US Healthcare Systems PDF

US Healthcare Systems History of Pharmacy Pharmacy Organizations Prof. Dan Krinsky [email protected] 330.715.4689 Healthcare in the United States (or is it Sickcare?! More to come…) Prof. Krinsky Learning Objectives 1. List the key components of the...

US Healthcare Systems History of Pharmacy Pharmacy Organizations Prof. Dan Krinsky [email protected] 330.715.4689 Healthcare in the United States (or is it Sickcare?! More to come…) Prof. Krinsky Learning Objectives 1. List the key components of the US healthcare system 2. Describe the impact of insurance, regulation, policy, and public health on the US healthcare system. 3. Describe the recommendations from the Institute of Medicine report To Err is Human 4. Define the new areas of focus for Healthy People 2030 Top 10 Topics regarding Healthcare in the US 1. Healthcare providers 2. Components of healthcare 3. Delivery systems/models 4. Infrastructure 5. Regulation, Policy, Oversight 6. Public policy, prevention, reform 7. Payment: Insurance 8. Financing 9. Affordability/access 10. Pharmaceuticals and medical devices Intro: Ask yourselves these questions…  Is healthcare in America the best in the world? Close?  How are healthcare outcomes measured?  Is access to quality healthcare ATTAINABLE (for some? Most? All?)?  Is access to quality healthcare FAIR?  How much emphasis do we as a society place on PREVENTIVE care? Your New Health Care System | Visual.ly Intro: U.S. Healthcare System Recent information Healthcare - USAFacts  Intro: U.S. Healthcare System???  Health Care System OR - Sick Care System  Health Care System OR - Health Care Fragments Goals to be achieved by 2020:  Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death  Achieve health equity, eliminate disparities, and improve the health of all groups  Create social and physical environments that promote good health for all  Promote quality of life, healthy development, and healthy behaviors across all life stages  Leading Health Indicators: By 2020  Access to Health Services  Nutrition, Physical Activity, and Obesity  Clinical Preventive Services  Oral Health  Environmental Quality  Reproductive and Sexual Health  Injury and Violence  Social Determinants  Maternal, Infant, and Child  Substance Abuse Health  Tobacco use  Mental Health Leading Health Indicators: How’d we do? Leading Health Indicators Status Persons with medical insurance Improving Persons with a usual primary care provider No Change Persons with diabetes with A1C greater than 9% No Change Adults with hypertension with BP under control Improving Children receiving immunizations Improving Suicide Getting Worse Adolescents with major depressive episode in past 12 months Getting Worse Obesity among adults, children, and adolescents No Change Adults binge drinking in the past month No Change Adult cigarette smoking Improving Adolescent cigarette smoking in the past 30 days Target Met https://www.healthypeople.gov/2020/data-search/midcourse-review/lhi Released in August of 2020; Achieve by 2030  355 measurable objectives with 10-year targets  Newer Areas of Focus:  Opioid use disorder (OUD)  Youth e-cigarette use  COVID-19  Social determinants of health https://health.gov/healthypeople Health Disparities  Disparity exists when any population-level factor is related to a difference in a health outcome  Race, ethnicity, sex, sexual identity, age, disability, socioeconomic status, geographic location  Health Equity (Healthy People 2020 and 2030)  Attainment of the highest level of health for all people  Assessing the impact of social determinants of health Health Disparities Health Disparities Influence of Technology on Healthcare  Prescription processing  Prescriber order entry  Pharmacy automation  Decision support  Electronic health records  Therapeutic algorithms for decision support  Information Overload  Patients  Providers  1. Who provides/delivers care? Healthcare Providers Hospitals and Clinics: These range from large, specialized hospitals to smaller community clinics and urgent care centers. Primary Care Physicians: Often the first point of contact for patients, handling routine and preventive care. Specialists: Medical professionals with advanced training in specific fields, such as cardiology or orthopedics. Primary Care Physicians: Generalists who provide routine and preventive care. Specialists: Medical professionals with advanced training in specific areas of medicine. Nurses: Professionals who provide direct patient care, support, and education. Allied Health Professionals: Includes a range of roles such as physical therapists, occupational therapists, and medical technologists who support medical care. Pharmacists: Experts in medications who provide advice and dispense drugs.  2. Components of Healthcare Preventive Care: Services aimed at preventing diseases and maintaining health, such as vaccinations, screenings, and health education. Primary Care: Basic, ongoing health care provided by general practitioners, family doctors, pediatricians, and internists. Primary care focuses on overall health maintenance and management of common illnesses and conditions. Specialty Care: Advanced medical care provided by specialists in specific fields (e.g., cardiology, oncology). Specialists often manage complex or chronic conditions that require more detailed knowledge and treatment. Emergency/Urgent Care: Urgent treatment provided in emergency situations, typically at emergency rooms or urgent care centers.  