PH 602 Introduction to U.S. Health Care Services
Fall 2015
Meeting Details
Tuesdays, 9:00AM – 11:40AM
Room: Biomed D-207
Instructor Information
Tetine Sentell, PhD
(808) 956-5782 (office), (510) 325-4059 (cell)
Biomed T-102B
Office Hours: Mondays 10AM – Noon, and by appointment
Course Description
This course is an overview of the historical, conceptual, ethical, organizational, and political context for health care delivery in the US. It explores current trends, practices and issues in the delivery of health care services in both the public and private sector. We will compare
the US health care system to other countries’ health service systems and we will also pay
particular attention to Hawaiian health services and to relevant health care access and delivery
issues in Asian, Native Hawaiian, and other Pacific Islander populations.
Learning Objectives
By the end of the course, each student should be able to:
1. Identify, summarize, present, and discuss components of the health services in the United
States including: managed care, health care institutions, health care professionals/personnel,
public health promotion, and disease prevention, Medicare, Medicaid, health care economics
and financing, long term care, pharmaceuticals, medical technologies, health planning and
management.
2. Review, analyze, and evaluate health service problems, practices, differences, limitations,
and/or trends in health service in the U.S.
3. Critically compare and contrast the U.S. health services system with those from other countries. 4. Critically analyze the structure and functionality of the current health services delivery system in the U.S., particularly in terms of access, cost, politics, health disparities, and
quality of care.
5. Research, summarize, and present on the status of various local health care organizations in
Hawaii.
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Required Texts
Books:
Shi, L. & Singh, D.A. (2015). Delivering Health Care in America: A Systems Approach.
(Sixth Edition). Jones & Bartlett Publishers, MA.
Cohn, J. (2007). Sick: The Untold Story of America’s Health Care Crisis- and the People who
Pay the Price. Harper Collins, NY. ($11.66 on Amazon.com)
Articles (on Laulima):
Liu DK, Blaisdell RK, Aitaoto N Health Disparities in Hawai‘i: Part 1. Hawaii Journal of
Public Health. 1: 5-13. Online at http://www.nnaapc.org/pdf/Current-Articles/Hawaii-PublicHealth-Journal.pdf
Lantos, J. (2010). Cruel Calculus: Why Saving Premature Babies Is Better Business Than
Helping Them Thrive. Health Affairs. 29: 2114-2117
http://content.healthaffairs.org/cgi/reprint/29/11/2114.pdf
Gawande, A. (2015). Overkill: An avalanche of unnecessary medical care is harming patients
physically and financially. What can we do about it? Annals of Health Care. May 11, 2015 Issue.
New Yorker. http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
Required Movies:
1) Michael Moore, Erin O'Hara, Christopher Seward, and Geoffrey Richman (2007) Sicko.
Weinstein Company (You just have to watch this. You don’t have to own it.)
2) TR Reid. (2008). Frontline report: Sick Around the World
Available at http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/
3) Obama’s Deal (2010). Available at: http://www.pbs.org/wgbh/pages/frontline/obamasdeal/
Optional Books and Resources:
(You are not required to read any of these books, but they offer more personal insights and
discussion about issues discussed in class, and are very interesting and well written.)
1) Sered S.S. & Fernandopulle, R. (2007). Uninsured in America. University of California
Press, CA.
2) Abraham, L.K. (1993). Mama Might be Better off Dead: The Failure of Health Care in
Urban America. The University of Chicago Press, IL.
3) Fadiman, A. (1997). The Spirit Catches You and You Fall Down: A Hmong Child, Her
American Doctors, and the Collision of Two Cultures. Farrar, Straus, and Giroux, NY.
4) TR Reid (2009.) The Healing of America: A Global Quest for Better, Cheaper, and
Fairer Health Care. The Penguin Press.
Evaluation:
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This course is designed to provide students with a foundation for understanding the
U.S. Health Care System. Evaluation will be based on the following criteria:
1. Participation: Each student is expected to attend class regularly. This class requires you to
be an active participant in your own and your peers’ learning process. You should come to
class prepared to discuss the readings each week, and openly exchange ideas in the class.
You will have in-class activities to complete as well. You will also have a few homework
assignments that are included in this grade.
