I. Health care delivery system in US

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

7. III. Health care insuranceoverview • 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

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

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

16. Medicaid (or Medical in cal’)

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

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 – • Get a court order to start his life support • Follow wishes of his wife • Carryout the pt’s will • Ask the pt’s adult children for permission • 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