2. Components of Healthcare Hospital Care: Includes inpatient care (care provided when a patient is admitted to a hospital) and outpatient care (treatment that does not require an overnight stay). Long-Term Care: Services for individuals who have chronic illnesses or disabilities that require extended assistance, such as nursing homes or assisted living facilities. Mental Health Care: Services focusing on mental and behavioral health, including counseling, therapy, and psychiatric care. Palliative and Hospice Care: Focused on providing relief from symptoms, pain, and stress of serious illness, with the goal of improving quality of life, especially for those with terminal conditions.  3. Delivery Systems/Models Private Sector: Includes private hospitals, clinics, and individual practitioners. Public Sector: Includes facilities and services provided by government agencies, such as Veterans Affairs hospitals and public health departments. Fee-for-Service: Traditional model where providers are paid for each service rendered. Value-Based Care: Focuses on providing high-quality care while managing costs. Providers are often incentivized based on patient outcomes and efficiency. Integrated Care Systems: Networks that coordinate care across different types of services and providers, often through Accountable Care Organizations (ACOs) or Patient-Centered Medical Homes (PCMHs). Networks of providers that offer a continuum of care, often including hospitals, primary care, specialty care, and ancillary services (e.g., Kaiser Permanente). 4. Healthcare Infrastructure  4. Healthcare Infrastructure Health Information Technology: Systems like electronic health records (EHRs) that support data management and communication across the health care system. Research Institutions: Universities and research centers that conduct studies to advance medical knowledge and improve health care practices. Public Health Programs: Initiatives focused on community health, disease prevention, and health education, often managed by local and state health departments.  4. Healthcare Infrastructure Evidence-Based Practice (EBP) http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021  4. Healthcare Infrastructure EBP (or Evidence-Based Medicine) Process STEP Explanation ASSESS the patient Clinical questions come from taking care of patients ASK the question Construct a well-built clinical question ACQUIRE the Select the appropriate resources and conduct a search evidence APPRAISE the Evaluate the validity (truthfulness) and applicability (usefulness) of evidence the information APPLY to the patient Talk to the patient, integrate the evidence with clinical knowledge and skills along with patient preferences to make decisions for care Self-evaluation Evaluate your performance with this patient  4. Healthcare Infrastructure Patient-Centered Medical Home Patient-Centered Medical Home or PCMH | Valor Health | Emmett Idaho  4. Healthcare Infrastructure Accountable Care Organization (ACO) BMC and Accountable Care - Boston Medical Center 4. Healthcare Infrastructure Bright Idea: How Accountable Care Organizations are changing healthcare | Blue Cross Blue Shield (bcbs.com) 5. Regulation, Policy, and Oversight  5. Regulation, Policy, Oversight Federal: Agencies like the Centers for Medicare & Medicaid Services (CMS) regulate and oversee national programs and standards. o Health and Human Services (HHS): ▪ Centers for Medicare & Medicaid Services (CMS): Oversees Medicare and Medicaid programs. ▪ Food and Drug Administration (FDA): Regulates pharmaceuticals, medical devices, and food safety. ▪ Centers for Disease Control and Prevention (CDC): Focuses on public health, disease prevention, and health promotion. ▪ National Institutes of Health (NIH): Conducts and funds medical research.  5. Regulation, Policy, Oversight State: States regulate health insurance markets, implement Medicaid programs, and set specific health care regulations. Regulatory Bodies: Organizations like the Centers for Medicare & Medicaid Services (CMS) and the Food and Drug Administration (FDA) oversee standards and regulations. Quality and Accreditation Organizations: assess and accredit health care organizations to ensure quality and safety. o The Joint Commission (JCAHO): Accredits and certifies health care organizations and programs. o National Committee for Quality Assurance (NCQA): Evaluates and accredits health care organizations for quality. o Institute of Medicine (IOM) o Healthcare Effectiveness Data and Information Set (HEDIS)  5. Regulation, Policy, Oversight  Starting January 1, 2022, consumers have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.  