Lecture 1-3 Flashcards
Ecological Model
- framework to illustrate multi-level context of our environment and how factors at various levels can influence one another
- integration across all levels provides you with how healthcare is delivered in the US
Societal
health, economic, and educational policies and political systems as well as the culture and national norms
Community
workplace, neighborhoods, health agencies, where relationships occur
Relationships
social network of family, peers, religious groups that influence behavior
Individual
biological and personal history factors of the person
How does the Ecological Model effect health care?
- individuals are recipients of health care
- Social networks in relationship level can affect how individuals seek health care
- Neighborhoods can influence what type of health care is available
- Societal can dictate public health
Paradoxes in Health Care in the U.S
THE UNITED STATES HAS HIGHEST HEALTH CARE STANDARDS, BEST, MOST ADVANCED TECHNOLOGY AVAILABLE, AND HIGHEST EXPENDITURE PER CAPITA. Ex: Professional and facility licensures and certifications.
2.IN CONTRAST, THE UNITED STATES HAS FRAGMENTED SYSTEM OF CARE, HIGHEST RATE OF MEDICAL ERRORS, AND INEQUITY IN ACCESS TO CARE. Ex:
Fragmented system of care (paradox)
- how health services are financed, organized and delivered
- underperforms on access, safety, coordination, efficacy and equity
Highest rate of medical errors (Paradox)
- 44,000-98,000 deaths per year
- serious medications errors in 5-10% of hospital patients
- 1 of 25 patients in acute inpatient care has a health associated infection
Inequity in access to care (paradox)
- 46.3 million Americans without health insurance (pre-PPACA, 2007)
- PPACA helped substantially with increased access overall and partially thru expansion of medicaid eligibility
- Nearly 25m americans have policies that do not cover important aspects such as prescription costs
- Worse health outcomes and disparities
- lack of access to health care in rural areas
Practitioners in the 19th century
- Allopathic physicians and sectarian(no formal training) practitioners usually required payment at the time a service was provided (fee-for-service)
- many americans in the lower class first treated illness using home remedies or low coast alternative concoctions to avoid fee-for-service
- services in physicians offices, drugstores and “cure establishments” were mainly sought by middle and upper class
Pure Food and Drug Act of 1906
- addressed accurate labeling
- Forbade the manufacture or sale of mislabeled or adulterated food or drugs, it gave the government broad powers to ensure the safety and efficacy of drugs in order to abolish the “patent” drug trade
National Hospital Survey and Construction Act of 1946
Hill-Burton Act - funded construction of new hospitals and public health centers
- ensure that hospitals were an important element in delivering health care
- medicase and medicaid emerged from governments pursuit for service programs
Medical Education in the United States and Canada (1910)
Flexnor Report (1910)
- changed standards for medical education
- higher accreditation for medical schools and higher admission standards for medical students
- admitted fewer students from lower classes, ethnic minorities, and women
- standardized 4-year curriculum (2 didactic, 2 clinical)
- abandoned apprenticeship model
Post WWII “biomedical model”
1945+
predominated-emphasis placed on the subcellular and molecular level of life processes
1970s
new emphasis on social inequalities as more women and minorities were admitted into medical schools
1980s and 1990s
response to managed care and new concerns about physician autonomy and quality of patient care
(21st century) Patient-centered medical home (PCMH) model
- primary care is a way in which policy has supported expansion of primary care
- patients were seen as whole persons not disease states
1860-1870s
physical sciences and laboratory instructions basis of curriculum
1900s
Expansion of schools and drugstores
- apprenticeship no longer adequate
- More than 50 colleges and departments of pharmacy
1915
Challenges in pharmacy professionalization: Flexner considered pharmacy a part of the medical profession, not individual profession on its own
1922
American Pharmacists Association Code of Ethics
- “the service it can render to the public in safeguarding the handling, sale, compounding and dispensing of medicinal substances”
- Compatible with Flexner’s view
1975: Pharmacist for the Future
- called for 6 year program to educate rather than train pharmacists
- pharmacists assume responsibility for drug-related needs and held accountable
1990 Omnibus Budget Reconciliation Act (OBRA)
- mandated evaluation of drug therapy in review of patient profiles
- established standards for medication counseling
Third party payers and managed care
limited pharmacists ability to practice pharmaceutical care in health care settings
Pharmaceutical Code of Ethics (1994)
- covenantal relationship between the patient and pharmacist
- promotes caring, compassionate and confidential services to the community, individual and societal needs
- Pursuit of justice in distribution of health resources
Medicare Modernization Act of 2003 and 2006 Medicare Part D
Medication therapy management in institutional and community settings
2010 Patient Protection and Affordable Care Act
Expanded role for pharmacists in medical home models of care
Pharmacy leaders in Patient-Centered Primary Care Collaboration
- Task force report Patient-Centered Medical Home (PCMH)
- integrating comprehensive medication management to optimize patient outcomes
