Lecture 1: Healthcare System Trends

Question 1

What were the roles for pharmacists and physicians in the 18th century?

Answer 1

-Only a few physicians and apothecaries due to lack of education/training
-Medicines compounding done by physicians
-***physicians did pharmacy role

Question 2

How did where people live (rural vs. urban) and their level of wealth impact their
access to healthcare/health status? (trend started in 19th century)

Answer 2

-Level of wealth determined your well-being; basically if you were wealthy, better health status
-If you lived in an urban area, there were often better healthcare services. Wealthy people tended to live more in urban areas. We see that same income difference disparity today between urban and rural areas

Question 3

What were the roles for pharmacists and physicians in the 19th century?

Answer 3

-Pharmacists compounded and dispensed prescriptions in apothecaries
-wealthy people had health and pharmacists started compounding and dispensing prescriptions

Question 4

What were the roles for pharmacists and physicians in the 20th century?

Answer 4

-Early 1900s, pharmaceutical manufacturing starts, we start to see a growth in products and it reduced that pharmacist role because they didn’t have to compound everything
-APhA Code of Ethics (1952): pharmacists did not have the right to discuss the therapeutic effects or composition of prescription with a patient (pharmacist couldn’t even talk to patients about their medication)
-Millis Report (1970s): pharmacist role required more education and training; focused on pharmacy management and education
-OBRA (Omnibus Budget Reconciliation Act 1990): mandated evaluation of drug therapy and review patient profiles and established counseling patients; ensure patients were getting correct education
-Physicians: highly respected, highly paid, gatekeepers and view of patients they are an authority figure; physicians expertise is growing in expanding from primary care to specialty care; physician extenders due to physician shortage, could pharmacist have those extended roles as well?

Question 5

What was the APhA Code of Ethics (1952)?

Answer 5

pharmacists did not have the right to discuss the therapeutic effects or composition of prescription with a patient (pharmacist couldn’t even talk to patients about their medication)

Question 6

What was the Millis Report (1970s)?

Answer 6

pharmacist role required more education and training; focused on pharmacy management and education

Question 7

What was the OBRA (Omnibus Budget Reconciliation Act 1990)?

Answer 7

mandated evaluation of drug therapy and review patient profiles and established counseling patients; ensure patients were getting correct education

Question 8

Pharmacist’s education and training has evolved in response to?

Answer 8

Role evolution/expansion

Question 9

What was the intent of the Hillburton Act (1946)? (address problem then solution)

Answer 9

Problem: not enough hospitals and that leads to access problem
Solution: use federal funding to states to build hospitals and public health centers

Question 10

Describe the evolution of hospital care.

Answer 10

Shifted from charity care to patients paying for care

Question 11

Describe 8 characteristics of the U.S. Healthcare System that make it different from other
developed countries in the world.

Answer 11

1. No central agency oversight: no national programs that covers healthcare for all citizens
2. Access based on insurance coverage, only a small % pay cash
3. Third party insurers (many insurance companies)
4. Many stakeholders ***both 3 and 4 examples of how US is a complex system, makes it hard to learn
5. Providers have legal risk
6. High technology results in increased demand: advanced technologies are great but drives up cost
7. Continuum of services (continuum of care): expanding places where people get care leads to better health outcomes for patient
8. Focus on attaining quality: paying providers for outcomes, keeps their patients healthy is incentivized and physicians are reimbursed for that; paying for performance and not amount of patients you see

Question 12

What is the continuum-of-care? ***healthcare delivery

Answer 12

-Shift from fragmented care to continuum of care
-The idea of healthcare providers following patients as they receive care at different times and locations (following patients through their healthcare journey)

Question 13

What does continuum-of-care require from healthcare providers?

Answer 13

Coordination and communication (Ex/access to patient records and network of payers)

Question 14

What is the goal of continuum-of-care?

Answer 14

Goal: Better care and improved patient outcomes
Need communication and technology to make this happen

Question 15

How does National Health Expenditures (NHE) in the United States compare to other
developed countries? (*think GDP)

Answer 15

The USA spends significantly more of its GDP on healthcare than other countries

Question 16

What types of healthcare service/goods contribute most to NHE in the United States?

Answer 16

1. Hospitals
2. Other Health (Administration, net health insurance, personal care)
3. Physicians and clinics

Question 17

Describe an Integrated Healthcare Delivery System (IHDS). Are IDHSs financially
accountable for the patient care they provide? Can IDHS include pharmacists?

Answer 17

-Provide a coordinated continuum-of-services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population serviced (different than continuum of care because it has that financial part)
-Fiscally accountable: how are physicians being reimbursed?
- Yes it does include pharmacists specifically in the reimbursement system, how do we hold the pharmacist fiscally responsible?

Question 18

What are some examples of IDHS?

Answer 18

Veterans Administration (VA), Medicare program, Accountable Care Organizations (ACOs)

Question 19

What are the 5 major tends related to cost in the U.S. healthcare system?

Answer 19

1. Rising healthcare and rising prescription drug costs
2. Insurance premiums are rising faster than wages
3. People are living longer but that means they use a lot of healthcare services
4. The NHE (percentage USA spends on healthcare) has continuously been increasing
5. Drug spending: patients need specialty drugs but they are expensive increasing drug prices

Question 20

What are the 4 major tends related to access in the U.S. healthcare system?

Answer 20

1. Nonelderly american do not have health insurance or they have insurance but it doesn’t cover everything
2. Uninsured people have poorer health and are less likely to get preventive health care (not getting care=you get sicker=enter the healthcare system go to the ER=money to take care of you at the hospital
3. Uninsured people often use hospital emergency rooms for care because they don’t have a physician to go to
   -Safety net for patients
   -Most costly setting for care (reason why NHE is so high)
   -Opportunity for continuity of care is lost because they are not follow up with healthcare providers (no continuum of care)
4. Affordable Care Act (2010s): did decrease uninsured people

Question 21

What are the 6 major tends related to quality in the U.S. healthcare system?

Answer 21

1. Lack of evidence based medicine (if we are making decisions on evidence leads to higher quality health care
2. Lack of comparative effectiveness research (Drug A vs. Drug B, which is better to treat patient)
3. Lack of communication and coordination leads to medical errors
4. Quality defects-overuse, misuse, underuse
5. System doesn’t focus on prevention or wellness like how to keep people healthy; we only worry about when people are sick
6. Lower life expectancy in the USA compared to other developed countries but then we are spending the most on health

Question 22

What happens to a patient and their care if they do not have health insurance (uninsured) or not enough health insurance (underinsured) to cover their needs? (Think about the importance of health insurance and how this gives patients access to the healthcare system to
get the care they need).

Answer 22

1. Can’t see a physician
2. postpone seeking care due to cost
3. go without care due to cost
4. delayed filling or did not get need prescription due to cost