New rules aimed to:  protect consumers  restrict excessive out-of-pocket costs  emergency services must continue to be covered without any prior authorization  regardless of whether or not a provider or facility is in-network. cms.gov/nosurprises Consumer Information and Insurance Oversight | CMS Status of U.S. Healthcare  Institute of Medicine’s (IOM) Committee on the Quality of Healthcare in America  Two reports were published  To Err is Human: Building a Safer Health System (1999)  Crossing the Quality Chasm: A New Health System for the 21st Century (2001)  “To Err is Human” (remember, pre-2000 numbers)  44,000-98,000 people die in hospitals each year from preventable errors  $17-29 billion per year  Loss of trust in the system by patients  Loss of morale by health care providers  System errors are more common than individual errors  Potential causes:  Fragmented nature of health care delivery  Lack of education on error avoidance  Medical liability  Little financial incentive to improve the system “To Err is Human” Recommendations  National agency focused on patient safety  Public reporting system for errors  Increased performance expectations  Culture of safety  IOM: “Crossing the Quality Chasm”  Six aims for improvement: 1. Safe: avoiding injuries to patients from the care that is intended to help them 2. Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit 3. Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions  “Crossing the Quality Chasm” Six aims for improvement (cont.): 4. Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care 5. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy 6. Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status HHS: Department of Health and Human Services  NIH: National Institutes of Health  CMS: Centers for Medicare and Medicaid Services  FDA: Food and Drug Administration  CDC: Centers for Disease Control and Prevention  AHRQ: Agency for Healthcare Research and Quality  IHS: Indian Health Service  HRSA: Health Resources and Services Administration https://www.hhs.gov/about/agencies/hhs-agencies-and-offices/index.html State Level  Regulator  Boards of Medicine, Pharmacy, Nursing, Others  Payer  Medicaid  Provider  Departments of Health Payers  Insurance Companies  Organization  Employers  Contracts with providers  Government  Providers as employees  Services carved out  Payment Models  Pharmacy Benefit Managers  Fee-for-service  Influence  Capitation  Pricing  Quality Incentives  Services Covered  Providers Eligible Accreditation: Who is involved?  NCQA: National Committee for Quality Assurance  HEDIS (Healthcare Effectiveness Data and Information Set) Measures for health systems and plans  Joint Commission  Accreditation of hospitals  Pharmacy Accreditors  Center for Pharmacy Practice Accreditation (CPPA)  URAC https://www.urac.org/ HEDIS (Healthcare Effectiveness Data and Information Set) Measures  Developed by NCQA  Purpose: Quality, Benchmarking, Regulation/Accreditation  Five domains of HEDIS: 1. Effectiveness of care 2. Access/availability of care 3. Experience of care 4. Utilization and risk adjusted utilization 5. Health plan descriptive information/measure collected using electronic clinical data systems. Quality Measurement & Quality Improvement  Quality Improvement  Framework used to systematically improve care  Seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations  Quality Measurement  Allows identification of best practices in care 6. Public Health, Prevention and Healthcare Reform Centers for Disease Control and Prevention (CDC): Focuses on public health, disease prevention, and health promotion. National Institutes of Health (NIH): Provides funding for medical research and supports various health initiatives. Legislation: Laws and policies, such as the Affordable Care Act (ACA), that shape how health care is delivered and financed. Advocacy Groups: Organizations that influence health care policy and reform, advocate for patient rights, and promote public health initiatives.  6. Public Health/Reform What is Obamacare, or the Affordable Care Act (ACA)?  The comprehensive health care reform law enacted in March 23, 2010 (sometimes known as ACA, PPACA, or “Obamacare”). The law has 3 primary goals: Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level (FPL). o If your income is above 400% FPL, you may still qualify for the premium tax credit in 2022. o If your income is at or below 150% FPL, you may qualify to enroll in or change Marketplace coverage through a Special Enrollment Period. Expand the Medicaid program to cover all adults with income below 138% of the FPL. (Not all states have expanded their Medicaid programs.) Support innovative medical care delivery methods designed to lower the costs of health care generally. Affordable Care Act (ACA) - Glossary | HealthCare.gov  6. Public Health/Reform What is Obamacare, or the Affordable Care Act (ACA)?  How the health care law protects you Requires insurance plans to cover people with pre-existing health conditions, including pregnancy, without charging more Provides free preventive care Gives young adults more coverage options Ends lifetime and yearly dollar limits on coverage of essential health benefits Protects choice of doctors Affordable Care Act (ACA) - Glossary | HealthCare.gov Health insurance rights & protections | HealthCare.gov 7. Insurance Private Insurance: Offered by employers or purchased individually. Major providers include UnitedHealthcare, Blue Cross Blue Shield, and Aetna. Public Insurance: Includes government programs like: o Medicare: A federal program primarily for people aged 65 and older, as well as younger individuals with disabilities. o Medicaid: A joint federal and state program that provides health coverage to low-income individuals and families. o Children’s Health Insurance Program (CHIP): Provides coverage to children in families with incomes too high to qualify for Medicaid but too low to afford private coverage.  