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I. Health care delivery system in US. Hospitals Too many hospitals (>6000) and too many beds (> 1 million) – 33% beds are vacant In most cases -in pt.

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Presentation on theme: "I. Health care delivery system in US. Hospitals Too many hospitals (>6000) and too many beds (> 1 million) – 33% beds are vacant In most cases -in pt."— Presentation transcript:

1 I. Health care delivery system in US

2 Hospitals Too many hospitals (>6000) and too many beds (> 1 million) – 33% beds are vacant In most cases -in pt stay is 6 – 7 days Voluntary, non profit private owners like churches / universities are more Profit oriented, investors owned – general & specialty care - 12% Municipal (city govt) – often teaching hosp affiliated to med schools Psychiatric – few only – state govt – no of cases decreasing Veteran hosp – fed govt – reserved for veterans

3 Nursing homes 25K with 1.5 million beds – long term care – cost being 35K – 75K per year Rehabilitation centers – short term care – to re enter society Visiting nurses assn – domiciliary nursing – funded by Medicare Hospice orgzn; support to terminally ill pts – Medicare – pain medications liberaly

4 Physicians 126 med school & 16 osteopath schools – graduating annualy 15K M.Ds & 1.8K D.Os – called as physicians Training of MDs & DOs. Currently 650K physicians – in which 35k are DOs. & 140K are FMGs Earn 200K Primary care physicians > Ratio of physicians to patients in US

5 Average 5 visits / year – when compared to other developed countries – it is fewer High income grp / low income grp Women frequently than men 75% seek medical aid in a year – most common is URI & injuries

6 II. Cost of health care Health care expenditure is - 15% of GDP – more than any other industrialised society Health care epxnsesSources of payment Hospitals Doctors fees Nursing homes Medications & med supplies Mental health & dental care Federal govt State Govt Private health insurers Individuals others

7 III. Health care insurance overview Only country (among developed) – no health care for all – higher infant mortality / lower life expectancy Most get health insurance by employers About 15% - no h insurance Certain citizen have govt funded health care – medicare for elderly - >65 - 34 million, medicaid for poor – for 25 million

8 Private health insurers 1. Blue cross / Blue shield – non profit – BC pays for hospital costs BS pays for hospital costs, physicians fee, & diagnostic tests 30 -50 % people covered Other Private insurers - 1000 – like Aetna / prudential

9 Fee for service care vs managed care Pts can choose either Fee for service plan – no restriction on provider choice / referrals – higher premium Managed care – restrictions on provider charge – low premium – about 50% of BC / BS subscribers opt for this Many plans have deductibles – (amount pt has to pay from his pocket – co pay – 20% approx

10 Managed care Managed by a group of providers – cost effective Pts are restricted to choice of Drs – more popular with govt Primary, secondary, & tertiary care primaryImmunization Improved obstetrical care secondaryEarly identification & treatment tertiaryPhysiotherapy / Occupational training

11 Types of managed care Health maintenance organizations (HMOs) Independent practice association (IPAs) Preferred provider organizations (PPOs) Point of service plans (POS)

12 Types of plan DefinitionComments 1. HMO Staff model / closed panel Physicians & health care personnel hired to provide services to group of people – including pediatric, eye & dental Choice of doctor not possible – primary care doctor (gatekeeper) 2. IPAPhysicians from private practice are hired by HMO Private practitioners get a fee from HMO

13 3. PPOInsurance co / trust contracts with private practitioner / hospital to provide service to its subscribers can choose a doctor in that net work No ‘gate keeper’ physician Pt can choose a doctor out of network by paying Extra amount 4. POSSimilar to PPO – companies contract with physicians – network. Pt can choose a doctor out of network by paying extra as in PPO - There is a gatekeeper physician as in HMO

14 Fed & state funded insurance coverage Fed & state funded – Medicare / medicaid Diagnostic related groups (DRG) – provided by Medicare – fixed amount for each illness

15 Medicare Fed gov – thru social security Persons above 65 age – regardless of income – 34 million people covered Part A: in pt hospital care Part B: Optional dialysis, lab tests out pt care – 20% copay

16 Medicaid (or Medical in cal’) Both Fed & state gov Indigent (very low income people) Covers 25 million people In pt & out pt hospital costs Physician service, home health care hospice care, lab tests, dialysis, drugs etc

