is a privilege VS healthcare is a right that should be distributed according to need -In developed nations, the allocation of healthcare according to need is the dominant belief, as demonstrated by the passage of universal or near-universal health insurance laws. -In the US, the failure to enact a national health insurance and the different opinions about the Affordable Care Act attest to the debate between health care as a privilege and health care as a right -If the opinion in the developed world holds that health care should be allocated according to need, then all people should have equal access to a reasonable level of medical care without financial barriers (i.e., people should have a right to health care). -The principle of distributive justice requires that all people equally receive a reasonable level of medical services based on medical need without regard to ability to pay

The Controversy of Universal Health Insurance

-To understand the debate surrounding universal health insurance, one must understand health care financing -The United States uses four basic modes of health care financing: ---Out of pocket ---Individual private insurance ---Employment-based private insurance ---Government financing

Fee-For-Service Reimbursement w/ Utilization Review

-Traditional type of payment plus third-party payer review ----Third-party payer can be private ins or public govt agencies ---Authorizes or denies payment for expensive medical services i.e. hospital admissions, extra hospital days or surgeries

U.S. Healthcare System

-U.S. Healthcare System is a 2.5 trillion dollar system. -Four major players: --1) Purchasers -----Include: individuals, employers, & government -----Purchasers supply the funds. They include individual consumers, businesses that pay for health insurance for their employees, government public programs (Medicare and Medicaid). --2) Insurers -----Insurers receive money from the purchasers (individuals and businesses) and reimburse the providers when the policyholders require medical care. Some insurers are the same as purchasers (ie. Medicare and Medicaid programs). --3) Providers -----Include: hospitals, nursing homes, home care agencies, physicians, pharmacies, etc. -----In the past purchasers viewed the expenses of the insurers, providers, and suppliers as an investment into better healthcare. -----Today there is a conflict- the purchasers want the healthcare industry (insurers, suppliers and providers) to reduce spending and the suppliers want to increase the amount spent on healthcare. --4) Suppliers -----Medical & pharmaceutical suppliers, computer equipment

Nurses serving in the U.S. Congress

-U.S. Rep. Karen Bass (California) -U.S. Rep. Diane Black (Tennessee) -U.S. Rep. Lois Capps (California) -U.S. Rep. Renee Ellmers (North Carolina) -U.S. Rep. Eddie Bernice Johnson (Texas) -U.S. Rep. Carolyn McCarthy (New York)

Medical Benefits

-United States ---Most people think that healthcare is a right If all people have the right to all beneficial health care, how are we (society/government) going to fund this? ---One approach may be to limit healthcare right to a basic package of services -----Any service not covered under the "basic package" may be purchased by the individual at their own cost -------This creates an ethical dilemma for those individuals that want the service but cannot afford to pay for it on their own

Care of Incurable Illnesses

-What amount of healthcare should be provided to individuals that are profoundly and incurably ill? -27% of Medicare's budget is spent on people in their last year of life -Almost 50% of the budget ($68 billion in 2009) is spent on the last 60 days

Medicare Long-Term Coverage

-Which services provided in a nursing facility or at home are covered by Medicare? ----The key distinction is between "skilled care," for which Medicare pays, and "custodial care," which is usually not covered. -A related issue is that of postacute VS chronic care. -Medicare usually covers services needed for a few weeks or months after an acute hospitalization, but often does not pay for care required by a stable chronic condition. -Some examples of skilled care VS custodial services ----Registered nurses in a hospital nursing facility, nursing home, or home care agency provide a wide variety of services, such as changing the dressing on a wound, taking blood pressures, listening to the heart and lungs to detect heart failure or pneumonia, reviewing patient compliance with medications, and providing patient education about diabetes, hypertension, heart failure, and other illnesses. ----Physical and occupational therapists work with stroke, hip fracture, and other patients to help them reach their maximum potential level of functioning. ----Speech therapists perform the difficult task of teaching stroke patients with speech deficits how to communicate. ----*These are all skilled services, usually covered by Medicare.* ----Custodial services involve assistance with ADLs and IADLs rather than treatment or rehabilitative care related to a disease process -------These are tasks such as cooking, cleaning house, shopping, or helping a patient to the toilet. -------These services, usually provided by nurses' aides, home health aides, homemakers, or family members, are considered unskilled and are often NOT covered by Medicare.

