Click here to load reader

Fall2010 Boss

  • View
    51

  • Download
    5

Embed Size (px)

Text of Fall2010 Boss

I. INTRODUCTION TO HEALTH LAW AND POLICY A. Introduction 1. Features of health care: a. Big business. b. Major chains set up clinics on-site. (ex. Walgreens) Nurse practitioners c. Expensive i. Health care inflation always exceeds general inflation. d. US worse than other countries that devote less money to health care. e. Insufficient financial incentives for MDs to improve health care quality. 2. Series of efforts to improve health care a. Provide financial incentives. Medicare/Medicaid wont pay extra-care costs associated with some never events. i. Eventually backs off b/c of arguments that its not easy to control. b. Pay for Performance (Hasnt been shown to work.) c. Ranking health-care systems i. US News Best Hospitals Rankings; Consumer Reports; Thomson Reuters; Zagats; Govt-run websites ii. Controversy over how the calculations are made. iii. Other factors in where people live. iv. MD-physician relationship is personal, trust built up, not easy to disturb. v. Research shows ratings have limited impact on patient behavior. vi. MDs file lawsuits challenging the rankings, claiming theyre unreliable. vii. Rankings encourage MDs not to tell, which lowers the quality of care. 3. Rationale Given for Medical Malpractice Litigation a. Promote patient safety i. Identify dangerous conditions ii. Bring malpractice epidemic to light iii. Provide incentive for patient safety iv. Teach how to avoid injuries & give incentive to do so b. Promote traditional American values i. Provide a system to right wrongs, access to justice ii. Promote personal responsibility & accountability iii. Need a right, not enough to be angry c. Provide needed compensation d. Avoid governmental intrusion 4. Defining Sickness & Health -- Note that this is important because we need a definition of health in order to assess the quality of care needed to promote or restore it. A malpractice suit or medical quality audit depends on an ability to distinguish a bad from a good medical care outcome. a. WHO definition: a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity b. Health as the performance by each part of the body of its natural function. Disease is a biological malfunction, and illness a subset of disease. (Borse) c. Illness a socially constructed deviancesomething more than mere biological abnormality. To be ill is to have deviant characteristics for which the sick role is appropriate. Thus, illness has many ramifications. First, it affects the individual. It

1

also relieves responsibility. ... Our understanding of illness also affects society: Defining a condition as an illness to e aggressively treated, rather than as a national condition of life to be accepted and tolerated, has significant economic effects. 5. Myths of Health Care (Alain Enthoven) a. Can diagnose, answer questions precisely, & prescribe correct treatment i. certainty vs. uncertainty b. There is a best treatment (so it is up to a doctor to know and use that treatment) c. Medicine is an exact science d. Standardized steps that should be taken/medical care a standard product e. More care is better than less care (even though more can be harmful) f. Money is no object g. Much of medical care is a matter of life and death (even though mostly about quality of life) B. Quality in Health Care 1. Hospital had a duty to the patient to mandate medical clearance before the procedure was done. Bonnie Bowser Hypo (57-58) a. Facts: Fell & severely injured elbow. Surgeon scheduled for corrective surgery next day. High risk candidate. After anesthesia administered, rapidly deteriorated, died. Autopsy: anesthesia cause of death as severely medically compromised i. Expert: elbow operation not justified; obvious risk b. Surgeons duty to the pt extends beyond technical proficiency to include the bigger picture. 2. Three major approaches to quality assessment: a. The structure: resources and system design i. The relatively stable characteristics of the providers of care, of the tools and resources they have at their disposal, and of the physical and organizational settings in which they work. ii. Easiest evaluation to do but least useful b/c connection not necessarily direct. b. The process of care: interaction between physician and patient i. Benefits: can specify criteria and standards of good care, establish a range of acceptable practice, assures documentation, attributes responsibility ii. Cons: Weakness of the scientific basis for much of accepted practice; emphasis on the need for technical interventions may lead to high cost of care; interpersonal process is slighted by focus on technical proficiency. c. Outcomes: A change in a patients current and future health care status that can be attributed to antecedent health care. i. Pros: focuses on what works, integratedconsiders patients actions. ii. Cons: duration/timing/extent of outcomes often hard to specify; often hard to credit a good outcome to a specific medical intervention; outcome often known too late to affect practice. iii. What constitutes a successful outcome? What order of priority? 1. Avoidance of death/Prolongation of life 2. Reduction of pain/Elimination of pain 3. Reduction of symptoms/Removing these symptoms 4. Gratification of patients desires? psych state?

