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Using pt as teaching tool in teaching hospital in direct view of pt, discussing case w/ colleagues in listening range of pt


Allostatic Overload

The wear and tear on the body and brain caused by chronically increased allostasis
*McEwen, 1998


Payment per patient (capitation)

Unit of payment = sum of pt's tx (monthly or yearly)
- pt registers w/ physician group
- emphasis on primary care
- fixed sum of $ per pt, regardless of # of services provided


Age/Gender Effects

Be aware of gender differences in communication styles



Relationship schemas
(Beliefs, expectations, perceptions from the past informing the present)


Who pays most healthcare financing in the US?

Government (46%)


Hospital payment per episode of hospitalization

Unit of payment = diagnosis-related groups (DRGs)
- single (bundling) of payment of all services for 1 pt for entire stay
- lump sum depends on pt dx
- started in 1983 for Medicare pt's


Physician Impairment

75% of cases are drug/ETOH related, 20% involve mental health



Unit of payment = procedure (inpt or output)
- private insurance (UCR) gave way to payer determined fee schedules
- Medicare (RBRVS) vary by geographic area
- managed care PPOs: discounted fees
*incentive for medical inflation


Hospital payment per institution

Unit of payment = global budget
- complete (bundling) of services: hospitals receive fixed budget per yr
*staff =-model HMOs w/ integrated hospitals
*some public sector hospitals


Healthcare in Canada

Single-payer model, Canada Health Act (1984) - comprehensive, accessible, portable, universal, publicly administered
*paid by "fee for service" and fees are negotiated


Allostatic load types

1. Repeated "hits" from multiple stressors (e.g. - child abuse @ same time every day, etc.)
2. Lack of adaptation
3. Prolonged response due to delayed shut down
4. Inadequate response that leads to compensatory hyperactivity of other mediators



Physician's relationship schemas


Boundary Crossings

Deviation from therapeutic activity that is harmless, non-exploitative, possibly supportive of therapy, slippery slope to boundary violation
E.g. - hug, excessive personal disclosure


Healthcare in Japan

Social insurance which is mandated
- large employers: mandated to operate their own plans
- smaller firms: employees enrolled in gov-managed insurance
- community-based insurance: self-employed and retirees known as "national health insurance" administered by municipal gov


Consolidated Omnibus Budget Reconciliation Act (COBRA)

Job loss, still have the right to continue under group coverage up to 18mo after, must continue to pay premium


4 parts of Medicare

A: hospitAl insurance
B: Basic medical Bills
C: (parts A + B) delivered by private Companies
D: rx Drugs (the "donut hole")


UK Health System

National Health Service (NHS) - primary/secondary/tertiary care triangle structure, general practitioner (GP) as "gate-keeper" is essential component, "pay for performance" has increased GP incomes


State Children's Health Program (SCHIP)

Created in 1997 to provide fed funds to states for child health, Medicaid expansion, provides coverage to children @ or below 200% poverty level


Cognitive impairment

Provide written instructions for memory impaired pt's, determine pt competency to understand and comply with tx rec's, refer for eval if needed


Reporting Misconduct

AMA mandates that you must report in accordance w/ legal requirements in each state


Payment per episode of illness

Unit of payment = global surgical and other fees for an illness or episode
- single (bundling) of payments for multiple services
- shifts financial RISK from payer to provider


Affect (MSE)

The observable emotional state of the pt, short time scale (as opposed to mood which is longer)


Preferred Provider Organization (PPOs)

PPO payer receives monthly premiums from subscribers and employers, pt req to select dr/hospital approved ("preferred") by payer


Race Effects

Understand how a long h/o racism in countries like US have led to racial disparities in tx and minority distrust of healthcare professionals


2 Tier Capitation

Health plan must pay fee to referral service to register w/ the physician group your health plan then pays the physician by means of capitation


Report to who?

Med student? Dean of med school
Resident? Residency director
Physician? Division/hospital chief
If conduct violates state licensing laws? Report to state licensing board
If conduct violates criminal statutes? Report to law enforcement


Yerkes-Dodson Law

- performance and adaptive learning are optimal under moderate levels of stress
- learning new/difficult tasks is optimal with low/moderate arousal levels
- performance of well-learned tasks is optimal w/ moderate/high arousal levels


Sexual Violations

Sexual contact or inapprop sexual behavior in the room w/ a pt, etc


Pt Self-Determnination Act

Est that pt's must be given written info about their health care decision making rights and the institutional policy on advanced directives