Commodity Scarcity: THE CASE OF ORGAN TRANSPLANTS

-While fiscal scarcity is the more common form of resource limitation, commodity scarcity provides an instructive example of the interaction of ethics and rationing -In 1951, the first kidney transplant was performed in Massachusetts. -In 1967, when Dr. Christiaan Barnard sewed a living heart into the chest of a person suffering end-stage cardiac disease ----This is when modern medicine fully entered the age of transplantation. -In 2010, 17,000 kidney, 2300 heart, 6300 liver, and 1800 lung transplants were performed in the US -70-80% of pts receiving heart, liver or kidney transplants survive at least 5 years after transplantation - Transplants is both medical and ethical concern WHO SHOULD RECEIVE ORGANS SHORT IN SUPPLY? -The number of persons on the national waiting list for organ transplants rose from 16,000 in 1988 to 111,000 in 2010, yet the pool of potential organ donors has been estimated at 14500 (the number of organs donors falls short of the number of that require an organ) -Transplantation presents a classic case of COMMODITY SCARCITY: ---There is insufficient supply to meet demand. --- Explicit rationing, is inevitable, which is a system that determines who gets organs and who does not ---For heart, lung, and liver transplants, rationing is all or nothing in that those who receive organs may live, while those who do not will die. -In the early 1980s, the major heart transplant center at STANFORD UNIVERSITY excluded people with "a history of alcoholism, job instability, antisocial behavior, or psychiatric illness," and required transplant recipients to enjoy "a stable, rewarding family and/or vocational environment." ----Stanford's recipients had a better than 50% chance of surviving 5 years, signifying that acceptance or rejection from the program was a matter of life and death. ----The US Department of Health and Human Services was concerned about Stanford's selection criteria, which favored those middle-class or wealthy people with satisfying jobs and the > $100,000 cost restricted heart transplants to those with insurance coverage or ability to pay out of pocket. ----Both the social and economic criteria for access to this lifesaving surgery raised serious issues of distributive justice. -The National Organ Transplantation Act of 1984 led to the federal government designated the United Network for Organ Sharing (UNOS) as a national system for matching donated organs and potential recipients. -According to the Task Force on Organ Transplantation (1986), organ allocation should be governed by MEDICAL CRITERIA with the major factors being urgency of need and probability of success. ----The Task Force recommended that if two or more patients are equally good candidates for an organ according to the medical criteria, length of time on the waiting list is the fairest way to make the final selection. HOW UNOS WORKS AND WHO RECIEVES ORGANS? -Overall, UNOS follows these recommendations, placing potential recipients of organ transplants on its computerized waiting list. -Recipients are prioritized according to a point scale based on severity of illness,time on the waiting list, and probability of a successful outcome -Problems have developed with the UNOS system, as patients with similar characteristics may have considerable variation in access to organs, but overall, a serious attempt has been made to allocate scarce organs on the basis of justice criteria. - ETHICAL DILEMMA in the prioritization process is the issue of ability to pay. --- In 2008, the average heart transplant cost $259,000, kidney transplant $51,000, and liver transplant $534,400. ----Transplant centers require recipients to pay cash in advance or show proof of insurance coverage. ----Currently, Medicare, some Medicaid programs, and a number of private insurers pay for needed transplants. ----The uninsured usually have no access to transplantation

Why People Lack Insurance

-Why has private health insurance coverage decreased over the past decades, creating the uninsurance crisis? -FACTORS THAT CAUSES A LACK OF INSURANCE (FIRST TWO ARE VERY IMPORTANT): --1) The skyrocketing cost of health insurance has made coverage unaffordable for many businesses and individuals. (INCREASING HEALTHCARE COST) ----From 2000 to 2010, premiums paid by employers rose 114% ---- In 2010, the average annual cost of health insurance, including employer and employee contributions, was $5049 for individuals and $13,770 for families ----Some employers responded to rising health insurance costs by dropping insurance policies for their workers. ----Many employers have shifted more of the cost of health insurance premiums and health services onto their employees, resulting in employees dropping health coverage because of unaffordability. ----Low-income workers are hit especially hard by the combination of rising insurance costs and declining employer subsidies --2)During the past few decades, the economy in the has undergone a major transition and the number of highly paid, largely unionized, full-time manufacturing workers with employer-sponsored health insurance has declined, and the workforce has shifted toward more low-wage, increasingly part-time, nonunionized service and clerical workers whose employers are less likely to provide insurance (CHANGING OF THE LABOR FORCE) --3) The unstable nature of employment ----People who are laid off from their jobs or who leave jobs because of illness may also lose their insurance. ----Family members insured through the workplace of a husband or wife may lose their insurance in cases of divorce, job loss, or death of the working family member. ----People who leave their employment may be eligible to pay for continued coverage under their group plan for 18 months, as stipulated in the Consolidated Omnibus Budget Reconciliation Act of 1985, with the stipulation that they pay the full cost of the premium; however, many people cannot afford the premiums, which may exceed $1000 per month for a family ATTEMPT AT A SOLUTION: - The expansion of public insurance coverage through the Medicaid and SCHIP programs. ----Without these changes, many more millions of Americans would currently be uninsured. PROBLEM WITH THIS SOLUTION/MEDICAID: -The often transient nature of employment-linked insurance is compounded by difficulties in maintaining eligibility for Medicaid. -Small increases in family income can mean that families no longer qualify for Medicaid. - The net result is that millions of people cycle in and out of the ranks of the uninsured every month. - 87 million, 29% of the entire US population went without health insurance for all or part of the 2-year period 2007-2008 - Health insurance may be a fleeting benefit.

