(2) US Health Care Delivery- Hospitals, Ambulatory Care, and Community Pharmacy

Early hospitals were mainly for:

• Poor patients (almshouses)

• Isolation (pesthouses)

Big changes that made hospitals “modern”:

• Germ theory → cleaner surgery + safer techniques

• New tech (anesthesia, X-rays)

• Flexner Report (1910) → changed medical education → hospitals became training sites

More health insurance →

hospitals became financially stable

more people used hospitals

Early insurance mostly covered…

 hospital stays → even routine testing happened as hospital admissions

Hill-Burton Act (1946)

•  helped expand hospitals/infrastructure

• Federal funding for hospital construction

• Expanded rural access

What type of shift happened with diseases shifts?

• With vaccines/antibiotics/public health:

  • hospitals shifted from acute infections → more chronic diseases

• Hospitals became hubs for innovation + advanced diagnostics

how did hospitals got paid before?

hospitals often got paid fee-for-service (paid for each item/service)

What major Medicare Part A switched happened?

in 1983, switched to DRGs (Diagnosis-Related Groups)

How did DRGs work?

• Hospital gets a flat payment for a diagnosis

• If hospital spends less → hospital keeps extra

• If hospital spends more → hospital eats the loss

DRGs results

• Hospitals pushed to be more efficient

• Shorter length of stay

• Services got unbundled (moved to before admission or after discharge)

• Inpatients became sicker/more acute overall

Private insurers also added…

cost-control tools:

• pre-approvals → care must be approved before it’s covered

• gatekeepers → primary provider controls referrals

• capitation (prepayment) → providers are paid in advance per patient

Hospitals reorganized:

• Horizontal integration = hospitals join/affiliate with hospitals

• Vertical integration = hospital links with other care sites (rehab, home health, outpatient, LTC)

 

Hospital classifications

Length of stay:

• Acute care < 30 days

• Long-term care > 30 days

Hospital classifications

Type:

• General

• Specialty (cancer, psych, VA, children’s)

Hospital classifications

Ownership:

• Public (gov)

• Private (nonprofit or for-profit)

Hospital classifications

Teaching status:

• Teaching = affiliated with a medical school

Hospital classifications

Size / access:

• Critical access hospitals usually < 25 beds (rural)

Hospital power structure (who runs what)

• Board: mission + big-picture oversight

• Administration: daily operations (nursing, pharmacy, lab, etc.)

• Medical staff: physicians often self-governing (may not “report to” admin the same way)

Pharmacist roles in the hospital (know the categories)

1. Distributive (meds moving safely)

2. Non-distributive (clinical + system work)

Pharmacist roles in the hospital (know the categories)

Distributive (meds moving safely)

• Verify orders

• Check IVs

• Manage Pyxis/Omnicell

• Inventory control

Pharmacist roles in the hospital (know the categories)

Non-distributive (clinical + system work)

(Just know the bold terms)

• Drug monitoring

• Pharmacokinetics

• Adverse event monitoring

• Patient counseling at discharge

• Committee work

Ambulatory care =

• = care for someone who is:

  • not bedridden

  • not admitted to a hospital or LTC facility

Ambulatory care

Examples:

• Clinic

• Urgent care

• ED

• Surgery center

• Infusion center

ED case types

• Emergent = immediate

• Urgent = within hours

• Non-urgent = minor problems (often could be handled elsewhere)

 

Community health centers serve…

underserved/high-poverty areas

Community health centers must provide…

 services including pharmacy

340B PROGRAM

Federal drug discount program.

340B PROGRAM

Purpose:

• Reduce drug costs for safety net providers

• Savings used to:

  • Expand services

  • Serve more patients

Community pharmacy is what type of sector?

is a large employment sector

Community pharmacy is a large employment sector, but:

• growth is shifting toward hospital + ambulatory/outpatient roles

• chain pharmacies face closures (retail competition + reimbursement pressure)