PHRC 4962 / PHRM 5962
Essentials of Professional Practice II
Ethics Application Reflection
Winter Semester 2021
INSTRUCTIONS
Use materials covered as part of this course (posted in Canvas and from in-class activities) and from
elsewhere to answer the following questions. These questions are reflective inquiries; answer
accordingly. In other words, reflect.
Use the process discussed for analyzing ethical situations
Reflect on key points
ETHICS IN HEALTH CARE
Case #1
Write up the case below using the systemic approach discussed in Buerki et al., in
this specific instance, to discover the right moral decision:
You, the chief hospital pharmacist, hired a new technician about 3 months ago.
The technician was the daughter of one of your closest family friends. She
appeared very personable, competent and dependable.
After 3 months, the pharmacy’s inventory records showed a shortage of
promethazine dextromethorphan. After watching the pharmacy personnel, the
new tech was observed putting the drug into the wastebasket. When she went
home at the end of the shift, she would empty the wastebasket.
How would you handle this situation?
Provide responses for each component discussing an ethical case in arriving at
your solution.
Case #2
Write up the case below using the systemic approach discussed in Buerki et al., in
this specific instance, to discover the right moral decision:
On a busy night in your pharmacy (outpatient hospital setting), a member of
the hospital board comes in with her sick child and asks that you fill his
prescription right away.
The child has a sore throat and red eye and he appears subdued, but alert.
You have a full pharmacy with about a 90-minute wait time.
What should you do?
What if she asks for the brand-named drug (non-formulary)?
Provide responses for each component discussing an ethical case in arriving at
your solution.
Be sure to consider as many consequences as possible
2
EPP-2 Ethics Application Reflection
Winter Semester 2021 (continued)
Format
This application reflection must be posted before the stated deadline. Your reflection should be
formatted in the same matter as the questions, with the question number listed and the corresponding
answer given below it. Your answer to each question should provide evidence of a deep reflection on
the topic asked.
Grading
This assignment is the comprehensive, end-of-Module assessment for this material; it is worth 14%
of your overall course grade. Your efforts to answer these questions should reflect the significance of
the assignment.
This assignment will be graded on your reflective insight, critical thinking involved in your answers,
and relevance to the modules presented.
Reflections must be posted by the due date using 12-point, Times New Roman font, and 1.5 line
spacing.
Due Date
Your Comprehensive EOS Reflective Assessment must be posted before Monday, 01 March 2021 at
23:55. You may upload this Learning Activity earlier if you wish.
Please post this EOS Comprehensive Reflective Assessment as Microsoft Word document only
(*.doc or *.docx).
PHRC 4962 / PHRM 5962
Essentials of Professional Practice II
Healthcare Finance Application Reflection
Winter Semester 2021
INSTRUCTIONS
Use materials covered as part of this course (posted in Canvas and from in-class activities) and from
elsewhere to answer the following questions. These questions are reflective inquiries; answer
accordingly. In other words, reflect.
OUT-OF-POCKET EXPENSES
Question #1
Please answer the following questions/statements.
Explain to a patient what out-of-pocket expenses are and what is included.
What impact do these expenses have on a patient’s access to care?
What impact do these costs have on population health?
FORMULARIES
Question #2
Please answer the following questions/statements.
How would you explain a formulary exclusion to your patient?
In your experience, are formularies useful? Why or why not?
PHARMACY BENEFIT MANAGERS
Question #3
Please answer the following questions/statements.
What roles do PBMs play in healthcare financing?
What are some of the current issues surrounding PBMs?
What will be the key impacts, according to you, of the Supreme Court’s ruling in
Arkansas vs. PBMs case?
Explain your answers.
AFFORDABLE CARE ACT
Question #3
Please answer the following questions/statements.
How are circumstances in the healthcare system between 2009 and now?
How will these similarities drive healthcare reform over the next two years?
What do you suggest be done to help solve some of the health care problems we see
now?
Support your reflections with facts.
2
EPP-2 Healthcare Finance Reflection
Winter Semester 2021 (continued)
Format
This application reflection must be posted before the stated deadline. Your reflection should be
formatted in the same matter as the questions, with the question number listed and the corresponding
answer given below it. Your answer to each question should provide evidence of a deep reflection on
the topic asked.
Grading
This assignment is the comprehensive, end-of-Module assessment for this material; it is worth 14%
of your overall course grade. Your efforts to answer these questions should reflect the significance of
the assignment.
This assignment will be graded on your reflective insight, critical thinking involved in your answers,
and relevance to the modules presented.
Reflections must be posted by the due date using 12-point, Times New Roman font, and 1.5 line
spacing.
Due Date
Your Comprehensive EOS Reflective Assessment must be posted before Monday, 01 March 2021 at
23:55. You may upload this Learning Activity earlier if you wish.
Please post this EOS Comprehensive Reflective Assessment as Microsoft Word document only
(*.doc or *.docx).
12/21/2020
The US Health Care
System
Its Evolution, and the Role that
Government Plays
Graciela M. Armayor, Pharm.D., M.S., BCPS
NSU College of Pharmacy
1
Learning Strategies & Assessments
• Self Study
▪ Video Lecture
• Quiz 1
• Exam 1
2
Learning Objectives
1. Identify the purpose and components of all health care systems (HCS),
their functions, and the major players in the U.S. HCS
2. Identify unique features and problems of the US HCS.
3. Discuss the impact of key events/factors/laws on the evolution of
health care in the U.S. from colonial times to present day.
4. Compare the role of the federal, state, and local governments in the
U.S. HCS and their impact on healthcare delivery.
3
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Health
“State of complete physical, mental and
social well-being and not merely the
absence of disease or infirmity”
Source: http://www.who.int/about/definition/en
4
Determinants of Health
▪ Genetic Inheritance
▪ Physical Environment
▪ Social Environment
▪ Health Behavior
▪ Health Care
5
Health Care System
“Health systems consist of all the people
and actions whose primary purpose is to
improve, restore, or maintain health.”
Goal of HCS:
Achieve the “Best Health” for its consumers
6
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Components of HC Systems
▪ Facilities
▪ Workforce
▪ Firms Producing Health Commodities
▪ Research and Educational Institutions
▪ Financing Mechanisms
7
Structure of Health Care Systems
Oak Tree
Most Countries
Banyan Tree
United States
8
Major Players in US HCS
▪ Government: Federal, State and Local
▪ Voluntary/Professional Agencies
▪ American Heart Association (AHA)
▪ American Medical Association (AMA)
▪ American Pharmacists Association (APhA)
▪ Private Enterprises
▪ Pharmaceutical Industry
▪ Health Insurance Companies
▪ Private Professional Practice
▪ Private Medical Practice
9
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Delivery of Health Care Services
▪ Primary Care
▪ Practice of basic general medicine
▪ Secondary Care
▪ Surgical procedures & diagnostic; treatment by specialists
▪ Tertiary Care
▪ Highly specialized diagnostic, therapeutic, & rehabilitative
services
10
Unique Features of the US HCS
▪ Fragmentation of health care regulations, financing and delivery
▪ “For-profit-nature” of health care service provision
▪ Absence of universal health insurance coverage
▪ Highest expenditure per capita ($8,233/yr) and highest % of GDP
spent on health services compared to other nations.
11
Evolution of the US
Health Care System
12
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U.S. Economic Transformation
Agricultural Era
▪ Late 18th and early 19th century
Industrial Era
▪ Late 19th and early 20th century
Information Era
▪ 1956 to present
13
Health Care During Colonial Times to Early 1800s
▪ Government Response: Weak
▪ Health care delivery:
▪ Provided by family, friends, clergy
▪ Healthcare practices-European & Native American
▪ No clear distinction between medicine & pharmacy
▪ No formal training in “healing arts”
▪ 1765 First Medical School
▪ 1820 First U.S. Pharmacopeia
▪ 1821 First College of Pharmacy
14
Health Care at End of the 1800s
▪ Reimbursement:
▪ Fee for service: “cash” or “in kind”
▪ Increased acceptance of Germ Theory of Disease
▪ Transformation of hospitals:
Charitable Institutions
Showcases of
modern technology
▪ Industrial Era: Large scale manufacture of “patent medicines”
15
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Patent Medicines
addition abuse
Need for Regulation was Recognized
16
1900 – 1940: Government Involvement
• Pure Food and Drug Act (1906)
▪ Initial legislation towards food and drug safety-misbranding of drug
product
▪ Accurate labeling, did not address efficacy
safetyNO
EfficacyNO
naked yes
1906
• Food, Drug and Cosmetic Act-FDC Act (1938)
▪ Created (Present–day) FDA—placed safety of drug under government
control
▪ Premarket approval by FDA-evidence of safety
▪ No formal distinction between prescription/non-prescription drugs
l938Saf
NondistincionOTCand Prescription
17
1900 – 1940 (continued)
▪ Public Health Service (1912)
▪ Children’s Bureau (1912)
▪ Sheppard-Towner Maternity & Infancy Act (1921)
▪ National Institutes of Health (1930)
▪ Establishment of first insurance plans (1929)
18
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Transition in Health Profession’s Education
▪ Medicine: 1910 Flexner Report:
▪ Revealed deficiencies of medical training
▪ Called for Reform:
▪
▪
▪
▪
Placed medical education within Universities
Accreditation under the control of the AMA
Closing of weaker schools
Start of the “Golden Age” of medicine
Abraham Flexner
▪ Pharmacy: 1927 Charters Report (Basic Materials for a
Pharmaceutical Curriculum)
▪ Studies needs of profession/curriculum
▪ Defined pharmacy as profession
▪ 1928, 4yr BS degree adopted
Source: Flexner, Abraham. Medical Education in the United States and Canada. Boston: Merrymount Press, 1910.
19
Eras of 20th Century Health Care
▪ 1940s – 1960s: Era of Expansion
▪ 1970s – 1980s: Era of Cost Containment
▪ 1990s – Present: Era of Assessment & Accountability
20
Era of Expansion (1940-1970)
Characterized by significant growth in facilities, insurance & utilization
▪ Hospital Survey & Construction Act (Hill-Burton, 1946)
▪ 18th and 19th Amendments to the 1935 Social Security
Act establish:
▪ Medicare/Medicaid programs (1965)
▪ Increased utilization of HC goods and services—due to
available funding
21
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cannotdispendwithoutprescription
Era of Expansion (1940 – 1970)
▪ Further regulation of drug products
Amendments to FDC Act of 1938
3
▪ 1951 Durham-Humphrey Amendment
▪ Creation of “legend” drugs
▪ 1962 Drug Efficacy Amendment (Kefauver-Harris)
▪ “Proof-of-efficacy and safety”
manufactors
Hubert Humphrey
(US Vice President, legislator & pharmacist)
▪ Advertising-disclose accurate information
▪ ADR required to be reported to FDA
▪ No longer can market generics as new costly drugs under a
different brand name
▪ Human studies required informed consent
▪ 1965 Drug Abuse Control Amendments-Establish the DEA in 1968
0
22
Marketing
Prescribing
Distribution
23
Cost Containment Era (1970–1980s)
▪ 1970’s-Exponential increase in HC Expenditures
▪ New expensive medications/technologies, medical diagnosis, and specialization of
professions
▪ Health insurance coverage encouraged overuse of HC services
25 employee ormond
to have HMO
▪ Measures to Control Cost
▪ Voluntary hospital planning
▪ Wage and price freezes
▪ Development of cost-effective HC delivery systems
▪ Health Maintenance Organization (HMO) Act (1973)
▪ Changes in reimbursement for services: Implementation of Medicare DRGs (1983)
▪ Utilization review
24
8
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Era of Assessment & Accountability: 1990-Present
▪ Health care outcome data essential to determine value of medical
care interventions for individual, populations & health system
▪ Development of:
▪ Standardization of care
1990
Bestdeliverysystem
Helfeave cost Kectrising
▪ Comparative effectiveness research
▪ Evaluation of medical errors
▪ Evaluation of population outcomes & disparities
▪ Reimbursement based on outcomes
25
Mobilityand mortality
Historical Perspective of Disease
▪ Colonial Era to early 20th Century:
▪ Americans affected by acute illnesses
▪ Infectious diseases (malaria, dysentery, respiratory infections)
▪ Malnutrition
▪ Injuries
▪ End 20th & Early 21st Century
▪ Shift from acute conditions to chronic illnesses (diabetes, cardiovascular
disease, cancer, etc.)
