pharmacy and the us healthcare system fourth edition smith michael ira

Pharmacy and the US Health Care System
Fourth Edition


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Pharmaceutical Press is the publishing division of the Royal Pharmaceutical Society


Pharmacy and the
US Health
Care System
FOURTH EDITION

Editors
Michael Ira Smith

PhD

President
MIS Pharmaceutical Consultants, Scottsdale, AZ, USA

Albert I. Wertheimer

PhD, MBA

Professor of Pharmacy
Department of Pharmacy Practice
Temple University School of Pharmacy, Philadelphia, PA, USA

Jack E. Fincham

PhD, RPh

Professor
Division of Pharmacy Practice and Administration
The University of Missouri Kansas City School of Pharmacy, Kansas City, MO, USA


Published by Pharmaceutical Press
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c Royal Pharmaceutical Society of Great Britain 2013
is a trade mark of Pharmaceutical Press
Pharmaceutical Press is the publishing division of the Royal Pharmaceutical
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ISBN 978 0 85711 022 0
All rights reserved. No part of this publication may be reproduced,
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The publisher makes no representation, express or implied,
with regard to the accuracy of the information contained in this book
and cannot accept any legal responsibility or liability for any errors or
omissions that may be made.
A catalogue record for this book is available from the British Library.

Dedication
MIS: To Rita, Neil, Bethany, Mason and Aiden
AIW: To Joaquima, Lia, Debbie and Andrew
JEF: To Melinda, Derek and Joni, and Kelcie for making it all possible



Contents
Foreword
Contributors
1

2

3

4

Health and health care in the United States
David M. Scott, MPH, PhD

xiii
xvii
1

Health and disease
Historical evolution of health services
The private health care sector

The public health care system
Health care: right or privilege?
Conclusion
References and further reading

1
5
9
12
17
19
19

Financing US health care
Leanne Lai, PhD

21

Health care financing
Funding sources of health care financing
Challenges for US health care financing
Conclusions
References and further reading

21
21
31
33
33

Managed care pharmacy
Judith A. Cahill, CBES

35

What is managed care?
Managed care pharmacy tools
Roles pharmacists play in managed care settings
References and further reading
Bibliography

35
38
48
52
52

The health professions
Albert I. Wertheimer, Jr., PhD, MBA

53

Prescribing authority
Health manpower
Physicians

54
57
59

viii

5

6

7

8

Contents

Pharmacy personnel and practice site
Pharmacy issues and trends
Appendix 4.1
Appendix 4.2
Appendix 4.3
Appendix 4.4
References and further reading
Bibliography

60
64
66
68
72
73
73
74

Pharmacists and US health care
Yifei Liu, BSPharm, PhD

75

The workforce of pharmacists in the United States
Conclusions
References and further reading

76
90
91

Pharmacy organizations
Joseph Thomas III, PhD

95

Role of pharmacy organizations
Historical development of pharmacy organizations
Specific pharmacy organizations
Current issues for pharmacy organizations
Individual decisions regarding organizations
References and further reading
Web sites for organizations discussed in this chapter
National practitioner organizations
Fraternal, leadership and honorary societies
National trade organizations
Education, regulatory, and foundation organizations

95
99
99
110
111
112
112
112
113
113
113

Emerging roles
Richard J. Bertin, PhD, RPh

115

Advanced practice credentialing
Collaborative drug therapy management
Other emerging practice models
Conclusion
Bibliography

116
122
124
125
126

Political realities of pharmacy
Robert I. Field, MPH, JD, PhD

127

Growth of pharmaceutical use and spending: prelude to intensifying
political conflict

128


Contents

ix

Regulation, patents and politics
Insurance for prescriptions
Pharmaceutical industry research and marketing
Medicare coverage
The role of pharmacists
The next political realities: genetics and personalized medicine
Looking ahead
References and further reading

130
135
138
141
143
144

146
147

Hospital and health care institutions
Sherilyn J. VanOsdol, PharmD, BCPS, and
Charles E. Daniels, BSPharm, PhD