17 Demographics of health Life style & dietary habits: Smoking & alcohol Socioeconomic status: poor & low educational level Gender health: Men have shorter life expectancy than women Women are at higher risk for autoimmune diseases, smoking related lung cancer, AIDs etc Age: although elderly comprises only 12 % of population – they utilise 30% of health care costs

18 Age groupCause of death Infants < 1 yearCongenital anomalies Prematurely, SIDS Children 1 – 4 yearsAccidents, cong’ anomalies, cancer (leukemia / cns tumors) Children 5- 14 yrsAccidents (failure to wear seat belt), cancer (leukemia / cns tumors) homicide, suicide Adolescents 15 - 24 yrsAccidents (motor vehicles), homicide, suicide

19 Adults 25 - 44Accidents, HIV, Cancer Adults 45 - 64Cancer, heart disease & accidents Elderly >65Heart disease, cancer stroke All ages combinedHeart disease, cancer (lung, breast, prostate & colorectal), stroke

20 Medical ethics & legal aspects A legally competent 65 yr old man signs a document & states that if he goes in to coma, no efforts need to be taken to prolong his life But later when he went on coma & brain death requiring life support, pt’s wife urges the physician to keep him alive. The physician should – A.Get a court order to start his life support B.Follow wishes of his wife C.Carryout the pt’s will D.Ask the pt’s adult children for permission E.Turn the case to ethics committee of the hospital

21 Legal competence To be legally competent to take health care decision, pt should understand the risk & benefits and likely out come of such decision An adult > 18 yrs of age is legally competent Minors; <18 yrs of age – not competent But emancipated minors are competent i.e 1. those who r self supporting / in military 2. If they r married 3. if they have children Mental pts’ competence – judge has to decide

22 Informed consent: Except for life threatening emergencies - Drs should get consent from competent, well informed adult pts. – get sig – not other hosp personal Pt should understand the health implications of their diagnosis, risks & benefits of trmt, availability of alternative trmt & also the likely outcome if they don’t consent They can withdraw the consent at any point of time

23 Pts’ can refuse to consent for religious or other reasons even if it costs his life Competent pregnant women can refuse medical / surgical intervention to protect the life of fetus Though the Dr should divulge all the medical findings to pts, in some case he can delay the findings to pts – E.g coronary pt – opinions of family members r not relevant If unexpected finding is there during surgery – pt should wake up & give consent

24 Treatment of minors Only parent / legal guardian can give consent for medical / surgical procedures for minors Parental consent not required: 1. emergency situations 2. trtmt of STD 3. prescription of contraceptives 4. medical care during pregnancy 5. trtmt of drug / alcohol dependence Most of the states require parental consent when a minor seeks abortion

25 confidentiality Drs ethically expected to maintain confidentiality. But they need not – 1.if they suspect child / elder abuse 2. pt poses a serious threat of suicide 3. pt poses a serious threat to another person

26 Notifiable diseases To CDC Varicella, hepatitis, measles, mumps, rubella, salmonella, shigellosis, TB, STDs like HiV, syphilis, gono & chlamydia Genital herpes not required to be reported

27 HIV ethical issues Dr cannot refuse to treat HIV +ve pts. But there is no legal requirement for a Dr to trt any pt Pregnant women cannot be tested for HIV against her will Drs r not required to maintain confidentiality when an HIV pt poses a threat to another person

28 Psychiatric pts hospitalization Psychiatric pts who are danger to themselves / others may be hospitalised against their will Hopitalised pts (voluntary / otherwise) can refuse treatment

29 Death & Euthanasia Legal death – cardiorespiratory criteria – irreversible cessation of all functions of the brain including brain stem Life support can be withdrawn Dr certify cause of death – natural, suicide / accident Euthanasia; mercy killing – not allowed under any circumstances – is a criminal act – but life support can be withheld if the competent pt has already signed for it

30 Medical malpractice Wrongful act of a doctor which causes damage to pt – dereliction / negligence of duty that causes damage directly to a pt Surgeons & anesthesiologists usually sued psychiatrist/family physicians least likely Malpractice is a tort / civil wrong – not a crime – if found correct – financial award to pt will be given by Dr – not a jail term

31 Damages may be compensatory / punitive Compensatory damages – to reimburse the pt for medical bills, lost salary & for pain & sufferings Punitive: is punishment in nature – rare – awarded only in cases of wanton negligence – e.g drunken Dr cut a vital nerve Impaired physician: due to drug / alcohol abuse, physical / mental illness or impaired due to old age – may be reported to concerned authorities


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