Each student is expected to attend class weekly. You are expected to be an active participant
in your own and your peers’ learning process. You should come to class prepared to discuss
the readings each week, and be prepared to openly exchange ideas in class. We will have
small group discussions. Also, we will have in-class assignments. Much of the content of
this course rests on the quality of your preparation and participation. Thus, class
participation carries 20% of the course grade and will be based heavily on the successful
completion of your assignments and discussions. Class participation carries 20% of the
course grade.
2. Quizzes: Two scheduled quizzes will be given to assess the student’s understanding of
course material, including lectures and readings The vocabulary for each quiz is attached.
(10% each for 20% of the course grade)
3. Round-Table Presentations: Each student will participate in three round-table
presentations over the course of the semester. These will concern: (1) another country’s
health care system, (2) a local health care organization, and (3) a health care policy issue
action. Students will able to choose which country, organization, and issue they would like to
cover. Detailed guidelines are included. (10% each for 30% of course grade)
4. Final Presentation and Paper: Sick is a powerful book because of the way the author ties
an insightful analysis of the health care system with moving description of individuals’
personal experiences within the US health care system. For this project, you will interview
someone who has had an important interaction with the US health care system. This
experience can be positive or negative or both. You will use this interview as the basis of a
6-7 page analysis of the US health care system, which will draw from the themes, concerns,
and information we will have discussed in class. You will also do a brief 3 slide presentation
about this project. This final project will make up 30% of your course grade.
Make-up examination policy: Make-up exams will be permitted only under extenuating
circumstances. Students will have to provide proof/documentation for consideration. Late papers
will be marked down at 25% per missed class.
Academic Integrity: Plagarism is unacceptable and will result in a failing grade for the assignment and possibly for the course. Please be familiar with the Hawaii Student Conduct Code. http://studentaffairs.manoa.hawaii.edu/policies/conduct_code/ 3
Grading: At the end of the course, a letter grade will be assigned based on the following grading
criteria:
Participation
Quizzes
Round Table Presentations
Final Paper and Presentation
20%
20% (2*10%)
30% (3*10%)
30%
Course Grade
A+ = 98 – 100 %
A = 93 – 97 %
A- = 90 – 92 %
B+ = 88 – 89 %
B
BC+
C
CF
= 83 – 87 %
= 80 – 82 %
= 78 – 79 %
= 73 – 77 %
= 70 – 72 %
= Below 70%
Disability Accommodation:
Any student who feels s/he may need an accommodation based on the impact of a disability is
invited to contact me privately. I would be happy to work with you, and the KOKUA Program
(Office for Students with Disabilities) to ensure reasonable accommodations in my course.
KOKUA can be reached at (808) 956-7511 or (808) 956-7612 (voice/text) in room 013 of the
Queen Lili'uokalani Center for Student Services.
Writing Resources and Campus Writing Center:
I want to see clear, concise, well-edited work for your policy action letter and especially your
final paper. It is essential that, as public health professionals, you are able to write clearly and
edit your work. When you turn in your final paper, I will grade down if there are numerous
grammatical errors, typos, and examples of non-standard English. You have plenty of time to
start this process early and to find someone who can help you meet these goals. You do not need
to do this alone. In fact, most writers do not. We are happy to look at earlier drafts and provide
advice and guidance, though I will not provide detailed editing for you. If you need assistance
with this, please contact the writing center and work with a writing tutor there. You should also
work with your peers to provide editing and constructive advice for each other. This is how I
often get excellent advice on my own writing and other work.
Here is a link to the Campus Writing Center website. They list information about their services
and have online resources as well. Please use them, if you need help! They are a great resource.
http://www.english.hawaii.edu/writingcenter/
Other Matters:
•
This class schedule may need to be revised as the semester progresses.
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Schedule of Classes, Readings and Examinations
(Please note that the course calendar is “subject to change with fair notice”)
Readings by Chapters to be
Date
Topic
done BEFORE the class week
for which they listed.