Wagner-Murray-Dingell Bill

1943 -Introduced by Democratic Senators Robert Wagner and James Murray, and Representative John Dingell -Plan based on social security system introduced in 1935 -Physician & Hospital care to be paid through: ----Federal social insurance trust fund who would then paid health providers --Social security insurance proposal -Eligibility ----Working people and their dependents were eligible because they made social security contributions ----Retirees were also eligible since they contributed to social security before retiring

History of Organ Transplant

1980s -Stanford University - Organ transplant program selection criteria ----Excluded individuals with a history of alcoholism, job instability, anti-social behavior, or psychiatric illness from the organ waiting list ----Stanford's recipients had a 50% or better chance of surviving 5 years -U.S. Dept. of Health & Human Services ----Concerned about Stanford University's selection criteria ----Favored middle-class or wealthy people with satisfying jobs -National Organ Transplantation Act of 1984 ----Designated United Network for Organ Sharing (UNOS) ------National system for matching donated organs with potential recipients

Fig. 3-3 Lack of Ins by Income

25% of individuals with annual household incomes less than $25,000 were uninsured, compared with 9% of individuals with household incomes of $75,000 or more

Policy

A plan or course of action of a government, political party or business used to influence and determine decisions or actions

Pharmaceutical Industry Comes Under Criticism (KNOW WHY CRITICIZED, WHY THEY HAVE POWER, NUMBERS?)

BOOK -Rising tensions among purchaser, insurers and providers spilled over to healthcare's major supplier: the pharmaceutical industry - In 1988 prescription drugs accounted for 5.5% of national health expenditures, 71% of drug costs were paid out of pocket by individuals, and only 18% paid by private insurance plans, these costs had little impact on insurer -By 2009, prescription drug costs had risen to 10.1% of total health expenditures, with only 21% paid out of pocket, the rest covered by employers, insurers, and governmental purchasers -The growing costs of drugs for the elderly became a major national issue ---Because of its unaffordable prices and high profits, the pharmaceutical companies became enemy #1 -In the U.S. drug companies are very profitable and earn net profits after taxes close to 20% of revenues compared with 5% for all Fortune 500 firms -Pharmaceutical companies argues that their high drug prices are justified due to the cost of research and development of new drugs, but the National Science Foundation estimates that R&D spend half of what they claim -R&D for the largest drug companies consumed only 14% of revenues in 2002, while marketing and administration accounted for 33% and after-tax net profits 21% -Unlike many nations, government in the United States does not impose regulated prices on drugs ----As a result of drug industry lobbying, the Medicare prescription drug coverage law passed in 2003 forbid the government to regulate drug prices ----Government regulations in the US serve mainly to reduce competition through a system of patent protection. -Companies developing a new brand-name drug enjoys a patent for 20 years from the date the patent application is filed, during which time no other company can produce the same drug. -Once the patent expires, generic drug manufacturers can compete, and do so by selling the same product at lower prices. -A number of drug companies have waged expensive legal battles to delay patent expirations on their brand name products, or have paid generic drug manufacturers not to market generic alternatives - In addition, the industry attempts to persuade physicians and patients to use brand-name products, spending $30 billion in 2005 on sales representatives' visits to physicians, journal advertising, sponsorship of professional meetings, and direct-to-consumer television ads -Four out of five physicians have some type of financial relationship with the pharmaceutical industry, ranging from accepting gifts to serving as a paid lecturer on behalf of a company. - These physician-industry relationships do influence prescribing behavior, in particular influencing physicians to prescribe new drugs that are the most expensive and whose safety has not been adequately evaluated - The federal Food and Drug Administration (FDA) has sent hundreds of letters to drug manufacturers citing advertising violations including minimizing side effects and exaggerating benefits - Most trials to determine the efficacy of prescription drugs are funded by that drug's manufacturer, and trials funded by industry are more likely than those with nonindustry funding to report results favorable to the funding company--- YET physicians base treatment decisions on these trials, which inform clinical practice guidelines. - Authors of clinical practice guideline have ties to the pharmaceutical industry - From 2006-2010, 18 new drugs were removed from the markey due to serious side effects, and in some cases the manufacturer knew about this and hid it from FDA or FDA ignored the evidence -Some members of a FDA committee recommending approval of a drug have ties to that drug's manufacturer, and these members with clear conflict of interest are often not recused - These revelations have tainted the image of the pharmaceutical industry in the eyes of the medical profession and the public. - Private health insurance companies have mounted the most effective response to the drug industry by creating tiered formularies in which generic drugs have lower copayments than brandname drugs. ---As a result, approximately 75% of all prescriptions filled in the United States in 2009 were for generic products. ----However, some brand-name drug companies are starting to produce generics, and the generic industry is starting to consolidate into fewer and larger companies ----These trends could mean that generic prices may rise to levels not far below current brand name prices. PPT -2009 ---Drug companies spent $7 billion on sales representative to visit physicians to persuade them to use brand name medications and not generic equivalents

