Watch the following Khan Academy Videos:
Module 1: Health care system overview 8 minutes
Explains how patients/populations, providers, and payors interact. Introduces government insurance, direct payment of patient to doctor, HMOs and PPOs. Explains the rationale for insurance to mitigate risk and discusses the need to manage “moral hazard” as well as over-utilization of services when not directly responsible for payment.
Module 2: Paying doctors 12 minutes
Defines FFS, capitation and salary. Describes the lack of cost accountability to patients and providers in the third party payor system. Describes issues with capitation with particular attention on “cherry picking” or patient shifting.
Module 3: Medicare overview 16 minutes
Introduces Medicare and Medicaid. Defines populations covered for Medicare (Elderly/ALS/ESRD) and Medicaid (low income) as well as funding source (Federal Government for Medicare and combined Federal and State for Medicaid). Defines Secretary of HHS and CMS (Centers of Medicare and Medicaid Services). Describes Medicare parts A-D.
Review the Fact Sheet on Healthcare Financing and Reform
Social Determinants of Health
“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”
From the World Health Organization
From the Oxford English Dictionary
- Diet: The kinds of food that a person, animal, or community habitually eats. ‘a vegetarian diet’
- Epigenetics: The study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself. ‘epigenetics has transformed the way we think about genomes’
- Disparity: A great difference. ‘economic disparities between different regions of the country’
Epigenetics, Social Determinants of Health and the Social Ecological Model
Keep the social determinants of health in mind while reading “Diet, the Gut Microbiome, and Epigenetics” by Hullar et. Al. The field of epigenetics is in its infancy. Consider how access to certain foods and environmental conditions may increase or decrease an individual’s cancer risk.
Remember the social history session from immersion? When you last took a social history was it in the context of the social ecological model? Think about your last patient encounter. Place that patient within the social ecological model. How has their life and health been influenced by individual, interpersonal, organizational, community and policy level interactions?
Racial Disparities in Cancer Treatment and Outcomes
Not that “Disparities in Cancer Care and Outcomes” was published in the Journal of the American College of Surgery. This article “explores radical disparities in the context of cancer surgery.” Take note of Figure 1. Do you think the steps present in this figure might help you explore disparities in outcomes in other conditions? How is it similar to the social ecological model? How is it different?
The Oxford English Dictionary defines health as “the state of being free from illness or injury.”
The constitution of The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
Fiona Goodlee, editor of the British Medical Journal and the editorial staff at The Lancet have both written editorials about the evolving definition of health. Click on the below links to read the two articles. Read the articles with the below questions in mind.
As you progress throughout your medical student career (and beyond) we would encourage you to return to this page to reflect upon:
- How do you currently define health?
- How has the definition of health changed over time?
- Does the definition of health change by perspective? Is health defined differently in the United States that it is in other countries?
- Do patients define health differently than their physicians?
- Does the public health system define health differently than hospitals?
Many of you are familiar with Atul Gwande and his writings. We will refer to The Bell Curve, What happens when patients find out how good their doctors really are? by Dr. Gwande many times in EHM. This article emphasizes many aspects of the course. Some of the major themes are health systems improvements, social determinants of health, inter professional education, communication, professionalism and ethics.
Click the link to download The Bell Curve highlighted for this reading.
We have highlighted the passages with in the reading that are directly related to this session.
- What did you find surprising about this article?
- How did you feel when you read about the initial appointment Honor and Don Page had with the team at Cincinnati Children’s Hospital?
- What did you think about the appointment Alyssa had with Cori Danes?
- Compare and contrast that with Janelle’s appointment with Dr. Warwick at Fairview-University Children’s Hospital in Minneapolis.
- Write down some different strategies employed by both care teams. Are there other strategies you might have employed when communicating with these two patients?
- Did this article make you rethink your understanding of ‘non-adherence’? If so, how?