8/25
Course Overview
(1) Text: 1
A Distinctive System of Health Care Delivery
(2) Sick: Intro, 1
System Framework
Systems Foundations
9/1
9/8
9/15
Health Care Reform
Beliefs, Values, and Health
Cost, Access, and Quality
The Evolution of Health Services in the United States
Health Care Reform
Other Countries’ Health Care Systems:
Round Table and Discussion
(1) Text: 2
(2) Sick: 2
(3) Health Affairs Article: Cruel
Calculus
(1) Text: 3, 12
(2) Sick: 3
(3) New Yorker article: Overkill
(1) Frontline Documentary: Sick
Around the World
System Resources
Health Services Professionals
Medical Technology
(1) Text: 4, 5
(2) Sick: 4
9/29
Health Services Financing
(1) Text: 6
(2) Sick: 5, 6
Make sure you have your
textbook during class this day!
10/6
Virtual Class
(1) Virtual Class 1 below
10/13
Outpatient and Primary Care Services
Inpatient Facilities and Services
(2) Text: 7, 8
9/22
System Processes
10/20
Hawaiian Health Services
Round-Table and Discussion
Discussion of Ideas for Final Projects
Quiz #1
(1) Sick: 7, 8
(2) Lui et al, 2009
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10/27
Long Term Care
Managed Care and Integrated Organizations
(1)Text: 9
(2)Text: 10
(3) Tell the story of tutu from
your virtual class
System Outcomes and Outlook
11/3
11/10
Virtual Class
Health Services for Special Populations
Quiz #2
11/17
Health Policy Action Round-Table and Discussion
Health Policy
Sicko Discussion
11/24
Future of Health Service Delivery
12/1
In class presentations for Final Projects
12/8
In class presentations
Final Papers due
Virtual Class #2 below
(1) Text: 11
(2)
(1) Prepare letter
(2) Sicko (the movie)
(3) Frontline Movie:
Obama’s Deal
(1) Text: 14
Turn in hard copy to me or email
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FINAL PROJECT
This project follows the model of the book Sick and allows you to construct an analysis of the
US health care system using a case study. You will have a detailed interview with a person
about an important interaction they have had with the US health care system. The person you
chose to interview can be someone you know well or someone you don’t know well, but they
must be someone who has had a significant interaction with the health care system. This
experience can be routine, but intense (e.g., having a baby), frightening (e.g., cancer
diagnosis/treatment), long-term (e.g., diabetes care), or even about someone else (e.g.,
description of end-of-life choices for parent). It does not have to be a negative experience. It
could be with someone who got extremely high-tech care that saved his/her life. It could also be
not about an interaction with a health problem, per se, but an issue with insurance, such as
someone with a pre-existing condition who struggled to find insurance or someone uncertain
about their insurance after a job loss. These are just some examples. You should find an issue
that is important to you.
This paper should be about 6-7 pages, 12 pt., double-spaced. Please note that, even though this
paper is not particularly long, this should not be taken as an invitation to write it carelessly and
quickly. It should be short b/c it’s written clearly, with cogent argumentation. Please use
specific examples and insightful analyses.
Paper Guidelines:
For the paper, please include the following. They do not have to be in exactly this order, but try
to cover as much of these subjects as are relevant to your topic.
I.
Description (approx. 2 pgs)
1. A description of the subject. (You can make up a name, or use the person’s real name,
depending on your preference)
2. A description the subject’s health care coverage.
3. A description of the subject’s health care issue
4. A description of the specific interaction with the health care system that will be the focus of
your analysis.
5. Any other relevant background info (e.g., a description the cost of care and/or impact on
finances)
II.
Analysis (approx. 4 pgs)
1. How does this person’s experience meet up with what we have discussed, and what you
believe should be the integral mission (and component parts) of a health care system?
2. What does this person’s experience bring you to conclude about social vs. market justice as a
philosophical position about health care access?
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3. How does this person’s experience show the strengths and/or weaknesses of the US health
care system?
4. What do think worked well and what did not work well in your subject’s health care
experience? Does your subject agree with this analysis?
5. Considering this person’s issues specifically, what do you think could change in the US
health care system to help fix these problems? What might such a change mean to the larger
health care system?
6. Do you the provisions in the Affordable Health Care Act address these issues?
7. What else do you think could be done to the US health care system to address these
concerns?
III.
Conclusion (approx. 1 pg.)
1. Update on how subject is doing.
2. A concise summary of your analysis.
3. Any final conclusions about the US health care system as it as, and/or as you think it should
be.
