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PHP 0310 (11)
Ira Wilson (11)


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Public Health
PHP 0310
Ira Wilson

PHP FINAL NOTES Lec1: intro to regulation • Wut is reg? o Controlling human or societal behavior by rules or restrictions o Many forms  Legal restrictions  Self­regulation by organization  Social regulation by norms  Market o How?  Hassle + costsx  Taxes  Fines  Public embarrassment  Legal actions  Revocation of license o How do markets fail  Development of monopoly/oligopoly  Collective action + public good  Inadequate info  Externalities • Healthcare reg o 3 domains  Cost, quality, access o Cost most important in regards to reg o Basic history  Early times: passive insurers + clueless patients = more cost  Mostly self­regulation  1970­1980s • hmo and capitation create concerns • for­profit healthcare created concerns • integration: monopoly concerns • scientific advance • development of health status measures • application of TQM/CQI  TQM/CQI (total/continuous quality measure/improvement) • Quality assurance: concept of inspection (throw out bad  stuff) • Find source of mistake o Reg necessary  Has evolved with healthcare business  Cost is biggest driver of reg  Modern quality improvement theory • Reg must evolve with society + econ o 3 levels: state, fed, private o physicians/professionals  state licensing boards issue licenses and enforce standards • also discipline • varies btwn states  fed oversight • NPD (national practitioner database) under HRSA (health  resources services administration) which is under HHS  (dept of health and human services) coordinate discipline • Manage workforce o Fund med schools, grants/loans, hospital  reimbursement for residency/fellowships, physician  compensation + RBRVS  Private oversight • FSMB (federation of state medical boards) o Collect information on state board actions • NBME (national board of medical examiners) o Uniform process for MD licensing • LCME (Liaison committee on medical education) o Sponsored by AMA and AAMC (American  association of medical colleges) o Accredits medical schools • ACGME (accreditation council for graduate medical  education o Accredits 7800 residency programs • ECFMG (education commission for foreign medical  graduates o Certifies international med grads for residency • FSMB > ACGME + ECFMG o Hospitals  JCAHO (joint commission on accreditation of healthcare  organizations)  • Certification from JCAHO satisfy reqs for state licensure  Fed • Certification of participation o Normally through JCAHO • EMTALA o Must provide emergency care regardless of factors • CLIA (clinical laboratory improvement amendments) o Quality standards • Hill­burton (1946) o Construction (expansion) funding • CON (certificate of need) (1974) o Goal: contraction o 36 states require now  private • JCAHO o Surveys (3 years) o Focus on outcomes and quality improvement o Health care financing  Gov pays for healthcare for 135 million ppl • 48 medicare • 58 medicaid • 9 federal employees benefits program • 20 in VA, DoD, indian health service • gov is rule maker and also the payer  private • private insurance heavily regulated o traditional indemnity insurance regulated o fed regulates self­insured companies • medicare and federal employees benefits program influence  private plans  regulation of managed care • HMO act of 1973 o HMO growth o First direct fed intervention in health insurance • NCQA o Supervise quality o Measure  Structural features of HMO  Patient satisfaction  HEDIS (health employer data information  set: clinical performance o PRIVATE regulating entity o Regulate plans o Lead in quality measurement + reporting Lec2 Fed Executive and Bureaucratic Agencies in Healthcare Regulation • 3 branches of gov o congress (laws) o courts (rule on laws) o executive (implementation + regulation of healthcare) • legal basis of regulatory power o agencies authorized to take executive, legislative, judicial actions o rules similar to statutes even though not issued by legislator o agencies require specialized knowledge  legislation only creates the mechanisms to address issues;  doesn't actually address • HHS (health and human services) duties  o Medicare/aid o Medical research o Prevention epidemics o Food + drug safety o Financial assistance o Maternal + infant health o Preschool  o Child abuse/domestic violence o Substance abuse o Seniors o Native American health services • CMS (Centers for Medicare & Medicaid Services) o Primary source of healthcare coverage for americans o Ensure effective, uptodate, quality healthcare o Administer medicare  Contracts w/ companies to pay claims o Administer Medicaid + chip o Regulate lab testing on ppl • NIH (National Institutes of Health) o Increase knowledge, apply new knowledge for better healthcare • AHRQ (Agency for Health Research and Quality) o Research to improve access, outcomes, quality, cost of healthcare • FDA (Food and Drug Administration) o Assess safety of various foods + drugs • Drugs + healthcare products o Drugs + tools needed for care o Fast technological improvement o Key drivers of costs o Import Drugs Act  Banned food + drug adulteration o Pure Food and Drug Act  Prohibitions against adulteration and misbranding of  food/drugs  Ingredients must be listed on package  Dangerous ingredients in drugs must be listed o Kefauver­Harris Efficacy Amendment   Required evidence of efficacy  o Medical Device Amendments  FDA authority expanded  Rules for testing devices become same as drugs o Drug Price Competition + Patient Term Restoration Act (Hatch­ Waxman Act)  Streamlined generics testing rules  Proof of equal bioavailability required o FDA Issues  What is food, what is drug?  Supplements are more like food  Consumer empowerment + internet marketing  Off­label prescribing  Direct advertising to consumer  Drugs costly to develop, but much safer • HRSA (Health Resources and Services Administration) o Provide resources and services to improve access to quality  healthcare Lec3 quality measurement • Wut is quality o Hard to define; relates to improvement of outcomes o Donabendian model  Structure: physical/organizational resources  Process: care delivery  Outcome: results/effectiveness of healthcare o Technical vs interpersonal care o Accountability  Chain of events/care for healthcare to properly function  Single weak link will crack chain o Measuring  Strong evidence of process­outcome linkage  evidence based medicine  technical care • more simple to measure • most accepted quality measures are technical measures  interpersonal care • must ask patient o surveys  issues • hard objectives (like mortality rate) often irrelevant • functional outcomes • risk adjustment always necessary o Trend of using market forces to drive quality improvement  Public reporting, pay for performance  Who drives this? • AHRQ disseminates data • New private organizations developed to meet needs of  payers Lec4  quality measurement 2 • Value: ratio of dollars to outcomes • Donabendian: structure, process, outcome • Science of quality measurement is advanced but complex • Process measures more commonly used o No risk adjustment required • Outcomes measurement: hard to use cuz of risk adjustment • Measurement science + cost o Evolution of private + public regulatory organizations o Measurement tool development and certification  NCQA  NQF (national quality forum) o Payer driven public reporting initiatives  Leapfrog  Pacific Business Group on Health • 3 Kinds of quality problems o Misuse (errors + mistakes) 
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