2

a. Promoting security/integrity of body/person 5. Avoiding unnecessary costs a. Promoting efficiency in health care 6. Promoting the greater good a. Innovation? General health of population? 7. What role for patients wishes/goals? Always objective or subjective too? 3. Possible Indicators of Good/Poor Quality Health Care a. Hospital mortality & morbidity rates i. People come in w/diff conditions, some dying b/c of underlying conditions and not b/c of MDs b. Adverse events that affect patients i. Distinguishing between adverse events and preexisting conditions c. Formal disciplinary actions by med board i. A lot of events dont end up w/boardMDs take care of their own d. Malpractice awards i. Clientele of one hosp more willing to sue than others ii. Most people that experience an adverse event dont sue e. Process evaluation of performance in treating a particular condition i. Subjective, time-consuming, difficult to assess f. Physician specialization i. Assumes specialization is better. Could fail to appreciate other risks. g. Patient self-assessment of own care i. Something could go wrong thats not MDs fault. h. Scope of hospital services as evaluated by external source such as JCAHO i. Market j. Efficiency? How much do we spend per person and for what results? 4. Means for Monitoring and Improving Health Care? a. Better health care providers i. training, CME requirements, Hippocratic Oath b. Better informed patients i. full disclosure, informed consent, report cards c. Better internal quality controls i. staff privileges, risk management, medical & administrative committees, administrative oversight d. Greater external oversight i. Joint Commission, accreditation; government regulation, certification e. Greater 3rd party oversight i. managed care, insurance, employers f. Greater medical profession oversight i. ethical standards, licensing boards, clinical standards of practice g. Recourse to judicial system i. malpractice suits, abuse/neglect statutes, criminal proceedings 5. Medical Practice Variation and the Nature of Quality in Medicine The phenomenon of medical practice variation highlights the role of uncertainty in the setting of medical standards. John E. Wennenberg has studied medical practice variation

3

based on studies of three categories of care a. Effective care : Interventions that are viewed as medically necessary on the basis of clinical outcomes evidence and for which the benefits so outweigh the risks that virtually all patients should receive them. b. Preference-sensitive care : treatments, such as discretionary surgery, for which there are two or more valid treatment alternatives, and the choice of treatment involves tradeoffs that should be based on patients preferences. Variation in such care is typified by elective surgeries, such as hip fracture, knee replacement, or back surgery. c. Supply-sensitive care : Services such as physician visits, referrals to specialists, hospitalizations and stays in intensive care units involved in the medical (nonsurgical) management of disease. In Medicare, the large majority of these services are for patients with chronic illness. --Doctors obviously make mistakes and some of these errors injure patients. -- The combined problems of variation in medical practice and lack of evidence of efficacy of many treatment approaches have launched a movement toward practice guidelines. -- Measuring appropriateness and developing parameters has its problems: it is easier to study overuse than underuse because of difficulties in defining relevant populations Medical practice variation and the nature of quality in medicine: Wennenbergs studies are based on studies of three categories of care: (1) effective care interventions that are viewed as medically necessary on the basis of clinical outcomes evidence and for which the benefits so outweigh the risks that virtually all patients with medical need should receive them. (2) preference-sensitive care treatments, such as discretionary surgery, for which there are two or more valid treatment alternatives, and the choice of treatment involves tradeoffs that should be based on patients preferences. Variation in such care is typified by elective surgeries, such as hip fracture. (3) supply-sensitive care services such as physician visits, referrals to specialists, hospitalizations and stays in intensive care units involved in the medical management of disease. In Medicare, the large majority of these services are for patients with chronic illness. -- Measuring appropriateness and developing parameters has its problems: it is easier to stu