26
Leading Cause of Death in U.S.
2018
1900
▪ Pneumonia & Influenza
▪ Cardiovascular Disease
▪ Tuberculosis
▪ Cancer
▪ Diarrhea, enteritis
00
▪ Accidents
▪ Cardiovascular Disease
▪ Chronic Lower Respiratory Disease
▪ CV Disease
▪ Stroke
▪ Accidents
▪ Cancer
▪ Senility
▪ Diphtheria
▪ Alzheimer’s disease
▪
▪
▪
▪
Diabetes
Influenza & pneumonia
Renal disease
Suicide
Center for Disease Control and Prevention. Leading Cause of Death. Death: Final Data for 2018. Available at http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm Accessed December 21, 2020.
CDC: Leading Causes of Death 1900-1998, Available at www.cdc.gov/nchs/data/dvs/lead1900_98.pdf
27
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50years to 80
years
Major Changes in 20th Century Health Care
▪ Professionalization of healthcare providers
equalsafecane to all
▪ Improvements in public health
▪ Improvement in medical knowledge/treatments
population
▪ Emergence of prepaid health services (public and private)
▪ Increased role of government in health care-regulation and funding
safety
▪ Outcome: Improved population health status
▪ Life expectancy increased almost 60%
28
The Role of Government
29
Government Authority in Health Care
example
Quarantine
• Not stated directly in the Constitution
• Claims authority-intent of the Constitution for government to
provide for well-being of the people
• Federal Authority
Regulate interstate & foreign commerce
Tax and spend
candotheduty
• State and Local Health Authority
• Police Power-to enforce laws and restrict behavior to ensure
for health, safety & welfare of people
30
10
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Responsibility of Government Branches
fallowthesame pattern
ofautoraty
• Legislative Branch - Creates laws
• To safeguard the public’s health
• Enacts the legal framework for HC delivery
• Judicial Branch - Interprets laws
• Ensures actions of other branches are in conformance
the Constitution
• Settles disputes arising under laws
• Executive Branch - Implements & enforces laws
• Administrative arm of government
• Delivers health care services
• Drafts and enforces provider/payer regulations
• Administers financing programs
31
Government’s Functional Role in the HCS
Federal, State, Local
▪ Financer
▪ Provider
▪ Regulator
32
morefinance
Federal Government as Financer
The Federal Government is the largest purchaser of health
care services
▪ Funds HC Services Directly for
▪ Veterans, Military personnel & dependents
directly
pay
▪ Elderly/Disabled & Poor (Medicare & Medicaid)
▪ As an employer (Government Agencies & Departments)
EachEstoystablisheach founding
stayneeds
each
for
▪ Indirectly
▪ Grants and contracts to private & government agencies
33
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12/21/2020
State & Local Government as Financer
▪ State Government
▪ Co-fund/administer Medicaid
▪ Fund/administer health care programs for those not
qualifying for federal aid
▪ As an employer (Government Agencies & Departments)
▪ Local Government
▪ Fund—city/county hospitals and clinics; emergency care
services
34
Federal Government as Provider
▪ Department of Defense: Armed forces active-duty, dependents
& survivors, retired personnel
▪ Department of Veteran’s Affairs-Veteran’s Health
Administration: US Veterans
Thelarger
▪ Indian Health Services: American Indians and Alaska Natives
▪ Prisons: Federal inmates
35
State & Local Government as Provider
▪ State
▪ Hospitals for the Mentally Ill & Developmentally Disabled
▪ Public and population health services
▪ Local
▪ County and City Hospitals, Health Care Clinics
▪ Public Health Services: vaccination programs, well child
care, health promotion campaigns, & public health
education
▪ Prisons
aliens
36
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12/21/2020
Federal Government as Regulator
• Develops and implements laws/regulations to ensure the
welfare of population throughout HCS-FDA, CMS, CDC, EPA
• Maintains surveillance by evaluating performance & ensuring
accountability of federal programs
• Oversight & Advisory Bodies
• Congressional Committees
• Government Accountability Office
• Office of Inspector General
• National Academy of Sciences
37
TheBoard
State & Local Government as Regulator
hed
havetheknow
makesureyou
• State Government
• Healthcare professional regulation & licensing
• Healthcare facility licensing
• Health Insurance Industry regulation
• Local Government
• Enforce local health codes: sanitation, food safety,
and water quality
• Collect data on frequency, trends and pattern of
diseases
38
Evolution of the Government Regulation of HC
• 1700-1800s -prevent epidemics, meet needs of poor
• 20th - 21st Century-regulation and funding
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Pure Food and Drug Act (1906)
Public Health Service (1912)
Children’s Bureau established (1912)
Sheppard-Towner Maternity & Infancy Act (1921)
National Institutes of Health (1930)
Food, Drug and Cosmetic Act (1938)
Hospital Survey & Construction Act (Hill-Burton, 1946)
Center for Disease Control and Prevention (1946)
Durham-Humphrey amendment to Food Drug, and Cosmetic Act (1951)
Kefauver-Harris Amendment to Food, Drug and Cosmetic Act (1962)
Medicare/Medicaid programs (1965)
Health Maintenance Organization (HMO) Act (1973)
Implementation of Medicare DRGs (1983)
Health Insurance Portability and Accountability Act (1996)
State Children’s Health Insurance Program (SCHIP) (1997)
Medicare Prescription Drug, Improvement, and Modernization Act (2003)
Patient Protection & Affordable Care Act (2010)
actives
before
39
13
12/21/2020
and
services
funds
administrant care
Deliveryregulated
Herald
Federal Departments/Agencies Involved in HC
11divitions
• Department of Health and Human Services (DHHS)
• Department of Veteran’s Affairs
• Department of Defense
• Department of Agriculture
• Environmental Protection Agency (EPA)
• Department of LaborOSHA
• Department of Justicecontrolstances
su
40
Majorfundionfeach
Department of Health & Human Services
• Centers for Medicare & Medicaid Services (CMS)
• Health Resources & Service Administration (HRSA)
• Indian Health Service (IHS)
• Food & Drug Administration (FDA)
• National Institutes of Health (NIH)
• Centers for Disease Control & Prevention (CDC)
• Agency for Health Care Research & Quality (AHRQ)
41
Paradoxes of the US Health Care System
While the US HCS
▪ Spends the most money on HC per capita
▪ Has the most advanced technology available
▪ Has the highest health care standards
▪ Professional, facility licensures & certifications
▪ Drug and medical device testing
problemsstillsexictseventhat we
of money
spend a lot
It has
▪ Uneven distribution of access to HC services
▪ Socioeconomic and racial disparities in outcomes
▪ High rates of medical errors (44-98K deaths/yr)
▪ Inefficient delivery and administration of services
42
pot
of
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12/21/2020
US Health Care System Problems Are…
▪ Not caused by:
▪ Technical or scientific inability to deal with disease
▪ Lack of money
▪ Caused by:
▪ Misuse and misallocation of resources
allications
43
Aims for 21st-Century HCS
base in scitificKnoLoge
Institute of Medicine (2001) Committee on Quality of Health Care in America:
Crossing the Quality Chasm: A New Health Care System for the 21st Century
Safe
Effective
Patient-Centered
Timely
patients
wantswant
no s
Efficient
Equitable
44
Go
Quality
ruseethicy
References
▪ Centers for Medicare and Medicaid. The CMS Chart Series: U.S. Health Care Overview.
Available at:
http://www.cms.hhs.gov/TheChartSeries/03_Health_Care_Facts_Figures.asp#TopOf
Page Accessed July 19, 2007.
▪ Cowan C, Catlin A, Smith C, Sensenig A. National Health Expenditures, 2002. Health
Care Financing Review 2004;25:143-166.
▪ Jonas S, Goldsteen RL, Goldsteen K eds. An Introduction to the U.S. Health Care
System, 6th Edition. New York, NY: Springer Publishing Company; 2007.
▪ McCarthy RL, Schafermeyer KW, Plake KS eds. Introduction to Health Care Delivery: A
primer for pharmacists, 5th Edition. Sandsbury, MA: Jones & Bartlett Publishers Inc.;
2011.
▪ Sonnedecker G, ed. Kremers and Urdang’s History of Pharmacy, 4th Edition. Lippincott
Company. 1976.
45
15
KominiutesVideo
12/21/2020
International Health Care
Systems
GRACIELA M. ARMAYOR, PHARM.D., M.S., BCPS
NSU COLLEGE OF PHARMACY
1
Learning Strategies & Assessments
• Self Study
▪ Video Lecture
• Quiz
• Exam
2
Learning Objectives
▪ Identify the sources of health care funding in the health care systems.
▪ Describe the characteristics of the major heath care system models used
throughout the world and how they compare to US health care delivery.
3
1
12/21/2020
Health Care Funding
▪ Private
▪ Out-of-pocket
▪ Private Insurance
▪ Public-Government
4
3wayy
Private
Private Funding
coparment
deducible
or
Citation: Paying for Health Care, Bodenheimer T, Grumbach K. Understanding Health Policy: A Clinical Approach, 7e; 2016. Available at: https://accesspharmacy.mhmedical.com/Content.aspx?bookId=1790§ionId=121191199 Accessed:
October 13, 2018 Copyright © 2018 McGraw-Hill Education. All rights reserved
5
Public Funding
Citation: Paying for Health Care, Bodenheimer T, Grumbach K. Understanding Health Policy: A Clinical Approach, 7e; 2016. Available at: https://accesspharmacy.mhmedical.com/Content.aspx?bookId=1790§ionId=121191199
Accessed: October 13, 2018 Copyright © 2018 McGraw-Hill Education. All rights reserved
6
2
12/21/2020
Health Care Models
▪ Beveridge
I
2
▪ Bismarck
▪ National Health Insurance
3 ▪ Out-of-Pocket
4
7
Beveridge Model
Named after the British social reformer William Beveridge
AKA - Socialized Medicine Model
Health care is provided and financed by the government through tax payments
Medical treatment is a public service; there are no medical bills
Government:
▪ Employs healthcare practitioners
▪ Owns healthcare facilities
▪ Administers the healthcare system
▪ Low costs per capita-government is sole payer and controls what doctors can do
and charge
▪ Countries: Great Britain, Spain, most of Scandinavia, New Zealand and Cuba
▪
▪
▪
▪
▪
8
Bismarck Model
▪ Named for the Prussian Chancellor Otto von Bismarck
▪ AKA – All Payer Model or Social Insurance Model
Privatewithgovernut
Morefreedom
▪ Uses private insurance plans “Sickness funds” — financed jointly by
employers and employees through payroll deduction
▪ Health insurance plans cover everyone; don’t make a profit
▪ Healthcare providers, hospitals, and payers are private
▪ Government tightly regulates medical services and fees-cost
control
▪ Countries: Germany, France, Belgium, the Netherlands, Japan,
Switzerland, and some Latin American countries.