153

History of hospitals in the United States
Scope of the US health care system
Focus on patient safety
Future challenges facing hospitals
Conclusion
References and further reading
Bibliography

153
156
173
175
176
176
178

10 Pharmacist role in long-term care
Richard G. Stefanacci, DO, MPH, and
Thomas R. Clark, RPh, MHS, CGP

179

9

The growing population of older adults
Demand for health care services
Medicare Parts A, B, C, and D in long-term care
Health care reform
Special considerations in the provision of health care to older adults
Long-term care
Nursing facilities
The role of the geriatric pharmacist in other long-term care settings
Conclusion
References and further reading
Online resources

11 The research manufacturing pharmaceutical industry
Jean Paul Gagnon, BS, PhD
Economic impact
US pharmaceutical industry state of affairs
Future outlook for the US pharmaceutical industry
References and further reading

179
181
182
183
184
189
190
199

207
208
214

215
215
217
221
225


x

Contents

12 Drug distribution
Sheryl L. Szeinbach, PhD, MS, BSPharm, and
Earlene Lipowski, PhD, BSPharm
Distribution and marketing strategy
Pharmaceutical trends
Pharmaceutical manufacturers
Health care distributors in the United States
Contributions of the distributor industry
Packaging
Distribution in large community pharmacies
Other distribution channels
Availability and distribution of generic drugs
Other trends in distribution
Achieving operational efficiency through automation
Specialty pharmaceuticals

Conclusion
References and further reading

13 The consumers of health care
Somnath Pal, BS(Pharm), MS, MBA, PhD,
Damary Castanheira Torres, BS, PharmD, BCOP, and
Maria Marzella Mantione, BS, PharmD, CGP
The definition of the health care consumer
Why the shift toward consumerism?
Where do consumers most often get their health information?
Changing demographics of health care consumers
Behavioral models in the patient–practitioner relationship
Health, illness, and sick-role behavior
Diversity in the US consumer
Conclusion
References and further reading

14 The drug use process
Jack E. Fincham, PhD, RPh
Drug use in the health care system
Self-care
Patient compliance
Drug use by the elderly
The epidemic of prescribed drug abuse
Health care reform and the drug use process

227

228
228

229
230
232
233
235
236
238
239
239
240
242
242

245

246
247
250
251
255
265
272
278
278

283
285
285
287
291

293
293


Contents

Summary
References and further reading

15 Patient safety and pharmacovigilance
Stephen F. Eckel, PharmD, MHA, BCPS,
Alexander T. Jenkins, PharmD, MS, and Kayla Hansen, PharmD, MS
Overview of pharmacovigilance and medication error reporting
Regulatory approval process and post-marketing surveillance
Risk evaluation and mitigation strategies
Conclusions
References and further reading

xi

294
294

297

298
298
303
312
313

16 Provisions of care to subpopulations: a cultural perspective
Eucharia E. Nnadi, RPh, JD, PhD, and
Tracy E. Okolo, RPh, BSN, PharmD, BCPS

317

Minorities: diversity in the health care field
Culture, race, ethnicity, and health care
Cultural sensitivity
Epidemiology, ethnic variations and access to care
Ethnic and racial difference in treatment outcome variations
Cultural influences and use of health care and pharmaceutical services
Culture and treatment compliance
Conclusion
References and further reading

325
341
341
344
345
346
351
353
354

17 Professionalism and ethics
Dean L. Arneson, PhD
Pharmacy code of ethics

List, explain and give examples of ethical theories
List, define and give examples of ethical principles
Distinguish the difference between virtues, values, morals and rights
List and explain a decision process for determining solutions to ethical
dilemmas
Discuss ethical dilemmas in process of providing patient care
What is professionalism?
List and discuss the characteristics of professionalism
Discuss the concept of professionalism
What is caring?
Conclusion
References and further reading
Bibliography

359
362
368
370
373
374
375
377
380
381
382
382
382
383

xii

Contents

18 Health information technology: emerging challenges for
pharmacy
Mark Brueckl, RPh, MBA, Norrie Thomas, PhD, MS, RPh, and
Abigail Stoddard, PharmD, MBA