Changes in Health and Sickness patterns
shift in leading causes of death from acute diseases ( influenza, pneumonia, TB) to chronic diseases (heart, cancer and stroke)
3 key factors cited explaining rise in life expectancy
- Improved standard of living including better hygiene, diet and housing
- Advances in public health
- Progress in medical practice, including therapeutic interventions . Ex: antibiotics have a 56.4 decrease in total number of deaths
Increased role of government legislation
- Pure Food and Drug Act (1906)
- Food, Drug and Cosmetic Act (1938)
Increased role of government funding
- Hill-Burton Act (1946)
- Institution of Medicare and Medicaid (1965)
Emergence of third-party payment system in 1929
Baylor Univ. Hospital enrolled school teachers in plan to cover hospital costs
Emergence of third-party payment system in 1938
Kaiser Permanente Medical Care Program to provide healthcare for workers on Grand Coulee Dam. Garfield modernizes the hospital to offer a prepaid health plan, group medicine and integrated services to the workers families
Emergence of third-party payment system in 1939
Blue Cross for hospitals and Blue Shield for physician fees
- health insurance in the US that is provided to more than 106m people
1973 Health Maintenance Organization Act
Mandated all employers with more than 25 employees to offer an HMO option as an offered health plan
- HMO has its own network of doctors and hospitals and gives you access to those certain doctors and hospitals for a monthly or annual fee
- growth of managed care
1996 Health Insurance Portability and Accountability Act (HIPAA)
- Addresses health care fraud and abuse
- set standards for using and disseminating health information
1997 State Children’s Health Insurance Program (SCHIP)
Re-authorized in 2007 (CHIPRA in 2009)
-SCHIP was created in 1997 to insure children in families with too much income to qualify for Medicaid and too little to afford private insurance
2003 Medicare Prescription Drug Involvement and Modernization Act (MMA)
Largest revision to Medicare
- Medicare Part D prescription drug benefit program was most important provision which was implemented in 2006
Health care reform
incremental vs comprehensive
Incremental
- employer mandates to provide health insurance (HMO act)
- expanded eligibility of medicare/medicaid (SCHIP)
- health savings account (MMA)
Comprehensive
single-payer
-health care vouchers (choice and competition)
2010 PPACA ( Patient Protection and Affordable Care Act)
- ensured more people have health insurance, reduce the cost of health care, and improve how patients get care
- expanded the role for pharmacists in medical home models of care
- mandates health insurance for most legal residents
- reduced the number of uninsured residents
- eliminated pre-existing conditions clauses
- removed financial barriers,
- invested in education and training for an expanded health workforce
- allowed young adults to be covered by parents insurance until age of 26
Medicine (1700s-1800s)
- pharmacists back then learned by being an apprentice (having no formal education)
- little to no concepts of diseases causes or processe
Primitive procedures
- blood letting, emetics: isolation and quarantine
- hospitals were “almhouses” ( house built for poor people to live in) or for quarantine. People would go there to die
- hospitals were just a place to separate the sick from the healthy
Medicine (1800s-1900s)
- medicine began to be established as a prestigious profession
- science and technology further developed as anesthesia, microbiology and antibiotics became a thing people knew about
Hospitals
early 19th century- hospitals had origins in the almshouse(poor) and quarantine (isolation)
- early 20th century physicians accepted the germ theory of disease -> hospitals: improving aseptic and surgical techniques
- hospitals grew in number from 100 to more than 5000
APhA Code of Ethics (1922)
primary objective is the service it can render to the public in “safeguarding the handling, sale, compounding and dispensing of medicinal substances
Pharmacist for the Future (1975)
- called for a 6-year program to educate rather than train pharmacists
1990
adoption of 6 yr PharmD curriculum for all new students
Medicare modernization act of 2003 and 2006 Medicare Part D
- Medication therapy management in institutional and community settings
- Pharmacist “paid” for medication review and counseling
major causes of death in 1900 compared to 2015
1900: Flu, Pneumonia, TB, digestive disease and heart disease
2015: Heart disease, cancer, lung disease and stroke
comparison in medicine and technology in 1900 to 2015
1900: No antibiotics or vaccines, TB was little understood. There were no screening tests, or medical treatments for infections or diseases. They didnt understand how lifestyle changes like diet and exercise can improve your life
2015: Most diseases are preventable though lifestyle changes. For ex: Stopping smoking can prevent lung cancer. Theres now screening for certain diseases and cancers. Diseases can also be prevented by exercise and diet
1954 Tax decision
Employer contributes for health insurance and gets a tax exempt from taxable income for employees
Purchasers
Individuals, employers and government
Insurers
Insurance companies
Providers
Hospitals, nursing homes, home care, pharmacies
Suppliers
Pharm, Medical Supply Co, computers and software vendors
US has
- the largest annual healthcare expenditure across all the countries
- mortality rate and life expectancy is also below the average in most industrialized countries
US Relative performance compared to OECD avg