9
3
12/21/2020
National Health Insurance Model
▪ AKA – Single Payer Model
▪ Payment comes from a government-run insurance program that
every citizen pays into.
morestriper varato mas
effort
▪ Services are provided by private-sector providers
▪ Cheaper and simpler to administer
▪ Control cost by:
▪ Having market power to negotiate lower prices for goods and services
▪ Limiting medical services paid for
▪ Making patient wait for treatment
▪ Countries: Canada, Taiwan, and South Korea
10
Out-of-Pocket Model
▪ AKA – Pay-to-Play or Market-driven Model
▪ System used by most countries
▪ Individuals pay out-of-pocket for health care services
mostcountryuse
it
sorganide
Notgood
▪ No private health insurance or government plans
▪ Services are provided by private-sector providers
▪ Only the rich get medical care; poor stay sick or get minimal care from
public, humanitarian institutions or local healers
▪ Countries: Rural regions of Africa, India, China and South America
11
United State Model
Mixall 4
▪ AKA – Patchwork Model
▪ Mix of private (individual or employer insurance) and public funding Government (Medicare, Medicaid, VHA, IHS)
▪ Most services provided by private-sector providers
▪ Separate systems for different populations
▪
▪
▪
▪
Elderly and Disabled- Medicare - like Canada - National Health Insurance model
Veterans, Military and Native Americans – like England - Beveridge model
Working Americans – like Germany - Bismarck model
Uninsured/Underinsured – like India - Out-of-Pocket model
▪ Cost – difficult to control due to multiple systems and for-profit nature of system
12
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12/21/2020
How Does the US Health Care
System Compare?
Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care.
13
Health Care Spending as a Percentage of GDP, 1980–2014
Percent
United States
GDP refers to gross domestic product. Data in legend are for 2014.
Source: OECD Health Data 2016. Data are for current spending only, and exclude spending on capital formation of health care providers.
E. C. Schneider, D. O. Sarnak, D. Squires, A. Shah, and M. M. Doty, Mirror, Mirror: How the U.S. Health Care System Compares Internationally at a Time of Radical Change, The
Commonwealth Fund, July 2017.
14
5domains
USDoeswell in
Health Care System Performance Rankings
AUS
CAN
FRA
GER
NETH
NZ
NOR
SWE
SWIZ
2
9
10
8
3
4
4
6
6
Care Process
2
6
9
8
4
3
10
11
Access
4
10
9
2
1
7
5
Administrative Efficiency
1
6
11
6
9
2
4
Equity
7
9
10
6
2
8
Health Care Outcomes
1
9
5
8
6
7
OVERALL RANKING
i
3
0
Source: Commonwealth Fund analysis.
0
UK
US
1
11
7
1
5
6
8
3
11
5
8
3
10
5
3
4
1
11
3
2
4
10
11
prevent'in
flu
engaich
couseling mamogrands
shoot
safety patient
Interactive Data
E. C. Schneider, D. O. Sarnak, D. Squires, A. Shah, and M. M. Doty, Mirror, Mirror: How the U.S. Health Care System Compares Internationally at a Time of Radical Change, The
Commonwealth Fund, July 2017.
15
Because
have
dont
or
insurance because
nonpaying
nonevent
pence
orprescription
so
was
5
1/13/2021
OBJECTIVES
1. Contrast health promotion, disease prevention, and advocacy
2. Evaluate the level, scope, and benefit of prevention strategies
3. Identify the salient features of health education, disease
prevention, and advocacy strategy
Public Health Strategies:
Health Promotion and
Disease Prevention
1
4. Identify the role of pharmacists in health promotion, disease
prevention, and advocacy
Georgina Silva-Suárez, PhD
PHRC 4962
Essentials of Professional Practice II
Winter 2021
2
HEALTH PROMOTION
Is defined as actions affecting one or more determinants of
health
Goal is to enable people to maintain or improve their
physical, mental, or social well-being
HEALTH PROMOTION
(Carter & Slack, 2010, p.162)
3
4
1
1/13/2021
HEALTH PROMOTION WITHIN AN ECOLOGICAL
FRAMEWORK
STRATEGIES FOR HEALTH PROMOTION
Positive interactions with
the external environment
improve health and wellbeing
1. Education: provide information that encourages healthy behaviors
and discourages unhealthy behaviors
Negative interactions with
the external environment
result in illness or disease
3. Combination of the two strategies: provide education and modify
the environment
2. Modifying the external environment to encourage interactions that
promote well-being rather than interactions that promote disease
(Carter & Slack, 2010)
5
(Carter & Slack, 2010)
6
COMPONENTS OF HEALTH EDUCATION
DEFINITION OF HEALTH EDUCATION
Awareness: knowledge that a health issue exists
Any activity intended to produce changes in knowledge or ways
of thinking that facilitates skill acquisition or behavior change
related to health
How-to knowledge: the skill to use the knowledge to promote
health
Knowledge of principles: why the action promotes health;
without knowledge of why, health promotion knowledge may be
misused
Most health promotion activities involve at least some education
Education may be aimed at community members or policymakers
(Carter & Slack, 2010)
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ROLE OF COMMUNITY PHARMACIST IN HEALTH
PROMOTION
Intended to maintain or improve wellbeing
Directed to everyone in a population
group
Expected to benefit everyone
regardless of current health status
HEALTH
PROMOTION
INTERVENTIONS
Community pharmacy is an ideal location for health
promotion activities
Pharmacists are trusted health care professionals
Most accessible health care professionals
Are based on the determinants of
health
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Respected position among the public
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ROLE OF COMMUNITY PHARMACIST IN HEALTH
PROMOTION
TAKE AWAY MESSAGES
Health promotion involves actions addressing one or more determinants of health
Ability to customize interventions to meet needs of
residents
Goal is to improve well-being
Address cultural issues in educational materials
Education is a critical component of health promotion
Adapt educational level of materials
Health promotion interventions consist of goals and rationale, the target
population, the intervention and outcomes/evaluation
Patient education skills
Role of pharmacist in health promotion
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Health promotion vs. Disease prevention
Health Promotion programs
Disease prevention programs
Are used to minimize the risk
of disease, injury and
premature death
Disease prevention
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Relationship between Continuum and
Health Promotion & Disease Prevention
Health-to-Death Continuum
Health Promotion – optimize overall health. LEFT side
Think about various levels of healthiness, sickness, and death
Disease Prevention – reduce occurrence and impact of specific diseases.
RIGHT side
Activities to reduce disease and increase health by where they are initiated on the
continuum
Figure 9.1
Figure 9.2
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Three Levels of Prevention
Primary Prevention
Reduce number of new cases
Goal
Rationale
Target population
Typical activities
Outcome measure
Rationale:
Reducing exposure rates and
increasing resistance can reduce
number of new cases
Late
Disease
Target population:
Early Disease
Those who are most likely to be
exposed and/or those with
increased susceptibility to a
disease if exposed
Exposed / risk factors
Whole population
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Remove or reduce source of the risk
Educate and make aware of disease
risk
Include behavioral changes to
reduce exposure
Improve general health
Outcome measure:
Incidence of exposure; incidence of
disease
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Secondary Prevention
Goal:
Reduce number of new cases;
reduce number of severe cases
Rationale:
Early identification of individuals
exposed or at early stage of a
disease allows early treatment
Target population:
Those who have been exposed to
the disease-causing agent or have
early symptoms of the disease
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Typical activities:
Goal:
Define levels by:
Tertiary Prevention
Typical activities:
Typical activities:
Goal:
Screening for exposure and/or
disease
Reduce mortality and morbidity
associated with a disease
Post-exposure prophylaxis
Returning to a state of health
Early treatment to reduce impact
of disease/reverse course
Rationale:
Outcome measure:
Minimize the impact that a disease
and its treatment has on a person
Incidence of disease
Reduction of the severity of
disease
Treatment tailored to the patient
Rehabilitation to promote recovery
Outcome measure:
Reduction in premature death and
long-term disability
Number of cases cured
Target population:
Those who have a disease and
need treatment
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Role of Pharmacists in Prevention
Levels of Prevention Table
Primary
Secondary
Tertiary
Population
General or at-risk
Exposed or early disease
Advance disease or
complications
Goal
↓ New cases
↓ severity
↓ complications
↓ Impact
↓death
Rationale
↓ Risk by exposure
Early identification allows
earlier treatment
Minimize impact of
diseased person
Interventions
Education
Prophylaxis
Health Promotion
Screening
Early treatment
Access to care
Treatment
Rehabilitation
Evaluation
(Outcomes)
↓ Incidence of exposure
↓ incidence of
disease
↓ morbidity
↓prevalence
↓morbidity
↓mortality
Traditionally involved in
Tertiary prevention for individuals
Secondary prevention for individuals
Can expand into
Primary prevention for individuals or populations
Tertiary or secondary prevention for populations
Table 9.1 Pharmacy in Public Health
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Take Away Messages
Disease prevention aims to reduce avoidable morbidity and
premature mortality by reducing exposure and disease severity
and facilitating recovery
ADVOCACY
Disease prevention efforts complement health promotion efforts
There are three levels of prevention. They vary in their target
populations, rationales, goals, activities, and outcome measures
Pharmacists can be involved in prevention at both the individual
patient and community or population levels
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What is advocacy?
Advocacy for health
WHO define advocacy as the combination of efforts of groups or organizations
that “aim at influencing decision-making with the goals of developing,
establishing or changing policies and of establishing and sustaining
programmes and services” (WHO, 2004)
A combination of individual and social actions designed to gain
political commitment, policy support, social acceptance and
systems support for a particular health goal or programme.
Advocacy
Advocacy also has a role in creating awareness in the minds of
the community regarding the rights of older persons.
Is active promotion of a cause or principle
Involves actions that lead to a selected goal
Is one of many possible strategies or ways to approach a problem
Can be used as part of a community initiative
WHO Glossary: http://www.who.int/kobe_centre/ageing/ahp_vol5_glossary.pdf
Community tool box: http://ctb.ku.edu/en/table-of-contents/advocacy/advocacy-principles/overview/main
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Advocacy and pharmacists
Health Policy
“Advocacy is a component of leadership and an essential competency
for future pharmacist” (Ross et al., 2013)
Pharmacists have the responsibility to:
Pharmacists should be encouraged to participate in
public health policy development, from local boards
of health to national programs.