7. Insurance Key aspects of health insurance: o Premiums: Regular payments made to an insurance company to maintain coverage. o Coverage: Health insurance plans typically cover a range of medical services, including doctor visits, hospital stays, prescription drugs, and preventive care. o Cost Sharing: Insurance plans usually involve cost-sharing mechanisms like: ▪ Deductibles: The amount you pay out-of-pocket before the insurance starts covering costs. ▪ Copayments: Fixed amounts you pay for specific services, such as $20 for a doctor’s visit. ▪ Coinsurance: A percentage of the cost of services you pay after meeting your deductible.  8. Healthcare Financing and Finances Key aspects include: Out-of-Pocket Payments: Payments made directly by individuals for health care services not covered by insurance. This includes copayments, deductibles, and full payments for services if uninsured. Insurance Payments: Health insurance plans cover part of the costs, based on the terms of the policy. Public Funding: Government sources that provide financial support for health care services. Examples include: o Medicare: Federal funding for seniors and certain individuals with disabilities. o Medicaid: Joint federal and state funding for low-income individuals and families. o CHIP: Federal and state funding for children in low-income families.  8. Healthcare Financing and Finances Key aspects include: Private Funding: Funds provided by private entities or out-of-pocket payments by individuals, including contributions from employers who provide health insurance benefits. Grants and Subsidies: Financial support provided by government or non-profit organizations to help cover the cost of health care services, often targeted towards specific populations or purposes. Healthcare System The Cost Conundrum: Pharma’s Role in US Healthcare (Infographic) | Reuters Events | Pharma Our Healthcare System Our Healthcare System  9. Affordability and Access Challenges: Many Americans face issues related to high costs, lack of insurance, and disparities in access to care. Affordable Care Act (ACA): Implemented in 2010 to expand access to insurance, improve coverage quality, and reduce costs. It introduced measures like the Health Insurance Marketplace and mandates for coverage. Access: Ensuring that all individuals have access to necessary health care services. Quality: Providing high standards of care and improving health outcomes. Cost: Managing and reducing the financial burden of health care on individuals and the system as a whole. 10. Pharmaceuticals and Medical Devices Regulation: The Food and Drug Administration (FDA) oversees the approval and safety of drugs and medical devices. Market: Includes a wide range of medications and technologies, often leading to high costs due to innovation and market dynamics. Other: New Regulations affecting Access, Payment, Structure  Outcomes  Outcomes  Cure of a disease  Elimination or reduction of a patient’s symptomatology  Arresting or slowing of a disease process  Preventing a disease or symptomology  Quality of Life  Satisfaction with life  Sense of well-being  Ability to perform activities (recreational and necessary)  Ability to meet social role expectations (worker, spouse, friend, parent) Consider This…  Is health care in America the best in the world?  How is health care quality measured?  Death rates  Lack of disease  Degrees of happiness  Quality of life Consider This…  Is access to quality health care attainable? Avoidance of disparities Proper technological advances How much can we pay? Best Healthcare in the World 2024 (worldpopulationreview.com) World Health Systems Facts - Just the facts. No Bias. Healthcare System What Country Spends the Most on Healthcare? (investopedia.com)  Key Points  Healthcare in America is delivered by myriad people, in various settings, through various channels, resulting in varying levels of quality and outcomes  We have a complex system that involves private and government funding  The US has the most expensive healthcare per capita, yet doesn’t crack the top 20 in quality  A number of organizations, such as the Institute of Medicine, have proposed ideas for quality improvement  New models such as the Patient Centered Medical Home, and Accountable Care Organizations, strive to put the patient first and focus on quality outcomes  65 History of Pharmacy & Pharmacy Organizations  66 Objectives At the conclusion of this part of the lecture, students will be able to:  Outline the professional origins of the American pharmacist  Describe the evolution of pharmacy practice and education  Identify significant milestones that influenced pharmacy practice  Recognize different pharmacy career paths and professional organizations  67 Resource for information The Pharmacist in Public Health: Chapter 2: Introduction to the History and Profession of American Pharmacy Available: www.PharmacyLibrary.com  68 Ancient Pharmacy  ‘Medicinals’ have been gathered or produced from vegetables, minerals, and animals for the mediation of disease and suffering since the dawn of humanity  Pharmacy existed for thousands of years before a specialized occupation and a set of scientific disciplines developed  Hippocrates (circa 425 BCE – ‘Before Common Era”)  Dietary regimens and environmental changes to produce health  Medicines were occasionally used  Galen (second century CE – “Common Era”)  Believed that drugs could restore the humoral balance within patients  Polypharmaceutical compounds → “shotgun prescription”  No distinct class of pharmaceutical practitioners  Fast forward to…. 