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PMD 350 Health Care Systems -- Summer 2004 2nd Edition
Bouvé College of Health Sciences
School of Pharmacy
Course Description:
This course examines the evolution of the American health care delivery system
from the early forms of organized institutional health care through the dynamic, and increasingly
integrated and managed care systems of the present health care industry. We will explore the
interactions of regulatory, economic, political and social aspects of the health care system with
particular emphasis on pharmacy practice. Current proposals for health reform and pharmacy
benefit coverage will be compared. Throughout the course we will analyze the impact and
consequences of actions in one era on the structure and function of health care and professional
pharmacy practice in later years and project these trends into the future.
Instructors:
Judith Barr, MEd, ScD; Associate Professor, School of Pharmacy
Office 105B DK
Phone 617-373-4188
e-mail j.barr@neu.edu
Gerald Schumacher, PharmD, PhD; Professor of Pharmacy
Office 105A DK
Phone 617-373-3203
e-mail g.schumacher@neu.edu
Credit hours:
3 semester hours
Meeting times:
Wednesday 8:30-10:20 and Thursday, 8:30-9:20am
Location:
CVS Amphitheater, 10BK
Text:
Understanding Health Policy: A Clinical Approach, 3rd Edition. Thomas Bodenheimer
and Kevin Grumbach. 2002; Lange Medical Books, McGraw Hill.
Reading packet:
There will be 2 packets at Gnomon Copy. The first is ready now; the second, in June.
Additional resources:
We encourage you to subscribe, at no cost, to the National Association of Chain Drug Store’s
(NACDS) SmartBrief, “a FREE news briefing delivered directly to you through e-mail.
Delivered daily, Smart Brief takes you straight to the news that retail pharmacy professionals
need to stay ahead.” The NACDS web site is http://www.nacds.org/ or you can subscribe
directly at http://www.smartbrief.com/nacds/.
Prerequisite:
Completion of PharmD curriculum through Spring semester third year.
Completion of middler year writing requirement
Commitments
We commit to providing a current and relevant course with fair evaluations returned in a
timely manner
Expectations:
1) Mutual respect -- be on time, turn off your cell phone, don't have in-class conversations,
outside of group discussions, when class is in session.
2) Mutual hard work
The Zeroth Law of Education Thermodynamics – “Nothing Works If The Students Don't”
• Check Blackboard and e-mail daily
• Read assignments BEFORE class
• Contribute to in-class discussion of topics, articles, and problem sets
• Ask questions and seek help if you are unclear
• Be an equal participant in your in-class discussions
• All work must be your own
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Course Policies:
1. You must have a Blackboard and e-mail account. We will communicate with you
about course updates, assignment changes, or other course information via Blackboard
and e-mail. You will be expected to check your e-mail daily. Remember, the content for
this course is part of the dynamic health care system and policy worlds. Things can
change frequently. An important part of the class requires you to monitor these policy
changes and assess their impact on the practice of pharmacy.
2. Grades will be posted on Blackboard. We will be as accurate as possible in posting
your grades; however, occasionally errors can occur with entering of data. It is your
responsibility to check Blackboard and confirm that the grade you received on the
returned assignment/test, is the grade that was posted. You must notify us within one
week of the grade’s posting if there is an error in your Blackboard grade.
3. You may tape record the lectures.
4. Tests are given ONLY at the scheduled times. There are NO provisions for make-up
tests or alternative date/time for scheduled tests.
5. Cell phone/pagers must be turned off before entering class. Head phones and
activated beepers and cellular phones are NOT permitted in the classroom. Unless
cleared with the instructor prior to the class, if a cell phone or beeper rings, you will be
told to leave the room for the remainder of the class.
6. Notes or other study aids may NOT be used during test taking. Calculators are not
required in this class and may not be used during exams. This includes palm pilots.
7. You must submit only original work; if not, you will FAIL THE ENTIRE COURSE.
8. You will receive a group grade for the group discussion. However, we reserve the
right to alter that grade if a student is not participating in the group discussion.
9. If you have a disability that requires special classroom seating, testing, or other
arrangements, notify us by Monday, May 10. Documentation from the Office of
Disability Resources may be required.
10. Given that this is a large class, we need your help so that we can get to know you. We
will give you a 5”x8” index card. Place a photograph of yourself on one side and on the
reverse list: your name, your e-mail address, your telephone number, where you were born,
where you graduated from high school, and any hobbies or interests. We have really found
these cards helpful to be able to link names with faces.
Academic integrity statement: All examination answers and all components of assignments submitted for
this class (unless properly attributed/quoted) must be original work. Any form of academic dishonesty will
result in a failure of the entire COURSE. A report of the academic misconduct will be filed with the Office of
the Dean, School of Pharmacy.
Other course policies:
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Assessment:
In addition to the above, students are expected to maintain the highest standards of
honesty and integrity according to the student code of conduct at Northeastern
University. The code of conduct is available at the following Web address:
http://www.neu.edu/handbook/studenthandbook.pdf
Students are expected to be familiar with the provisions of this code and conduct
themselves accordingly.
Any request to re-examine the grade on an assignment, test, or project must be made
within 24 hours of return of the graded material to students. Any exams/answer
keys/papers returned to the instructor for regrading that have been altered since the
graded material was returned will result in a grade of F for the entire COURSE.
SUMMARY – An automatic grade of F for the COURSE will occur if
• You incorporate ANY nonoriginal quotes/answers into your submitted
papers/exams without proper attribution.
• You alter graded and returned course material and submit it for regrading.