385

Key health IT concepts
HIT drivers
Key hit events and legislation
Future challenges: interoperability, HIT standards, and HIT
organizations
Implications for pharmacists
Research
The future of HIT
Questions for study
References and further reading

386
388
390
396

19 Unresolved issues in pharmacy: imagining the future
William A. Zellmer, BS (Pharmacy), MPH

413

Transformation: letting go of old dreams
Diffusion: steps toward the future
Imagination: measuring progress
Summary
Conclusion
References and further reading

20 The future
Eleanor L. Olvey, PharmD, PhD, and J. Lyle Bootman, PhD, ScD
Providing, demonstrating, and paying for value
Population dynamics
Technology
Education
Conclusion
References and further reading

Index

401
403
405
405
409

413
415
418
423

423
423

425
426
432
433
435
436
437

441


Foreword
This is the fourth edition of this book, first published in 1991. Much has
changed in pharmacy and in health care in the United States even since
the third edition was published in 2004. In 2009 major health care reform
began with the passage of the Patient Protection and Affordable Care Act.
This act, while not perfect, begins to recognize prevention and the services of
pharmacists as important ways to manage health care costs. At this writing,
the paint on the canvas of regulations is not dry.
Notably, the debate over health care reform spurred a new era of collaboration among the national and state pharmacy associations—the “N’s”
(National Associations of. . . ) and “A’s” (American Associations of. . . ) of
pharmacy. This collaboration continues in the form of the Joint Council of
Pharmacy Practitioners (JCPP) and numerous formal and informal collaborative initiatives, all designed to enhance consumer access to high-quality
pharmacist services. The old complaint that “I wish the pharmacy organizations could work together” is simply not relevant today, and every pharmacist
should be proud of that.
The pharmacist shortage of a few years ago has been replaced with an
“embarrassment of riches” in the form of existing school expansion and

new school openings during a time when fewer pharmacists are retiring and
many mid-career part-timers are going back to full-time work. Soon our
nation’s approximately 120+ pharmacy schools will be graduating 14,000
new practitioners annually, and these highly trained and motivated pharmacists will provide patient care—the kind of care being pursued through the
collaborative efforts described above. This is relevant because our health care
system is challenged to keep up with the demand for primary care services,
at least as they are currently available in the mainstream. If we do this right,
the bolus of well-trained pharmacists will establish new roles in primary care
and other areas to meet our nation’s need for chronic disease management.
Pharmacy is gearing up to meet the demand! Independent and chain
community pharmacy organizations are investing heavily in systems to accommodate and document patient care services. Many have seen the writing
on the wall that “buy low/sell high” is not going to work much longer as
a business model, and the forward thinking organizations are investing in
pharmacist and technician training. Today, through APhA’s immunization
Certificate Training Program, over 175,000 pharmacists (including me) have
been trained to immunize. No one would argue that the public health


xiv

Foreword

demand for improved access to immunizations has been largely met; nor is it
a stretch to say that consumers’ view of pharmacists as caregivers has been
greatly enhanced by the millions of vaccines administered by pharmacists
during last season’s H1N1 flu pandemic.
Meanwhile, over 450,000 pharmacy technicians have been certified by
the Pharmacy Technician Certification Board (PTCB), established in the
mid-1990s. These technicians support pharmacists in their patient care and
drug distribution responsibilities. PTCB is now exploring new areas of certification for technicians, such as specialty or advanced practice.

