Background:
2 trillion/year; 16%GDP; 47 million uninsured. Science/med not CL, so fast, new.
Definitions: matter b/c $ hinges on. “covered”?; expectations alter; gate-keeping; doc priorities
Def of Health: species difficult functioning. Deviation from biological norm. Root cause (unnatural? Underlying pathology?)
Concepts of illness, sickness, health= hybrid. Social/biological/economic.
Law: has a job. Standards for med & law. What is an illness, what’s a health care issue (aging, depression, obesity, etc.)
Health/illness/disease= hybrid. Biology(something “wrong”), medicine (“understand deviation as threatening”?”), value judgment (“this person appropriate for sick role/resource use?”)
Defining Illness
Katskee v Blue Cross of NE (NE 2004)- pg 3. ovarian carcinoma syndrome, ovarian cancer hard to detect, doc recommends removal b/c 50%+ risk of cancer, insurance won’t cover, sues for breach of contract.
LC: no illness. Will open floodgate. CofA: Genes are what’s messed up. Statistical deviation meets def of illness.
Timing important. Dealing w/def written before consideration of predictive genetics. Her docs didn’t know her genetics. Also, what’s right # for cutoff? Court arbitrarily settled for 50%.
Coverage for Infertility- 3 states mandate coverage. Couple has bad simmers/irregular ovulation. Sickness b/c deviation from normal functioning, plus med service provided by docs. BUT, not sick, its combo of the 2 people that creates prob. Use curve against people-normal includes both ends (1st try + never), not in biz of fixing curve, also not impossible just improbable. Law, policy, value judgments. Root cause issue. Contract ambiguous- how broad? Ambiguity in insurance contracts always construed against insurer, for patient b/c power/powerless relationship.
What’s inside/outside the health care system? 3 criteria:
1) service to fix/lessen burden of disease 2) Subject to quality standards (Wedge herbs- what’s acceptable quality, what’s not) 3) accountability for error (but, what even is error?)
Movement for Quality: Structure, process, outcomes. “Total quality management” “continuous quality improvement.” How u put together program to systemically improve health care over time. Comprehensive, less blame/bad apple, if blame people less forthright, need process lets people talk up hierarchy.
Flaws of quality movement: can patients really asses quality of their care? Market/consumer mechanisms. Quality depends on who u ask b/c inherently subjective. Using malpractice as indicator- what if hospital serves more medically challenged pop/takes on harder patients?
1) STRUCTURE- stuff/people (#docs, # operating rooms). Pro: easy. Con: Crude measure, indirect.
2) PROCESS- procedures for fighting infection. Observe teaching/instruction in law school. Con: bad for measuring b/c aren’t seeing outcomes. Also, if u rely on people to say what “right” processes are, could rigidify error. Ex- med fads (tonsils out), sometimes honest uncertainty.
3) OUTCOMES- *best!* How many people die after surgery, measure success via clinical benchmarks (rates of readmission, how long in hospital after surgery, retrospective reanalysis of med records. Look @ relationship between quality & legal system. Ask docs to asses quality of outcomes. Patient satisfaction. Iatrogenesis? Morbidity?
Problem of Medical Error
Accountability for Error- 5 iatrogenesis categories:
1) Willful/reckless acts- (ex- knowingly recommending unnecessary surgery)
2) Neg- inattentiveness, function of bad training, impairment (doc drunk)
3) Error due to patient variation (expected risks happen)
4) Injuries of Ignorance- limits of med knowledge (try out new chemo, some % patients get tumors elsewhere as consequence
5) Iatroepidemics- erroneous embrace of bad practice by whole med profession (ex- lobotomies, tonsils)
a. Culpability for which? 1, 2, sometimes 3. Maybe for 5 if no other means to initiate change. Tort system goes after people w/reference to their peers, thus hard to go after 4 or 5.
Iatrogenesis- question of iatrogenic infection huge. Ex- 2 year old goes in fo
$ on line. Required disclosure for errors/near misses. Unclear if you REALLY have to tell. JCAHO notoriously slow to respond/put on watch list. OK to report to JCAHO instead of patient? Trade-off between incentivizing hospital disclosure v. JCAHO saying you’ve gotta come clean. What about doc-patient trust? Tension between disclosure & secrecy!
CMS- huge piece of healthcare pie. Actions matter. Requires a system of quality improvement. Weaker than JCAHO, but penalty tougher b/c threaten to exclude hospital from fed program. Power of purse.
Barry Levy- bioterrorism- Public Health- Health of pops not inds. Aggregate #s, safety of entire patient pop, bigger than ind. power. Monitoring, epidemiology, envtl health, epidemics, disease/injury control/reporting. Ex- how big a prob? What part of country/pop affected? Co-factors?). Aggregate steps taken to improve health of pops (ex-water)
HIV Contact tracing-u voluntarily give us names of people who may’ve been exposed, we’ll contact.
Does conceptualizing something as PH prob give us more justification for intervening in personal freedoms? Ex- obesity
Model State Emergency Health Powers Act- during PH emergency (declared by governor), groups(uh-oh)/people can be isolated. Pendulum swinging, going back to how coercive can we get.
Anxiety over global pandemics- forcing issue again. Natural or man-made, emergence of these threats in public mind have prompted leg change (MSEHPA).
Isolation-already have bug. Quarantine-we don’t know if u got it, but exposed/reason to think yes. Sordid history of vaccinations/quarantines. Immigrants, ethnicity, low SES, racial categorization.