Professionalism/Ethics Exam 1

Andrew Taylor Still's Many Roles included...

First Osteopath
Medical Doctor
�Lightning Bone Setter�
�Magnetic Healer�
Farmer
Inventor
Machinist
Frontiersmen
State legislator
Civil War Veteran and patriot
Expert Hunter
Husband, father who was dedicated to his family

Where was AT Still born?

Jonesville, VA

What year was AT Still born in?

1828

AT Still's Timeline

Age 6- Family moves from Jonesville, VA to Market, TN
Age 8- Family moves from Market, TN to Missouri (took 7 weeks by
covered wagon)
Age 24- began physician apprenticeship with father and 2 brothers.
Moved to Kansas and worked at Shawnee (Wakarusa) Mission
Became an avid Anatomist moving from hunting kill dissections to
cadaveric (dissected Shawnee Indians), Highly influenced by Shawnee Indians
Became profoundly influenced by the Shawnee spiritual beliefs of the
Great Architect and Creator

AT Still's father's name was

Abram Still
Farmer, Methodist Minister, Medical Doctor

AT Still's Mother's name was...

Martha Poague Moore

AT Still had how many siblings?

9

AT Still had how many children

12 (6 children died before the age of 12, 4 (3 from Meningitis in
1864, 1 infant from Pneumonia) of the 6 died within 4 weeks of his
return from the Civil War)

AT Still was married how many times? and to whom?

Twice
Mary Vaughn (died after 10 years of marriage)
Mary Turner (married for over 50 years)

Abb's Valley Massacre

Late 1700s
A.T. Still�s Maternal Grand Father, James Moore was captured by
the Shawnee Indians and sold as a slave.The Shawnee Indians brutally
murdered James� father Captain Moore, his mother, and most of his
brothers and sisters at Abb�s Valley. James Moore returned to the
original homestead in Tazewell County, married, and had children, one
of which was A.T. Still�s mother Martha Pogue Moore in 1800.

The Methodist Church was split in what year? Into what groups?

1840
Southerners (seceded)
Abolitionists
Conservatives
Methodist Episcopal North and South (Abram Still remained with the North)

Kansas Nebraska Act of 1854

Fight over whether Kansas would be admitted to the Union as a slave
state or a free state. Uncle Tom�s Cabin won over hundreds of
thousands of individuals to the abolitionist cause. The
Kansas-Nebraska Act of 1854 provided that the settlers in those two
territories would decide the question for themselves.
Civil war raged in Kansas as both sides tried to gain control of
the territorial government.

What happened in 1857?

In 1857, Still was elected to represent Douglas and Johnson Counties
in the Kansas territorial legislature. AT Still and his brothers,
Edward and James, participated in the Bleeding Kansas
battles between the pro and anti-slavery citizens.

Kansas was admitted to the union as a free state in what year?

By August 1858, a free-state constitution had been passed and Kansas
was admitted to the Union as a free state in 1861.

What did AT Still do in the 9th Kansas Calvary?

Still enlisted in the 9th Kansas Calvary and served as a hospital
steward and scout surgeon. (Note specific example of man who was shot
through thigh, doctors wanted to amputate, but Still noted that the
femural artery was still in tact and could be cleansed and boxed)

What went into an old fashioned, standard issue medical kit?

Calomel
Quinine
Whiskey
Opium
Rags
Knife

Did Kansan Soldiers die from disease or injury

Disease
dysentery, malaria, typhoid, smallpox, cholera (Note specific
example of Still practicing manipulation on pt.'s with cholera and
helping them pass urine), pneumonia and TB.

What infectious diseases did AT Stills children die of?

Meningitis (3) in 1864
Pneumonia (1 infant)

Why was AT Still dissatisfied with medicine of the 1850s

The germ theory had lost favor
The most useful tool for house calls was a lancet for bloodletting
Moliere observed that most men die of remedies, not their diseases
People commonly died from infectious diseases such as malaria,
smallpox, typhoid fever, pneumonia, scarlet fever and typhus

Benjamin Rush

Father of Heroic Medicine
Argued that fever alone, by producing tension in the blood
vessels, caused disease. Believed that the body was a machine, and
that all disease was one disease- an overstimulation of nerves and
blood. The cure for overstimulation was "heroic" medicine:
bleeding, blistering, purging (with calomel), and vomiting to restore
the natural balance.