69 The Middle Ages to the 17th Century  Pharmacy as a specific occupation arose in the Islamic world during the Middle Ages (circa 400 CE – 1453)  Scholars built on the writings of Greek medical authorities to create a set of basic medical texts  Traders brought new medicinals from Asia into the Materia medica  Demands for new medicinals lead to specialists → precursors to today’s pharmacists  Drug shops catered to the needs of physicians and the public  Pharmacy in southern Europe had separated from medicine (mid 1200s)  Apothecaries in European cities became established members of the emerging middle class of small merchants and protoprofessionals  70 Middle Ages to the 17th Century  Modern worldview began with the huge cultural shift during the Renaissance (1400s)  The end of the 1400s brought many new medicinal discoveries  ID of new diseases and new medicines encouraged the development of the pharmaceutical enterprise  Development of medical and pharmaceutical books (herbals, medicinal plants, formulas)  Some of these became the first pharmacopeias – milestone in the development of the pharmacy profession  For nearly 500 years, pharmacopeias have served the purpose of defining the characteristics of the drugs and preparations made and dispensed by pharmacists  Physicians desired standards to yield uniformity in the preparation of drugs and their prescriptions by apothecaries  71 Middle Ages to the 17th Century  Apothecaries on the European continent solidified their position as an occupation that controlled medicine-preparation and sales during the 16th and 17th centuries  England: haphazard healthcare system blocked the development of professional control  University-educated physicians, apprenticeship-trained apothecaries, chemists, and druggists controlled the drug trade  English settlers came to dominate the North American continent during this period  The foundations of the American health care system arose in the disarray of the English style rather than the stability of the continental European system  72 Colonial America (1600-1800s)  Apothecary shops were found only in the largest cities in colonial America  Operated more as manufacturers and wholesalers of drugs and medicines than as retailers  Because physicians dispensed their own drugs, prescriptions rarely found their way to apothecaries  73 Colonial America (1600-1800s)  Philadelphia established the Pennsylvania Hospital in 1751, which included the first hospital pharmacy  The hospital pharmacist’s duties: going on rounds, practicing some minor medicine, taking care of the hospital’s accounts and library, performing odd chores, and managing the pharmacy  John Morgan (hospital pharmacist) – one of the pivotal characters in the history of American medicine and pharmacy  Proposed separation of the practices of medicine and pharmacy  Physicians should write out their prescriptions for pharmacists to compound and dispense  Separation of practices led to unhappy patients and financial disparities for physicians  Pharmacy and medicine were still not clearly distinct occupations in the United States by the end of the 1700s Early Landmarks in American Pharmacy 74 1800’s – origins of the Pharmacist position  Two notable events demonstrated that pharmacy had arrived as a separate occupation in American society 1. A group of physicians founded the United States Pharmacopoeia in 1820  Book of standards to prevent trouble or uncertainty in the relationship between physicians and apothecaries – initial standards for early pharmacists 2. Establishment of the Philadelphia College of Pharmacy in 1821  Became a model for occupational development that was emulated in other large cities in the United States  Development of the American Journal of Pharmacy – the first pharmacy journal  Composed the first code of ethics for pharmacists  Relationships with Physicians 75  Physicians supported the appearance of pharmacists near their practices and welcomed them as subordinate colleagues  Pharmacists and apothecaries did not compete directly with physicians for business  Provided checks and balances and helped ensure drug quality  The relationship between physicians and pharmacists varied over the next few decades  Medical schools increased their output of physicians during the 1840s  Physicians reverted to setting up shop and selling drugs as well as advice  Pharmacists competed by doing the same  The borders between pharmaceutical and medical practice became unclear again during the 1850s  Pharmacists