Category Archives: Healthcare Systems

Patient care, quality improvement, patient safety, value based care, accountable care

Healthcare Financing and Reform

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 Ecological Model

Social Ecological Model

McLeroy, Bibeau, Steckler and Glanz are generally credited with creating the social ecological model of care.  A quick Google search for the social ecological model will reinforce how widely it has been adopted.  There are numerous community, state, national and international organizations that utilize this model in their programs.

Think back to your session in immersion on the social history.  How often do you think beyond the individual and interpersonal factors that influence you and your patients health?

Image result for social ecological model uw

 

From CDC Colorectal Cancer Control Program (CRCCP)

Epigenetics and Social Determinants of Health

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?

What is Health?

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?
  • How are medical schools accountable for health?

The Bell Curve

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?

Lexicon

This is a partial list of some important terms. For a more complete list, see the Diversity and Inclusion Dictionary.

Diversity: Diversity means more than just acknowledging and/or tolerating difference. Diversity is a set of conscious practices that involve:

  • Understanding and appreciating interdependence of humanity, cultures, and the natural environment.
  • Practicing mutual respect for qualities and experiences that are different from our own.
  • Understanding that diversity includes not only ways of being but also ways of knowing;
  • Recognizing that personal, cultural and institutionalized discrimination creates and sustains privileges for some while creating and sustaining disadvantages for others;
  • Building alliances across differences so that we can work together to eradicate all forms of discrimination.

Diversity includes, therefore, knowing how to relate to those qualities and conditions that are different from our own and outside the groups to which we belong, yet are present in other individuals and groups. These include but are not limited to age, ethnicity, class, gender, physical abilities/qualities, race, sexual orientation, as well as religious status, gender expression, educational background, geographical location, income, marital status, parental status, and work experiences. Finally, categories of difference are not always fixed but also can be fluid. Diversity includes respecting an individual’s right to self-identification and recognizing that even though hierarchies based on identity are built into systems, no one culture or identity is intrinsically superior to another.

Identity:  the qualities, beliefs, etc., that make a particular person or group different from others. Some ways in which we identify are connected to groups which are socially ascribed such as gender, race, age, class, sexual orientation, ability, nationality and citizenship, etc.

 Implicit Bias:  Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.  These biases, which we all hold and which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or control.   The implicit associations we harbor in our subconscious cause us to have feelings and attitudes about and different responses to people based on characteristics such as race, gender, age, and appearance. These associations develop over the course of a lifetime beginning at a very early age through exposure to direct and indirect messages.  In addition to early life experiences, the media and news prograaming are often-cited origins of implicit associations. Implicit biases are malleable, and since they are learned, they can be gradually unlearned through a vareity of debiasing techniques.

Intersectionality:  Though theories related to intersectionality have been around since the 19th century, Kimberlé Crenshaw professor of law and an expert on critical race study first coined the term intersectionality in 1989 to describe how social and cultural identities/categories interrelate on concurrent and multiple levels to create interlocking systems of social inequality.  Intersectionality is a theory or standpoint that allows us to see and understand the ways in which social categoris of difference like gender, race, age, class etc are woven together.  For example, if a person is transmasculine, brown, and working class with no health insurance, they may have a much more difficult time accessing trans*affirming health care than a transmasculine, white, middle class person with health insurance.

Power: One definition of power that is both simple and useful is: “the ability to get what you want.” Power is a relational term. It can only be understood as a relationship between human beings in a specific historical, economic and social setting. It must be exercised to be visible.

It is worth noting here the difference between forms of power that are ‘power-over’ and ‘power-with’. Power-over is power that is used in a discriminatory and oppressive way: It means having power over others and therefore domination and control over others (e.g. through coercion and violence). Power-with is power that is shared with all people in struggles for liberation and equality. In other words, it means using or exercising one’s power to work with others equitably.

Privilege:  A special right, advantage, or immunity granted or available only to a particular person or group of people whether they want those privileges or not, and regardless of their stated intent.  Privilege is characteristically invisible to people who have it. People in dominant groups often believe that they have earned the privileges that they enjoy or that everyone could have access to these privileges if only they worked to earn them. In fact, privileges are unearned and they are granted to people in the dominant groups whether they want those privileges or not, and regardless of their stated intent.  Unlike targets of oppression, people in dominant groups are frequently unaware that they are members of the dominant group due to the privilege of being able to see themselves as persons rather than being constantly regulated to the level of stereotype. Privilege operates on personal, interpersonal, cultural, and institutional levels and gives advantages, favors, and benefits to members of dominant groups at the expense of members of target groups.

Oppression/Target Groups: Oppression is the combination of prejudice and institutional power, which creates a system that discriminates against some groups (often called “target groups”) and benefits other groups (often called “dominant groups”). Examples of these systems are racism, sexism, heterosexism, cis-sexism, ableism, classism, ageism, and anti-Semitism. These systems enable dominant groups to exert control over target groups by limiting their rights, freedom, and access to basic resources such as health care, education, employment, and housing.