Pierre Louis

Father of the m�thode expectante, a therapeutic doctrine
that states the physician's role is to do everything possible to aid
nature in the process of disease recovery, and to do nothing to hinder
this natural process.
Introduced statistics in studying medical outcomes
Founder of the "numerical method" and known for
empirical medicine-evidence based medicine was born! (did research on bloodletting)
Oliver Wendal Holmes, Sr (later Dean at Harvard Medical School)
emphasized careful history, physical examination, post mortem studies
and empirical studies of diagnosis and treatment with them.

Wooster Beach

Eclecticism

Electicism

Took the best from empirical medicine, regular medicine, Indian
doctors and botanic practitioners to find effective medical techniques.
The system was focused on the application of
non-invasive practices through the use of botanical
remedies or other healing therapies that were in harmony with the
body�s natural curative properties.

Samuel Hahnemann

Father of Homeopathy
Homeopathy appeared in the US in 1824 which held that the most
effective drugs were those that induced symptoms similar to those of the disease

,
diluted to as much as a decillionth part
Because of its conservative nature, Homeopathy enjoyed tremendous
popularity,as an alternative to the tortuous bleeding and purging methods.

Homeopathy

Most effective drugs were those that induced
symptoms similar to those of the disease, diluted to as much
as a decillionth part

Where did AT Still draw his influence for osteopathy from?

Methodist perfectionism-God created in man the ability to heal from within
Herbert Spencer�s mechanical views on the interrelatedness of
structure and function (cause and effect)
Darwinian evolution (adaptation to resist and recover from disease).
Believing the Creator provided for self healing when
the mechanics of the body were positioned as divinely
intended, Still developed a drugless approach, emphasizing the
importance of attending to the body, mind and spirit of his patients.

The 4 Basic Tenets of Osteopathic Medicine

1. The body is a unit; body, mind, and spirit
2. The body is capable of self-regulation, self-healing, and
health maintenance
3. Structure and function are reciprocally interrelated.
4. Rational treatment is based upon an understanding of the basic
principles of each of the above.

What year did AT Still fly the banner for Osteopathy

1874

First School of Osteopathy was named what? and was started in what year?

American School of Osteopathy in Kirksville, Missouri
1892

First African American Osteopathic Physician was? went to what
school? and in what year did she graduate?

Meta Christy graduated from PCOM in 1921

National School of Osteopathy in Baxter Springs, Kansas

Elmer and Helen Barber opened the school in 1895

Pacific College of Osteopathy in Anaheim, CA

George Burton opened the school in 1896

Northern Institute of Osteopathy in Minneapolis, MN

Ed Pickler opened the school in 1896

Western College of Osteopathy in Denver, CO

Nettie Bolles opened the school in 1897

Massachusettes College of Osteopathy

Established in 1897 (did not survive the Flexner Report)

Columbian School of Osteopathy

Marcus Ward (in direct competition with ASO) opened the school in 1897

The Flexner Report

Came out in 1910
Suggested reforms:
Close proprietary schools;
Increase admissions standards;
Each college should become an integral component of a major university;
Alter the financing of medical school education.
160 MD Schools-->66
8 DO Schools-->7

When and why were DO recognized nationally?

The Great swine flu pandemic (1918) killed 650,000 individuals in the
US and 40 million worldwide.
Allopathic treatment as described was calomel to �open the
bowels� and strychnine for cardiac weakness.
Osteopathic treatment consisted of manipulative treatments
including those that promoted pulmonary function, isolation, hygiene,
and fluids.
0.2% mortality rate for osteopathic patients compared to 5-15%
allopathic treatment
Of those with pneumonia, osteopathic physicians lost 10% compared
to 25-60% reported by allopathic institutions.

What year was pharmacology allowed in the osteopathic curriculum

1929

John Cline, MD

President of the AMA, called for acceptance of and removal of the
stigma against osteopathic medicine in 1952

Which was the first state to license DOs and in what year?

Vermont in 1896
followed by North Dakota and Missouri in 1897.
Mississippi was the last state to fully license osteopathic
physicians in 1973

The California Merger and its implications

1962/1963
Equalizing MDs and DOs

What year were the armed services ordered to accept qualified DOs?

1966

First State supported school

MSUCOM in 1969

Osteopathic Code of Ethics

formulated by the AOA
to guide its member physicians in their professional lives.
to address their ethical and professional responsibilities to self,
to patients, to the osteopathic profession, and to society at large.