The US Surgeon General recently published a report, “Improving patient
and health system outcomes through advanced pharmacy practice1 ” that describes the positive impact of pharmacists in the Public Health Service and the
benefits of their principles for collaborative practice that could be adopted
in the private sector. The pharmacy profession is not at a crossroads today,
as we’ve read for generations. Rather, we are at a major inflection point,
with clear direction in a rising curve of innovation and new role adoption.
New medications, services, systems, and technology are carrying health care
solutions inexorably closer to the consumer. While there is a human tendency
to seek a comfortable steady state, the “winners” will not resist these changes
but instead will embrace, harness, and optimize their uses. Change has one
constant characteristic: acceleration. Robotics, new audio, video, and social
media communication technologies will empower consumers in ways that
have not yet been imagined. But the dreamers, entrepreneurs, and change
agents are hard at work on the next disruptive solution to old problems of
access, quality, and cost of health care.
“The most valuable form of communication is face-to-face. The next
most valuable is by phone or videoconference. . . . The least valuable forms
of communication are e-mail and texting.”2
While “face-to-face” may have clear advantages as a communication
method, there are hundreds, if not thousands, of pharmacists communicating with patients telephonically, electronically, or via video conference,
and this trend will accelerate. Many pharmacies and pharmacists work
in collaboration with physicians, nurses, and physician assistants to better
manage medication use. These pharmacists have created numerous ways to
accomplish this, from working as employees of physician group practices or
health systems, to establishing themselves as solo practitioners, to working on
a contract basis at a community pharmacy. Some pharmacies offer primary
care services, with various practitioners working in the same location as the
dispensing pharmacy, and are changing practice models to deliver highly
enhanced medication therapy management services.
Some health systems have achieved integrated electronic health records

(EHR), and the more advanced ones have integrated pharmacist documentation, in addition to medication dispensing records, into these records,
thus achieving “functional use” of the EHR by the pharmacist. Organized
pharmacy’s collaboration to promote functional use is a great example of the
high level of collaboration noted above. These new technologies and practice


Foreword

xv

models should be viewed not as endpoints but rather as part of a continuum
of change that will go on indefinitely.
The JCPP 2015 Vision for Pharmacy Practice calls for “autonomy, authority, accountability and outcomes.” Authors who describe disruptive innovation describe the need for measurability and predictability. In 2009 we
began exploring the pros and cons of community pharmacy standards and an
accreditation process. In 2011 the APhA House of Delegates passed a policy
that called for our leadership in the development of standards. To that end,
and in collaboration with the National Association of Boards of Pharmacy,
we have formed the Center for Pharmacy Practice Accreditation, with the
expressed goal of creating consensus-based, profession-developed standards
that payers will value as an important step in achieving our mission and the
needs of payers for measurability and predictability. Perhaps the 5th edition
of this book will describe the profession’s successful implementation of those
standards and the resultant enhanced patient care.
In the 2004 edition of this book, my predecessor, John Gans, wrote
in the foreword, “Today, the successful pharmacist must know more than
therapeutics, understanding the environment in which pharmacy is practiced,
and the forces at work both within and outside the profession that are critical
to being successful. This book is the single place where one can gain the data
and the perspective on the forces that are currently affecting the profession.
In addition, it can also give the pharmacist a perspective on the forces facing

other professions.” These words are still true today.
My predecessor also wrote about pharmacy’s tendency to work in isolation. This, however, is far less true today, as we are breaking down those
barriers with compelling public health contributions and a collaborative
spirit that can stand up to the harshest critics.
Our star is rising! I hope you’ll use this book to stimulate your own
journey to new heights. Don’t be afraid to take a flying leap. Pharmacists
are blessed with training that gives us a wide range of career options. The
profession needs you to innovate if we are to achieve our full potential in a
system that values our patient care contributions. Our patients are waiting.

References
1. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through
advanced pharmacy practice. a report to the U.S. Surgeon General. Office of the Chief
Pharmacist. Rockville, MD: U.S. Public Service, December 2011.
2. Pentland AS. The new science of building great teams. Harvard Bus Rev 2012; April 2012:
65.