Presentation Guidelines:
In the final two weeks of class, we will do in-class presentation of your projects. These should
have 4 slides that include (1) Slide 1: An overview of the story; (2) Slide 2: The key parts of your
analysis; (3) Slide 3: Resolution of this issue (e.g., do you think the ACA will help solve this
problem generally, are there other policies that will?); (4) Slide 4: What you learned. You will
have 5 minutes to make your presentations.
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ROUND-TABLE DISCUSSIONS
Over the course of the semester, we will have 3 round-table discussions where you will each
prepare a short, structured presentation about each of the topics below that should last no more
than 5 minutes. The time line will be tight, so you should prepare your presentation carefully.
We will then discuss what we have learned and ask questions.
Round Table 1: Other Countries’ Health Care Systems
Our first round-table discussion will concern the specifics of other countries’ health care
systems, and compare them with the US. You can pick a country of your choice. This selection
will be confirmed in our class in September. You should cover:
1)
2)
3)
4)
5)
6)
7)
8)
The country’s location
The country’s population
The country’s total cost for health care
The country’s total cost/person for health care
The average life expectancy in your country
The country’s style of health care system according to models discussed in class
The country’s major health issues
Anything else you feel is critical
Round Table 2: Hawaiian Health Care Organizations
From the list of local organizations to be distributed in class, you will choose one and will
provide specifics of that organization. You should cover:
1)
2)
3)
4)
5)
6)
Name and location of the organization
Target clientele
Operating budget and funding sources
Major programs, activities, services
Anything particularly noteworthy or interesting about the organization
If you can bring in a pamphlet from the organization, that would be nice.
Round Table 3: Health Care Action
This is a very exciting and dynamic time in US health care reform. I want you to join this debate
using the information you have gathered from this class and your final project preparation, as
well as other courses, your professional experience, and your personal experience. I want your
voice heard about a health care issue you care about.
Please pick a publication or a policy-maker of your choice, and write a letter addressing what
you feel is a critical factor in health care today. This should be written in a highly digestible and
accessible form and should be no more than one page. It would be great if you can link this
letter to a specific article or a specific bill that is pending. Depending on your topic of choice,
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however, this may not be feasible and is not required. (A preliminary selection of the issue you
plan to discuss should be confirmed in our class on September, though you will be able to change
it, if something else strikes your fancy during the course of the semester.)
I will post links with advice about writing a good letter to an editor or policy-maker on our
laluima site and we will discuss this as well.
For our final round-table discussion, we will read and discuss these letters in class. After class,
you should make any changes you would like to make based on our discussion and your
classmates letters, if you have any to make, and then you should mail them! Also, please turn in
a final copy to me. And, of course, let me know if it get published or mentioned again!
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VOCABULARY FOR QUIZ #1
Here is the vocabulary you should pay attention to in your reading and in class in preparation for
the first quiz.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
20
21
22
23
24
25
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Adverse Selection
Categorical programs
Clinical information systems
Cost-benefit analysis
Cost-containment
Defensive medicine
First-dollar coverage programs
Indemnity plan
Maldistribution
Market Failure
Means Test
Medicaid
Medicare
Medical Arms Race
Moral Hazard
National health expenditures
National health insurance (NHI)
National health systems (NHS)
Non-Profit
Advanced Practice Nurse
Physician Assistant
Reinsurance
Single-payer system
Social health insurance (SHI) systems
Supplier-induced demand
Technological imperative
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VOCABULARY FOR QUIZ #2
Here is the vocabulary you should pay attention to in your reading and in class in preparation for
the second quiz.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
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Managed Care Organization
HMO- Staff Model
HMO- Group Model
HMO- Network Model
HMO - IPA
PPO
Pay or Play
Non-Profit
Prospective Reimbursement Retrospective reimbursement Supply-­‐Side rationing Demand-­‐side rationing Provider-­‐Induced demand Medicare Part A Medicare Part B Medicare Part C Medicare Part D Community Rating Experience Rating Insurance Mandate Underinsured capitation POS Medicaid Carve Out 12
MPH Competencies
This course (602) meets the interdisciplinary MPH competencies listed below.
ENVIRONMENTAL HEALTH COMPETENCY
CPH 9: Describe how environmental factors (biological, physical, and chemical) affect the health of a community.