Serve as leaders and advocate in their own practices
Advocate on behalf of their patients for the right to safe and effective
medication
Advocate on behalf of the profession through legislative, regulatory, and
public health policy efforts.
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As medication-use experts
APhA Policy/Advocacy priorities
Pharmacists can and should contribute to the development of
public-health related legislation and regulation and should be
involved in public program oversight and administration.
Provider status
Legislators, regulators, and program managers at all levels of
government should be educated to utilize this expertise.
Biologics and biosimilar
Other improvement in Medicare
Prescription drug misuse and abuse
Health information technology
Compounding
Example: A program guide for public health: Partnering with Pharmacists in the
prevention and control of chronic diseases
http://www.cdc.gov/dhdsp/programs/spha/docs/pharmacist_guide.pdf
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Track and trace
http://www.pharmacist.com/apha-advocacy-issues
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Test your knowledge by completing the
following non-graded quiz
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Diseases in the News
COMMUNICABLEAND NON-COMMUNICABLE
DISEASESFROM A PUBLICHEALTH PERSPECTIVE
NSU- College of Pharmacy
Winter 2021
Silvia E. Rabionet, EdD
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NON
COMMUNICABLE
DISEASES
CLASSIFYING DISEASES FROM A
PUBLIC HEATH PERSPECTIVE
Non-Communicable diseases
Communicable Diseases
Chronic Diseases
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Chronic Diseases
Chronic Diseases
◦ Defined broadly as conditions that last 1 year or
more and require ongoing medical attention or
limit activities of daily living or both.
◦ Mostly due to degenerative, genetic, hereditary,
and environmental conditions and life habits
such as nutrition.
◦ Chronic diseases such as heart disease, cancer,
and diabetes are the leading causes of death
and disability in the United States.
◦ During the twentieth century, the “diseases of
modern life” or noninfectious conditions
became the leading causes of morbidity and
mortality in developed countries
◦ They are also leading drivers of the nation’s
$3.3 trillion in annual health care costs.
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Risk factors-behaviors
What are we talking about?
For example,
◦ Cardiovascular
Diseases
◦ Chronic Lung Disease
◦ Diabetes Mellitus
◦ Cancer
◦ Chronic Liver Disease
◦ Visual Disorders
Many chronic diseases are caused by a short list of
risk behaviors:
◦ Hearing Disorders
◦ Mental Disorders
◦ Tobacco use and exposure to secondhand smoke.
◦ Disabling Conditions
◦ Poor nutrition, including diets low in fruits and
vegetables and high in sodium and saturated fats.
◦ Trauma, Violence, and
Injury
◦ Lack of physical activity.
◦ Excessive alcohol use.
◦ Neurologic Disorders
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Chronic conditions place a heavy
burden on the individual, the
family, and society as a whole in
terms of morbidity and
mortality.
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Causes of Death- US (2018)
Homepage - Health, United States - Products (cdc.gov)
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The Global Burden of Chronic
Conditions
◦ Today, over 75% of all deaths in lowand middle-income countries are due
to NCDs
exams
◦ While in high-income countries
NCD-related deaths occur later in
life, premature disability and death
before age 70 is a leading health and
development issue in low- and
middle-income countries.
World Health Organization Targets
◦ Chronic disease and the lack of basic
health care in developing countries affects
U.S. national interests.
Target 1: Reduce early mortality from NCDs
◦ High rates of NCDs and injuries place an
additional burden on already fragile
health systems, making countries less
resilient when emergencies like infectious
disease outbreaks or natural disasters
strike.
Target 2: Reduce harmful use of alcohol
◦ Countries with healthier populations are
more stable and prosperous; they are
more viable trading partners; and they are
better able to protect themselves.
Target 6: Reduce prevalence of raised blood pressure
Target 3: Reduce prevalence of physical inactivity
Target 4: Reduce salt intake
Target 5: Reduce tobacco use
Target 7: Halt the rise in diabetes and obesity
Target 8: Provide drug therapy to prevent heart diseases
Target 9: Provide essential medicines
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pharmacyist
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The CHRONIC DISEASE INDICATORS (CDI) are a set of surveillance
indicators developed by consensus.
CDI enables public health professionals and policymakers to retrieve
uniformly defined state and selected metropolitan-level data for chronic
diseases and risk factors that have a substantial impact on public health.
These indicators are essential for surveillance, prioritization, and evaluation
of public health interventions.
https://www.cdc.gov/cdi/index.html
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Public health challenges
Public health strategies
◦ Promote healthy middle aged and elderly
populations by reducing risk factors through
health promotion and effective medical care.
◦ Screening for early detection
◦ Multiple risk factor interventions
◦ Identification of cost effective treatments
◦ Genetics counseling
◦ Intervention research
◦ Strengthen access to prevention and care
◦ Improve nutrition, social support, and medical
care.
◦ Eliminate health disparities.
Pharmacists are critical for these actions
Explain why!!!!!
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Let’s take a look…
Life Expectancy
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http://gamapserver.who.int/gho/interactive_charts/mbd/life_expectancy/atlas.html
◦ Life expectancy is an important health status indicator based
on average number of years a person at a given age may be
expected to live given current mortality rates.
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◦ Life expectancy can be measured at age 0, or any other
specific age, representing expected survival time once a
person has reached that age; for example, at age 15, 60, or 75
by gender and by ethnic group.
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Life expectancy at birth: US
Life expectancy
◦ Increased dramatically in the United States from 47.3 years in 1900 to 68.2 years in
1950.
◦ Since the 1950s, life expectancy increased to 73.7
years in 1980, and to 78.8 years in 2017 (76 years for
men and 81 for women).
◦ In other parts of the world, life expectancy is even longer.
◦ However, other part of the world lack behind US in 1950
Products - Data Briefs - Number 355 - January 2020 (cdc.gov)
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Phramacoeconomics (PE) as a tool to
impact the burden of Chronic Diseases
Potential strategies to improve malignancy screening and prevention
in the community pharmacy
OPPORTUNITY
PROMOTING GENERAL
PUBLIC AWARENESS
ON PREVENTION AND
SCREENING
POTENTIAL STRATEGIES FOR
IMPLEMENTATION
•Increasing the availability of
promotional materials (e.g., brochures,
posters, educational videos)
POTENTIAL AREAS OF IMPACT
• General risk reduction (all types of
malignancies)
EDUCATION ON
CANCER PREVENTION
FOR VULNERABLE
POPULATIONS
•Providing education when
dispensing high-risk medications
•Providing education during
medication assessments
• Development of formalized
screening processes
•Individuals with low health literacy, limited
education or lower economic status (all types
of malignancies, smoking cessation, skin
protection)
RISK ASSESSMENT AND
REFERRAL FOR
FURTHER TESTING
•Performing risk assessment and
recommendations during medication
assessments
• Partnerships with stakeholders
• Development of formalized
screening processes
•Rural communities/underserved
populations (breast, cervical, colorectal,
skin cancer)
RISK ASSESSMENT
AND TESTING WITHIN
THE PHARMACY
SETTING
•Performing risk assessment and
recommendations during medication
assessments
• Partnerships with other
stakeholders
• Development of formalized
screening processes
• Testing could be performed on
location
• Rural communities/underserved
populations
• Mammography, FOB or FIT test (ex.,
breast, colorectal cancer)
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Havlicek AJ, Mansell H. The community pharmacist’s r
in cancer screening and prevention. Canadian
Pharmacists Journal / Revue des Pharmaciens du
Canada. 2016;149(5):274-282.
doi:10.1177/1715163516660574
ole
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:
Pharmacists´responsibilities in pha. rmacogenomics services:
Addressing chronic diseases
◦ Advocating for the rational and routine use of
pharmacogenomic testing.
January 2021
◦ Providing test result interpretation and clinical
◦
guidance in collaboration with other health care
professionals.
◦ Optimizing medication therapy based on
COMMUNICABLE
DISEASES
pharmacogenomic test results.
Educating on the clinical application of
◦ pharmacogenomics to health professionals and
patients.
Participating in research, consortia, and networks
that guide and accelerate the application of
pharmacogenomics to clinical practice
Infectious Diseases
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Dorfman R, Khayat Z, Sieminowski T, Golden B, Lyons R. Application of personalized medicine to chronic disease: a feasibility
assessment. Clinical and Translational Medicine. 2013; 2:16.
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Challenges
Communicable Diseases
◦ Despite advances in medical sciences and public health,
infectious diseases remain a central task of public health in the
twenty-first century, especially HIV/AIDS, TB, malaria, SARS,
avian flu, EBOLA, ZIKA V, COVID-19
◦ A communicable disease “is an illness due to a
specific infectious agent or its toxic products that
arises through transmission of that agent or its
products from an infected person, animal, or
inanimate reservoir to a susceptible host.”
◦ Globalization has facilitated the spread of many infectious
agents to all corners of the globe.
◦ Mass travel, economic globalization, and climate changes along
with accelerating urbanization of human populations are
causing environmental disruption.
https://wwwnc.cdc.gov/travel/
◦ Transmission may be direct from person to person,
or indirect through an intermediate plant or animal
host, vector, or the inanimate environment.
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Public health applies a wide variety of tools for the
prevention of infectious diseases and their transmission.
Classification
◦ Filtration and disinfection of community drinking water to
environmental, vector control, pasteurization of milk, and
immunization programs.
◦ Communicable diseases may be classified by a variety
of methods:
◦ by clinical syndrome or symptoms,
◦ mode of transmission,
◦ methods of prevention (e.g., vaccine-preventable),
◦ major organism classification; that is, viral,
bacterial, fungal, and parasitic disease.
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◦ Organized programs to promote self-protection, case finding,
and effective treatment of infections to stop their spread to
other susceptible persons (e.g., HIV, sexually transmitted
infections, tuberculosis, malaria).
◦ Planning measures to control and eradicate specific
communicable diseases is one of the principal activities of
public health and remains so for the twenty-first century.
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Public Health Strategies
Arbovirus
◦Vaccination
◦Environmental
◦Education/social/behavior measures
◦Animal and food control
◦Case finding and treatment
◦Occupational measures
◦ A term used by epidemiologists to refer to any of
numerous viruses that replicate in blood-feeding
arthropods such as mosquitoes and ticks and are
transmitted to humans
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ARBONET MAP
◦ bitinghttps://wwwn.cdc.gov/arbonet/maps/ADB_Diseases
_Map/index.html
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ZIKA VIRUS
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CDC, Newsweek,
Wall Street Journal.