US has many factors lower than OECD avg like life expectancy in both males and females, low mortality rate, high obesity, high asthma
Socialized Medicine (Beveridge Model)
- Provides health care to all citizens and is financed by the gov. through tax payments
- employs practitioners, owns facilities and administers the healthcare system
Examples of Socialized Medicine
UK, Cuba, Spain and New Zealand
Decentralized National Health Program (Bismarck Model)
- employers and employees are required to obtain private health insurance usually provided by nongovernment insurance companies
- these health insurance plans do not make a profit and must include all citizens
- facilities like hospitals and clinics are privately owned
Examples of Bismarck Model
Germany, France, Belgium, Netherlands, Japan and Switzerland
National health Insurance
Socialized health insurance model
- a single government-run insurance program that finances health care services that are provided by private payers with negotiated reimbursement
- health care delivery facilities are mostly privately owned
National health Insurance example
Canada and Taiwan
Out of pocket model
- found in the majority of the world and is common in developing countries
- no private health insurance or gov. sponsored health care system
- accompanied by shortages of healthcare facilities, low expenditures and poor health outcomes
- people that can afford health care get it and those who cant afford it stay sick and die
Out-of-Pocket example
Africa, India, China, and South America
How does funding effect health care delivery?
Public funding focuses on efficient allocation of resources
- higher proportion of public funding -> better and more equitable health outcomes
- better outcomes partially due to more equitable distribution of scarce resources
Developed Countries
High Income Economies
- Mostly industrialized capitalist democracies
- Strong health infrastructures
- Positive healthcare outcomes
Developing countries
Low-income & middle income economies
- 85% of the worlds population
- 12% of global world expenditures
Portability of benefits
Coverage even when one is not in the province
Comprehensiveness
coverage for all necessary services- physician and hospital services
Universality
Same services for all citizens of a province
Accessibility
Reasonable access to services is assured
Reasonable access to services is assured
plan is run by a nonprofit, public organization accountable to the provincial government
Structure of Canadian Health Care System
- Private insurance is allowed as supplemental coverage
- public facilities often have long wait times
- Private facilities provide better access to services and higher paid MDs
- must rely on private supplemental Rx coverage or out-of-pocket
Medicare
- covers outpatient prescription drugs for the following groups: seniors, low-income individuals, and patients with specific diseases states
German health care system
Krankenkasse “sickness funds”
- initiated to cover certain occupations and regions, but now covers all citizens
- worlds oldest national health care system
- 85% of germans covered
- 11% have private insurance
- 4% recieve free medical services
- has a copay for some health services
Self-govenance
administered by self managing organizations
Social partnership
employer and employee have a share in the system
Social solidarity
ensuring equality in health care through some members subsidizing the health care costs of others
Retail pharmacies in germany
- must be owned by a pharmacist
- each pharmacist can own up to 4 pharmacies
- three as branches of original in same or neighbor country
Three innovations of National Health Service(NHS) Act (1946)
- Universal and comprehensive service
- Financing through general taxation with little or no change at point of service
- Nationalization of the country’s hospitals
Principles of UK health care system
- True socialized medicine
- most services are provided by practitioners that work for the government
- gov. controls establishment of primary-care practices
- secondary and tertiary care is provided by hospitals
- patients must be referred by their GP and wait times can be long
National Institute for Clinical Excellence (NICE)
- evaluates efficacy and cost-effectiveness of all NHS- approved drugs
Negative Formulary
a list of drugs that the health care program wont cover. Then it determines which drugs it will provide on a subsidized basis
Principles of Cuban Health Care System
1: Healthcare is right
2. Health care is the responsibility of the state
3. Preventative and curative services are integrated
4. Everyone participates in the function of the health care system
5. Health care activities are integrated with economic and social development
The US has
elements of all 4 models of health care
- Employer based benefits-Bismarck model
- VA, military, and Native American health systems- Beveridge Model
- Elderly, disabled, indigent in Medicare/Medicaid- National Socialized health insurance model
- Uninsured- out-of-pocket
Implications for US
- The U.S relies on private systems and funding for health care
- people with the ability to pay can get best possible health care
- spends more per person on health care than any other country yet doesn’t achieve better health outcomes on average
Public health
is strongly linked to government regulations, policies, and political activity
Improving economic performance
- make patients more sensitive to health care costs and quality
- report costs, quality, and quantity (performance) of services of providers to promote competition
- design physician and hospital reimbursement with incentives to reduce costs