Your grade for this course is determined by your performance on four methods of
assessment: a midterm, a cumulative final, summaries of group discussions, and an
individual paper. At a minimum, you must achieve a grade of 70% or higher on at least one
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of the tests. Overall, you must achieve an average grade of 73% (C) to successfully complete
the course. If not, the course is next offered in Summer 2005.
1. Midterm
25%
June 23
2. Final (cumulative)
30%
3. Group summaries
25%
We will include at least 11 small group discussions during the 28 class sessions.
The purpose of these discussions is to enable you to examine issues more deeply and to
develop critical thinking and communications skills. By discussing and applying, with a
small group of fellow students with varying early pharmacy practice experiences, you
will be able to apply the topics of the course, examine your assumptions concerning these
topics, relate the topics to new situations, examine your own beliefs, and develop
consensus opinions. For all class sessions, sit with your group in the indicated area and
discuss the questions you are given.
Members of the group will rotate three roles: prompting the discussion,
summarizing the comments, and writing a brief paragraph of the group's conclusions. All
members of the group sign the report, indicating your role for that discussion topic. Your
group will receive a grade of "2" for acceptable, "1" for needs improvement, or "0" for
not acceptable. You must be present to receive credit for a group summary. If you are
present and participate in all group discussions, you will receive the group grade;
however, we do reserve the right to modify that grade if you are not an active participant
in these group discussions.
Some of the group discussions will be small projects/activities and will receive
double credit. These will be identified in advance.
20%
Paper due July 15
4. Individual Paper
A 5-page paper on a contemporary issue confronting health care or pharmacy policy practices.
Use at least 10 references (at least 5 must be primary sources), all of which must be no more
than 2 years old; journals, newspaper, magazines, and Web sites may be your best sources. A
detailed description of the requirements for the paper, which includes a reflection section, will
be distributed separately.
Goals:
The goals of this class are to prepare future pharmacists
• to critically analyze the incentives and disincentives inherent within the components of the health
care delivery system so that as pharmacists, you can maximally contribute in an ethical and costeffective manner, to your clients and institutions
• to be contributing members to the conversation on the future of the American health care
systems, the future of pharmacy practice, the future of health care and pharmacy benefit coverage,
and the future of the health of the nation.
To achieve these goals you need to be aware of the past and present so that you can influence the
future. When reading the text and articles, integrate them with earlier class assignments and
discussions and ask yourself:
• Why and how did this happen? What were the alternatives? What incentives
or disincentives were created? For whom?
• What is its impact on access and equity? health outcomes?
• How might it affect the quality of care?
• Could it change how and where health care is delivered? how you practice?
• What are the major social, political, and economic consequences of this topic?
• How has the changing health policy affected the structure of health care delivery?
• How will the changing health care system and policy affect the practice of pharmacy?
• How have policies and structures affected the health of the nation?
Course objectives:
Content objectives are found at the end of the syllabus.
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1. Wednesday, May 5
Course overview
Bloom's Taxonomy of Learning
“Major Categories in the Taxonomy of Educational Objectives” accessed at
http://faculty.washington.edu/krumme/guides/bloom.html
Code of Ethics of Pharmacists and Oath of a Pharmacist
Medicare Prescription Drug Benefits
To have completed by first class: Take the Medicare Prescription Drug Benefits
Continuing Education course offered by NACDS at the following site:
http://nacdsfoundation.org/ Click on the first main link to the CE, then, register at that
site. Submit the print-out of your CE credit and make a copy to include in your portfolio
http://www.cms.hhs.gov/media/press/release.asp?Counter=990
2. Thursday, May 6
Medicare Prescription Drug Benefits
Packet: Medicare Approved Drug Benefit Discount Card Tip Sheet. Accessed at
http://www.medicare.gov/Publications/Pubs/pdf/11071.pdf
Packet: Kowalczyk, L. Drug discount plan moot for many in Mass. The Boston
Globe, April 20, 2004
Objective: Given a patient inquiring about the Medicare drug benefit program, determine
the appropriate response to the question, the eligibility of the individual for the
program, and the economic impact to that individual.
3. Wednesday, May 12
The Uninsured: National Cover the Uninsured Week
Home Web site for the week: http://covertheuninsuredweek.org/
Packet: Health Care Coverage in America: Understanding the Issues and Proposed
Solutions accessed at http://covertheuninsuredweek.org/materials/files/IssuesGuide.pdf
Packet: Guide to Finding Health Insurance Coverage: Massachusetts accessed at
http://covertheuninsuredweek.org/stateguides/pdf/MA.pdf
Text: Chapter 3, pp 15-19
4. Thursday, May 13
What can pharmacists do to help the uninsured?: Panel Discussion
Yolanda Hardy, PharmD: NU faculty member at Upham’s Corner Health Center
Michelle Jacobs, PharmD: NU faculty member at Whittier Street Health Center
Jenny VanAmburgh, PharmD: NU faculty member at Harborview, Neponset Health Center
Objective: Given an uninsured individual inquiring about drug benefits, recommend at least
three possible sources of assistance with medication coverage.
Web site assistance: http://www.needymeds.com/
5. Wednesday, May 19
The Massachusetts Legislature and How a Health Care Bill Becomes Law
What is pharmaceutical care?