Thomas E. Menighan,
Executive Vice President and
Chief Executive Officer
American Pharmacists Association
Washington, DC



Contributors
David M. Scott, MPH, PhD, RPh
Professor, Department of Pharmacy Practice, College of Pharmacy, Nursing,
and Allied Sciences, North Dakota State University.
Leanne Lai, BS(Pharm), PhD

Professor, Department of Sociobehavioral and Administrative Pharmacy,
College of Pharmacy, Nova Southeastern University.
Judith A. Cahill, CBES
Chief Executive Officer, Academy of Managed Care Pharmacy, Alexandria.
Albert I. Wertheimer, PhD, MBA
Professor, School of Pharmacy, Temple University.
Yifei Liu
Assistant Professor, Division of Pharmacy Practice and Administration, The
University of Missouri – Kansas City School of Pharmacy.
Joseph Thomas III, PhD
Professor, College of Pharmacy, Purdue University, West Lafayette, IN.
Richard J. Bertin, PhD
Certification and Accreditation Consulting, Brookeville.
Robert I. Field, JD, MPH, PhD
Professor of Law, Earle Mack School of Law at Drexel University and
Professor of Health Management and Policy, Drexel University School of
Public Health.
Sherilyn J. VanOsdol, PharmD, BCPS
Assistant Professor of Clinical Pharmacy, Department of Clinical Pharmacy,
Medication Outcomes Center, University of California, San Francisco.
Charles E. Daniels, RPh, PhD
Professor of Clinical Pharmacy, Associate Dean, and Pharmacist In Chief,
University of California San Diego.
Thomas R. Clark, RPh, MHS, CGP
Director of Clinical Affairs American Society of Consultant Pharmacists/
ASCP Foundation, Alexandria.


xviii

Contributors

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD
Associate Professor Health Policy, University of the Sciences/Chief Medical
Officier, The Access Group/Chief Clinical Officier, TabSafe Health System.
Jean Paul Gagnon, PhD
Pharmaceutical Policy Consultant, Pittstown, New Jersey.
Sheryl L. Szeinbach, MS, PhD, RPh
Professor, Division of Pharmacy Practice and Administration, Ohio State
University, College of Pharmacy.
Somnath Pal, BS(Pharm), MS, MBA, PhD
Professor of Pharmacy Administration, Department of Pharmacy Administration & Allied Health Sciences, College of Pharmacy & Health Sciences,
St. John’s University, NY.
Jack E. Fincham
University of Missouri Kansas City.
Stephen F. Eckel, PharmD, MHA, BCPS
Assistant Director, Department of Pharmacy, UNC Hospitals, NC and Clinical Assistant Professor, UNC Eshelman School of Pharmacy.
Alexander T. Jenkins, PharmD, MS
Manager, Department of Pharmacy, WakeMed Health & Hospitals, Raleigh,
NC.
Kayla Hansen, PharmD, MS
Clinical Manager, Department of Pharmacy, University of North Carolina
Hospitals, NC.
Eucharia E. Nnadi, RPh, JD, PhD
Vice President for Academic Affairs & Program Planning, Roseman University of Health Sciences.
Dean L. Arneson, PharmD, PhD
Academic Dean, Concordia University Wisconsin, School of Pharmacy.
Norrie Thomas, RPh, MS, PhD
President, Manchester Square Group, Minnesota.
William A. Zellmer, BS Pharm, MPH

President, Pharmacy Foresight Consulting, Bethesda, Maryland.
J. Lyle Bootman, PhD, ScD
Dean, College of Pharmacy, Professor of Pharmacy, Medicine, and Public
Health and Founding Executive Director, Center for Health Outcomes and
Pharmacoeconomic, (HOPE) Research.


1
Health and health care in the
United States
David M. Scott, MPH, PhD
Health and disease
Although the purpose of health care is to promote health, the US health care
system is concerned primarily with the diagnosis and treatment of disease
rather than the promotion of health. The primary focus of a health professional’s (e.g., pharmacist, physician) education traditionally has focused on
the pathophysiology of disease and drug treatment, rather than promoting
health. However, this situation is changing. As costs continue to rise, the
health care system has been undergoing increased scrutiny by consumers,
employers, health professional groups, and policy makers.

