The Structure of Healthcare

by Tyler Cymet, DO, FACOFP

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    00:01 Health system science, yeah! We’re going to talk about the structure of healthcare.

    00:06 We’re going to talk about how things are set up so that people can get care, what kind of care they’re going to get, and who does what and how you know what somebody is going to do.

    00:16 So this is really an administrative lecture— how we put things together and what they mean, and what they’re supposed to mean because it’s getting confusing out there.

    00:28 So osteopathic medicine is a field, and a philosophy, and a technique.

    00:35 When we talk about the regulation of osteopathic medicine – the standards, the norms, the culture— we’re talking about a lot of different things.

    00:43 So why bother? Well, if you’re practicing osteopathic medicine, it means you’re an osteopathic physician or trained in osteopathic manipulative techniques.

    00:54 Typically, the government will mandate what it means.

    00:57 There’s some type of regulatory body that licenses people that tells you what you should do if you say you’re an osteopathic physician.

    01:06 If you say you’re an osteopathic physician, you’d likely trained in osteopathic medical school, or got additional training in osteopathic manipulative therapy, and understand osteopathic principles and practices.

    01:18 If you put a sign up on your store and say, “WTF— we treat feet,” people will expect you to treat feet.

    01:26 If somebody walks into WTF and someone starts pushing on their belly, WTF—that’s the feet.

    01:33 What are you doing pushing on the belly? Maybe the ankle, but once you get up to the knee, you’re not treating feet anymore.

    01:40 So WTF, if you’re saying you treat feet, you should be treating feet.

    01:46 So those are standards we put in place so that people understand what they’re getting.

    01:52 If you say you’re going to a hospital, do they take care of emergencies or do they just do certain tests? You can’t just do what you want to do.

    02:00 You have to start from where the person is in front of you, and the standards in place will say what kind of care you get and what kind of language you can use to describe that care.

    02:11 You can’t say you’re a foot specialist and then start focusing on the abdomen.

    02:15 Then, you’re no longer a foot specialist.

    02:18 And if you are trained in certain things, how much training do you need to do a colonoscopy, to do a full exam, or to do a limited exam? Those are the standards that the government puts in place through licensure and regulating bodies.

    02:35 Osteopathic medicine is a profession that has developed its own standards that set its own record of what every osteopathic physician knows and can do.

    02:45 So if you say you’re an osteopathic physician, you know to do an osteopathic musculoskeletal exam which includes the nervous system and the musculoskeletal system.

    02:54 You’re good at examining people and you’ve met a basic standard.

    02:59 You can name the muscles, you can treat the muscles, and you can assess the motion of the muscles.

    03:04 That’s basic and we try and fit it into the whole system so that even though you’re an osteopathic manipulative medicine specialist, or trained in osteopathic manipulative medicine techniques, you can continue on and specialize.

    03:22 Every DO student learns 7 different types of manual therapies.

    03:27 Seven different ways they can do manipulation to effect the musculoskeletal system.

    03:32 Yes, there are over 30 types, and in residency, you can be trained in manipulation under anesthesia.

    03:39 You can be trained in the fascial distortion method or facilitative positional release.

    03:44 Those are residency level techniques that you get some exposure to in osteopathic medical schools but not entirely.

    03:52 And what this does is, when you say you’re an osteopathic physician, there’s an expectation that you, at some point in your career, were trained and were competent in these therapies.

    04:05 It also says that when you started an osteopathic medical school, you ascribed to a philosophy that looks at structure and function and its interrelatedness.

    04:15 You look at the mind, body and spirit and treat more than just the disease in front of you.

    04:20 You treat the person you’re taking care of, and all care has to start from the person.

    04:25 The person is the one who gives you the history, they tell you the chief complaint, they tell you why they’re there, and that’s where it starts.

    04:34 The disadvantages to self-developing standards, is we tend to get very narrow.

    04:40 We tend to focus on what we’re interested in.

    04:43 We tend to focus on what we’re good at.

    04:45 We tend to focus on where we want people to be who are calling themselves osteopathic physicians, but other physicians may disagree.