Massachusetts and the Collaborative Practice Act - The Intersection of Pharmacy Practice and
Political Action
Todd Brown, RPh, MHP, Associate Clinical Specialist, NU
Executive Director, Massachusetts Independent Pharmacists Association
Packet: The United States House of Representatives’ Legislative Process as accessed
at: http://www.house.gov/house/Tying_it_all.html
Packet: Lawmaking in Massachusetts as accessed at:
http://www.state.ma.us/legis/lawmkng.htm
Packet: How a Bill Becomes Law in Massachusetts as accessed at:
http://www.ma.lwv.org/govbilllaw.shtml
Packet: Hepler CD, Strand LM. Opportunities and responsibilities in
pharmaceutical care. Am J Hosp Pharm 1990;47:533-43
Packet: Ramsey LA, Ross B. Innovation in pharmacy practice: disease
management. Drug Topics, May 20, 2002.
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6. Thursday, May 20
The Massachusetts Collaborative Practice Bill S 2158
Objective: Express your opinion concerning S2158 in written form to a member of
a Massachusetts legislative body
7. Wednesday, May 26
Is Health Care an Economic Market?: Payment Systems or Rationing
How Do We Pay for Healthcare?: Evolution in the forms of health insurance.
The distorting effect of health insurance on the supply, demand, and price of health care
services
Medicare 2004 Benefits as accessed at
http://medicare.custhelp.com/cgibin/medicare.cfg/php/enduser/std_adp.php?p_faqid=1444&p_created=1066324968
Text: Chapters 2, 4, 8 (Chapter 3 complements the Cover the Uninsured material)
Packet: “Why health care has no Wal-Mart”, Business Week, April 21, 2004 as
accessed at
http://www.businessweek.com:/print/bwdaily/dnflash/april2004/nf20040421_2730_d
b_080.htm
Reinhart UE, Hussey PS, Anderson GF. US health care spending in an international
context. Health Affairs 2004;23:10-25.
8. Thursday, May 27
Introduction to Managed Care and Capitation
Text: Chapter 5
Packet: Aventis/Managed Care Digest Series 2003/HMO-PPO/Medicare-Medicaid
Digest as accessed at www.managedcaredigest.com pp 5-16, 50-52, 65-69 , 88.
9. Wednesday, June 2
Managed Care, Its Forms, and Its Impact on Health Care Systems
Organization of Healthcare
Text: Chapters 6 and 7
Packet: Aventis/Managed Care Digest Series/Institutional Digest 2003, p20-24, 32
as accessed at www.managedcaredigest.com
10. Thursday, June 3
How Is Pharmacy Organized?
Pharmacy Manpower
Text: Chapter 17
Packet:
1. “Implementing Effective Change in Meeting the Demands of Community
Pharmacy Practice in the United States”. A White Paper co-written by National
Association of Chain Drug Stores (NACDS), American Pharmaceutical Association
(APhA), and National Community Pharmacists Association (NCPA). August 1999.
2. “Electronic Prescribing and the Pharmacy”, NACDS Chain Pharmacist Practice
Memo, August 2000.
3. To send letter to your Congressperson about the Pharmacy Education Aid Act of
2003: http://capwiz.com/taacp/mail/oneclick_compose/?alertid=4424501
11. Wednesday, June 9
Health Promotion and Disease Prevention (HPDP)
http://www.healthypeople.gov
Paper Topic and Outline Due
Text: Chapter 11
Packet:
1. Healthy People 2010 (list of indicators and goals)
2. King, D. “State of the nation’s health: needs improvement” with “Healthy People
2000 Report Card. The Boston Globe, 12/27/1999.
3. Heaton A. Public health, managed care, and pharmacy: an evolving trifecta. J
Managed Care Pharm 2001; 7:12-16.
4. Kotecki JE, Elanjian SI, Torabi M. Health promotion beliefs and
practices among pharmacists. JAmPharmAssoc 2000;40:773-779.
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5. Stein R. “Obesity passing smoking as top avoidable cause of death”, Washington
Post, March 10, 2004
6. Healthy habits pay off, literally”. newsobserver.com, May 16, 2004. Accessed at
http://newsobserver.com/business/v-print/story/3591218p-3192841c.html.
12. Thursday, June 10
Ethics in Health Care
Text: Chapter 13
Packet: http://www.csmonitor.com/2004/0426/p11s01-usju.html "Pharmacists' Moral
Beliefs vs Women's Legal Rights", Christian Science Monitor 4/26/04. (in packet)
13. Wednesday, June 16
Cost Controls
Videotape: "Dr Solomon's Dilemma"
Text: Chapters 8 (review), 9, and 16
Packet: Lando L. “Six prescriptions to ease rationing in US health care”. Wall
Street Journal, December 22, 2003. http://online.wsj.com/article_print
14. Thursday, June 17
Methods to Contain Pharmacy Costs: Increased Co-Payments, Tiered Co-payments,
Pharmacy Benefit Managers, Genetic Substitution, Closed Formularies
Packet: 1. Fuhrmans V. Higher co-pays may take toll on health. Wall Street
Journal, May 19, 2004.
2. Goldman DP et al. Pharmacy benefits and the use of drugs by the chronically ill.
(abstract) JAMA 291:2344-2350.
3. Martinez B. Pharmacy-benefit managers at times toil for drug firms. Wall Street
Journal, August 14, 2002.