HEALTH POLICY AND MANAGEMENT COMPETENCIES
CPH10: Identify the components and issues of the organization, financing and delivery of health services and PH systems in the
U.S.
CPH11: Discuss the policy process for improving the health status of populations.
SOCIAL BEHAVIORAL HEALTH SCIENCES COMPETENCY
CPH13: Interpret the causes of social and behavioral factors that affect health of individuals and populations.
DIVERSITY AND CULTURE COMPETENCIES
CPH 14:Describe the roles of history, power, privilege and structural inequality in producing health disparities.
CPH 15.Demonstrate ability to interact respectfully and effectively in diverse groups.
SYSTEMS THINKING COMPETENCY
CPH16: Recognize system-level properties that result from dynamic interactions among human and social systems and how they
affect the relationships among individuals, groups, organizations, communities, and environments.
COMMUNICATIONS - INFORMATICS COMPETENCY
CPH17: Communicate in writing and orally, in person, and through electronic means, with linguistic and cultural proficiency
ETHICS AND PROFESSIONALISM COMPETENCIES
CPH18: Apply public health ethical standards of practice into all interactions with individuals, organizations, and communities.
Health Policy and Management Competencies
This course (602) also meets the following Health Policy and Management Competency
HEALTH POLICY & MANAGEMENT SPECIALIZATION COMPETENCIES
HPM3. Apply quality and performance improvement concepts to improving health.
HPM4. Demonstrate leadership skills for building partnerships.
HPM5. Analyze and translate the impact of current and proposed policy on public health.
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Virtual Class #1
PH 602
Sentell
1. Activity 1 (~45 mins)
Your beloved 83-year-old grandmother, Tutu Cupcake, has fallen and broken her hip. She also
has mild dementia. She has been living alone, but she will now no longer be able to take care of
herself. She needs to move into an assisted living facility that would be convenient to you so
you can visit her regularly (since you are her very favorite of all her 27 grandchildren, or at least
that’s what she always tells you). Please identify and consider at least 2 realistic options here in
Hawai‘i and use these to answer the following questions.
1.
2.
3.
4.
What are the names and locations of the places you picked?
Why did you pick these two places?
How much would it cost per day? Can you tell? Why or why not?
What else would you want to know, if this really was your grandmother and she really
needed care?
5. What did you learn from this exercise?
2. Activity 2 (~30 mins)
Choose two of these drugs and find 4 cost options for you to buy them. Some possibilities: Out
of pocket at a pharmacy, with insurance at a pharmacy, online through a Canadian pharmacy,
and/or any other realistic options. You can consider generics vs. brand names if you like.
1. Xanax (alprazolam) 1mg
2. Viagra (sildenafil) 100mg
3. Zoloft (sertraline) 100mg
4. Amoxicillin 500mg
5. Metformin 500mg
6. Lipitor (atorvastatin)
7. Lexapro (escitalopram) 10 mg
8. Zyvox (linezolid) 600mg
9. Pick your own
Fill in the table and answer the following question:
Drug 1
Location to Purchase
Cost
Drug 2
Location to Purchase
Cost
Source for Info
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1. What was your best choice for drug 1 in terms of cost? What was your best choice for
drug 2 in terms of cost?
2. What do you need to do to get them legally from another country?
3. Can they be reimbursed by your insurance if you get them from another country?
4. What issues did you come across in considering this question?
5. What did you learn from this exercise?
3. Activity 3 (~30 mins)
Pick a state Medicaid program (you can do Hawaii or somewhere else), download the relevant
application, and apply for aid in 20 minutes or less. You can fill it out as yourself or as a pretend
person. You do not need to upload the completed application for the class to see, but please do
go through the process of filling it out.
1.
2.
3.
4.
5.
6.
7.
Was this hard or easy for you?
What challenges might someone have who doesn’t speak English well?
What challenges might someone have who doesn’t read well?
What other groups might be challenged?
If you really needed to fill this out, what else would you need?
How long do you think it would take to fully complete this document?
What did you learn from this exercise?