began “counter prescribing” – recommending favorite preparations “over the counter” for customers  They also solidified their position as the prime sellers of patent medicines (new concept)  Founding of the 76 American Pharmaceutical Association  William Proctor Jr. and Edward Parrish  Aimed to establish standards for imported drugs and form a national pharmaceutical organization  American Pharmaceutical Association (APhA) national organization – established in 1852  Exerted great influence on professional development  Thefounding of APhA came at an opportune time, when pharmacy needed a voice of leadership  77 Mid 1800’s/Civil War  The growth of American pharmacy accelerated as the 1850s progressed while the number of physicians slightly declined  Resulted from the entry of large-scale manufacturing into pharmacy  With large firms doing much of the complicated work, “shopkeepers” entered the ranks of pharmacists  Physicians saw pharmacy declining  Late 1850s: increased the tension between physicians and pharmacists  American pharmacy and medicine communities ceased their battles and called a truce with the beginning of the Civil War (1861)  Business in the cities slowed during the war → many pharmacists lost their stores  The war greatly helped the manufacturers of medicines – sold huge quantities to the armed forces  Wholesalers and Corner Drugstores 78  Many early American pharmacies arose from the “front ends” of wholesale businesses  Drug wholesalers fixed up a public entrance to the warehouse for physicians and shopkeepers to enter for placing orders → attracted walk-in customers  Work areas of the apothecary were at the front of the shop  Providedlight from the windows and allowed customers to watch the apothecary in action  The Classic Drugstore with Soda 79 Fountain: Post Civil War  Redesign of the American drugstore into its classic form  The worktable was moved to the rear of the store and hidden behind a screen  The preparations necessary for compounding prescriptions were now made outside the pharmacy  Front end became more ‘retail’: sale of tobacco, fancy goods, candy magazines, and soda fountain specialties  By 1929, almost 60% of American drugstores had a soda fountain  The corner druggist was now established as part of American life  ‘Drugstore Era’ in Retrospect 80  Pharmacy’s place in American culture is strongly tied to the vision of the pharmacist as the proprietor of a drugstore  The proprietors of drugstores were called “druggists” by the public  BUT: within the profession, they preferred the term “pharmacist”  “Apothecary” was still retained by a few shop owners or those who operated a prescription laboratory only  Pharmacist position in the American health care system was firmly established by the end of the 1800s  Physicians agreed to dispense medicines only rarely  Pharmacists agreed to limit their diagnosing and prescribing to cases of minor ills and emergencies  The pharmacist was known to be the compounder of prescriptions  ‘Drugstore Era’ in Retrospect 81  Pharmacists gave up their role as primary medical practitioners but continued to act as secondary providers through the sale of over-the-counter remedies and first-aid items  The drugstore era saw the beginnings of modern professionalism in the passage of state pharmacy laws mandating examinations and licensing  Modern schools of pharmacy set the stage for scientific advancement and professional development  At the end of the drugstore era, the seeds of great change were already sprouting  Department stores began adding pharmacies in the late 1800s  Had mixed success but foreshadowed pharmacies in mass merchandisers  82 Credentials and Models of Professionalism  State schools of pharmacy played an important role in the development of pharmacy as a recognized profession  Roughly 1 in 20 American pharmacists had finished formal schooling in pharmacy prior to the Civil War  By the 1870s professional credentialing popular in the United States  Prestige attracted students to the growing number of schools even though state laws did not require a pharmacy school diploma for licensure until the early 20th century  Disagreement over the new professionalism led to a split within the ranks of APhA  For most of the next century, this division hindered the profession’s climb toward full professional status  Pharmacy in the 20th Century 83 Practice Reform and Education  Almost all pharmacists worked in small independent pharmacies, large established hospitals, or clinics by the beginning of the 20th century  New York passed a law stating that all new pharmacist registrants in that state would be required to possess a diploma from a recognized school of pharmacy after 1910  The minimum course was 2 years of study  A wide variety of schools were available  During the next half century, efforts were concentrated on educational reform as the vehicle for professional improvement  The pursuit of professional status charged forward with the pharmacy curriculum as its standard  Pharmacists’ Extended Training 84 Early 1900’s Two events took place in 1915 that changed many pharmacists’ minds about educational requirements and spurred their leaders into action  Abraham Flexner – respected reformer of medical