15. Wednesday, June 23 Midterm Examination
16. Thursday, June 24
Quality of Care
Text: Chapter 12
17. Wednesday, June 30
Quality of Care
Videotape: "Escape Fire", Dr Donald Berwick
18. Thursday, July 1
Medication Errors: Reasons and Possible Methods to Reduce Their Occurrence
1. “Frequently Asked Question”, Institute for Safe Medication Practices, accessed at
http://www.ismp.org/Pages/ismp_faq.html (in packet)
2. “Medication Errors” on web, U.S. Food and Drug Administration • Center for Drug
Evaluation and Research at http://www.fda.gov/cder/drug/MedErrors/default.htm
3. Required CE: “Bar Coding of Unit Doses Can Reduce Medication Errors”, at
http://www.ismp.org/MSAarticles/WhitepaperBarCodding.htm
4. “FDA Issues Bar Code Regulation Fact Sheet”, February 25, 2004: at
http://www.fda.gov/oc/initiatives/barcode-sadr/fs-barcode.html (in packet)
5. The National Coordinating Council for Medication Error Reporting and
Prevention at http://www.nccmerp.org/
6. http://www.SureScripts.com (electronic prescription arrangement through NACDS)
19. Wednesday, July 7
FDA Issues: 1) Dietary Supplements and 2) Direct-to-Consumer Ads
Packet:
1. Overview of Dietary Supplements. US Food and Drug Administration, Center for
Food Safety and Applied Nutrition, January 2001. accessed at http://www.cfsan.fda.gov.
2. Summary of Qualified Health Claims Permitted, CFSAN/Office of Nutritional
Products, Labeling, and Dietary Supplements, September 2003
3. Herper M. “Prescription drug ads are no blockbusters”. Forbes, May 2, 2003 as
accessed at http://www.forbes.com/2003/05/02/cx_mh_0502drugads_print.html
3. Flynn LT. Yes: “Direct –to-Consumer” advertising of prescription drugs benefits
the public’s health. drkoop.com, 2001
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4. Alper PR. No: “Direct-to-Consumer” advertising of prescription drugs is more
harmful than helpful to consumers. Drkoop.com, 2001
20. Thursday, July 8
Pharmaceutical Industry/PhRMA
http://www.phrma.org/
Packet: Hoffman JM, Shah ND, Vermeulen LC, Hunkler RJ, Hontz KM. Projecting
future drug expenditures – 2004. Am J Health-Syst Pharm 2004;61:145-158.
Additional material as assigned
21. Wednesday, July 14
Consequences and reaction to pharmaceutical cost increases
Political responses: Medicare Drug Benefit Reform and Drug Reimportation
Packet: 1. “Medicare Prescription Drug Law Fact Sheet” accessed at
http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile.cfm&
PageID=33325. Kaiser Family Foundation, March 2004.
2. Tsao A. A primer on drug “reimporting”. Business Week, April 21, 2004
accessed at
http://www.businessweek.com:/print/bwdaily/dnflash/apr2004/nf20040421
22. Thursday, July 15
Paper Due
The Purple Pill Saga
Packet: Swidey, N. "The Costly Case of the Purple Pill". The Boston Globe
Magazine, November 17, 2002
23. Wednesday, July 21
Managed Care Pharmacy,
Packet:
(1) Fry RN. The role of pharmacists in managing pharmaceutical costs. TEN
2000;2:64-69.
(2) Eichenholz J. Trends in managed care pharmacy: Preparing for the future. J
Managed Care Pharm 2001;7:105-110.
(3) Aventis Managed Care Series, Pharmacy Sections
24. Thursday, July 22
PhRMA in Underdeveloped Countries:
AIDS Treatment and Clinical Trials
Professor Brook Baker, School of Law, Northeastern University
Packet: Chart: Steps in Discovery, Development, and Approval (with time frames)
PhRMA in underdeveloped countries: AIDS treatment and clinical trials
25. Wednesday, July 28
What are the Issues? Controversies, Unresolved Problems, Future Changes
Presidential Politics and Their Health Care/Pharmacy Policies
Text: Chapter 16
Packet: To be distributed
26. Thursday, July 29
Long Term Care
Text: Chapter 10
Packet: 1) Is assisted living the right choice? Consumer’ Reports. January 2001; 26-31
2) Medicaid’s Role in Long-Term Care: Kaiser Family Foundation, May 2004 accessed at
http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=3
6296
27. Wednesday, August 4 Health Care in Other Countries
Text: Chapter 14 and excerpts from Health Affairs, May/June 2004.
Controversies in a Program of National Health Insurance
Text: Chapter 15 and 18
Packet: revisit in front of packet Reinhart UE, Hussey PS, Anderson GF. US health
care spending in an international context. Health Affairs 2004;23:10-25.
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28. Thursday, August 5
Review
OBJECTIVES
Enabling Objectives for Sessions #1 and 2: Medicare Approved Drug Discount Card (MADDC)
1. Describe the characteristics of individuals eligible for the Medicare Approved Drug Discount Card, and the
limitations on number of cards and location of coverage benefits.
2. Describe the characteristics of an individual eligible for the $600 drug credit. If a person is eligible, describe
the difference between the $600 benefit in 2004 and 2005.
3. Describe the effective dates of the enrollment period, the coverage period for 2004, the coverage period for
2005, and the period within which MADDC coverage can be changed.
4. Describe the eligibility requirements of programs that wish to offer a MADDC, and the terms of their
participation.
Enabling Objectives for Sessions #3 and 4: Cover the Uninsured
1. Describe the overall percent of Americans without health care and their percent distribution by age, income,
employment status, ethnicity, size of company, and geographic locations
2. Describe five of the major reasons for individuals to lack health care insurance.
3. Discuss the impact of lack of insurance on health.
4. Identify the major methods by which Americans receive health care coverage.
5. Describe three approaches to covering the uninsured. Identify which you think is most viable and why.
6. Be able to answer questions on page 209-210 of text.
Enabling Objectives for Sessions #5 and 6: Legislative Process and Collaborative Practices
1. Track the path of how a bill affecting the practice of pharmacy would work its way through the
Massachusetts legislative process, and its requirements to become law. Describe how YOU could
affect this process.