4. Activity 4 (~30 minutes)
Congrats! You are going to have a baby! You want to start planning right away and put money
aside! You also want to find out all your options. Please find out how much an uncomplicated,
vaginal delivery and a c-section are likely to cost you (or your female partner). You can consider
your personal insurance status, if you have that information.
Total
Cost
Cost to you
Insurance Status
Source for Info
Uncomplicated
Vaginal Delivery
C-Section
1. What challenges did you have in finding this information?
2. What else would you want to know to really calculate this?
3. What did you learn from this exercise?
5. Activity 5 (~10 minutes)
By midnight on October 9, please post your information in a message in the discussion section of
Laulima.
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5. Activity 6 (~20 minutes)
By Monday Oct 12, please read and comment thoughtfully on two other persons' activities. Some
ideas: You can mention something you found interesting, something that related to what you
found, something else they could think about, etc.
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Virtual Class #2
PH 602
Sentell
1. Activity 1 (90 mins movie, 30 mins comments): Money-Driven Medicine
6. Please watch the film “Money-Driven Medicine” either during the class screening on
11/3 at 10am or on your own. (90 mins)
7. Answer the questions below and post your responses on Laulima by 11/6 at midnight.
(~20 mins)
8. Comment on two classmates’ responses by 11/9 at midnight. (~10 mins)
Money-Driven Medicine Response Questions
1. What did you learn from this film about the US health care system?
2. Were any of your key vocabulary words or key class concepts discussed in this film? If
so, please list 3?
3. What do you think our society should do to mitigate the problems seen in Money-Driven
Medicine?
2. Activity 2 (45 minutes): Current Issues in Health Care
Find the subject that goes with your last name below and make 1-2 slides showing the
information you are asked to provide.
1
2
3
4
5
6
7
8
9
Accountable Care Organizations RoundTable
I represent Group Health Cooperative of Puget Sound.
Let me (briefly) tell you about my ACO. (Integrated
Delivery System)
I represent the Cleveland Clinic. Let me (briefly) tell
you about my ACO. (Multispecialty Group Practice).
I represent the Community Care of North Carolina. Let
me (briefly) tell you about my ACO. (Virtual Physician
Organizations)
Accountable-care organizations are working!
Accountable-care organizations are failing!
Patient Centered Medical Homes
I represent Sustaining Healthcare Across Integrated
Primary Care Efforts (SHAPE) in Colorado. Let me tell
you about my Patient Centered Medical Home.
I represent The Integrated Behavioral Health Project
(IBHP) from California. Let me tell you about my
Patient Centered Medical Home.
Patient Centered Medical homes are working!
Patient Centered Medical homes are NOT working as
intended!
Cost Issues: Defend your Position
Name
Bacon
Bradley
Cagasan
Casson, Cook
Colon, Elliott
Ferrer
Filippoli
Holmes, Lacobie
Kalama, Lacsina
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14
15
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21
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We should use cost-effectiveness data to make decisions
about health coverage.
We should use cost-effectiveness data to make decisions
about health coverage.
Health care procedure costs should be transparent for
consumers.
It is unrealistic to expect that health care procedure costs
can be made transparent for consumers.
Primary Care Scope of Practice Debate: Defend
Your Position
More nurse practitioners should be able to see patients
and prescribe medications without a physician’s
supervision or collaboration
Nurse practitioners should only practice under the
authority of a physician
Psychologists should be able to prescribe medicine
Medication should be left to psychiatrists
Coverage
Everyone should be able to buy into Medicaid. Why not
Medicaid for all?
Medicaid is a failed system! Shut it down!
I am the governor of (pick a state that did expand
Medicaid) and I expanded Medicaid for these reasons.
I am the governor of (pick a state that did NOT expand
Medicaid) and I did NOT expand Medicaid for these
reasons.
I am the governor of Arkansas. Let me tell you how I
expanded Medicaid.
Li, Pang
Martinez, Park
McCullough, Peshlakai
Pagud, Protzman
Raidoo, Sabharwal
Reilly, Schumacher
Saad-Jube, Yang
Sabagala
Shigesato
Smith
Su
Tome
Vegas
Notes:
• We will go over these slides the weeks after the virtual class (depending on the subject-it may be a few weeks after) so don’t forget what you learned doing this exercise!
3. Activity 3 (~10 minutes)
Send me your slides by 11/9 at midnight!
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