What is health?
Webster’s Unabridged Dictionary defines health as “physical and mental
well-being, and freedom from defect, pain or disease.” The World Health
Organization (WHO) in 1958 defined health as “a state of complete physical,
mental and social well-being, and not merely the absence of disease or
infirmity.”1 This definition has been criticized as describing an unrealistic,
ideal state. Other definitions of health have emphasized life functioning, such
as that of Banta and Jonas, who defined health as “a state of well-being,
of feeling good about oneself, of optimum functioning, or the absence of
disease, and of the control and reduction of both internal and external

risk factors for both disease and negative health conditions.”2 Risk factors
include environment, living conditions, and personal habits that increase the
possibility of developing a disease or negative health condition in the future.2
In 1979, the US Public Health Service published Healthy People: The
Surgeon General’s Report on Health Promotion and Disease Prevention.3
The Department of Health and Human Services (DHHS) has published the
framework of this work, “Healthy People 2020,” which represents the fourth


2

Pharmacy and the US Health Care System

time they have developed a 10-year healthy lifestyle objective for the United
States.4 This is a valuable asset for pharmacists, physicians, and educators
who seek to improve health care delivery in the United States. The vision
of Healthy People 2020 is “a society in which all people live long, healthy
lives,” and this resource recognizes that health outcomes are derived from
five determinants: (1) biology and genetics; (2) individual behavior; (3) social
environment; (4) physical environment; and (5) health services. Healthy
People 2020 includes 43 topic areas (Table 1.1), with objectives listed for
each area. The major health focus areas for the nation include physical
activity, nutrition, obesity, tobacco use, substance use, and access to health
services. For instance, two physical fitness objectives to be attained by the
2020 are (1) to increase the proportion of children and adolescents aged
2 years through 12th grade who view television, videos, or play video games
for no more than 2 hours a day and (2) to increase the proportion of adults
who engage in aerobic physical activity of at least moderate intensity for at
least 150 minutes per week. Although some progress has been made to attain
healthy lifestyles, much more remains to be accomplished.

Health problems: impact of public health and lifestyle
The leading causes of death changed significantly between 1900 and 2007
(Table 1.2). In 1900, the leading causes of death, in descending order,
were influenza and pneumonia, tuberculosis, diarrhea, heart disease, senility,
ill-defined or unknown, stroke, renal disease, accidents, cancer, and diphtheria.5 In 2007, the ten leading causes of death, in descending order, were
heart disease, cancer, stroke, chronic lower respiratory diseases, unintentional
or accidental injuries, Alzheimer disease, diabetes, influenza and pneumonia,
renal disease, and septicemia. These ten leading causes of death accounted
for nearly 75 percent of all deaths in the United States.6 Infectious diseases
accounted for five of the ten leading killers in 1900; that number dropped to
three by 2007. Whereas in 1900, communicable diseases led to the majority
of deaths, today they have mostly been replaced by chronic diseases. For
today’s top killers, lack of physical activity, poor nutrition, obesity, alcohol
abuse, and tobacco use all represent major risk factors.
US health levels have seen major improvements in since 1900. Between
1900 and 2007, the overall (crude) death rate declined by 50 percent and the
infant mortality rate (IMR) declined by 90 percent. The major contributor
to this decline is the remarkable drop in mortality in younger age groups. In
2007, the IMR was a record low of 6.8 deaths of infants under 1 year of age
per 1000 live births. The IMR for white infants declined to 5.6, while the rate
for black infants declined only to 13.2, which has widened the gap in infant
mortality between the two races.7 About two-thirds of all infant deaths occur
during the neonatal period (first 27 days of life), and the neonatal mortality


Health and health care in the United States

3

Table 1.1 Healthy People 2020 objective areas
Access to health services

HIV

Adolescent health

Immunization and infectious diseases

Arthritis, osteoporosis, and chronic back conditions

Injury and violence prevention

Blood disorders and blood safety

Lesbian, gay, bisexual, and transgender health

Cancer

Maternal, infant, and child health

Chronic kidney disease

Medical product safety

Dementias, including Alzheimer disease

Mental health and mental disorders

Diabetes

Nutrition and weight status

Disability and health

Occupational safety and health

Early and middle childhood

Older adults

Educational and community-based programs

Oral health

Environmental health

Physical activity

Family planning

Preparedness

Food safety

Public health infrastructure

Genomics

Respiratory diseases

Global health

Sexually transmitted diseases

Health communication and health information
technology

Sleep health

Health care–associated infections

Social determinants of health

Health-related quality of life and well-being

Substance abuse

Hearing and other sensory or communication disorders

Tobacco use

Heart disease and stroke

Vision

(Data from U.S. Department of Health and Human Services. Healthy People 2020. />2020/topicsobjectives2020/pdfs/HP2020objectives.pdf [accessed December 6, 2012]).