Why is professionalism important in medicine?

We uphold and promote the integrity of the profession through
self-regulation and autonomy
We support the deliberative process by which professional
associations establish and promote standards for medicine

Declaration of Professional Responsibility

Our global profession must reaffirm its historical commitment to
combat natural and man-made assaults on the health and well being of mankind.
We respect life, treat those in need, advocate and educate.
We apply our knowledge and skills when needed, though doing so, may
put us at risk
We teach and mentor those who follow us for they are the future of
our caring profession.

How did the professional code of ethics arise?

Developed through a process of collaboration & consensus, to
finally become codes or regulations

Who drafted the first code

The Code first drafted by Dr. Bell and Dr. Hays was based on
conceptions of professional ethics of Thomas Percival (1740�1804)
Oath parallels Code

Oath: I do hereby affirm my loyalty to the profession I am about to enter
(by so doing, you surrender to oversight by members of your
profession and the state medical board)

Code: �The osteopathic medical profession has an obligation to
society to maintain its high standards and to continuously self regulate�

Oath: I will be mindful always of my great responsibility to
preserve the health and life of my patients

Code:
Section 3. In emergencies, a physician should make her/his services
available. (duty)
Section 4. A physician is never justified in abandoning a patient.
The physician shall give due notice to a patient or to those
responsible for the patient's care when she/he withdraws from the case
so that another physician may be engaged

Oath: to retain their confidence and respect both as a physician and
a friend who will guard their secrets with scrupulous honor and fidelity

The physician shall keep in confidence whatever she/he may learn
about a patient in the discharge of professional duties.
The physician shall divulge information only when required by law or
when authorized by the patient.
Section 3. A physician-patient relationship must be founded on
mutual trust, cooperation and respect.

Duty

Responsibility and Reliability

Responsibility

To maintain the patient�s well-being as your main focus and primary responsibility.

Reliability

Providing care by being
where and
when you are expected, acknowledging strengths
and limitation, providing assistance when able, and seeking assistance
when unsure

Oath: �to perform faithfully my professional duties�

Code: Section 2. The physician shall give a candid account of the
patient's condition to the patient or to those responsible for the
patient's care (Autonomy)
Code: Section 3.
A physician-patient relationship must be founded on mutual trust,
cooperation, and respect.
The patient must have complete freedom to choose her/his physician.
The physician must have complete freedom to choose patients whom
she/he will serve.
However, the physician should
not refuse to accept patients because of the patient's
race, creed, color, sex, national origin or handicap.

Oath: Employ only those methods of treatment consistent with good
judgment and within my skill and ability

Code: Section 5.
A physician shall practice in accordance with the body of
systematized and scientific knowledge related to the healing arts.
A physician shall maintain competence in such systematized and
scientific knowledge through study and clinical applications.
Code: Section 9.
A physician should not hesitate to seek consultation whenever she/he
believes it advisable for the care of the patient.

Oath: I will be ever vigilant in aiding in the general welfare of the
community, sustaining its laws and institutions.

Code: Section 14. In addition to adhering to the foregoing ethical
standards, a physician shall recognize a responsibility to participate
in community activities and services.

Oath: �Sustaining community laws and institutions��

Code: Section 13. A physician shall respect the law. When necessary a
physician shall attempt to help formulate the law by all proper means
in order to improve patient care and public health.
Code: Section 6. The osteopathic medical profession has an
obligation to society to maintain its high standards and to
continuously self regulate.

Oath: Not engaging in those practices which will in any way bring
shame or discredit upon myself or my profession.

Section 12. Any fee charged by a physician shall compensate the
physician for services actually rendered.There shall be no division of
professional fees for referral of patients
Section 7. Under the law a physician may advertise, but no physician
shall advertise or solicit patients directly or indirectly through the
use of matters or activities, which are false or misleading.

How is the "Practice of Medicine" defined?