education  Declared that pharmacy was not a profession  He argued that although pharmacists did contribute to society through their specialized skill, physicians bore the responsibility for the medicines ordered  The War Department decided that registered pharmacists would not routinely receive commissions because their professional education was so minimal  Pharmacists turned to the best schools and colleges of pharmacy to help strengthen their position as professionals  By the middle of the 20th century, pharmacy schools taught students the science and technology behind medication manufacturing  Pharmaceutical Survey and the 5-Year 85 Program: Mid 1900’s  The Pharmaceutical Survey was inaugurated on April 15, 1946  Stimulated by the decision of the War Emergency Advisory Committee that indicated a low regard for pharmacists  Nearly every aspect of pharmacy was scrutinized  The nation turned to the issue of health  Congress passed the Hill-Burton Act – resulted in the building of hospitals and clinics in underserved areas  The federal government turned its attention to the regulation of medicines in the community setting  The Supreme Court (1948) ruled that FDA could enforce its designation of prescription-only status for certain medicines  Pharmaceutical Survey and the 5-Year 86 Program: Mid 1900’s  General Report of 1949 recommended development of a six-year program of education and training → professional degree of Doctor of Pharmacy  Adoption of the 5-year program (1954) – beginning with the entering class of 1960  When the PharmD debate began in the 1950s it occurred in the context of broadening the education of the future pharmacist  Much of the attraction of the professional doctorate was the added opportunity for more liberal education  Pharmacists who followed this new course of study would be well educated and thus worthy of the respect of other professionals and of the public.  87 Early Legislation and RPh Role  Amendment to the 1938 Food, Drug, and Cosmetic Act  Introduced in 1951 by congressman Carl Durham and Senator Hubert Humphrey  Clarified the nature of what constituted a prescription drug  Medicines were divided into prescription-only and nonprescription (over-the-counter) medicines  State laws (1950s): forbid the substitution of a generic drug for a prescribed brand product  Retail pharmacists protested but followed the new law  Hospital pharmacists resisted and worked to devise systems that allowed for generic substitution  Blanket procedures allowed hospitals to run under efficient formulary systems by the 1960s  The restrictive anti-substitution laws remained until the 1970s → tied the hands of community practitioners  The APhA Code of Ethics of 1952 made the pharmacist’s limited role quite clear:  “The pharmacist does not discuss the therapeutic effects or composition of a prescription with a patient”  Academic and Practice Reforms 88 The period of academic reform solidified the place of pharmacy within academia  Pharmacists of the 1950s were more concerned with products, not patients  Professional opportunities available to pharmacists were extremely limited → pharmacists concentrated on overall service to the customer  Attempts to use a more extensive pharmacy school curriculum failed  Pharmacy students learned all the steps necessary for manufacturing medicines  Found their practice reduced to counting and pouring  Different issues confronted institutional pharmacy  While the scope of community practice shrank in the 1950s, practice in the hospital setting expanded  Hospital pharmacists expanded their responsibilities – prescription practice, bulk manufacturing, advanced administrative duties, sterile techniques, drug information  The stage was being set for change in American pharmacy!  Clinical Pharmacy Era 89 (1965-1990)  The clinical pharmacy era (1965–1990) was seen as a transitional period in professional development – primarily in HOSPITALS  Pharmacists’ roles transitioned from “count and pour” to “drug information experts”  P&T committees and hospital formularies brought pharmacists into the therapeutic side of practice  Pharmacist’s clinical role was expanding  A great paradigm shift had begun in community pharmacy  The person who stood across the counter from the pharmacist was undergoing a transformation from “the customer” into “the patient”  After150 years of serving the desires of customers, pharmacists were caring for the needs of patients (sometimes…) P&T = pharmacy and therapeutics  Clinical Pharmacy Era 90 (1965-1990)  A few progressive schools of pharmacy quickly adapted to the new concept by adding a few courses in clinical therapeutics to their curricula  Graduates of pharmacy schools in the 70’s entered a health care environment not quite ready for ‘clinical pharmacy’  The community setting dismissed clinical pharmacy as too expensive and time consuming  Therapeutic advances and the flourishing drug industry of the 1960s forced pharmacists into decision-making roles → pharmacy profession added drug information and patient counseling  Change occurred throughout the 1970s  Professors turned their teaching toward contemporary practice issues and future challenges  Millis Commission report (1975) – encouraged the