for black infants was 2.4 times greater than that for white infants.7 This
suggests that both pre- and postnatal care, especially for black infants, needs

improvement.
Life expectancy rose from 47.3 years in 1900 to 77.9 years in 2007,
a record high. In 2007, life expectancy was 80.4 years for women and
75.4 years for men. The gender gap reached its peak in the late 1970s,
and has been narrowing since then. This trend may be fueled by factors
such as improvements in smoking, high blood pressure, and obesity. Life
expectancy at birth for the white population is 78.4 years, 4.8 years longer
than that for the black population.8 Lifestyle factors account for some of this


4

Pharmacy and the US Health Care System

Table 1.2 Leading causes of death in the United States in 1900 and 2007
1900a

2007b

Cause of death

Percent of
all deaths

Cause of death

Percent of
all deaths

Influenza and pneumonia

11.8

Heart disease

25.4

Tuberculosis

11.3

Cancer

23.2

Diarrhea, colitis, enteritis

8.3

Stroke

5.6

Heart disease

8.0

Chronic lower respiratory diseases

5.3

Senility, ill-defined or unknown

6.8

Unintentional injuries (accidents)

5.1

Stroke

6.2

Alzheimer disease

3.1

Renal disease (kidney)

4.7

Diabetes

2.9

Unintentional injuries (accidents)

4.2

Influenza and pneumonia

2.2

Cancer

3.7

Renal disease (kidney)

1.9

Diphtheria

2.3

Septicemia

1.4

All other causes

32.6

All other causes

24.1

a Data from Centers for Disease Control and Prevention. National Office of Vital Statistics. Leading causes of

death, 1900–1998:67. www.cdc.gov/nchs/data/dvs/lead1900_98.pdf [accessed July 6, 2011].

b Data from Centers for Disease Control and Prevention. National Office of Vital Statistics. www.cdc.gov/

NCHS/data/nvsr/nvsr58/nvsr5819.pdf [accessed July 5, 2011].

difference in life expectancy. However, health care access, quality of care, and
environmental factors also contribute.
The United States’ reliance on sophisticated technology for the diagnosis
and treatment of disease has overtaken the ability to pay for it. In 1960, about
5 percent of the gross domestic product (GDP) paid for health care services;
in 2009 this figures was estimated at 17.6 percent (note: this represents a
14.9 percent average annual increase from 1993 to 2007).9 Many of the
leading causes of death are preventable, and given the escalating costs of
health care, an economic imperative is to renew interest in health promotion
and disease prevention.
In efforts to improve US health status, Victor Fuchs concluded that “the
greatest current potential for improving the health of the American people is
to be found in what they do or don’t do for themselves.”10 Breslow showed
that life expectancy and better health are significantly related to a number
of simple basic health habits, including (1) three meals a day at regular
times instead of snacking; (2) breakfast every day; (3) moderate exercise
two or three times a week; (4) 7 to 8 hours sleep a night; (5) no smoking;
(6) maintain moderate weight; and (7) no alcohol, or use in moderation.11
Breslow’s health habits provide the background for Healthy People 2020’s