1.Advertising, holding out to the public, or
representing in any manner that one is authorized to practice medicine
in the jurisdiction
2.Offering/undertaking to prescribe, order, give, or
administer any drug or medicine
3.Offering/undertaking to prevent and/or
diagnose, correct, and/or
treat in any manner or by any means, methods, or
devices any disease, illness, pain, wound, fracture, infirmity,
defect, or abnormal physical or mental condition of
4.Offering/undertaking to perform surgery
5.Rendering a written or otherwise documented medical
opinion concerning the diagnosis or treatment of a patient
or the actual rendering of treatment to a patient within a state by a
physician located outside the state as a result of transmission of
individual patient data by electronic or other means from within a
state to such physician or the physician�s agent;
6.Rendering a determination of medical necessity or
a decision affecting the diagnosis and/or treatment of a patient
7.Using the designation Doctor, Doctor of Medicine, Doctor
of Osteopathic Medicine/Doctor of Osteopathy, Physician,
Surgeon, Physician and Surgeon, Dr., M.D., D.O.

Medical Practice Act

Practice of medicine is regulated by states through their Medical
Practice Act
According to the Medical Practice Act you must:
Medical Education: Graduate from accredited MD or DO school
Medical Training (Residency/GME):
Complete at least one year GME Training
Performance on National Licensing Exam: COMLEX or USMLE
Fitness to Practice (Physical, Mental, Moral)

Boards of Medicine

Functions
Issue licenses: undifferentiated, not based on specialty or
personal interests
Investigate complaints
Discipline those who violate the law
Conduct physician evaluations
Facilitate physician rehabilitation
Adopt policies & guidelines
51 allopathic or composite (MD + DO)
14 osteopathic
5 US Territories

Is the practice of medicine a right or a privilege?

Privilege!
10th Amendment

National Licensing Exams

COMLEX and USMLE
FSMB and AMA recognize the USMLE and COMLEX-USA as equally valid
exams

Types of Unprofessional Physician Conduct

We have a duty to report!
1.Alcohol & substance abuse
2.Sexual misconduct
3.Neglect of a patient
4.Failure to meet the accepted standard of care in the state
5.Prescribing drugs in excess or without legitimate reason
6.Dishonesty during the license application process
7.Conviction of a felony
8.Fraud
9.Delegating the practice of medicine to an unlicensed individual
10.Inadequate record keeping
11.Failing to meet continuing education requirements

Malpractice

Relates to tort law
4 elements include duty, breach of duty, injury due to breach, damage
Frequently relates to insurance settlements (not a reliable
measure of physician incompetence)

Medical Board Disciplinary Action

Relates to practice of medicine and not harm
Breach of Medical Practice Act
Medical Board may use malpractice claims data to determine if
unprofessional conduct occurred
Range of actions: revocation, restriction, education, treatment,
� etc.

Roles of Federal Agencies

DEA-law enforcement
FDA-regulation
CMS-funding
NIH-research
CDC-expertise
USPSTF-guidance

Drug Enforcement Administration (DEA)

1 of the Federal Agencies involved in law enforcement
Enforce the controlled substances laws and regulations of the US
Bring to the criminal and civil justice system those involved in
the growing, manufacture, or distribution of controlled substances
destined for illicit traffic in the US
Support programs aimed at reducing the availability of illicit
controlled substances on the domestic and international markets
MUST HAVE A DEA # TO PRESCRIBE CONTROLLED SUBSTANCES. YOU CAN STILL
PRESCRIBE NON-CONTROLLED SUBSTANCES WITHOUT A DEA

5 Classes of Drugs under Controlled Substances

1.Narcotics
2.Depressants
3.Stimulants
4.Hallucinogens
5.Anabolic Steroids

Nasty Drugs Hurt
Sad Adults

Control Substance DEA Schedules

1-5 based on abuse potential, medical value, danger of serious
physical effects to the user
Schedule 1 (high abuse potential, not used medically, high
dependence): Ex. LSD and Heroine
Schedule 5 (low abuse potential, medically used, low risk
dependence�limited quantities of narcotics): Ex. Cough preps with
limited amt. of codeine

Schedule 1


high abuse potential, no medical use (currently
accepted for treatment in US)
Ex. heroin, lysergic acid diethylamide (LSD), marijuana (cannabis),
peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (�ecstasy�).

Schedule 2


high abuse potential which may lead to severe
psychological or physical dependence
Ex. NARCOTICS-morphine and opium-hydromorphone
(Dilaudid�),meperidine (Demerol�), oxycodone (OxyContin�)
STIMULANTS-amphetamine (Dexedrine�, Adderall�) and methylphenidate (Ritalin�).
cocaine, amobarbital

Schedule 3

lower abuse potential relative to substances in schedule 1 and 2 and
abuse may lead to moderate or low
physical dependence or high
psychological dependence.
Ex. NARCOTICS-combination products (Vicodin�) & (Tylenol w/codeine�)
Also included are buprenorphine (Suboxone� and Subutex�) used to
treat opioid addiction
NON-NARCOTICS include ketamine and anabolic steroids

Schedule 4

lower abuse potential relative to substances in Schedule 3.
Ex. Ambien� and the benzodiazepines, Xanax�, Klonopin�, Valium�,
Ativan�, Versed�.

