Responsibilities of Professional

(6)

1.  Licensure

2.  Duty (fiduciary)-Must put welfare, health, and safety of community abover other considerations

3.  Duty (to members of profession)-Adherence to a Code of Ethics

4.  Adherence to laws (federal and state)

5.  One must be licensed which is a revocable privalage

6.  Professionals have liabilities others do not

1.  Technical skill

2.  Social responsibility

3.  Knowledge of history

4.  Knowledge of literature and the arts

5. Personal integrity

6.  Faith that there is some meaning and value to life

7.  "The grace of humility"

1.  Easily disseminated

2.  Errors are easily apparent

3.  Writings must be factual, not opinion based

4.  Do not put in writing anything you don't want subpoenaed

1.  Tone

2.  Word Choice

3.  Grammar

1.  Eye contact

2.  Schedule enough time for conversations

3.  Be genuine

4.  Avoid emotionality and attacks of others

5.  Paraphrase the message you heard

6.  Keep still and silent; do not talk to fill pauses

7.  Ask clarifying questions

8.  Avoid distracting gestures

Morals are personal judgements as to right and wrong

Typically societal in nature and can be thought of as shared ideals of a group even if not practiced

Morals differ between societies because of the different emphasis placed on them

Standards of right and worng dictaing actions in a given situation

Do not include personal feelings, morals, laws, or social standards

1.  Rights

2.  Obligations

3.  Benefits to society

4.  Fairness

5.  Specific virtues

1. Autonomy

2. Beneficence

3. Nonmaleficence

4. Truthtelling

5. Confidentiality

6. Justice

Year and founding and role of Society of Apothecaries

1617

1st example of pharmaceutical regulation by allowing inspection of apothecary shops (REALLY SECOND CASE OF REGULATION BECUASE KING FREDERICK II WAS THE FIRST!!!)

1.  Most practitioners illiterate

2.  Combined medicine and pharmacy practiced by political leaders, clergymen, and midwives

3.  Only apothocary shops were in large cities

4.  No clear distinction between medicine and pharmacy

5.  Most medical conditions were acute

Early 19th Century America

1.  What prevailed as health risk?

2.  What began during this time period important to pharmacy?

1.  Infectious disease because of population boom

2.  Retail pharmacies began to open door

1821

Philadelphia College of Apothecaries

1.  Drug Importation Act

2.  Domination of department and chain drug stores

3.  Huge advances in tech, diagnostic tools, available services, and drugs

4.  Need for regulation of pharmacy as a profession becomes evident to all parties

1.  Traditional (1900-1940)

2.  Transitional (1940-1970)

3.  Patient-Care (1970-Present)

Required inspection of imported drugs

Rapidly became corrupted

1852, College of Pharmacy of the City of New York

Focused on pharmacist competancy and greater regulation which lead to uniform pharmacy act which created state regulations creating pharmacy as a profession

1920s

The direct responsible provision of medicatio-related care for the purpose of achieving definite outcomes that improve a patients quality of life

Reduce Disease symptoms and prevent disease

1.  Class in P3

2.  NAPLEX

3.  Practice with metabolism screenings etc

4.  Law with increased liability

1.  Normal dosage calculated from means of studies from fairly homogenous population

2.  Outcomes of individual trials as it relates to published literature

Warfarin PGx

Two Important Enzymes and Functions

1.  VKORC1-Reduces vitamin K to allow coagulation.  Mutations that inhibit enzyme lead to less clotting anyway making warfarin overdose more dangerous

2.  CYP2C9-Metabolizes warfarin so that mutations inhibiting function can lead to decreased warfarin metabolism and increased bleeding risk

Define:

1.  Nonmaleficience

2.  Beneficence

What is relevance to pharmacogenomics

1.  to do now harm and prevent harm

2.  to do good

Relevance to nonmaleficince is that you can withhold a drug that would do harm or tweak a dose

Relevance to beneficence is that alterative therapy treatment becomes more efficacious

Azathioprine PGx

1.  Function

2.  Uses (3)

3.  Mtabolism

4.  Rare Adverse rxn

5.  What is mutatated and what does this mean

6.  Why is test not performed to detect mutation?

1.  Immunosuppressant

2.  Kidney transplant, severe rheumatoid arthritis, inflammatory bowel diseases

3.  Methylated by thiopurine-s-methyltransferase (TPMT) and elminated from body

4.  Myelosuppression

5.  TPMT is mutated (homozygotes worse off than heterozygotes)-->Give less azathioprine to prevent myelosuppression

6.  Not FDA approved or required meaning FDA doesn't consider genotype as cause (nonmaleficience bad)

Finding of Pate v. Threlkel, Florida Supreme Court 1995

1. What was case about

2.  Finding

1.  Woman sued b/c mom had inherited thyroid cancer and physican did not let mother of woman know so the woman did not know of increased risk

2.  Physician negligent, but had no right or obligation to disclose the information to the daughted b/c of patient-doctor confidentiality

Safer v. Pack, New Jersey Superior Court Appellate Division 1996

1.  Case

2.  Finding

1.  Woman sued father's physican b/c father had polyp condition in colon she was not informed of so that she could not obtain preventative screening

2.  Court found liability with physican b/c he was obligated to protect the life of the daughter

1.  What is GINA

2.  What is not covered (3)

1.  Genetic Information Non-discrimination Act of 2008

Prevents discrimination based on genetic by health insurers and employers

2.  Life, Diability, and Long-term care insurance

1.  Inform risks and benefits

2.  Warn of hazards of genetic discrimination

3.  Do not talk with family unless given permission

4.  Encourage patients to discuss results with at-risk relatives

5.  Allow patients to make their own informed decisions regarding all issues related to genetic testing

Assesses how decision-making process works prior to decision

How do you organize your activities to further human welfare, what is right and fair, and what are the reasons for doing right