January, 2016
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CORONAVIRUSES (COV)
COVID 19
The Pandemic of the Century
▪ Coronaviruses are a large family of
viruses that can cause illness in animals
or humans
▪ In humans, several known coronaviruses
can cause respiratory infections
Ranging from the common cold to more
severe diseases such as severe acute
respiratory syndrome (SARS), Middle East
respiratory syndrome (MERS) and coronavirus
disease 2019 (COVID-19)
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COVID-19: EMERGENCE
COVID-19: TRANSMISSION
▪ The primary transmission of COVID-19 is from
▪ Identified in Wuhan, China in
person to person through respiratory droplets
December 2019
Droplets are released when someone talks, sneezes, or
coughs
Infectious droplets can land in the mouths or noses of
people who are nearby or possibly be inhaled into the
lungs
▪ COVID-19 is caused by the virus
SARS-CoV-2
▪ Early in the outbreak, many patients
were reported to have a link to a
large seafood and live animal market
▪ COVID-19 may also be spread if you touch
contaminated objects and surfaces
Later, no link to the market indicating
person-to-person spread of the disease
▪ Travel-related exportation of cases
reported
▪ Recent data suggest transmission by people who
are not showing symptoms
https://www.healthpolicy-watch.org/
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COVID-19: PEOPLE AT HIGHER RISK FOR SEVERE
ILLNESS
COVID-19: TRANSMISSION
▪ Current data do not support long range aerosol transmission of
SARS-CoV-2 such as with measles and tuberculosis
▪ In some cases, people who get COVID-19 can become seriously
▪ As with many respiratory pathogens, short-range inhalation
ill and develop difficulty breathing
aerosols is a possibility for COVID-19 transmission
Particularly in crowded medical wards and inadequately
ventilated spaces
These severe complications can lead to death
▪ The risk of severe disease increases steadily as people age
▪ Those of all ages with underlying medical conditions appear to be at
▪ Certain procedures in health facilities can generate fine
higher risk to develop severe COVID-19 compared to those without
these conditions
aerosols and should be avoided whenever possible.
▪ As more data become available, additional risk factors for severe
COVID-19 may be identified
See WHO Guidance:Modes of transmission of viruscausing COVID-19: implications for IPCprecaution
recommendations
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WHAT IS IPC?
▪ The practice of preventing or stopping the spread of infections
during healthcare delivery
Hospitals, outpatient clinics, dialysis centers, long-term care facilities,
traditional practitioners
▪ IPC Goal for COVID-19: To support the maintenance of
INFECTION PREVENTION AND CONTROL (IPC)
FOR COVID-19
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essential healthcare services by containing and preventing
COVID-19 transmission within healthcare facilities to keep
patients and healthcare workers healthy and safe
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STANDARD AND TRANSMISSION-BASED
PRECAUTIONS
COVID-19: IPC PRIORITIES
▪ Rapid identification of suspect cases
▪ Standard Precautions
Screening/triage at initial healthcare facility encounter and rapid implementation of
source control
Limiting entry of healthcare workers and/or visitors with suspected or confirmed
COVID-19
Set of practices that apply to care of all patients in all
healthcare settings
▪ Immediate isolation and referral for testing
Group patients with suspected or confirmed COVID-19 separately
Test all suspected patients for COVID-19
▪ Transmission-Based Precautions
Set of practices specific for patients with known or suspected
infectious agents that require additional control measures to
prevent transmission
Used in addition to Standard Precautions
▪ Safe clinical management
Immediate identification of inpatients and healthcare workers with suspected
COVID-19
▪ Adherence to IPC practices
Appropriate personal protective equipment (PPE) use
Strategic Priority IPC Activities for Containment and Prevention
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Intersection of Chronic and Infectious
Diseases: The Case of COVID 19
The cases…the numbers
◦ Adults of any age with the following conditions are at increased risk of severe illness
from the virus that causes COVID-19:
◦ Cancer
◦ Chronic kidney disease
◦ COPD (chronic obstructive pulmonary disease)
◦ Down Syndrome
◦ Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
◦ Immunocompromised state (weakened immune system) from solid organ transplant
◦ Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
◦
◦
◦
◦
◦
Severe Obesity (BMI ≥ 40 kg/m2)
Pregnancy
Sickle cell disease
Smoking
Type 2 diabetes mellitus
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CDC COVID Data Tracker
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Mortality: Excess Death
Mortality: Excess Death
◦ Estimates of excess deaths can provide information about the burden of mortality
potentially related to COVID-19, beyond the number of deaths that are directly
attributed to COVID-19.
◦ Excess deaths are typically defined as the difference between observed numbers
of deaths and expected numbers.
◦ https://data.cdc.gov/NCHS/Excess-Deaths-Associated-with-COVID-19/xkkf-xrst/
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Vaccination
◦ Pre-exposure to protect individuals and the
community (herd immunity);
◦ Post-exposure for individual protection (e.g., for
rabies following animal bite, or contact after
exposure to measles cases);
◦ Immunization of animals to prevent infected meat
or milk transfer of disease to humans (e.g.,
brucellosis)
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https://covid.cdc.gov/covid-data-tracker/#vaccinations
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Pharmacy Partnership for Long-Term
Care Program for COVID-19 Vaccination
Pharmacy Partnership for Long-Term
Care Program
Participating Pharmacies
◦ The Pharmacy Partnership for Long-term
Care (LTC) Program provides end-toend management of the COVID-19
vaccination process, including cold chain
management, on-site vaccinations, and
fulfillment of reporting requirements, to
facilitate safe vaccination of this patient
population, while reducing burden on LTC
facilities and jurisdictional health departments.
The services will be available in rural areas that
may not have easily accessible pharmacies.
LTCF staff who have not received COVID-19
vaccine can also be vaccinated as part of the
program.
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◦ CVS
◦ Walgreens
◦ Select pharmacies that are part of the MHA network:
◦ Absolute Pharmacy (in Ohio)
◦ Community Pharmacy (in Iowa and Nebraska)
◦ Consonus Pharmacy (in Oregon and Nevada)
◦ HealthDirect/Kinney Drugs (in New York and Vermont)
◦ Pharmscript (in Indiana, Illinois, New York, Ohio, and Texas)
◦ Senior Care Pharmacy (in Alabama)
◦ Thrifty Drug Stores (in Minnesota and North Dakota)
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Can we eradicate communicable
diseases?
Updated health information
Countries | World Health Organization (who.int)
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◦Eradication is defined as the
achievement of a situation whereby no
further cases of a disease occur
anywhere and continued control
measures are unnecessary
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Eradication of Diseases
Eradication vs elimination
◦Since the eradication of smallpox, much
attention has focused on the possibility of
similarly eradicating other diseases, and a list
of potential candidates has emerged.
◦Some of these have been abandoned because
of practical difficulties with current
technology.
◦
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Reducing epidemics of infectious diseases, through
control and elimination in selected areas or target
groups, can in certain instances achieve eradication
of the disease.
◦ Local elimination can be achieved where domestic
circulation of an organism is interrupted with cases
occurring from importation only.
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Eradication
Conditions for Eradication
◦ Diseases that have been under discussion for
eradication have included:
◦ measles,
◦ polio,
◦ and some tropical diseases, such as malaria and
dracunculiasis
◦
Scientific feasibility
◦ Epidemiologic vulnerability; lack of nonhuman reservoir,
ease of spread, no natural immunity, relapse potential;
◦ Effective practical intervention available; vaccine or other
primary preventive or curative treatment, or vectoricide
that is safe, inexpensive, long-lasting, and easily used in the
field;
◦ Demonstrated feasibility of elimination in specific
locations, such as an island or other geographic unit.
World Health Organization. 1992. Update International Task Force
for Disease Eradication 1991. Morbidity and Mortality Weekly
Report, 41:40–42.
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Challenges to erradicate or eliminate
COVID 19
Conditions for Eradication
◦
Political will/popular support
◦ Perceived burden of the disease; morbidity, mortality,
disability, and costs of care in developed and developing
countries;
◦ Expected cost of eradication;
◦ Synergy of implementation with other programs;
◦ Reasons for eradication versus control.
◦ Coronavirus can be present in asymptomatic carriers.
◦ Coronavirus can infect many different kinds of animals.
◦ There is no highly effective vaccine or antiviral treatment for coronavirus.
◦ Lack of a concerted global effort
World Health Organization. 1992. Update International Task Force for
Disease Eradication 1991. Morbidity and Mortality Weekly Report, 41:40–
42.
January 2021
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January 2021
@ Silvia Rabionet
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Take Away Messages
◦ Pharmacists can be instrumental in the public
health response addressing chronic and infectious
diseases.
◦ Health and disease indicators can provide pathways to
enhance the impact of public health strategies.
◦ Pharmacists should acquire skills to assess and measure
health and disease at the population level.
◦ Adequate use of medications and vaccines are vital to
reduce the burden of diseases.
◦ Pharmacists´ expertise is needed to escalate innovations.
Oct 19, 2018
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Essentials of Professional
Practice II
What is Public Health?
Georgina Silva-Suarez, PhD
Winter 2021
1
3
Review
“Public health is what we, as a
society, do collectively to assure
the conditions in which people
can be healthy.”
Population Approach to Health
Health Promotion and Disease Prevention
INSTITUTE OF MEDICINE (US) COMMITTEE FOR THE STUDY OF THE FUTURE OF PUBLIC HEALTH. THE FUTURE OF PUBLIC
HEALTH. WASHINGTON (DC): NATIONAL ACADEMIES PRESS (US); 1988. SU MMARY AND RECOMMENDATIONS. AVAILABLE
FROM: HTTPS://WWW.NCBI.NLM.NIH.GOV/BOOKS/NBK218215/
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What does public health do?
What does medicine do?
Saves lives one at a time
Saves lives millions at a time
What is the ecological approach to public
health?
(CDC, 2013)
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7
Health and the Natural History of Disease
Ecological approach to Public Health
MAINTAIN HEALTH
Principle of the ecological approach:
◦ The relationship of the individual with his/her environment has
an impact on their individual health
a
RECOVERY
c
◦ Positive or negative
HEALTH
AT RISK FOR
DISEASE
b
DISEASE
PROCESS
INITIATES
ILLNESS/
SUFFERING
d
◦ Direct: daily life interactions (e.g., going to school, work)
DISABILITY
or DEATH
◦ Indirect: government actions, events that occur in other parts of the
world, natural disasters
Public Health Interventions
Clinical Treatment
(Carter & Slack, 2010, p. 7)
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HEALTH PROMOTION
Clinical Treatment vs. Public Health
CLINICAL TREATMENT
PUBLIC HEALTH
1. Occurs late in the natural history of
disease
1. Early in the natural history of
disease
2. Patients have symptoms already
2. Occurs when the person is healthy
or is at risk for exposure to the
disease
3. Diagnosis and treatment
4. Does not prevent disease
5. Is ‘reactive’
Is defined as actions affecting one or more determinants of
health
Goal is to enable people to maintain or improve their
physical, mental, or social well-being
3. Focuses on prevention and avoiding
the need of clinical treatment
4. Considered as ‘proactive’ approach
(Carter & Slack, 2010)
(Carter & Slack, 2010, p.162)
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STRATEGIES FOR HEALTH PROMOTION
1. Education: provide information that encourages healthy behaviors
and discourages unhealthy behaviors
Public Health Strategies:
Health Promotion and
Disease Prevention
2. Modifying the external environment to encourage interactions that
promote well-being rather than interactions that promote disease
Georgina Silva-Suárez, PhD
PHRC 4962
Essentials of Professional Practice II
3. Combination of the two strategies: provide education and modify
the environment
Winter 2021
(Carter & Slack, 2010)
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DEFINITION OF HEALTH EDUCATION
Health-to-Death Continuum
Think about various levels of healthiness, sickness, and death
Any activity intended to produce changes in knowledge or ways
of thinking that facilitates skill acquisition or behavior change
related to health
Activities to reduce disease and increase health by where they are initiated on the
continuum
Most health promotion activities involve at least some education
Education may be aimed at community members or policymakers
Figure 9.1
(Carter & Slack, 2010)
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15
Relationship between Continuum and
Health Promotion & Disease Prevention
Intended to maintain or improve wellbeing
Directed to everyone in a population
group
Expected to benefit everyone
regardless of current health status
Health Promotion – optimize overall health. LEFT side
HEALTH
PROMOTION
INTERVENTIONS
Disease Prevention – reduce occurrence and impact of specific diseases.