Schedule 5

low abuse potential relative to substances listed in Schedule 4 and
consisting primarily of preparations containing limited quantities of
certain narcotics generally used for antitussive, antidiarrheal, and
analgesic purposes.

Demonstrating Ongoing Competence

Maintenance of Licenture
Maintenance of Board Certification/Continuous Certification

Typical Requirements for Maintenance of Board
Certification/Continuous Certification

1.Maintenance of unrestricted Medical Licensure
2.Continuing Medical Education
3.Cognitive Exam (like certifying boards)
4.Practice Assessment & Improvement

AMA's Definition of an Impaired Physician

one who is �unable to practice medicine with reasonable skill and
safety to patients because of physical or mental illness, including
deterioration through the aging process or loss of motor skill, or
excessive use or abuse of drugs including alcohol.

Impaired Medical Student

one who is unable to perform academic duties or participate in the
practice of medicine with reasonable skill and safety to patients
because of physical or mental illness or excessive use or abuse of
drugs including alcohol.
Impairment in a medical student is any condition that impacts
their ability to perform the technical standards for
admission and continued enrollment.

What Constitutes Impairment

Psychiatric Disorders
Other Medical Illnesses
Substance Abuse

Impairment effects what typically later rather than being an
early sign?

Work function
By the time a physician�s practice is affected often adverse
consequences to the physician�s social life, family life, financial
status, and even physical health has occurred

Medical Impairment

Refers to any situation in which the health of a physician negatively
impacts their ability to provide safe and effective healthcare. Can
include, but are not limited to any disease and/or treatment for a
disease that causes neurological dysfunction. (i.e. encephalopathy,
brain tumors, uncontrolled seizures or movement disorders, confusion,
serious mental illness or other debilitating state that alters mental
status or physical ability to perform duties in a safe and effective manner.)

How does medical impairment impact Medical Students?

Impact ability to learn and make academic progress
Impact ability to safely attend class or the clinical setting

Medical Leave Policy at VCOM

6 month window for treatment and/or recovery
After 6 months, students are eligible for readmission when
recovered sufficiently

Depression and Anxiety

Nearly 21 million American adults in a given year (9.5 percent) have
a mood disorder.
Over 27% of medical students are estimated to suffer from
depression in the first 2 years of school
Depression in physicians exceeds the general population and
depression rates among interns is cited as high as 27-30%
Nearly 40 million American adults in a given year (18 percent)
have an anxiety disorder.
Lifetime risk of suicide in adults with
depressive and anxiety disorders is about 10-15%

Physician Suicide Rate Compared to the General Population

The overall physician suicide rate is reported as between 28-40 per
100,000, compared to the overall rate in the general population of
12.3 per 100,000. TWO TIMES THE GENERAL POPULATION.
Men>Women suicide rates (general population)
Men=Women (3-4x age matched controls) suicide rates (medical students)

Rates of Illicit Drugs, Prescription Narcotic, and Alcohol Abuse
among Medical Students

7 � 18%
Physicians=General Population
However, abuse of prescription medications are higher among physicians

Principal Cause of Medical Student and Physician Impairment

Substance Use Disorders
Loss of control over substance use, overuse, intoxication, withdrawal:
?Poor occupational functioning
?Inability to practice safely
?Potential harm to patients

Characteristics of Addiction

Medical complications
Behavioral dysfunction
Social dysfunction

Examples of Illicit Substances

Marijuana
MDMA
Heroin
Hallucinogens
Opiates
Steroids (non-prescribed)
Stimulants (cocaine, methamphetamine)
Other prescription drugs used for recreation

Addiction Cycle

Substance Use-->Escape (feeling good)-->Negative
Consequences-->Stress-->Substance Use

Co-Occurrence of Substance Use Disorders and Mental Illness

Dual Diagnosis
Substance use disorders often co-occur with depression.
Suicide risk is additive
Suicide completion risk increases when judgment is impaired due to intoxication

Can Impairment Be Predicted

Yes
Students exhibiting unprofessional behavior in medical school were
3 to 8X more likely to have been disciplined by their regulatory
Boards when they reached their 40�s than those students without
behavioral issues

The largest number of disciplinary actions nationwide were related
to the use of alcohol and drugs.