Kohlberg in 1958

Grounded in Piage's pioneering theories of how children develop logical and moral reasoning skills

Describes underlying innate mental process by placing interest on how decisions are arrived at

Different ages can hold the same view and arrive at that view through completely different reasoning

Self interest (pre-conventional)

Relationships (conventional)

Ethical Principles (post-conventional)

1.  Level of principled thinking

2.  Degree to which non-principled items receive lower ratings

Brand-$155.45

Generic-$39.73

Mail-order is number 1

Chain stores are number 2

Typical Community Pharmacy

1.  Open how many days per week

2.  % of Sales based on medicines compared to chains

1.  6 days a week

2.  95% independents and 69% chains

1.  Insurance reimbursement based on discount from AWP

2.  Pharmacies recieve small dispensing fee (<$5)

1.  Reimportation of drugs from Canada

2.  Medication errors and drug-related problems (DRP)

3.  Managed care and other cost-reduction efforts are leading people to obtain medications in different ways (ie mail and internet)

1.  Study and training

2.  Code of ethics

3.  Associations

4.  Fiduciary responsibility to put client interest above self-interest

1.  Who regulates OTC drug advertising

2.  Who regulates prescription drug advertising

1.  FTC

2.  FDA

1.  Licensure

2.  Laws

3.  Rules and Regulations

4.  Code of ethics

50% by 3rd parties (Pharmaceutical Benefit Managers)

25% by cash

25% by state funded health insurance

1.  What does Medicare not cover (3)?

2.  What % do seniors have to pick up?

1.  Dental, hearing, or vision

2.  22%

National Health Spending

1.  $ amount in 2007

2.  Projected $ amount 2009

1.  $2.2 trillion

2.  $2.5 trillion

National Health Spending as a Share of GDP

1.  What accounted for full % jump in healthcare as it related to GDP in 2009?

2.  Healthcare will account for $_ of every $_ of economic activity by 2018

1.  Recession

2.  $1 of every $5

National Health Spending Per Persion (1997-2009)

1.  % increase in the amount spent per person on healthcare b/t 1997-2009

Major Programs as a Share of the Federal Budget

1.  What has been gaining on Social Security recently?

Health Care Spending in Selected Developed Countries

1.  US spending greater than other developed countris in two ways...what are they?

2.  What is the majority of expense in other countries compared to US?

1.  Per capita spending and %GDP

2.  Public sector for other developed countries (private in US)

Spending Distribution by Category, 2007

1.  What accounts for largest share of healthcare dollar in US?

2.  What % is from prescription drugs?

1.  Hospital and physician services

2.  10%

Spending Summary, by Category

1.  What has declined and grown over the past 20 years as a share of health care dollars spent?

Spending Distribution in Healthcare, by contributers (2007)

1.  3 major contributers to financing health care

1.  Buy services directly

2.  Purchase private insurance

3.  Fund public programs

1.  State and local government

2.  Federal government

3.  Household

4.  Private Business

Services paid by Government by %

1.  Lowest type of treatment and %

2.  Prescription drug %

1.  Dental is the lowest at 6.4%

2.  Prescriptino drugs at 35.5%

Private vs. Public Spending Distribution

1.  % comparison between public and private on hostpital and long term care

What % of private insurance is spent on

1.  Hospital

2.  Physician Services

3.  What is consumer out-of-pocket concentrated in with private insurance (3)

1.  33%

2.  31%

3.  Prescription drugs, dental, and other professional services

1.  2 largest contributors to increase in health spending and their % contribution

2.  Other contributions and percentage

1.  Medical price inflation (>50%) and More tests and more expensive tests (25%)

2.  Population increase and old people (<25%)

1.  What has seen the largest increase in prescription spending since 1980

2.  Why did Part D not increase government prescription spending

1.  Private insurance

2.  Part D just shifted cost form Medicaid to Medicare both of which are federal programs

1.  Fragmented and inefficient

2.Spends more for less result than any other country

3.  Massive uninsured, uneven quality

4.  Administrative waste

Oregon Health Plan

1.  # of people Medicaid expanded to

2.  What did it do for pre-existing conditions

3.  Based on

4.  How did it manage care?

5.  Did it work?

1.  120,000

2.  High-risk pool

3.  Prioritized list of diagnoses and treatments removing quality of life measures

4.  Placing strict capitation (payment guidelines) on physicians

5.  So far the results have been positive

TennCare

1.  # of new Medicaid patients

2.  Method of paying for it

3.  Why did it not work (3)?

4.  Benefits found (4)

1.  500,000

2.  Sliding scale for premioums and cost sharing based on means

3.  Rapid implementation, lack of provider participation, and underfunded

4.  Decreased uninsured, increased satisfaction, decreased hospital utilization, and improved outcomes for asthma and diabetes

Massacheusetts Health Reform

1.  Method of operation

2.  Good and bad

1.  Impose financial penalty for those who don't get coverage and provide subsidies for low income

2.  Good is more people covered, bad is that costs increased if you don't qualify for subsidies

1.  Curative treatments

2.  Rehabilitative interventions

1.  Aging population

2.  Increased longevity, immigration, culturally diverse aged

3.  Major gaps in delivery system

4.  Multidisciplinary care needed

5.  More culturally sensitive, geriatric providers needed

6.  Chronic disabilities of age not covered

7.  New technology increasing costs

8.  Lack of mental health coverage