Health and health care in the United States

5

objectives concerning healthy lifestyles. Although these health habits appear

to be common sense, they are not common practice. Some policy-makers
believe the primary barrier to good health is lack of financial access to quality
health care. While the need for quality health care for all Americans is an
important issue, the primary cause of poor health and premature death in the
United States today is the unhealthy lifestyle practices of many Americans.
Health is largely a result of the complex interaction among genetic factors,
environmental factors, lifestyle, and health care.12 The individual’s genetic
make-up certainly plays an important role and has been linked to diseases
such as alcoholism and obesity. Environment also plays a key role in determining health and disease. A fertile area for continued research is to investigate the interrelationships between genetic factors and the environment in
producing disease. Risk factors such as diet, pollution, occupational hazards,
and smoking also are related to the genesis of chronic disease.
Most of the improvement in reducing the death rate from infectious disease such as tuberculosis is due not to effective drug therapy, but to improvements in nutrition, water supply, sewage disposal and other hygienic measures. Tuberculosis mortality rates had fallen from approximately 250 per
100,000 in 1890, to 35.6 in 1938.13 However, specific anti-tuberculosis drug
treatment was not in general use until 1938. Mortality from tuberculosis
and other communicable diseases was greatly reduced without effective drug
therapy measures, apparently in response to improvements in nutrition and
hygienic measures.14
In addition to environmental and genetic factors, important social and
psychological factors also have a significant impact on disease and health.
America’s health care system is focused primarily on treating disease rather
than promoting health. The United States spends billions of dollars to prolong the life of elderly citizens near the end of their lives, while spending very
little to promote healthy lives for elderly citizens, as well as the general population. The United States spends enormous amounts of dollars on high-tech
machines to save low-birthweight babies, yet spends very little to reduce the
incidence of low-birthweight babies.2 From a societal standpoint, America’s
economic resources are not providing the most health benefit for the least
cost.

Historical evolution of health services
1850 to 1900
From colonial times, most sick people were treated at home by the family

using medicinal herbs, relying on friends and family for advice, and later by
use of medical guides for lay people. Most physicians were trained under
an apprenticeship system and were also referred to as apothecaries. The
first medical school was established in 1756 at the College of Philadelphia


6

Pharmacy and the US Health Care System

(later renamed the University of Pennsylvania).15 The role of the apothecary
later evolved into being solely the compounder and dispenser of medications,
and people frequently sought medical advice from the apothecary, as they
do from today’s pharmacist. The first college of pharmacy was established
at the Philadelphia College of Pharmacy in 1821. Students were pharmacy
apprentices who worked full-time and attended classes at night.
Acute infectious diseases were the most critical health problems for most
Americans during the period 1850 to 1900.16 Many of these diseases, such as
cholera and tuberculosis, were associated with inadequate sewage disposal,
contaminated water, and impure food. As Boston, New York, Philadelphia,
and other cities developed sewage systems, water purification systems, and
improved standards for milk and food, the prevalence of diseases such as
cholera and tuberculosis declined.

1900 to 1945
The period from 1900 to the conclusion of World War II was an era of rugged
individualism and a pay-as-you-go system for health services. Communicable
disease epidemics were largely brought under control due to improved nutrition and improved environmental conditions. In 1906, the Food, Drug
and Cosmetic Act was passed, which established guidelines to prevent the
adulteration and misleading labeling of drugs and foods in the United

States. Most of the Act’s impact was on food rather than drugs. In 1910,
the Flexner Report,17 published by the Carnegie Foundation, provided a
scathing review of US medical school education. This report brought about
necessary changes in the formal training of physicians and established The
Johns Hopkins School of Medicine, and its new 4-year curriculum, as the
preferred model for medical education. As a consequence of the Flexner
Report, many schools closed and others revised their curricula. State licensing
boards were empowered to raise practice standards and were encouraged to
establish rigorous qualifications for licensure. Physician training continued
to focus largely on general practice, which met most health care needs of
the time.
Notable therapeutic breakthroughs included the discovery of insulin in
1922 by Banting and Best, and, beginning in 1928, several discoveries by
Fleming that led to the development of penicillin. The discovery of penicillin
began the “era of antibiotics,” and this “miracle drug” revolutionized the
treatment of infectious diseases. Now, instead of disease leading to long-term
disability and possible death, in many cases a patient could be given an
injection of penicillin and sent home. With the eventual ability to treat many
infectious diseases by penicillin and other antibiotics, people lived to be older,
and chronic illnesses became the predominant problem of elderly American
citizens.