Red Flags

Irresponsibility (unreliable attendance at clinic and not following
up on activities related to patient care)
Diminished capacity for self-improvement (failure to accept
constructive criticism, argumentativeness, and display of a poor attitude)
Poor initiative (lack of motivation or enthusiasm or by passivity)

High Risk

Family history of mental illness or substance use
Access
Poor self-care
Domestic breakdown, stress at home
Unusual stress at work (malpractice suit)
Self-diagnosing and self-prescribing

Treatments

Inpatient/Residential Treatment
Detoxification
Individual/Group therapy
Family Therapy
Caduceus Groups
?Alcoholics Anonymous/Narcotics Anonymous

Is Treatment an Effective Means of Resolving Substance Abuse in Physicians?


81% successfully completed treatment and
returned to practice under monitoring

19% of impaired physicians failed
the monitoring program (usually by relapse early in treatment

Health Care system

All the activities whose primary purpose is promote, restore or
maintain health�
�Improve population health
�Respond to expectations
�Provide financial protection against the cost of poor health

What do we want a health care system to provide

Accessibility
Cost
Quality/Desired Outcome = Improved health status/Value

Equation for Value

Quality(outcomes,safety,services)/Total Costs

Factors Increasing Cost of Health Care

1.More old people
2.Technology can be expensive
3.Pharmaceutical expenses
4.Lifestyles
5.Fee-for-service medicine
6.High prices
7.Waste
8.High administrative costs
9.Governmental regulations

Access

The timely use of personal health services to achieve the best health outcomes

2 Components of Access

Ability to pay
Availability (i.e. Facilities and health professionals,
Transportation, Culturally competent, Timely)

% Decrease in number of uninsured since the ACA

0.44

What are the health issues faced by the uninsured?

1.Less likely to report medical issues
2.Less likely to obtain suggested treatments
3.More likely to be hospitalized for avoidable treatments
4.Less likely to be knowledgeable about or practice healthy habits
that will lead to poorer health
5.Less likely to receive preventative care
6.More likely to develop life-threatening conditions
7.More likely to use an ER for routine care
8.May not receive the same level of care
9.Financial issues may create stress that impacts health status
10.Research demonstrates that gaining health insurance improves
access to health considerably and diminishes the adverse effects of
having been uninsured

Quality of Care

The degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent
with current professional knowledge

3 Major Organizational Segments of the US Healthcare System

1. Provider Segment
2. Payer/Purchaser Segment
3. Support Segment
all of which are centered around the patient

Provider Segment Private Sector

Acute care hospitals
Physicians and other professionals
Diagnostic services

Provider Segment Public Sector

Veterans Administration
US military hospitals and clinics
US Pubic Health Service

Payer/Purchaser Segment Private Sector

Private insurance companies
Employers
Individuals

Payer/Purchaser Segment Public Sector

Medicare � elderly
Medicaid � low income
Tricare � military retirees

Medicare

Covers age 65 or older, under age 65 with certain disabilities and
any age with permanent kidney failure.
Covers approximately 15.5% of U.S. population.
Made up about 20% of total healthcare spending in 2015
Second largest federal program after Social Security

Medicaid

Covers low income and disabled.
Federal law mandates that states cover poor pregnant women,
children, poor elderly, and the disabled
States administer the program and can choose to cover additional
services (such as dental/vision)

Payment Methodology

Fee for Service Capitation Per Diem
Global Payments

Fee for Service

a fee (often discounted rate) for providing a specific service

Capitation

A fixed fee per member for a specific period of time (typically a
month) (ex. pt. is allotted 600 dollars per month)

Per Diem

Daily rate (ex. pay 1500 dollars for the first day in hospital, 1000
dollars for second day and so forth)

Global Payments

One combined payment to cover a single episode of care

Support Segment Private Sector

Health IT companies
Billing companies
Education and training
Supply chain

Supports Segment Public Sector

US Department of Health and Human Services
State health departments
Local health departments

United States Department of Health and Human Services (DHHS)

