This is a library of case studies written by students with faculty mentors. This site contains information about writing cases, as well as using them to promote discussion. In addition, the site includes a series of shorter clinical vignettes, which can also be used to stimulate discussion.

2011

Accountable Care Organizations  
Ali Alhassani

Most medical care in the US is paid for on a fee-for-service (FFS) basis, which can lead to a fragmented delivery system. Moreover, FFS incentivizes increased volume of services, particularly the more lucrative ones. One alternative model to the status quo is the accountable care organization (ACO). An ACO is an integrated network of providers (hospitals, physician practices, or both) which contracts with a payer (public or private) to be responsible for the full continuum of care of a defined group of patients. The ACO faces some level of financial accountability for both the cost and quality of care provided. ACOs were a major part of the 2010 Affordable Care Act and this year Medicare is rolling out a new ACO system (called the “Shared Savings Program”) across the country. Many state and private health care payers are following suit.

Constitutional Aspects of the Patient Protection and Affordable Care Act  
Karly Burke

Under the 2010 Patient Protection and Affordable Care Act, individuals must maintain a specified minimal level of health insurance coverage or face financial penalty.  Proponents of this “mandate” argue that Congress has the constitutional right to regulate health insurance markets under the Commerce Clause.  Individual coverage is necessary for the national market and does not violate individual liberties.  Opponents argue that Congress has overstepped its enumerated powers and has invaded individual liberty.  Specifically, Congress cannot regulate non-economic behavior under the guise of interstate commerce.  The U.S. Supreme Court will likely decide the constitutionality of this provision.

Factsheet: Measuring Hospital Quality and Public Reporting  
Paula Chatterjee

The Institute of Medicine defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Measuring the quality of care in hospitals has become an important concern for patients, physicians, and policymakers; however, there is little consensus in defining the most appropriate metrics, and how such metrics should be used to incentivize improvements in care at lower costs. This factsheet introduces the concept of public reporting of hospital quality metrics, and the benefits and challenges surrounding Value-Based Purchasing.

Meaningful Use: The Promise of Health Information Technology  
Shaan-Chirag Gandhi

The enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 has encouraged the rapid expansion of electronic health record (EHR) use in the United States through format standardization and direct subsidies to providers. However, the HITECH Act aims to do more than accelerate the computerization of medical recordkeeping–it aims to promote the “meaningful use” of such EHRs. In this factsheet, the deeper implications of meaningful use are explored and future health care reforms made possible by expanded EHR use are discussed.

Medical Loss Ratios  
Jeet Guram

A “medical loss ratio” (MLR) is a measure of the proportion of money that an insurer collects from premiums that is spent on medical care.  Typically, an MLR is calculated as total claims divided by total premium revenue.  Prior to passage of the Patient Protection and Affordable Care Act (PPACA), the regulation of MLRs fell to individual states.  Effective January 1, 2011, PPACA transferred jurisdiction of MLRs from the state level to the federal level and enacted new minimum MLR requirements nationwide.  The new PPACA regulations on MLRs will have widespread effects on private insurance markets.

Pay for Performance and Red Blood Cell Transfusion Appropriateness  
Daniel Kim

P4P is a concept that was originally developed in the business world to help improve efficiency and productivity. In health care, P4P refers to a payment model that offers financial incentives to physicians and hospitals for meeting pre-established clinical performance measures. The goal is to link financial incentives, in part, to the quality and efficiency of health care provided, as opposed to current payment systems that pay providers based only on the volume of services. The following case takes a glimpse into the a P4P measure at the hospital level, specifically red blood cell transfusion appropriateness.