expansion of PharmD programs through the addition of more clinical education and instruction in social and behavioral pharmacy  Other Transitions in Health Care 91 During the ‘Clinical Pharmacy’ Era  Other important transitions occurred during the clinical pharmacy era  Health insurance developments (1950s) and the passage of Medicare and Medicaid legislation (1965) created a system of third-party payment for pharmacy services  Drug companies shifted some medicines from prescription-only to nonprescription status  Hospital pharmacists assumed primary responsibility for the preparation of intravenous products and established advanced drug distribution systems  Introduction of computer systems that allowed pharmacists to track patient profiles, check for drug interactions, and improve record keeping  Technology applied to dispensing improved workflow for pharmacy practitioners  Managed Care vs. Pharmaceutical 92 Care  A new direction for success was shown in practices where concrete strategies were developed to manage medication problems with specific diseases  Pharmacists in Asheville, NC demonstrated that active management of diabetes treatment could reduce costs and improve the health of patients in the late 1990s  Medication therapy management (MTM) captured the attention of professional leaders and governmental officials as a framework of care  The Medicare Prescription Drug Improvement and Modernization Act of 2003 and the introduction of the Medicare prescription medication benefit (Part D) in 2006 pushed MTM to the forefront of pharmacy’s consciousness The Pharmacy Profession Today 93 Pharmacy Today and Tomorrow 94  95 Summary  At the beginning of the 1800s, pharmacists became common in American cities and towns  Provided drugs and medicines of reliable strength and purity  Utilized specialized knowledge of botany, chemistry, and pharmacy to compound medicines  Pharmacists invented the drugstore  Unique part of American culture where health care and retail intermingled  A century and a half later, American pharmacists invented clinical pharmacy and began the transformation of a customer into a patient  By accepting responsibility for proper drug use and implementing this decision through therapy management strategies, pharmacy is on the threshold of a new era Pharmacy Organizations  97 Objectives At the conclusion of this part of the lecture, students will be able to:  Define the role of professional pharmacy organizations  List at least 3 of the main professional pharmacy organizations and the types of pharmacists they represent  Describe why it is important to join and be involved in a professional pharmacy organization Pharmacy Organizations: Alphabet Soup 98  99 Pharmacy Organizations  What is their role? Professional pharmacy organizations educate, support, and unify members. They also help influence and monitor pharmacy-related legislation, promote research in the field and standardization, and strive to improve patient care.  Why should you join one? More than one? Which one?  100 Pharmacy Organizations: Examples American Pharmacists Association (APhA)  Oldest and largest pharmacy organization  Occupies a prominent position in the nation’s capital both politically and geographically  More than 50,000 members  Pharmacists, pharmaceutical scientists, pharmacy students, pharmacy technicians Congress expects the APhA to speak for pharmacy  101 Pharmacy Organizations: Examples American Society of Health-System Pharmacists (ASHP)  Represents pharmacists who serve as patient care providers in hospitals, health systems, ambulatory clinics, and other healthcare settings.  Accrediting body for pharmacy residency programs  ASHP midyear clinical meeting attracts 20,000 participants and hundreds of exhibits  Its research and education foundation funds numerous fellowships in specialized areas of pharmacy  102 Pharmacy Organizations: Examples National Community Pharmacists Association (NCPA)  Founded in 1898  The voice for independent pharmacy, representing over 19,400 pharmacies that employ more than 230,000 individuals nationwide. Independent pharmacy is a $94 billion marketplace.  Community pharmacists are local health care problem-solvers who can customize solutions to local health challenges for groups and employers.  103 Pharmacy Organizations: Examples American Association of Colleges of Pharmacy (AACP)  Founded in 1900  National organization representing pharmacy education in the United States.  Advance pharmacy education, research, scholarship, practice and service, in partnership with members and stakeholders, to improve health for all.  104 Pharmacy Organizations: Examples American Society of Consultant Pharmacists (ASCP)  Org that promotes healthy aging by empowering pharmacists with education, resources, and innovative opportunities.  Pharmacists and pharmacies that manage medications of older people and the medically complex  Pharmacists practice in:  Long-term care facilities  Academia and government American College of Clinical Pharmacy (ACCP)  Represents the interests of clinical pharmacists  The driving force behind the recognition of pharmacotherapy as a certifiable pharmacy specialty and board certification (BCPS, others)  105 Pharmacy Organizations