RIGHT side
Are based on the determinants of
health
Figure 9.2
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Three Levels of Prevention
Define levels by:
Goal
Rationale
Late
Disease
Target population
Typical activities
Early Disease
Outcome measure
Essentials of Professional
Practice II
Georgina Silva-Suárez, PhD
Winter 2021
DETERMINANTS OF HEALTH AND VULNERABLE
POPULATIONS
Exposed / risk factors
Whole population
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OBJECTIVES
Levels of Prevention Table
Primary
Secondary
Exposed or early disease
Advance disease or
complications
Goal
↓ New cases
↓ severity
↓ complications
↓ Impact
↓death
Rationale
↓ Risk by exposure
Early identification allows
earlier treatment
Minimize impact of
disease on person
Interventions
Education
Prophylaxis
Health Promotion
Screening
Early treatment
Access to care
Treatment
Rehabilitation
↓ Incidence of exposure
↓ incidence of
disease
↓ morbidity
↓prevalence
↓morbidity
↓mortality
Evaluation
(Outcomes)
1. Define social determinants of health
Tertiary
General or at-risk
Population
2. Evaluate the role played by social determinants in health and disease
3. Identify factors that contribute to health disparities
4. Assess the role of pharmacy in addressing health disparities
5. Analyze the impact of social determinants on medication use
6. Define vulnerable and special populations
Table 9.1 Pharmacy in Public Health
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BACKGROUND- ECOLOGICAL APPROACH HEALTH
DETERMINANTS
BACKGROUND- ECOLOGICAL APPROACH
HEALTH DETERMINANTS
Thomas McKeown
Ottawa Charter of Health Promotion (1986):
Established 8 prerequisites or determinants for health:
1. Peace
2. Shelter
3. Education
4. Food
5. Income
6. A stable eco-system
7. Sustainable resources
8. Social justice and equity
1976 – “The Role of Medicine”
Attributed the modern rise in the world population and the reduction in
mortality from infectious diseases to improvements in overall standards of
living, especially diet and nutritional status, resulting from better economic
conditions
(CDC, 1986)
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BACKGROUND- ECOLOGICAL APPROACH HEALTH
DETERMINANTS
HUMAN RIGHT AS FRAMEWORK FOR PUBLIC HEALTH
We have proposed that the human rights framework describes the essential preconditions for health
Alma-Ata Declaration (1978)
better than any conceptual model or analysis thus far proposed from within biomedicine or public
Health for All by 2000
Health as a basic human right
The Primary Health Care model as articulated at Alma-Ata “explicitly stated the need for a
comprehensive health strategy that not only provided health services but also addressed the underlying
social, economic, and political causes of poor health” (WHO, 1978).
PHC included intersectoral actions to address social and environmental health determinants
In addition to health sector, included agriculture, food, industry, education, housing, communication, public
works, among others
health. We suggest that a society in which human rights are promoted and protected, and in which
human dignity is respected is a healthy society; that is, a society in which people can best achieve
physical, mental and social well-being. Obviously, people living in a society respectful of human
rights will still suffer illness, disability and premature death; epidemics will still occur, and while
human suffering can be reduced, it will not be eliminated. Nevertheless, within its material and
resource capabilities, the people living in such a society will enjoy the "highest attainable standard
of health."
J. Mann 1995
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SOCIAL DETERMINANTS OF HEALTH
The social determinants of health are the conditions in which people are born,
grow, live, work and age.
These conditions are shaped by the distribution of money, power and resources
at global, national and local levels.
IMPORTANT CONCEPTS
(WHO, n.d.)
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HEALTH INEQUITIES
CONDITIONS AND CIRCUMSTANCES…
“Are avoidable inequalities in health between groups of people within countries and
between countries”.
Within:
…such as social, economic, and physical.
…experienced in e.g., school, church, workplace, and neighborhoods.
…that impact patterns of social engagement and sense of security and well-being.
In Bolivia, infant mortality rates in:
Babies born to women with no education: 100 per 1000 live births
Babies born to women with at least secondary education: 40 per 1000 live births
…related to resources such as safe and affordable housing, access to education,
public safety, availability of healthy foods, local emergency/health services, and
environments free of life-threatening toxins.
Between:
▪The infant mortality rate is 2 per 1000 live births in Iceland and over 120 per 1000 live births in
Mozambique;
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SOCIAL DETERMINANTS OF HEALTH BY LEVELS
Individual Level
Community Level
State & National Level
Global level
Physical
Economics
Communication networks Communication networks
Socioeconomic Status
Food supplies
Government
Public health
organizations
Educational attainment
Water and sanitation
Public Health System
Violence
Psychological factors
Housing
Health insurance/health
systems
Global climate change
Behaviors
Physical environment
Social environment
Education & social
services
World Health Organization
Local government
Primary care
(Carter & Slack, 2010, p.127)
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10 MAJOR SOCIAL DETERMINANTS OF HEALTH
(WITH HARD EVIDENCE!)
SOCIAL DETERMINANTS OF
HEALTH: THE EVIDENCE
30
Social
Gradient
Unemployment
Stress
Social support
Early life
Addiction
Social
exclusion
Food
Work
Transport
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SOCIAL GRADIENT
STRESS
The poorest of the poor, around the world, have the worst health.
Long-term stressful circumstances, that make people feel worried,
like:
Within countries, the evidence shows that in general the lower an individual’s socioeconomic
position the worse their health.
lack of control over work and home life
lack of supportive friendships (social support) is damaging to health and
increases the risk of poor mental health and premature death
Life expectancy is shorter and most diseases are more common down in the social ladder in
each society.
The longer people live in stressful economic and social circumstances, the greater physiological
effect they suffer, and the less likely to enjoy healthy long age.
(Wilkinson, & Marmot, 2003)
(Wilkinson, & Marmot, 2003)
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OCCUPATIONAL LIFE EXPECTANCY
IN ENGLAND & WALES, 1997- 99
STRESS, CONT.
If individuals feel tense too often and for too long, they become more
vulnerable to conditions such as:
Infections
Diabetes
High blood pressure
Heart attacks
Stroke
Depression
Aggression
(Wilkinson, & Marmot, 2003)
Source: Donkin A, Goldblatt P, Lynch K. Inequalities in life expectancy by social class, 1972-1999. Health Statistics Quarterly 2002;15:5-15
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http://art-of-stories.com/stress-and-your-writing/
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SOCIAL SUPPORT
EARLY LIFE
Social support and good social relations make an important
contribution to health
Important foundations of adult health are laid in
early childhood and before birth.
(Wilkinson, & Marmot, 2003)
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SOCIAL SUPPORT
Poor fetal development is a risk for health later in life.
Social support
Lack of social support
Friendship, good social relations and
strong supportive networks improve
health at home, at work and in the
community.
Societies with high level of inequalities
tend to have less social cohesion.
People feel cared for, loved, esteemed
and valued.
Supportive relationships may also
encourage healthier behavior patterns.
EARLY LIFE
Slow growth and poor emotional support raise the lifetime
risk of poor physical health and reduce cognitive and
emotional functioning in adulthood.
Poverty contributes to social exclusion
and isolation.
Less social support is associated:
Slow or retarded physical development in infancy is
associated with reduced cardiovascular, respiratory,
pancreatic and kidney development and function, which
increase the risk of illness in adulthood.
with depression
greater risk of pregnancy complications
disability from chronic diseases
(Wilkinson, & Marmot, 2003)
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ADDICTION
SOCIAL EXCLUSION
Drug use is a response to social breakdown
People turn to alcohol to numb the pain of harsh economic and social
conditions, and alcohol dependence leads to downward social mobility
Social deprivation (poor housing, low income, lone parenthood, unemployment
or homelessness) is associated with higher rate of smoking and low rates of
quitting
Life is short where the quality is poor
(Wilkinson, & Marmot, 2003)
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ADDICTION
SOCIAL EXCLUSION
Alcohol dependence, illicit drug use and
cigarette smoking are all closely
associated with markers of social and
economic disadvantage
Poverty, deprivation, social exclusion, discrimination, racism and hostility have
a major impact on health and premature death
Absolute poverty and relative poverty are associated with shorter lives
The greater time people live in disadvantaged circumstances the more likely to
suffer from a variety of health problems, particularly cardiovascular disease.
(Wilkinson, & Marmot, 2003)
(Wilkinson, & Marmot, 2003)
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UNEMPLOYMENT
FOOD
Unemployed people and their families suffer a much
higher risk of premature death
http://www.localfoodcampaign.org/aboutus.html
http://insightbulletin.com/how-to-handle-job-rejection/
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UNEMPLOYMENT
FOOD
Higher rate of unemployment causes more illness and premature
death
Good diet and adequate food supply are central for promoting health and
well-being
To the unemployed and their families
Food poverty co-exists with food plenty
An important public health issue is the availability and cost of healthy and
nutritious food
The effects start when people first feel their jobs are threatened
Anxiety about job insecurity is also detrimental to health
The main dietary difference between social classes is the source of nutrients
Very unsatisfactory or insecure jobs can be as harmful as
unemployment
The poor tend to substitute cheaper processed foods for fresh food
People on low incomes are less able to eat well
(Wilkinson, & Marmot, 2003)
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TRANSPORT
Three overarching recommendations:
1. Improve daily living conditions
2. Tackle the inequitable distribution of power, money,
and resources
3. Measure and understand the problem and assess the
impact of action
https://en.wikipedia.org/wiki/Transport_in_Copenhagen
“Healthy transport means less driving and more
walking and cycling, backed up by better public
transport”
(Wilkinson, & Marmot, 2003)
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TRANSPORT
Cycling and walking promote health in:
SOCIAL
DETERMINANTS
OF HEALTH IN US:
RESOURCES
Reducing fatal accidents
Increasing social contact
Reducing air pollution
Promoting exercise
Regular exercise protects against heart disease, promotes a sense of well-being and
protects older people from depression
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VULNERABLE POPULATIONS
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VULNERABILITY
Is the susceptibility to harm.
HEALTHY PEOPLE
2030
It results from an interaction between the resources available to individuals and
communities and the life challenges faced.
For example:
developmental problems,
personal incapacities,
disadvantaged social status,
inadequacy of interpersonal networks and supports,
degraded neighborhoods and environments,
and the complex interactions of these factors over the life course.