Coordinating Care for Patients with Multiple, Poorly- Controlled Chronic Illnesses: A “Hot-Spot” for Cost-Savings, Quality Improvement, and Patient-Centered Care  
Jonathan Lee

In 2009, the United States spent nearly $2 trillion (17.9% of GDP) on total health expenditure. More money is spent on care delivered in the hospital setting than any other facet of healthcare in our country. Recent data also indicate that 5% of the U.S. civilian, non-institutionalized population account for 49% of overall health care spending. These individuals have multiple chronic illnesses, higher rates of hospitalizations and emergency room-visits, and lower incomes. Efforts to improve the care – both at the organizational and policy level – for such individuals has the potential to improve health outcomes and reduce overall spending.

Healthcare Reform and Undocumented Immigrants  
Gibran Minero

About 11 million undocumented immigrants currently live in the United States. PPACA explicitly excludes them from its provisions. By 2016, one third of the uninsured will be undocumented immigrants, and this proportion will continue to grow. Currently, illegal immigrants and their children, 70% of whom are US citizens by birth, have four times the uninsured rate of US born adults. This case examines the state of healthcare reform, demographic trends, and healthcare access and spending in relation to undocumented immigrants, and explores the effects of policies and the challenges healthcare professionals face meeting clinical needs with economic and legal constraints in caring for undocumented immigrants with life-threatening illness.

Inequalities in Health Care Access and Outcomes  
Yonina Murciano-Goroff

A large body of research has demonstrated the existence of differences in access to medical care as well as disparities in health outcomes among different patient groups.  Patients may experience numerous, interrelated barriers to quality care.  Addressing healthcare inequalities constitutes a challenge, not only at the level of policy, but also in terms of educational practice and in clinical encounters.  This case reflects on existing research, while seeking innovative modes of addressing inequalities, with emphasis on inequalities prevalent in the United States.

2010

Approaches to Rural Health Care:  The Indian Health Service  
Emily Hinchcliff

Rural communities represent nearly 20 percent of the population and are incredibly heterogeneous in their culture, population density, economic and geographic characteristics.  This case aims to illustrate the challenges faced by rural populations with respect to their health care and the problems involved in the provision of such care. This case is centered on the Indian Health Service, a federal health care system  responsible for the health care of nearly 2 million American Indian and Alaskan Natives across the United States.

Complementary and Alternative Medicine in the United States  
David Nemer

Complementary and alternative medicines (CAM) are widely used. A National Health Interview Survey in 2007 revealed that 38% of American adults and 12% of children used some type of CAM in the prior 12 months. Despite high demand, rates of insurance coverage for CAM remain low. This case discusses common perspectives of CAM within the medical community and decisions made by the insurance companies when deciding whether or not to provide reimbursement for a particular medical service.

Drug Development and Regulation: The Case of Provenge  
Akash Chandawarkar

The FDA is charged with ensuring the efficacy and safety of a drug before allowing its distribution to the American public. This case investigates the development of Provenge, immunotherapy for prostate cancer, and the challenges it faced in passing FDA approval, choosing an appropriate price and meeting demand.

End-of-Life Care and Policy  
Jay S. Reidler, Deep J. Shah

In recent years, assisting patients with advanced care planning has become an important aspect of caring for seriously ill patients. This case provides a brief overview of prominent legislation related to the end-of-life and its introduction into the clinical setting.  It also describes several topics relating to the care of patients with serious illnesses – advance directives, health care proxies, palliative care, and hospice care—and broader issues relating to end-of-life decisions, such as cost and government policy.

High Deductible Health Plans  
Reid Merryman

A deductible is an amount of money that an individual must pay out-of-pocket before a health plan begins to cover expenses. High deductible health plans (HDHPs) are fee-for-service insurance plans with higher than normal deductibles, defined by the federal government as greater than $1200 per year for a single person or more than $2400 for a family. Proponents of these plans assert that these plans will motivate individuals to use less unnecessary care and therefore lower their overall health spending. This case explores this relatively new addition to the health insurance market.

Massachusetts Health Reform  
David Mou, Aartik Sarma

As national health reform took center stage in the Obama administration in 2008, policymakers turned the spotlight onto Massachusetts, where a model that virtually achieved universal coverage had been pioneered two years earlier. The path that Massachusetts took resulted in near-universal coverage of its citizens. This case outlines the strengths and weaknesses of the MA health care system and its influence on the reform debate.