    04:54 There’s some overlap and there’s arguing around the edges.

    05:00 So in healthcare, if you’re an institution, you get accredited.

    05:04 You can say we are a hospital, we are a medical school, we are a healthcare facility, and we’re a health facility that works to optimize health and teach in that way.

    05:16 The accreditation is for institutions.

    05:20 Certification is when an individual has met a standard, completed a course of study, been assessed and been evaluated.

    05:28 They can become certified.

    05:31 Those are the systems in place.

    05:34 States and federal governments license you.

    05:38 They will say whether or not you can do something in public, whether it’s safe, and they’ll dictate the edges of what healthcare is.

    05:47 So when people come to a physician, or come to a provider, they want to optimize health.

    05:53 They want to be able to do more than they were able to do before.

    05:56 They want to feel better, stronger, and healthier and that’s why they’re coming.

    06:03 What can you do has to be within the balance of the science you’re practicing under or the system you’re working within.

    06:11 So there’s a difference between what you’re licensed to do and what you’re paid to do.

    06:15 If you’re licensed, it means you’ve satisfied the basic requirements to get a license for the state to say what you’re doing makes sense and is safe.

    06:23 That doesn’t mean someone is going to pay for it.

    06:26 Those are determined by other organizations, and in the US, it’s Medicare and insurance companies.

    06:32 Medicare sets a standard for what’s covered and what will be paid for by Medicare.

    06:39 Insurance companies can modify it.

    06:41 They can add or they can take away, and they work around the edges, and they play a lot more with more of the expensive therapies or treatments.

    06:50 So cancer chemotherapy— Medicare says it’s covered— they may give you 3 or 4 options of what can be done.

    06:59 Insurance companies can limit that to one and they say, “we want this one as the most cost effective.” For back pain— do you get manipulation, do you get x-rays, do you get injections, or do you get acupuncture? All of those things are determined outside of the licensure.

    07:17 Licensure says you can do it.

    07:19 It says it is part of what you’re trained to do.

    07:21 It is part of what’s safe and it is part of what’s been studied and approved, but that doesn’t mean it’s going to get paid for, and that’s where Medicare matters and that’s where the insurance company matters.

    07:33 A monopsony is when you no longer have true competition.

    07:36 It’s when you have few basic companies that control a market, and because there’s no true competition, they can dictate what’s covered and what's not covered and how you move forward.

    07:49 To understand the structure of education and how you get able and accredited and certified to do things, your institution will be accredited.

    08:00 In college, there are 6 regional accrediting bodies mostly based on geography.

    08:05 There’s western states, northern states, and mid-Atlantic that initially accredited colleges in their geographic area.

    08:13 In today’s day and age, we’re no longer restricted by geography and you can have the northern states accredit a southern school or the western states accredit an eastern school, but their standards are consistent and there’s a lot of overlap.

    08:27 The differences were meant to be regional and to adapt to different realities in a wide open area of the west versus a more urban area of the northeast.

    08:38 That’s how colleges are accredited.

    08:41 In medical education, we have different accrediting bodies for DO schools which is the COCA, the Commission on Osteopathic College Accreditation, and the LCME, the Liaison Committee for Medical Education.

    08:54 Both of these organizations accredit medical schools.

    08:57 They say the medical schools have a curriculum that fits, they have a faculty that fits, and they have the clinical resources to matter because one of the hallmarks of medical education is that it is education that takes place outside of an educational environment.

    09:12 You’re trained where care is delivered.

    09:14 You’re trained where people are being treated because that’s where you’re going to see what’s going on.

    09:21 The assessment piece is done by the NBOME or the NBME, the National Board of Osteopathic Medical Examiners or the National Board of Medical Examiners, and they’re the people who test you either in person at clinical skills testing or via computer with online tests, and they do the assessment to say you can move on.

    09:45 In graduate medical education, there is only one organization that accredits institutions and that’s the ACGME, the Accreditation Council for Graduate Medical Education, and they’re the people who are going to make sure that when you’re in graduate medical education there is a learning community, there is a learning environment, there are people around to teach you, to oversee you, and to give you feedback, and if you don’t have the time to learn, then you shouldn’t be accredited, and that’s what the ACGME does.