Centers for Medicare & Medicaid Services (CMS)
Health Resources and Services Administration (HRSA)
Centers for Disease Control and Prevention (CDC)
Food and Drug Administration (FDA)
Indian Health Services (IHS)
National Institutes of Health (NIH)
Agency for Healthcare Research & Quality (AHRQ)
Administration for Children & Families (ACF)
Administration for Community Living (ACL)
Agency for Toxic Substances & Disease Registry (ATSDR)
Substance Abuse & Mental Health Services Administration (SAMHSA)

Centers for Medicare & Medicaid Services (CMS)

Division of the US Department of Health and Human Services
Largest division of DHHS
Operates Medicare and Medicaid
Largely responsible for implementing the ACA

Health Resources and Services Administration (HRSA)

Division of the US Department of Health and Human Services
Main focus is preserving access to essential health
services for poor, uninsured, rural, medically isolated, and
socioeconomically depressed populations.
Operates the National Health Service Corps (NHSC). NHSC is
important in medical student loan repayment assistance activities.
Oversees the 1,128 Federally Qualified Health Centers (FQHCs)
Controls the National Practitioner Data Bank, an essential
component of the medical licensure and hospital credentialing process
Manages the national Organ Procurement and Transplantation Network (OPTN)
Provides a significant number of healthcare training grants and
scholarships, focusing on underserved areas and populations
Designates geographic areas that are Health Professional Shortage
Areas (HPSAs) and Medically Underserved Populations (MUPs), important
for medical student loan forgiveness and federal grants.

Center for Disease Control & Prevention (CDC)

Division of the US Department of Health and Human Services
.Headquartered in Atlanta
Is the national public health institute for the United States
Primary mission is to protect public health and safety.
The CDC especially focuses on infectious disease, food borne
pathogens, environmental health, occupational safety and health,
health promotion, injury prevention and public health and safety
educational activities.
Among the primary activities of the CDC are:
Surveillance activities to monitor and prevent disease outbreaks,
including instances of bioterrorism
Implementation of disease prevention strategies
Maintenance of national health statistics data
Providing immunization services
Creation of workplace safety policies and practices
Environmental disease prevention efforts
Providing a repository for evidence-based health education for
patients and healthcare professionals

Affordable Care Act


Phase 1 � �Coverage/Access Agenda� (2010 � 2014)
Goal: �to provide the coverage people want and need� But Phase 1
reform alone �will not solve the problems, because it is not sustainable�

Phase 2 � �System Improvement Agenda� (beyond 2014) � The
Triple Aim
�Goal: �to make the security achieved in Phase 1 sustainable�
Better care Better health Better cost

The Five Coverage Expansion Strategies of the Coverage/Access Agenda

1.Insurance coverage must be provided to certain classes of
individuals often not able to afford coverage
2.Individuals must have coverage
3.Employers with more than 50 employees must provide affordable coverage
4.Health Benefit Exchanges
5.Medicaid Expansion

U.S. Preventive Services Task Force (USPSTF)

The USPSTF is an independent panel of non-Federal experts in
prevention and evidence-based medicine and is composed of primary care
providers (such as internists, pediatricians, family physicians,
gynecologists/obstetricians, nurses, and health behavior specialists).
The USPSTF conducts scientific evidence reviews of a broad range
of clinical preventive health care services (such as screening,
counseling, and preventive medications) and develops recommendations
for primary care clinicians and health systems. These recommendations
are published in the form of "Recommendation Statements.

Pay for Performance

Initiatives aimed at improving the quality, efficiency and overall
value of healthcare through financial incentives to providers
Pay providers more for achieving quality standards and less if
they don�t (i.e. Hospital Readmissions Reduction Program, Hospital
Acquired Conditions Program)

Patient Centered Medical Home

A new model of medical practice that provides a transition away from
a model of reactive symptom and illness-based episodic care, to a
proactive system of comprehensive coordinated care. Patient
centeredness refers to an ongoing, active partnership with a personal
primary care physician who leads a team of professionals dedicated to
providing proactive, preventive and chronic care management through
all stages of life.