2. Define with examples: pharmaceutical care, disease state management, collaborative practice.
3. Describe the connection between collaborative drug therapy management (CDTM) and state
pharmacy practice acts.
4. Describe advantage/disadvantages of CDTM to the patient? To the pharmacist? To the physician.
5. Describe the legal requirements of a collaborative practice agreement. What aspects of
pharmaceutical care are covered under the agreement.
6. You are a pharmacist in MA and are interested in establishing a CDTM. Describe characteristics
of your practice that would make it a suitable candidate for CDTM.
7. Describe the diversity of CDTM approaches across states. Compare and contrast the CDTM
authority and coverage in Hawaii, Florida, Ohio.
8. Describe the common obstacles to obtaining CDTM authority. Describe obstacles likely to be
present in Massachusetts, and what strategies might be possible to reduce those obstacles.
Enabling Objectives for Sessions #7: Economic markets, Health care markets, and Methods of payment
Chapter Eight – Painful versus Painless Cost Control
In addition to the questions on page 211-212,
1. Distinguish between “painful” versus “painless” cost controls. Give examples of both.
2. Define with examples the law of diminishing returns. Draw that curve with proper labeling of
axes. Describe interventions that would be represented on different parts of the curve. Identify the
area of “Flat of the curve medicine” and describe the implications to the product function curve in
that area. Describe the implications for American health care expenditures if this curve describes the
relationships between inputs and outputs in our health care system. Describe the effect of shifting the
curve in Figure 8-3 up or down.
3. Identify at least five characteristics of the economic market. For each, identify an example of a
method to introduce that characteristic into the medical marketplace. Argue the pro and con of
introducing more market forces into health care.
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4. Contrast and compare current American medical care practices with the health care practices of
other countries when the outcome of health for the latter systems is the overall health of a
population.
5. Contrast and compare methods to reduce costs (while maintaining effectiveness) that target 1)
price reduction and 2) quantity reductions.
6. Describe how the law of diminishing returns affects the demand for additional healthcare services in 1) FFS, 2)
capitated, 3) uninsured, and 4) medical savings account payment systems.
7. In our present health care system financing, describe 1) where money comes from to cover health care expenses
and 2) where money is distributed to cover health care expenses.
Chapter Two: Paying for Health Care
1. Differentiate among the four major sources of payment for health care service: out-of-pocket, individual private
insurance, employment-based private insurance, and government financing. In each method describe who/what
pays, what type of individuals are most likely to have that type of insurance, and how/why that form of payment was
established.
2. Compare and contrast the incentives under experience rating versus community rating for insurance.
3. Given various patient scenarios, determine whether or not the individual is eligible for Medicare A, Medicare B,
and/or Medicaid coverage.
4. Explain why the two parts of Table 2-1 (top: percent distribution of "type of payment" and bottom: "principle
source of coverage" in are different.
5. Compare and contrast the impact of regressive, progressive, and proportional forms of payment on high and low
income population.
6. Explain the difference in how Medicare and Medicaid is financed and administered to include: why are they
different?, what is a means test and what is an entitlement?; what do those term mean?; what is FICA and what is
its relationship to health insurance?; what is Medigap coverage?
7. Discuss the difference between the distribution and Medicaid population and the % distribution of Medicaid
money differ?
8. Describe the impact of insurance on overall national health care costs and why this has occurred.
9. Identify how much the US spent on health in 2003, what % that was of the GDP, how much that is per person,
and what the change was from last year. Describe the trends in those figures over the last 30 years.
Chapter Four: Reimbursing Health Care Providers
1. In Table 4-1 explain why these units of payment are organized from least to most aggregated for both physician
and hospital payment.
2. Compare the payment method of a British physician and a managed care payment using a two- or three-tiered
payment method.
3. Contrast and compare the characteristics of three major forms of managed care: fee-for-service with utilitzation
review, PPOs, and HMOs. What is an IPA? What is capitated payment? What is "pmpm"?
4. Describe the course of the money in a two-tiered and three-tiered capitated payment structure.
5. Under each system, describe the incentives for physicians, for hospitals, for pharmacists.
6. Medicare pays hospitals by DRGs. Describe what DRGs are and how they work.
7. Medicare pays physicians by RBRVS. Describe what RBRVS is and how it works.
8. Describe rationing issues that could arise under various methods of payment.
Enabling Objectives for Sessions #8 and 9: Healthcare Systems, Managed Care, and Structural Impact on
Payment Methods and Costs
Chapter Five: Capitation Payment in Managed Care
1. Define provider "risk". Describe the incentives and disincentives of putting providers “at risk”.
2. Follow the money from the employer through an HMO/IPA arrangement, through the provision of care.
3. Give examples of "carve out", "risk-adjusted capitation", "stop loss insurance"
4. Argue -- "Capitation and managed care is the best thing that has happened to health care"
5. Argue -- "Capitation and managed care is the worst thing that has happened to health care"
6. Describe ethical principles that could be affected by capitation. Argue: capitation is/is not rationed health care.
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Chapter Six: How Health Care is Organized - I (Levels of care, regionalization, physician roles, patient flow)
In addition to the questions and discussion topics on page 211,
1. Give examples of primary, secondary, and tertiary care. Include who is most likely to deliver it and where it is
delivered.