    10:17 They make sure the standards are there, other people are there, the oversight is there, the protection is there, and that you are going to be safe to both practice and learn at the same time.

    10:29 This is different than the specialty colleges which tell you when you can be certified as an individual to practice a certain specialty and that gives you additional freedoms to do procedures and to take care of people with specific conditions that may need more specialized care, more followup, and more interventions.

    10:52 Internationally, there are very different systems.

    10:55 The ECFMG is the organization that’s going to put the stuff together.

    11:01 They’re going to evaluate your credentials, keep your credentials in one place, and make sure the international medical school that the person went to is accredited either by an accrediting body in their own country or an international accrediting body that has standards that are consistent and observable.

    11:21 FAIMER is part of the ECFMG that does help set the standards and develop the knowledge needed to understand what is going on in other countries.

    11:30 And this is all based on the concept that medical education should be interchangeable.

    11:35 That if you learn anatomy here, it’s going to be the same anatomy that you learn here.

    11:39 ERASMUS is the European system to make sure that things that happen in Belgium can be done in Germany, and things that occur in Bulgaria will mean the same thing it does in Greece.

    11:50 And that you can move from one country to another, and you can transfer from one school to another.

    11:55 And if you’ve conquered a field of study, if you’ve passed a certain amount of knowledge, that it’s consistent and we’re moving toward interchangeable parts and getting it to where we do have one system of knowledge that can be obtained in different ways— some online, some in person— and the assessment is what matters, but making sure that it’s interchangeable counts too.

    12:21 In America, this is seen in the establishment of an interstate compact.

    12:26 So if you’re licensed in one state, and you practice telemedicine, can you cross over the border? Can you write a prescription in Pennsylvania that will be filled in West Virginia? Right now, 22 states have signed an agreement saying that there is some reciprocity because while some states say one year of graduate medical education is enough, others say you need two, and others say it might be three.

    12:51 If you’ve done the most, and you have completed a residency and are board certified, then you’ve met the requirements to be part of the interstate compact— to have your license in West Virginia and work in Nevada or Utah, to make sure that Arizona and Montana have some reciprocity.

    13:12 This is the interstate compact that the FSMB has been advancing and the concept of getting credentialed once, of having one standard and using systems to share information and to keep those together.

    13:28 So the specialty colleges in the osteopathic world— they’re separate from the ABMS or allopathic world.

    13:35 Osteopathic specialty colleges want you to be conversant in osteopathic principles and practice; to have the philosophy of a DO; to understand the mind, body, and spirit connection; to work on structure and function interrelatedness; and to start from the individual in front of you.

    13:53 They also want you to be trained with a certain level of expertise in osteopathic manipulative therapy, to understand that 60% of the body is the musculoskeletal system, and how you treat the musculoskeletal system as both an organ system and as a biomechanical system matters.

    14:11 The ABMS specialty colleges are also ACGME certified as all osteopathic ones will be by 2020 and they have less stringent requirements in terms of philosophy and in terms of musculoskeletal medicine and the training you get.

    About the Lecture

    The lecture The Structure of Healthcare by Tyler Cymet, DO, FACOFP is from the course Osteopathic Principles and Tenets.

    Included Quiz Questions

    1. Regulation
    2. Training
    3. Standards
    4. Norms
    5. Qualification
    1. Narrow standards
    2. Recognized local weakness
    3. Progressive steps
    4. Optimized for local use
    5. Leads to recognition
    1. Individual
    2. Institution
    3. Medical school
    4. Hospital
    5. Health facility
    1. ACGME
    2. COCA
    3. LCME
    4. NBOME
    5. NBME
    1. COCA
    2. NBME
    3. NBOME
    4. ERASMUS
    5. ACGME
    1. NBOME
    2. ERASMUS
    3. ACGME
    4. COCA
    5. LCME
    1. ECFMG
    2. ERASMUS
    3. ACGME
    4. COCA
    5. NBOME

    Author of lecture The Structure of Healthcare

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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