Mental Health Parity: The Case of Diego Garcia  
Rifaquat Rahman

Approximately one in four adults in the United States experience a mental health disorder in a given year, and mental illness costs society over 100 billion dollars in lost productivity per year, yet mental services have historically struggled to achieve insurance coverage on par with general medical and surgical care.  This case explores access to mental health care among lower-income people, and changing policies on coverage.

National Health Reform: The Patient Protection and Affordable Care Act of 2010  
Michael Honigberg

The Patient Protection and Affordable Care Act (PPACA) of March 2010 represents the most significant government overhaul of the U.S. healthcare system since the passage of Medicare in 1965. It includes a wide range of provisions, including expanded insurance coverage, regulation of the private insurance market, and longer-term changes to care delivery aimed at improving quality of care and containing the nation’s high and growing healthcare costs. This case examines the effects of the legislation on decisions made by individuals and their families while pursuing insurance coverage.

Paying Physicians  
Vinod Nambudiri

The challenge of establishing systems of physician compensation has been recognized since the earliest days of formalized medical practice. While a basic fee-for-service approach can still be found in American health care, it is supplemented by several alternative models. Of the many models in place today, four common approaches that together cover the majority of compensation practices for base compensation are fee for service, episode of illness/diagnosis-related group, capitation, and salary.

Preventive Health and the HPV Vaccine  
Amanda K Johnson

The HPV vaccine, which showed greater than 90% efficacy in preventing the development of certain kinds of cervical cancer, was approved by the FDA in 2006. Both Australia and the UK made vaccination compulsory and administered the vaccinations through schools. This case explores the variation in US guidelines on vaccination and screening for cervical cancer.

Value Based Insurance Design (VBID) Case Study: VBID Adoption at the University of Michigan  
Sariah Khormaee, Rena Xu

Value Based Insurance Design (VBID) represents a strategy of using attractive pricing to steer patients towards better health and, in the long term, lower overall health care costs. It focuses on pricing as a mechanism to encourage patients to use medicines beneficial to their health instead of solely attempting to dissuade them from using expensive medications.  This case follows the University of Michigan’s efforts to introduce VBID to its employees.

2009

Conflicts of Interest and Patient-Physician Trust 
Zirui Song

In a 1993 article published in the New England Journal of Medicine, author Dennis Thompson states that a conflict of interest exists under circumstances in which the professional judgment concerning a primary interest is influenced by a secondary interest. The primary interest may be the patient’s health or the validity of research, while the secondary interest could take such forms as financial gain through industry relationships or equity holdings, the desirability of positive research findings, and offers of gifts or vacations. This case examines conflicts of interest as they relate to medical research and patient care.

Health-Information Technology and the Use of Computerized Records in Medicine  
Katrina Abuabara, Julia Adler-Milstein

Lucy Sawyer is a 65-year-old diabetic with a history of hypertension. She is joining a new primary care practice, and her physician has taught her to navigate through the patient portal feature of the hospital’s recently implemented electronic medical system. Ms. Sawyer uses the portal to view lab results, learn about her medical problems, schedule appointments, refill prescriptions, follow postprocedure protocols, communicate with her physician, and track her blood-sugar fluctuations. Her use of the patient portal saves the physician time when taking a patient history, ordering prescriptions, and answering questions. Nevertheless, the electronic system is not without hitches. Ms. Sawyer’s CT results from an emergency room visit (which indicate an abdominal aortic aneurism) were not rapidly transferred to her new hospital, and she becomes concerned that some sensitive information in her health record might be available to health care professionals other than her PCP.