2. Contrast and compare the strengths and limitations of a regionalized health care system (such as the UK) and a
dispersed model (such as the US). Include point-of-entry, patient autonomy, cost implications, quality of health
care services.
3. Contrast and compare a "pyramidal" system versus a "diamond" structure for health care delivery?
4. Contrast and compare the distribution of medical specialty types in the UK and the US. Include the
implications for these distributions on the location of practice, intensity of care, and cost of services.
5. Identify evidence to support: the American health care system is a "nonsystem of care" consisting of
"fragmentation, chaos, disarray" and "uncontrolled growth and pluralism". Define pluralism.
6. "The American health care system is precariously off balance." (p65) Describe how the structure and
specialization of the American health care system become so out of line with the health care needs of the
American population?
7. Identify the key tasks of primary care practitioners. Describe the effects of good primary care on patient health
care outcomes.
8. Identify how the good managed care organizations are trying to modify the structure of American health care
delivery. How might distributive justice affect how they structure their organization?
9. Differentiate between a "gatekeeper" and a "gateshutter". How do these two differ in providing beneficence,
nonmaleficence, and autonomy?
10. Define, with examples, iatrogenic illness.
11. Define "population health" (community-oriented primary care)? How does Dr. Service do it (p61-62)? To
whom is Dr Service accountable? How might the organizational model of managed care rather than fee-forservice improve "population health"?
12. Suggest how community pharmacists can apply elements of population health to improve the health of those
who receive their prescriptions from each store.
Chapter Seven How Health Care is Organized - II
1. As identified in this chapter, trace the evolution of the structure of medical practice over time as well as the base
of patients for hospitals changed over time?
2. Contrast and compare the practice of a contract doctor, multispeciality group practice, community health
centers, prepaid group practices, and IPA-HMO models.
3. Identify the factors resulting in the hospital, rather than the community, becoming the organizing focus for
American health care.
4. Discuss the clinical and economic implications of melding the financing and delivery of care into a single
organizational structure; i.e., prepaid group practice/health maintenance organizations.
5. Contrast and compare the 1st (pre-paid group practice) vs 2nd generation (IPA-model) of HMOs.
6. Define with examples vertical and virtual integration.
7. Contrast and compare how plans such as Kaiser’s vertical integration similar and dissimilar from the British
NHS. Include the differences in receiving and paying for care among a prepaid group practice, an IPA-HMO
model, a point-of-service plan, and a preferred provider organization.
Enabling Objectives for Session #10: How is Pharmacy Organized? Emphasis on Pharmacy Manpower
1. Describe the underlying reasons behind the growth in volume of pharmaceutical products and services and in the
range of activities available to today’s pharmacists.
2. Describe the factors affecting the demand for pharmacists from the perspective of patient populations, the
pharmaceutical industry, and the health care system. Suggest methods to ensure that the demand for
pharmacists and pharmaceutical products is appropriate and not a supplier-induced demand. Critique methods
designed to restrain demand for pharmaceutical products as to their impact on costs and patient care quality.
3. Discuss how managed care has affected the demand for pharmacists and pharmaceutical products.
4. Discuss the factors contributing to insufficient supply of pharmacists to meet demand of the industry.
5. Describe the consequences of insufficient pharmacists on the role and function of pharmacists, the operations of
pharmacies, and the care of patients.
6. Describe the provisions of Pharmacy Education Aid Act of 2003 and how it is designed to reduce the shortage of
pharmacists and the provision of pharmaceutical care.
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Enabling Objectives for Session #11 Health Promotion and Disease Prevention
Chapter Eleven: The Prevention of Disease
1. Health Promotion and Disease Prevention (HPDP)
1.1 Describe the purposes of "Healthy People 2010"
1.2 Identify the major goals, and the reasons for these specific goals, of "Healthy People 2010"
2. Leading Causes of Mortality
2.1 Identify the 5 leading causes of death in the United States
2.2 Identify the primary risk factors for (1) cardiovascular and (2) cancer mortality
3. Key contributors in HPDP
3.1 Name 5 major contributors (e.g., tobacco) that must be reduced or improved if their role in HPDP is to be
improved; for each, state why it is a contributor to poor health.
4. Pharmacists' Role
4.1 Describe the role of the present role of the pharmacist, if any, in HPDP activities
4.2 Describe what role the pharmacist could play in HPDP activities.
4.3 Describe the reasons advanced that have limited the pharmacist role compared to what is desirable
5. Design a program to provide incentives that promote health promotion/disease prevention.
Enabling Objectives for Session #12-14: Ethics and Application to Health Care Services and the Practice of
Pharmacy
Chapter Thirteen: Medical Ethics and the Rationing of Health Care
1. Ethics
1.1 Define the four basic ethical concepts in terms of healthcare
1.2 Describe how professional ethics may come into conflict with cost containment in terms of health care
2. Rationing
2.1 Define rationing in terms of healthcare
2.2 Differentiate rationing from cost containment
2.3 Describe different types of rationing in healthcare
3. Pharmacist's Role
3.1 Describe potential conflicts between the pharmacist's role and ethical behavior.
3.2 Describe potential conflicts between the pharmacist's role and rationing
3.3 Describe potential conflicts between the pharmacist's role and cost containment
4. Given an ethical situation, identify the ethical elements involved, identify possible courses of action, select and
justify your preferred course of action.