Four Levels of Oppression/”isms”:

  • Internalized / Personal Oppression: Values, Beliefs, Feelings
  • Interpersonal Oppression: Actions, Behaviors, Language
  • Institutional and Structural Oppression: Rules, Policies, Procedures
  • Cultural Oppression: Beauty, Truth, Right

Oppression Internalized (inferiority and superiority): Internalized inferiority is the process whereby people in the target group make oppression internal and personal by coming to believe that the lies, prejudices, and stereotypes about them are true. Members of target groups exhibit internalized oppression when they alter their attitudes, behaviors, speech, and self-confidence to reflect the stereotypes and norms of the dominant group. Internalized oppression can create low self-esteem, self-doubt, and even self-loathing. It can also be projected outward as fear, criticism, and distrust of members of one’s target group.

Internalized superiority is the process whereby people in the privileged group make oppression internal and personal by coming to believe that the lies, prejudices, and stereotypes about people in a target group are true, which positions people in the privileged group as superior.  Members of privileged group often exhibit internalized superiority by assuming they are smarter and more deserving of decision making power, comfort, and authority than people in the associated target group.  This is often expressed through perfectly logical explanations that justify and normalize discriminatory behavior.

Race: Someone has said that “race is a pigment of our imagination”. That is a clever way of saying that race is actually an invention. It is a way of arbitrarily dividing humankind into different groups for the purpose of keeping some on top and some at the bottom; some in and some out.  Ant its invention has very clear historical roots; namely, colonialism. “Race is an arbitrary socio-biological classification created by Europeans during the time of worldwide colonial expansion, to assign human worth and social status, using themselves as the model of humanity, for the purpose of legitimizing white power and white skin privilege” (Crossroads-Interfaith Ministry for Social Justice).

To acknowledge that race is a historical arbitrary invention does not mean that it can be, thereby, easily dispensed with as a reality in people’s lives. To acknowledge race as an invention of colonialism is not the same as pretending to be color blind or declaring, “I don’t notice people’s race!”  For example, it has been demonstrated that health professionals are less likely to prescribe painkillers for people of color who are experiencing the same symptoms as white people. So, even though race is a social construct, when someone doesn’t get the pain medication that they need because of implicit bias, race and racism have real consequences.  Our world has been ordered and structured on the basis of skin color and that oppressive ordering and structuring is racism.

 Racism: Racism is a system in which one race maintains supremacy over another race through a set of attitudes, behaviors, social structures, and institutional power. Racism is a “system of structured dis-equality where the goods, services, rewards, privileges, and benefits of the society are available to individuals according to their presumed membership in” particular racial groups (Barbara Love, 1994. Understanding Internalized Oppression). A person of any race can have prejudices about people of other races, but only members of the dominant social group can exhibit racism because racism is prejudice plus the institutional power to enforce it.

Stereotype: An exaggerated or distorted belief that attributes characteristics to members of a particular group, simplistically lumping them together and refusing to acknowledge differences among members of the group.

Cultural Competency: Cultural competency is a common, well-intentioned approach to teaching (presumably) privileged people that cultural mastery of traits, beliefs, traditions, etc. of marginalized communities is possible.  While it is certainly important to be aware of cultural practices that are outside one’s own lived experiences and world view, this definition and concept is problematic because it harbors unstated assumptions that trainees are necessarily from a privileged cultural group, that patients of a particular background share homogeneous beliefs, that the complex nuances of difference can be “mastered”, and that ethnic similarity between clinician and patient mandates mutual understanding.  Most importantly, traditional cultural competency training, like traditional medical training, is externally focused, primarily concerned with mastering the Other, rather than examining the internal cultures, prejudices, fears, or identifications of the Self in relation to that Other.

Narrative Humility/ Narrative Competence: Craig Irvine describes humility as “The sense of humility toward that which we do not know—the face of the Other, the face we cannot know but to which we are responsible.”  Narrative humility acknowledges that patients’ stories are not objects that can be mastered, but rather dynamic entities that can be engaged with, while simultaneously remaining open to their ambiguity and contradiction.  Narrative humility means engaging in constant self-evaluation and self-critique about issues such as one’s own role in the story, one’s expectations of the story, one’s responsibilities to the story, and one’s identifications with the story.  Narrative humility allows clinicians to recognize that each story heard holds elements that are unfamiliar—be they cultural, socioeconomic, sexual, religious, or idiosyncratically personal.  Narrative competency, on the other hand, is not an end point—but rather a skill set that is developed through the practice of narrative humility, which needs to be exercised just like a muscle.

References:

AMSA website: http://www.amsa.org/advocacy/action-committees/gender-sexuality/lgbt-local-projects-in-a-box/

MSU Extension Multi-Cultural Awareness Workshop and http://www.amsa.org/advocacy/action-committees/gender-sexuality/lgbt-local-projects-in-a-box/

Ignite! A Toolkit for Anti-Racist Education: http://antiracist-toolkit.users.ecobytes.net/?page_id=124

Kirwan Institute for the Study or Race and Ethnicity: http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/

  Sayantani DasGupta:  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60440-7/fulltext

Queensborough Community College: http://www.qcc.cuny.edu/Diversity/definition.html

Text adapted from CEDI Resources and References