Post-Approval Medication Surveillance: The Case of Antidepressants in Children  
Lauren Gold

This case follows a 15-year-old girl whose parents notice several behavioral changes in their daughter, including sulking, secretiveness, lower grades, and loss of interest in her sport. Her pediatrician diagnoses depression and prescribes an antidepressant, Paxil. Who should decide that medication is warranted for this girl? Are antidepressants appropriate and safe for children and adolescents? This case discussions a number of issues related to this question and provides background information on antidepressant medications and their approval process through the Food and Drug Administration.

The Transformation of the Veterans Health Administration: The Case of Dr. Sarah Biel  
Robert Michael Daly

This case focuses on the efforts undertaken by the Veterans Health Administration (VHA) to transform itself from a ridiculed health care network of last resort to a model health care system praised for the quality of care provided to its patients. The case tells the story of Dr. Sarah Biel, a fictional VA psychiatrist and administrator, who is charged with the turnaround of a poorly performing VA institution. In her quest to improve the performance of Islesford VA Hospital, Biel and her team of providers embrace many of the key initiatives that helped transform the VHA and enabled it to shake off its reputation for poor-quality care and earn the respect of veterans, providers, politicians, and academics. Specifically, the case examines the VHA strategies of information technology, internal reporting and root cause analysis, and accountability.

2008

Consumerism in Health Care  
Lindsay Cole

Involving the patient as a consumer of health care represents one strategy to control rising health care costs. This case follows a patient diagnosed with breast cancer as she navigates her way through the health care system as a “consumer” of health. The first and second vignettes focus on the best known example of consumer-oriented health care: consumer-directed health plans (CDHPs), which are characterized by high deductibles and health savings accounts (HSAs). These accounts are funded through employer and employee contributions and can help cover the deductible costs. Plans do not typically include copayment requirements, but may require coinsurance for out-of-network providers.

Medical Malpractice: The Case of Julie Freeman  
Matthew Rivara

Julie Freeman, MD, is a 32-year-old pediatrician who develops acute lower abdominal pain one afternoon while at work. After the pain intensifies, she presents to the local emergency room, where she is found to have evidence of ovarian torsion by pelvic ultrasound. Through lack of clear communication among providers, poor trainee supervision, and conflict between the OB/GYN team and ED physicians, Julia’s diagnosis is delayed dramatically, which ultimately leads to loss of her left ovary. Frustrated and angry over the quality of care she received, Julia considers filing a malpractice claim.

2005

Disparities in Access to Renal Care and Transplantation  
Risha Irby

This case discusses the difficulties in properly caring for patients with diabetes and renal problems.

2004

A Recipe for Trouble? Navigating the Private Health Insurance Market  
Cindy Lin

This case discusses the complexity of the private health insurance market.

A Smoking Lung: A Story of Medicare and the Elderly  
Cindy Lin

This case chronicles the difficult decisions that must be made when payment for essential health services must come into question.

Ms. Pierre’s Story: Challenges Accessing Health Care and Adhering to Treatment Regimens Among HIV-Positive Individuals  
Mitul Kadakia

This case deals with access and HIV issues.

Quality of Care in Special Populations: The Disabled  
J Travis Hinson, Dorothy Weiss

This case discusses the difficulties in providing care to disabled populations.

The ABC’s of Managed Care: HMO, PPO, POS, and Everything in Between  
Cindy Lin

This case explores health insurance options for people leave employer-based insurance. In doing so, it introduces common types of insurance plans or products — preferred provider organizations (PPOs), health maintenance organizations (HMOs), and point of service plans (POS), and traditional indemnity insurance.

Understanding Surgical Errors: Sarah Gomez’s Misplaced Heart  
Conor Kleweno

This fictional case is based on certain events surrounding the tragic death of Jesica Santillan at Duke University Medical Center.

2003

Confronting Mistakes in Ambulatory Care: The Case of Phillip Jackson  
Sachin H Jain, Kiran Kakarala

A case that examines the mistakes that occur in the care of chronic blindness.

Resident Work Hours: The Case of Dr. Jorge Alvarez and Paul Nelson  
Ryan Gerry, Kiran Kakarala

This case discusses the arguments for and against reduced resident work hours.