Chapter Nine – Mechanisms for Controlling Costs. In addition to the questions on page 212,
1. Distinguish between financing and reimbursement.
2. Follow the trail of money from payers to providers. Identify strategies (and their advantages and
disadvantages) to control costs along the trail.
3. How does US tax policy affect the perceived cost of health insurance? Does this affect the
financing or reimbursement of health care? How can employers and employees become more
price sensitive to the cost of insurance?
4. Define and explain the method by which “defined contribution” could affect total health care
costs. Is the defined contribution approach regressive, progressive, or proportional?
5. Define with examples adverse selection, moral hazard, patient churning, capitation, DRG,
variation analysis, physician/practice profiling, Roemer’s Law, supplier-induced-demand.
6. Contrast and compare the advantages and disadvantages of price controls such as uniform fee
schedules for physicians and/or other health care services?
7. Compare the economic incentives for a hospital, its admission policies, its diagnostic services, and
pharmacy services for patients financed by fee-for-service, Medicare, capitation, per diem, and
Medicaid.
8. Describe how consumer deductibles, co-insurance, and co-payment affect the utilization and
appropriateness of services. How might patient cost-sharing affect the quality of care?
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9. Describe the rationale for utilization review. Who/what are likely to conduct utilization review?
To whom is it directed?
10. Compare cost control methods targeted to reduce the demand for health care services and those
directed to the control the supply of these services.
11. Compare the mechanism and effectiveness of the types of managed care cost control strategies
practiced within 10 PPOs, 2) IPAs, and 3) group/staff model HMOs. Which target the demand
versus supply side of the health care market?
Dr. Solomon’s Dilemma (application of ethics or rationing to practice decisions)
1. Compare and contrast the economic and treatment incentives in a physician group practice of 1) FFS, 2)
capitation for physician services, 3) capitation for physician and hospital services, and 4) global capitation.
2. Dr Solomon’s group elected to accept global capitation for Secure Horizons so that they could control their
practice. Discuss strategies that they have to put in place so that they would be able to better manage the
income and expenses of their practice under this payment method.
3. Describe how the individual physicians in the “pod” could work as a collective to better the economic, as
well as clinical outcomes, of their group?
Drug Benefit (application of ethics to drug therapy restrictions, incentives, and expansions)
1. Explain the yearly double-digit growth in the cost of pharmaceuticals over the last 10 years.
2. Compare and contrast the methods to reduce the cost of drug benefits by 1) restrictions on medication
directed primarily at physicians and 2) economic incentives primarily directed at patients. Be able to give
examples and explain their mechanism of action for the methods discussed in class. From the Joyce JAMA
2002 article, describe the impact of numbers of tiering and the levels of co-payment within each tier on the
total annual drug expenses.
3. Apply Daniels’ ethical template for pharmacy benefits to a formulary consideration.
4. While some segments are trying to restrict coverage, others are trying to expand. Identify populations which
have few drug benefits. Critique the strategies proposed by President Bush (both managed Medicare with
drug benefits and Medicare Approved Drug Discount Card), private efforts through the pharmaceutical
companies, Maine state program, Massachusetts Prescription Advantage, consumer initiated activities.
5. Describe the composition and principles of the Pharmacy Benefit All Coalition..
Enabling Objectives for Sessions #16-18: Quality of Care and Medication Errors: Are They a Problem?
Chapter Twelve: Quality of Health Care: Errors and Methods of Quality Improvement in Health Care
1. Define Continuous Quality Improvement.
2. Differentiate between the health care providers accredited and monitored by JCAHO and NCQA.
3. Describe HEDIS and its contribution to quality of health care.
4. Identify and describe 3 activities that pharmacy can provide to improve the quality of health care.
5. Identify 3 activities that can improve the quality of health care in general.
6. Differentiate problems with providing health care that are (I) largely the result of the system in place for
providing the care as compared to (II) poor performance by providers.
7. Discuss the recommendations of the “Implementing Effective Change in Meeting the Demands of Community
Pharmacy Practice in the United States”. Critique the components of the recommendations as to the
importance, feasibility and potential impact of each.
8. Describe several methods to re-engineer the pharmacy workplace. Describe the potential contribution of eprescribing, bar coding, and automated dispensing systems to the pharmacy workforce shortage. Describe
situations in which these types of technology would and would not be useful.
Backfire
1. Describe how and why Dr Berwick applies the Backfire example to healthcare. Discuss what he has
identified as the problem, what are the possible solutions he suggests, and your assessment of the feasibility
of his recommendations. .Discuss whether you agree/disagree with his premise and apply your analysis to
pharmacy and medication errors.
Medication Errors and Methods of Improvement to accompany quality of care classes
1. Differentiate between an adverse drug reaction and a medication error.
2. Describe 3 types of medication errors that largely result from system errors.
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3. Describe 2 types of medication errors that largely result from provider errors.
4. Describe the Institute of Medicine (IOM) report on medication errors.
5. Describe 3 factors that contribute to the increasing frequency of medication errors observed in this country.
6. Describe 3 factors that should reduce the frequency of medication errors.
Enabling Objectives for Session #19: FDA/DTC/OTC
Food and Drug Administration, Dietary Supplements, Direct to Consumer Ads
1. Describe the provisions and impact of three bills regulating components of the drug manufacturing and
marketing processes:
1984 Drug Price Competition and Patent Term Restoration Act (Waxman-Hatch)
1992 User Fee
1997 Food and Drug Modernization Act
2. Describe the role and function of the following agencies/departments in regulating herbal and dietary
supplements.
