Week 1 Exam Study

Issues with the US healthcare system

1. Access

   • 33M uninsured and underinsured

   • No access to physicians, etc.

2. Affordability

   • Cost to patients and health system

   • OOPs – premiums, deductibles, copay, coinsurance, non-covered services

   • Health system - $3.8T

3. Accountability

   • Outcomes DO NOT justify the costs

   • US spends more on health care per capita than any other developed nation, yet not even in the first 20 countries in terms of health indicators

Factors that impact healthcare

PESTEL framework

1. political

2. economic

3. social

4. technological

5. environmental

6. legal

Political

1. Who is in the White House

2. Who controls the Senate

3. Who controls Congress

4. and what issues are on the political platform, all affect the health care system

Economic

When the economy is strong, people may have more access to services, jobs, and insurance.

When the economy is weak, people may delay care, skip medications, or avoid physician visits.

Social

What society accepts, values, or expects changes in over time.

Hip replacements, knee replacements, bariatric surgery, fertility care, mental health care, and other services may be more accepted.

Technological

History of US healthcare from pre-1850 to now

• From Acute infections to Chronic and behavioral issues

• From No treatment To Technological options

• From Moral focus To Root causes of diseases

• From Fee for service To Complex payment systems

• From no focus on cost To Extremely expensive

• No structure To Some with managed care

Subsystem model of health care in the US

5 subsystems

1. Middle class model

2. Poor model

3. Veterans

4. Public programs

5. Military

Middle Class Model

Regularly employed, middle income families with continuous health insurance coverage

Poor model

Poor, unemployed, or underemployed families without continuous health insurance coverage

Veterans

VA health care system

Public programs

Government public health programs

Military

Active-duty military personnel and their dependents: TRICARE

Types of Managed Care Organizations (health plans)

1. HMO (different types based on

   relationship with participating

   physicians)

2. PPO

3. POS

Characteristics of HMOs

1. Contracts with a group of physicians who take total responsibility for the care of enrollees; primary and referrals

2. Capitated reimbursement

3. Restricted choice of providers (need preauthorization)

4. Tighter and formal linkages

5. Advantages

PPOs

Providers discount services in exchange for a guaranteed pool of patients and prompt payment by the plan

Characteristics of PPOs

1. Network of providers

2. Benefits to choosing within network

3. Negotiated payment rates

4. Rapid payment terms

5. Utilization review

6. Consumer choice

Point-of-service plan (POS)

User makes purchase decision at the time medical care is sought

• Decision between HMO or indemnity for each instance of care

• Price is determined by whether user consults part/non-part provider

Hybrid of HMO and PPO

Freedom of choice to enrollee

HMO plans with POS have high cost sharing

Purpose of ACA

High rate of uninsured

Unsustainable spending

Focus on preventative care

Improve health outcomes

Address disparities in health with respect to income and demographics

5 core stakeholders

1. Healthcare consumers: patients, families, caregivers, communities.

2. Insurers and payers: private plans, Medicare, Medicaid, employers, patients paying OOP.

3. Healthcare providers: professionals and organizations delivering care.

4. Medical suppliers: pharmaceutical, device, technology, wholesalers, pharmacies.

5. Policy-makers and regulators: federal, state, local, accrediting, and licensing bodies.

Patient is central, but not all power is central

Patients and Families

1. Use healthcare services, medications, insurance benefits, and community supports.

2. Make daily decisions about symptoms, appointments, refills, adherence, diet, activity, and cost tradeoffs.

3. Bring beliefs, language, culture, health literacy, financial constraints, and prior experiences.

4. Can be empowered, but often do not control the system around them.

5. Patients are experts in their own lives

Healthcare Providers

Individuals: physicians, pharmacists, nurses, dentists, NPs, PAs, therapists, technicians, social workers.

Organizations: hospitals, clinics, pharmacies, long-term care facilities, home health agencies.

Provider behavior is shaped by training, scope of practice, time, reimbursement, quality metrics, and staffing.

Medication safety depends on interprofessional coordination.

Payers and Insurers

Examples include private insurance companies, employer-sponsored health plans, Medicare, Medicaid, and other public programs.

Decide what services and meds are covered under a plan.

Set cost-sharing: deductible, copay, coinsurance, maximum out-of-pocket.

Use networks, formularies, prior authorization, step therapy, and utilization management.

Can improve affordability for covered services but create barriers for noncovered or restricted services.

Medical Suppliers and Industry

Develop, manufacture, distribute, and support drugs, biologics, devices, diagnostics, and health technologies.

Also includes wholesalers and distributors

Influence clinical care through evidence generation, labeling, supply, education, marketing, pricing, and patient assistance.

• Depend on patent/exclusivity periods, competition, regulation, supply chains, and market access.

• Create pharmacy career pathways beyond dispensing

Policy Makers and Regulators

Their responsibilities occur at the federal, state, and local levels.

Federal agencies set national standards, program rules, approvals, and funding priorities.

States regulate professional licensure, scope of practice, Medicaid details, insurance rules, and public health operations.

Local agencies deliver public health services and respond to community needs.

Accrediting organizations influence quality, safety, documentation, and institutional credibility.

Employers: A Hidden Healthcare Stakeholder

Employer-sponsored insurance remains a major coverage pathway for nonelderly Americans.

Employers help select plans, benefits, networks, pharmacy benefits, premium sharing, and wellness programs.

Work schedules and leave policies affect whether patients can attend appointments and pick up meds.

Occupational health, workplace exposures, and income stability also shape health.

Primary Care: The System’s Front Door

First-contact, comprehensive, continuous, and coordinated care.

Handles prevention, screenings, vaccines, common acute illnesses, and chronic diseases.

Coordinates referrals to specialists and higher levels of care.

Shortages in primary care create opportunities for pharmacists, NPs, PAs, and team-based care.

California SB 493

Recognized pharmacists as healthcare providers under California law.

Expanded pharmacist authority for selected medication-related services.

Created a pathway for Advanced Practice Pharmacist recognition.

Illustrates the difference between being trained, being legally authorized, and being reimbursed.

SB 493 Authorities for All California Pharmacists

Travel meds - Furnish certain travel-related meds that do not require diagnosis

Hormonal contraceptives - Furnish self-administered hormonal contraception under protocol

Nicotine replacement - Furnish NRT for smoking cessation

Tests and vaccines - Order/interpret drug-therapy tests; administer ACIP vaccines age 3+

Travel Medicine Services

Assessment includes destination, duration, urban/rural exposure, travel purpose, activities, medical history, pregnancy, allergies, and current meds.

Pharmacist uses CDC travel guidance and state protocol requirements.

May involve prophylaxis, vaccines, traveler’s diarrhea self-treatment, medication storage, and medication legality abroad.

Requires training, documentation, counseling, and communication with the patient’s primary care provider.