U.S. Federal Government System

Be familiar with this concept

American Nurses Association (ANA)

CODE OF ETHICS FOR NURSING -Consists of 9 provisions -Per ANA (2010), "Ethics is an integral part of the foundation of nursing. A code of ethics makes explicit the primary goals, values, and obligations of the profession." NURSING'S SOCIAL POLICY STATEMENT (2003) -"Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through diagnosis and treatment of human response and advocacy in the care of individuals, families, communities and populations." (American Nurses Association, 2003) -Knowledge Base for Nursing Practice ---"Nursing is a profession and a scientific discipline." ------Combines theoretical and evidence-based knowledge -Scope of Nursing Practice ---One scope of practice that spans from the novice to the expert nurse ---How one individual nurse engages in the profession depends on their education, experience, role, and patient population they serve. ---All nurses are responsible for practicing in accordance with their scope of practice -Nursing practice includes but is not limited to: ----Initiating and maintaining comfort measures ----Promoting and supporting human functions ----Establishing an environment conducive to well-being ----Providing health counseling and teachings ----Collaborating on health regimen

U.S. Congressional Delegation in Florida

Every state has 2 elected senators -U.S. Senator Bill Nelson (ACTIVE) -U.S. Senator Marco Rubio (ACTIVE) -U.S. Rep. Alcee Hastings (District 20) -U.S. Rep. Ted Deutch (District 21) -U.S. Rep. Lois Frankel (District 22) -U.S. Rep. Debbie Wasserman-Schultz (District 23) -U.S. Rep. Frederica Wilson (District 24) -U.S. Rep. Mario Diaz-Balart (District 25) -U.S. Rep. Joe Garcia (District 26) -U.S. Rep. Ileana Ros-Lehtinen (District 27)

EXAM: U.S. Attempts At National Health Insurance

KNOW THESE DATES

Financing Long-Term Care

PEPPER COMMISSION (1990) --Recommended that the government create a social insurance program to finance long-term care --This program would be financed like Medicare through an increase in social security contributions by employers and employees --Program would pay for caregivers to provide services not covered by Medicare: ----In-home help (feeding, dressing, bathing, toileting, housework, grocery shopping, transportation and assistance with ADLs and IADLs

American Association for Labor (AALL): Legislation Plan

U.S. IN THE EARLY 1900'S -40% of people who became sick did not receive any medical care AMERICAN ASSOCIATION FOR LABOR -Published a national healthcare insurance proposal --Insurance would cover low-paid workers with earnings less than $1200 a year and provide the following: ----Medical care ----Sick pay ----Funeral expenses --Plan would cover dependents --Program would be run by states --Financed by tax-contributions (mandatory tax) from employers, employees and state governments --Government-financed program --1st attempt at a national health insurance

NATIONAL HEALTH INSURANCE

UNITED STATES -For over 100 years, policy reformers have campaigned for the passage of a national health insurance program -National health insurance has been a topic of debate during: ---1912 to 1916 ---1946 to 1949 ---1963 to 1965 ---1970 to 1974 ---1991 to 1994 ---2009 to 2010

Organ Allocation

UNOS --Recipients are prioritize according to the following factors: ----Severity of illness (per point scale) ----Time on waiting list ----Probability of a successful income --Individuals on the list who lack health insurance are often rejected

Ethical Considerations: Open vs Closed- Range Medical Care Systems

US -Open-range -Principles of beneficence and autonomy are key OTHER NATIONS -Closed-range or fenced-in systems ---Use a more expansive principle of beneficence, autonomy and distributive justice to allocate resources within the medical commons area.