David Mechanic and Jennifer Tanner, “Vulnerable People, Groups, And
Populations: Societal View “ 2007 Health Affairs ~ Vo l u m e 2 6 , Nu m b e r 5
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VULNERABLE POPULATIONS FROM A HEALTH
CARE PERSPECTIVE
30 years ago...in the US
HISTORICAL
LOOK AT THE
CONCEPT AND
APPROACHES TO
VULNERABILITY
…are groups that are not well integrated into the health care
system because of ethnic, cultural, economic, geographic, or health
characteristics.
This isolation puts members of these groups at risk for not
obtaining necessary medical care, and thus constitutes a potential
threat to their health.
• dominance of health services and
focus on health interventions
directed to people in need.
NOW…
• focus on the causes and elimination
of unnecessary negative impact.
• dominance of proactive integrated
services targeting social
determinants
Youth Health Services Corps, 2013 CT Area Health Education Center
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Categories And Overlap Of Vulnerable Populations In The US Health Care System.
SINNERS VERSUS VICTIMS...
The behavior that the public views as personally controllable is
fundamental to whether they see people as sinners or victims.
Perceptions have political salience and affect social policies.
Federal and state government are more likely to provide assistance to
those who are not seen as responsible for their vulnerability.
Examples________.
When people are seen as responsible for their life circumstances.
Examples________________.
Lewis V A et al. Health Aff 2012;31:1777-1785
©2012 by Project HOPE - The People-to-People Health Foundation, Inc.
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VULNERABILITY IS CONTINGENT ON SCIENTIFIC PARADIGMS, PUBLIC
UNDERSTANDING, AND MEDIA INFLUENCES.
SYSTEM PREPAREDNESS...
(PERSONAL CONTROL VERSUS SCIENTIFIC PARADIGMS)
Alcohol abuse and obesity
At times, the existing health system may be too slow to address
emerging health needs and there is frequently a problem of an
inadequate access to care due to different barriers, which may
be economic, geographic, social, prejudice, or lack of
awareness.
attributed to lack of personal responsibility or discipline and therefore stigmatized
reframed as diseases or linked to environmental conditions such as poor food environments that are
less under individual control.
Lung cancer
once primarily seen as an individual problem resulting from the personal choice to smoke
seen increasingly as a public health problem partly because of media exposure of tobacco
manufacturers’ efforts to induce addiction.
Can you think of another example?
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TEMPORARY VERSUS PERSISTENT VULNERABILITIES
FACTORS THAT CAN ENHANCE VULNERABILITY:
Vulnerabilities may be temporary, stressing individuals and groups
during particular life crises such as acute illness, family breakup,
unemployment, community disasters, or other severe losses.
By the fact of birth in a special group or at any point in life, every
person can become a member of a community with special health
needs.
Race
Ethnicity
Age
Sex
Income
Insurance
coverage
Housing
Poverty
Inadequate
education
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VULNERABILITY
AND
INTERSECTION
WITH HEALTH AND
DISEASE
1/20/2021
• Evidence now suggests that medical care accounts for
only 10 to 15 percent of preventable early deaths.
ROLE ASSOCIATED WITH MEDICATIONS
• Some Americans will die 20 years earlier than others
who live just a few miles away because of
differences in education, income, race, ethnicity and
where and how they live.
Individual level: improving individual health by preventing disease
and disability
• College graduates can expect to live five years
longer than those who do not complete high school.
Community level: availability of medication and pharmaceutical
care
• Middle-income people can expect to live shorter
lives than higher income people, even if they are
insured.
State, national and global levels: promotion of policies, laws or
regulations that assure safe and effective medication
• And people who are poor are three times more
likely to suffer physical limitations from a chronic
illness.
(Marks, 2009)
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ROLE ASSURING CONDITIONS FOR EFFECTIVE
MEDICATION USE
THE ROLE OF HEALTH PROFESSIONALS
Health professionals should build relationships of trust and respect with
their patients
They should promote collaboration and communication with local
communities
Take social history as well as medical information
Individual level: assuring conditions for effective and appropriate
medication use
Community level: improving conditions that enhance medication
effectiveness and avoiding inappropriate use of medications
State, national and global levels: advocate for and support policies,
regulations or laws that assure the availability of essential medications
and the appropriate use of medication
Provide better care, including referrals
Analyze aggregate data to better understand
Refer patients to a wide range of services
Become advocates
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REFERENCES
Braveman, P. (2010). Social Conditions, health equity, and human rights. Health and Human
Rights Journal, 12(2).
Wilkinson, R. G., & Marmot, M. G. (2003). Social determinants of health: the solid facts. World
Health Organization.
World Health Organization. (n.d.). Social determinants of health: Key concepts. Retrieved
September 06, 2016, from
http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/
World Health Organization. (n.d.). Social determinants of health. Retrieved September 06,
2016, from http://www.who.int/social_determinants/en/
World Health Organization. (1978). Alma Ata Declaration. Geneva: World Health
Organization.
World Health Organization. (1986).The Ottawa Charter for Health Promotion. Retrieved
September 06, 2016, from
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/
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Essentials of Professional
Practice II
Georgina Silva-Suarez, PhD
gsilvasuar@nova.edu
Winter 2021
70
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34
A Health Economics
Perspective on Public
Health
Ioana Popovici, Ph.D.
Associate Professor
Department of Sociobehavioral and
Administrative Pharmacy
College of Pharmacy
what is health economics
allocating limited healthcare
resources: disease treatment versus
health promotion, vaccination,
education
healthcare: right or privilege?
Module Topics
socioeconomic disparities in health and
the development of public health
insurance programs
Public Insurance programs (Medicaid,
Medicare, CHIP, etc.)
Private insurance (PPOs, ACOs, etc.)
socioeconomic disparities in health and
the need for health insurance reform
(reform efforts, Affordable Care Act)
implications for pharmacists
Module Objectives
Discuss the importance of health economics in the allocation of limited healthcare
resources
Contrast health promotion, disease prevention, education, and vaccination with disease
treatment from an economic perspective
Recognize the need for public health insurance programs and the need for health
insurance reform
Compare and contrast the public health insurance programs in terms of coverage and
eligibility (Medicare, Medicaid, CHIP, etc.)
Differentiate between the different private health insurance plans (PPO, HMO, etc.)
Compare and contrast between private and public health insurance programs
Describe how the ACA impacts healthcare coverage and services in the healthcare system
U.S. healthcare spending grew 4.6 percent in 2020, reaching
$3.8 trillion or $10,966 per person
Healthcare
Spending in
the U.S.
$3,800,000,000,000
As a share of the nation's Gross Domestic Product (GDP), health
spending accounted for 17.7%
Spending accounts for 1 of every 9 employees in the U.S.
US healthcare system is the most expensive in the world
5,000 hospitals, 30,000 nursing homes, 800,000 physicians, 2.8
million registered nurses, and 10 million other healthcare
workers (300,000 pharmacists)
Exercise: estimate the number of healthcare professionals
in Cooper City (population 35,000) based on approximate
U.S. population 300 million
By 2028, health spending is projected to reach $6.2 trillion
https://www.cms.gov/research-statistics-data-andsystems/statistics-trends-andreports/nationalhealthexpenddata/nhe-fact-sheet.html
Healthcare Spending in the U.S.
Sources of Financing 1929, 1970, and 2012
•
Getzen’s Health Economics & Financing, 5th Edition
•
Copyright © John Wiley & Sons, Inc.
Factors linked to increases in U.S.
Healthcare Spending
Inflation
Exercise: Convert $1 in 1929 dollars to 2021 dollars
Use inflation calculator here: https://data.bls.gov/cgi-bin/cpicalc.pl
U.S. population growth (122 million in 1929 to 330 million
today)
Increases in healthcare professionals’ incomes
Growth facilitated by the shift from individual payments to
third-party financing (cost-shifting)
Increases in range and intensity of healthcare services =>
increases in life expectancy => larger elderly population =>
more healthcare spending
Distribution of Individual Medical Care
Expenditures
The Concentration of Personal Health Expenditures
•
Getzen’s Health Economics & Financing, 5th Edition
•
Copyright © John Wiley & Sons, Inc.
Pharmaceutical Spending in the U.S.
U.S. Sources and Uses of Healthcare Funds, 2010
Pharmaceutical expenditures -10% of healthcare costs
Fastest growing segment
Expected to increase by 50% in the next decade
Americans spend more on medicines than Japan,
Germany, France, Italy, Spain, UK, Australia, New
Zealand, Canada, Mexico, Brazil, and Argentina…combined
•
Getzen’s Health Economics & Financing, 5th Edition
•
Copyright © John Wiley & Sons, Inc.
Sources of Funds for Pharmaceutical
Products
•
Getzen’s Health Economics & Financing, 5th Edition
•
Copyright © John Wiley & Sons, Inc.
Health Insurance
Healthcare in the U.S. – expensive
A small percentage of the population consumes a large share of the total
healthcare spent
Who pays for the healthcare of those who are sick?
Could the 1-5% with the greatest personal healthcare expenses be able to pay
for these without health insurance? Who pays?
Is it fair that we contribute to the healthcare expenses of others?
What is the reason we agree to contribute to the expenses of others?
Risk aversion
Health insurance protects us against this risk of sudden large healthcare
expenses
Trade health insurance premium every month for expenses coverage if sick
Methods for Covering Risks
Use private savings to pay for current expenses
Individuals trade with themselves at different time periods
Assistance from family and friends
Mutual obligation and reciprocity
Charity as a means of social exchange
Limited for most people
Social healthcare insurance
Contributions are mandatory through the tax system
Private medical care insurance
Individual perspective: trade monthly premium for affordable
treatment if/when sick
Societal perspective: risk pooling
Private Health Insurance Risk Pooling
Club with 100 members
Risk of getting sick: 1/100 (1%)
Healthcare expenditure: $5,000
Annual contribution per member: $50
Money earns interest in a bank account
Every year, money used to pay healthcare expenses of sick member
Society’s point of view: insurance is a method of pooling risk such that a
person’s loss (when sick) is shared across many people
Risk pooling: funds are collected from many people (most healthy) and used
to cover for a few people’s illnesses
Health Insurance Terminology (cont.)
Copayment
A form of medical cost sharing in a health insurance plan that requires an
insured person to pay a fixed dollar amount when a medical service is
received
Maximum plan dollar limit
The maximum amount payable by the insurer for covered expenses for
the insured and each covered dependent while covered under the health
plan
Maximum out-of-pocket expense
The maximum dollar amount a group member is required to pay out of
pocket during a year
Until this maximum is met, the plan and group member shares in the cost
of covered expenses
After the maximum is reached, the insurance carrier pays all covered
expenses, often up to a lifetime maximum. (See previous definition.)