Food and Drug Administration
Federal Trade Commission
United States Department of Agriculture
National Center for Complementary and Alternative Medicine
3. Distinguish between when a product is considered a drug versus a dietary supplement, functional food, or herbal
product
4. Describe the current regulations pertaining to dietary supplements/herbals. Discuss the advantages and
disadvantages of proposed changes to these regulations. Determine and justify your position as to whether
herbals/dietary supplements should be regulated by the FDA.
5. Given a patient request to identify the regulations pertaining to a product that that person is taking, determine
what type of product it is and what agency/department regulates it’s the products’ claim of effectiveness.
Direct to Consumer Ads
1. From the perspectives of a pharmaceutical company, a managed care organization, a physician, and a patient,
discuss the advantages and disadvantages of direct to consumer marketing of pharmaceutical products. Discuss
why this may vary among the perspectives.
2. Discuss why most countries prohibit direct to consumer advertisements.
3. Describe the characteristics of a medication appropriate for a drug to consumer advertisement campaign.
4. Identify the FDA section codes that pertain to DTC advertisements and the aspects of the advertisement that
each regulates.
5. Given a DTC advertisement: a) place it in one of the three types of ad groupings and b) evaluate if it meets the
two FDA section codes and the 1999 FDA broadcast ad guidance.
6. Discuss the impact of DTC on consumers, physicians, and costs.
Enabling Objectives for Sessions #20-24: Policies, Politics, and Components of the Pharmaceutical Industry
Growth in Medication Volume and Cost: Impact on Demand and Supply of Pharmacists, Pharmacists
Structure, Resources, and Services
1. Describe the underlying reasons behind the growth in volume of pharmaceutical products and services and in the
range of activities available to today’s pharmacists.
2. Describe the factors affecting the demand for pharmacists from the perspective of patient populations, the
pharmaceutical industry, and the health care system. Suggest methods to ensure that the demand for
pharmacists and pharmaceutical products is appropriate and not a supplier-induced demand. Critique methods
designed to restrain demand for pharmaceutical products as to their impact on costs and patient care quality.
3. Discuss how managed care has affected the demand for pharmacists and pharmaceutical products.
4. Discuss the factors contributing to insufficient supply of pharmacists to meet demand of the industry.
5. Describe the consequences of insufficient pharmacists on the role and function of pharmacists, the operations of
pharmacies, and the care of patients.
6. Describe the provisions of Pharmacy Education Act and how it is designed to reduce the shortage of pharmacists
and the provision of pharmaceutical care.
7. Compare and contrast the change in annual pharmaceutical sales in the US and internationally.
8. Describe the reasons why the same drug generally costs more in the United States than in other countries.
9. Argue for and against the statement: “American pharmaceutical companies are making excessive profits.”
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10. Argue for and against the statement: “American pharmaceutical companies are being ethically responsible in
meeting the pharmaceutical needs of underdeveloped countries.”
11. Argue for and against the statement; “The Medicare
Enabling Objectives for Session #25: 2004 Political Party Health Care Platform Positions
1. Compare and contrast the position of the Democratic and Republican Party and its nominees concerning
governmental and nongovernmental approaches to health care issues.
Enabling Objectives for Session #26: Long term Care
Chapter Ten: Chronic Illness and Long-Term Care
1. Describe the demographic and social changes that have affected the demand for long-term care services.
2. Differentiate between activities of daily living and independent activities of daily living.
3. Contrast and compare the difference in long-term care needs (and economic/insurance coverage) of a post-acute patient
versus a chronically ill patient.
4. Differentiate between skilled nursing care and custodial care. Give examples of each. Describe how those
differences affect the type of funding available to cover needed services.
5. Design an ideal continuum of long term care modalities from most to least community-based.
6. Describe the ownership patterns of the nursing home and home health care industries.
7. Contrast and compare the differences, and the reasons for these differences, in the distribution of payment mechanisms
between home health care and nursing home care (Table 10-2).
8. Describe the average characteristics of a nursing home resident.
9. Discuss the interrelationships among the type of care that is needed for a long-term care patient, where that care
could be delivered, and what funding sources are available to cover that care.
10. With the introduction of the Balanced Budget Act of 1997, describe the impact on long-term care services.
11. Given a patient description, discuss alternatives for needed care in nonhospital settings. Discuss the financial
and social impact on the patient, family, and payment systems.
12. Contrast and compare the differences in the composition of the Medicaid population and the distribution of
Medicaid dollars.
Enabling Objectives for Session #27:
Chapter Sixteen – Conflict and Change in US Health Care -- In addition to the questions on page 215,
1. Describe with examples horizon and vertical integration.
2. Describe how and why the payers of health care services increased their power between 1945 and 1995.
Discuss the impact of the alliance between insurers and providers of care until the mid-1970s and its
evolution over time.
3. Describe the factors leading to the growth of managed care organizations and then to the backlash against
managed care organizations.
4. Describe the motivation of employers to self-insure and the consequences of that action on the employers,
their employees, type of reimbursement methods, and structure and practices of providers of care.
5. Describe how defined contribution might affect the type of health insurance plans offered as well as the
consumer selection of insurance plans.
Chapter Eighteen: The Future
1. Describe the major issues that will be confronting health care and pharmacy over the next decade.
2. What are the possibilities for national health insurance in the United States?
3. In Table 18-1, Bodenheimer lists major tensions for the future. Evaluate these tensions and
explain which will affect the practice of pharmacy. Justify your answers.