Accountable Care Organization

A healthcare entity that is characterized by a payment and care
delivery model that seeks to tie provider reimbursements to quality
metrics and reductions in the total cost of care for an assigned
population of patients. While there currently are commercial ACO
initiatives, the largest ACO initiative is the �Medicare ACO Shared
Savings Program.�

Ethics

Ethics is a branch of philosophy concerned with how people:
should or ought to act,
the kind of life they should or ought to live,
the virtues and values they should acquire and cultivate
Requires deliberation and arguments to justify actions
Focuses on reasons why action is right or wrong
Uses rational arguments to persuade

Morality

Conduct that conforms to group customs/culture
Learned from parents, religious leaders
Often accepted without deliberation

Clinical Medical Ethics

Subdivision of ethics
Centered on the physician/patient relationship
When a physician is caring for a patient
May encompass relationships with others including family,
co-workers, institutions such as hospitals and insurance companies,
and research

Law vs. Ethics

The law establishes the minimal standard of conduct and often grants
physicians discretion
Ethics focuses on the right thing to do
Ethics and law might differ

Section 13 of the Code of Ethics

A physician shall respect the law. When necessary a physician shall
attempt to help to formulate the law by all proper means in order to
improve patient care and public health.

3 Steps to the Ethical Process

1.Gather Information (Clinical facts-best evidence based diagnosis,
treatment and prognosis, Identify the primary decision maker, review
with them acceptable ethical principles pertinent to case, Determine
the beliefs/values of the stakeholders, Consider external factors on case)
2.Discuss with patient, family, others affected (Identify points of
agreement and disagreement in six ethical domains, Summarize various
tensions, Frame the dilemma as simply as possible)
3.Make recommendations (Present pros and cons of various options,
Seek outside help if necessary Other health professional, Clergy,
Individuals from same culture as patient)

6 Principle of Medical Ethics

Guide ethical actions in clinical medicine, Determine if physicians
have neglected their ethical duty, Cases likely include more than one principle
1.Beneficence
2.Nonmaleficence
3.Autonomy
4.Utility
5.Justice
Fidelity

Beneficence

To do good!
�. . .the duty to try and bring about improvements in physical or
psychological health that medicine can achieve�

Nonmaleficence

Don�t do bad
�going about these activities [medical interventions meant to
improve health] in ways that prevent further injury or reduce its risk�

4 Criteria of Negligence

1.Physician must have a duty to the affected party
2.Breach of duty
3.Patient must experience harm
4.Harm must be caused by the breach of duty

Autonomy

Implies a respect for personal autonomy �acknowledging the moral
right of every individual to choose and follow his or her own plan of
life and actions�

5 Elements of Informed Consent

Stemming from Autonomy/Must be 18 years or older/Emancipated act as
an adult
1.Competence � patient has the mental capacity to understand
2.Disclosure � discussion of all options
Professional standard � what is customary in the medical community
Reasonable person standard � what a reasonable person would want to know
Subjective standard � disclosure of what is best
3.Understanding � verification that patient understands
4.Voluntariness � decision is not coerced or reached by manipulation
5. Consent � a final decision is reached
Come Down Underneath Very Carefully

Emergency Medical Treatment and Labor Act of 1986 (EMTALA)

Prevents hospitals from refusing to see uninsured patients in
emergent situations (patient dumping).
Requires hospitals to provide a medical screening to patients
presenting with an emergency medical condition
Requires hospitals to stabilize patients within capability of
facility and, if necessary, transport patient appropriately
Physicians must appear within a reasonable time frame, as defined
by hospital policy, if requested to do so.
Typically not acceptable to transfer patients to an on-call
physician who is seeing patients in an outpatient setting (need a
medical reason for doing so).
Severe penalties for not meeting EMTALA obligations

Utility

The duty to act in a way that provides the greatest positive
consequences (beneficence) and the least negative consequences (nonmaleficence).
Benefit/Risk Ratio
�Assessment of how much risk is justified for the intended benefit�

Justice

The moral principle of treating people fairly and without prejudice
Often refers to how health care resources are allocated
�Justice refers to those moral and social theories that attempt to
distribute the benefits and burdens of a social system in a fair and
equitable way among all participants in the system�

Fidelity

Physicians must not abandon patients, exploit patients, or place
interest of self/third parties higher than patient needs
In the event a physician feels he/she can no longer care for a
patient �. . . The best outcome is for the care to be graciously
transferred to another physician�

Conflicts of Interest

�Conflict of interest is often used to describe a situation in which
a person might be motivated to perform actions that his or her
professional role makes possible but that are at a variance with the
acknowledged duties of that role�
Physician ownership of services to which they can make
referrals Fee-for-service medicine Research
agenda Pressure from insurance companies or hospitals to
limit expensive services Obligations to take care of
oneself, family and maintain one�s moral integrity