Health Insurance Terminology
Premium for coverage
Agreed upon fees paid for coverage of medical benefits for a defined
benefit period
Can be paid by employers, unions, employees, or shared by both the
insured individual and the plan sponsor
Deductible
Fixed dollar amount during the benefit period - usually a year - that an
insured person pays before the insurer starts to make payments for
covered medical services
Plans may have both per individual and family deductibles
Coinsurance rate
A form of medical cost sharing in a health insurance plan that requires an
insured person to pay a stated percentage of medical expenses after the
deductible amount, if any, was paid
Public Healthcare Financing in the US
- Social Insurance
Insurer = Government
Mandatory contributions
Programs:
Medicare
Medicaid
Veterans Affairs healthcare (VA)
TRICARE
Indian Health Service (IHS)
Federal Employees Health Benefits Program (FEHBP)
Children’s Health Insurance Program (CHIP)
26
Medicare
Established 1965
~ 61 million beneficiaries in 2020
Beneficiaries: Who is eligible for Medicare?
> 65 years of age
< 65 years of age with disabilities
any age with end-stage renal disease (permanent kidney failure requiring dialysis
or transplant)
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Medicare
Structure:
Original Medicare – fee-for-service
Part A – hospital care
Part B - outpatient care and physician services
Part C – alternative option through private insurance plans
Part D – optional prescription drug coverage through private insurance
plans
MediGap – private plans standardized by the Centers for Medicare &
Medicaid Services (CMS) that cover out-of-pocket costs
Financing:
Beneficiary premiums
Payroll taxes (payroll tax = 2.9% paid jointly by employee -1.45%- and
employer -1.45%-)
2013 - tax increased to 3.8% for incomes above $200,000/year
General revenue
Cost Control in Medicare
Expensive – why?
Cost control mechanism
Diagnosis related group (DRG) system
Introduced in 1984
Rather than pay the hospital for each specific service it provides,
Medicare pays a predetermined amount based on the Diagnostic
Related Group, which is based on the patient’s age, gender, diagnosis,
and the medical procedures involved in your care
Reimbursements based on diagnosis, treatment, rather than length of
stay
Based on the care given to and resources used by a "typical" patient
within the group
Medicare Part A – Hospital Coverage
Medicare Part B - Doctor and Outpatient
Services
Medicare Part A covers hospital expenses such as
inpatient care in hospitals
skilled nursing facility care
nursing home care (inpatient care in a skilled nursing facility that’s not custodial or longterm care)
Medicare Part B covers medically necessary services such as
doctors’ services
hospice care
outpatient care
home healthcare
lab tests and diagnostic screenings
Eligibility: automatic enrollment in Medicare Part A for all Medicare recipients
medical equipment
Every American over age 65 is eligible to enroll in Part A
ambulance transportation
Disabled Americans who have been out of work for 2 years are also eligible
preventive care
Majority of Medicare Part A revenue is financed through payroll taxes
Eligibility: Medicare recipients - voluntary enrollment
Premiums: No fee for the majority of beneficiaries*
Medicare Part B is mostly financed by general revenues and beneficiary premiums
*A small number of beneficiaries (who didn’t pay enough Medicare taxes during their working
years) must pay a $471 monthly premium.
Premiums: $148.50 monthly for 2021
the vast majority of enrollees are exempt: those who worked in the U.S. for at least 10
years and paid the Medicare taxes
Individuals with an annual income of more than $88,000 pay a higher premium
Deductible: $1,484 in 2021
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Medicare Part C (Medicare Advantage)
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Medicare Part D - Prescription drugs
Eligibility: Medicare beneficiaries have the option to receive their Medicare
benefits through private health plans as an alternative to the federally
administered traditional Medicare program
Optional prescription drug coverage
Plans are offered by Medicare-approved private companies that must follow rules
set by Medicare
Prior to its introduction in 2006 (Medicare Prescription Drug, Improvement,
and Modernization Act), only 75% of elderly Americans had prescription drug
insurance => Within 1 year, over 90% had coverage
Plans cover everything that original Medicare covers
Eligibility: everyone with Part A or B - voluntary prescription drug benefits
Some plans pay for services that original Medicare does not, including dental and
vision care
Coverage is available through private insurance companies approved by
Medicare
Most plans also fold in prescription drug coverage
These private health plans receive capitated payments to provide all Medicarecovered services to plan enrollees (Medicare pays the private insurance company a
fixed amount every month to provide all Part A and B benefits)
In addition, Medicare makes a separate payment to plans for providing prescription drug
benefits under Medicare Part D
Medicare Part D is financed from general revenues and beneficiary premiums
Medicare Part D is financed from general revenues, beneficiary premiums,
and state payments
Premium: varies by plan, averages $30.50 monthly for 2021
Medicare subsidy covers most of that cost
Premium: $148.50 monthly for the Part B premium for 2021, plus any additional
premium set by the insurer
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Medicare Part D
What Medicare Part D drug plans cover
All plans must cover a wide range of prescription drugs
Formulary: the approved list of medications covered
Two ways to use Medicare Part D:
Plans include both brand-name prescription drugs and generic drug
coverage
Medicare prescription drug plans (PDP):
These plans add drug coverage to the original Medicare plan
The formulary includes at least 2 drugs in the most commonly prescribed
categories and classes
Must have Part A and/or Part B to join a separate Medicare drug plan
Medicare Advantage Plans (Part C) with prescription drug coverage
Tiers (to lower costs)
A specific Medicare health plan that offers Medicare prescription drug
coverage through private insurance companies
Most Medicare drug plans place drugs into different levels called “tiers”
on their formularies
Drugs in each tier have a different cost (a drug in a lower tier
will generally cost you less than a drug in a higher tier)
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Medicare Part D formulary tiers
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Medication Therapy Management
Example:
•
Tier 1—lowest copayment : most generic prescription drugs
•
Tier 2—medium copayment: preferred, brand-name prescription drugs
•
Tier 3—higher copayment: non-preferred, brand-name prescription drugs
•
Specialty tier—highest copayment: very high cost prescription drugs
CMS has mandated that Part D sponsors offer beneficiaries a Mediation
Therapy Management (MTM) program
MTM - free program offered by Part D plans to certain members to help
improve their medication use so they can better manage their chronic
conditions
Service: face-to face, via phone, mail, email, combination
Targeted beneficiaries:
Have multiple chronic diseases
Taking multiple Part D drugs
Likely to incur annual costs for covered Part D drugs that exceed $3,000
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Medicaid
Children’s Health Insurance Program
(CHIP)
Established 1965
Highly subsidized insurance coverage to low-income families, nearly free
Financed and ran jointly by state and federal governments
Eligibility: children up to 19 years of age whose parents earn too much to
qualify for Medicaid but not enough to afford private insurance
State governments have wide latitude to set budgets, determine eligibility rules, and
decide how generous their programs will be
State-federal partnership that provides health insurance to low-income
children
71 million Medicaid beneficiaries in 2020
~15% of state budgets,
2nd
Each state offers CHIP coverage and works closely with its state Medicaid program
to education
federal government matches state expenditures to help states finance Medicaid, but it
also mandates minimum levels of coverage and eligibility
Provides comprehensive coverage
Federal and state governments jointly finance CHIP
Eligibility vary state by state:
Financial Eligibility: low income
Premium: free or families may be required to pay a modest enrollment fee or
premiums
Non-Financial Eligibility criteria: marital status, number of children, pregnancy,
health (disabled, blind), immigration status
6.7 million children were enrolled in CHIP in 2020
Almost all expenses are paid with taxpayers dollars
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Veterans Affairs and TRICARE
VA and Tricare provide medical benefits in military including reservists, national guard,
military retiree and their dependents
Indian Health Services (IHS)
Eligibility:
Any individual who serves on active duty in the armed forces and is discharged
other than dishonorably is technically eligible to receive health services from the
VA
Provides health benefits to members of federally-recognized Native American
Tribes and Alaska Native people
Majority financed by the federal government
Majority financed by the federal government
VA operates the nation’s largest integrated healthcare system (approximately 1,700
hospitals, outpatient clinics, counseling centers and long-term care facilities) with
coverage for almost all medical services, such as
Health services are provided directly by the IHS, through tribally contracted
and operated health programs, and through services purchased from private
providers
Primary care or specialist physician office visits, immunizations, hospitalizations,
emergency room visits, medical and surgical supplies, as well as prescription
medications
Covers 2.6 million American Indians and Alaska Natives
VA provides care to nearly 9 million veterans
TRICARE
Insurance that is paid by the government, but uses private doctors and hospitals
Does not require services provided by the VA system
Financed by the federal government
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Federal Employees Health Benefits
Program (FEHBP)
Private Health Insurance Plans
Provides health benefits to civilian federal employees, former employees,
family members, and former spouses
Fee-for-service
Traditional type of insurance in which the health plan will either pay
healthcare provider directly or reimburse after claim is filed
FEHBP is financed and managed by the federal Office of Personnel
Management (OPM) (federal government) via a “managed competition”
system by allowing qualified insurance companies, employee associations, and
labor unions to promote health insurance plans to governmental employees
When medical attention is needed, the beneficiary can visit the doctor or
hospital of their choice
Managed care
FEHBP employers pay about 25% of the cost of insurance, the government
pays the rest (75%)
FEHB program is the largest employer-sponsored group health insurance
program in the world
covers 8 million federal employees, former employees, family members and former
spouses
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Managed healthcare
Managed healthcare plans are an alternative to traditional healthcare plans
like fee-for-service plans
Health Maintenance Organization (HMO)
•
Managed healthcare plans allow plan sponsors to negotiate reduced rates for
their policyholders with hospitals, medical service providers, and physicians,
by including them in the network
In the past few decades, managed healthcare plans have become a popular
health insurance choice, as healthcare costs have increased
The type of managed plan you have will dictate how you obtain your medical
services.
•
“Gatekeeper” principle
–
Primary care provider (PCP) serves as a gatekeeper and must authorize all
medical services (visit to specialist)
–
Services not authorized by the PCP will generally not be reimbursed
–
Rationale for gatekeeper is to avoid unnecessary expenses
Preferred networks
–
Plans will only pay for services provided by healthcare providers that they
have contracted with, aka “In Network” providers
–
Plans will not pay for “Out of Network” providers
Main types of network health plans include:
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Point of Service Plan (POS)
•
Patient premiums are generally lowest among managed care plans
Preferred Provider Organization (PPO)
•
No gatekeeper
–
•
Patients can choose their own providers (specialists) without having to use
a designated PCP first
Preferred networks with some out of network coverage
–
Patient can see any healthcare practitioner they want, but they are
financially incentivized to see in-network providers
•
•
e.g., Patient pays 10% to see in-network vs. 50% to see out-of-network
Patient premiums are generally higher than HMO premiums
Point of Service (POS)
Hybrid PPO-HMO plans
Gatekeeper system like HMO
Primary care physician who makes referrals to specialists as needed
Members who see providers in the POS plan network generally pay a reduced
service fee
Members can see providers outside the plan network only if they receive a
referral from their primary care physician, plus they’ll generally pay a much
larger percentage of the cost for out-of-network provider services
Higher copayments for outside plan providers but lower premiums than PPOs
Managed care comparison
Integrated Delivery System
(IDS)
A network of healthcare organizations all under the same parent company
Provides all healthcare services to a group of patients, such as within a geographic
location
Includes PCPs, physicians, hospitals, pharmacies, and insurers
Note: Not all models include all groups
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