The US Affordable Care Act Provides a Model to Improve Public … · Literature searches were...

The US Affordable Care Act Provides a Model to Improve

Public Health in Singapore Through Professional

Education and the Pharmacist Workforce

Cheong Hian Goh PhD, MPH candidate; Claude Desjardins

The US Affordable Care Act Provides a Model to Improve Public Health in Singapore Through Professional Education and the Pharmacist Workforce Page | 1

ABSTRACT

Context. The aim of this paper is to review selected concepts of the US Affordable Care Act

(ACA) to show how they served as a template for improving public health in Singapore

through the recent passing of Singapore Healthcare Masterplan 2020 (SHMP-2020).

Attention is focused on demonstrating how the ACA’s emphasis on professional education

and the pharmacist workforce was incorporated into SHMP-2020 to achieve improved access,

better quality and lower costs of healthcare for a nation of over 5.5 million people burdened

with a rapidly aging population.

Methods. Literature searches were conducted with the key words (Affordable Care Act;

Healthcare 2020, Singapore, Healthcare Providers, Pharmacists, Workforce, Elderly) on

PubMed® (2000-2017). Database searches were also performed from AFL-CIOa, AGCb,

ASHPc, CDCd, FIPe, MOHf, MOMg, NUSh, OECDi and WHOj.

Results. Elements of ACA provide both opportunities and challenges for the pharmacist’s

workforce shortage and professional education. The US and Singapore both confront similar

challenges: the need to remodel their healthcare systems and deliver efficient, cost-effective

care to an aging population with a growing burden of chronic diseases and conditions that

occasion catastrophic economic consequences. The concept of accountable care organizations

in the ACA with a framework for team-based healthcare, represents one aspect of the ACA

that can be exploited to deliver quality healthcare outcomes within the Singapore healthcare


system. Policy interventions and a strategy based on a phased approach provides a template

to maximize benefits of a remodeled healthcare system for Singapore.

Conclusion. The ambiguous status of the pharmacist as a healthcare provider has limited the

potential of pharmacists to lower overall healthcare costs. Singapore can expect improved

healthcare outcomes by exploiting the expertise of all participants in a healthcare team, such

as nurses, pharmacists, physiotherapists and other professionals. Pharmacists, for example,

can work collaboratively with physicians to provide efficient team-based healthcare to drive

high quality services at reduced costs for all patients. Achieving this goal requires sound

adjustments in health policy to improvements in healthcare outcomes.

Key Words: Affordable Care Act; Healthcare 2020, Singapore, Healthcare Providers,

Pharmacists, Workforce, Elderly

(a) American Federation of Labor and Congress of Industrial Organizations, (b)

Attorney-General’s Chambers, Singapore, (c) American Society of Health-System

Pharmacists, (d) Centers for Disease Control and Prevention, (e) Fédération Internationale

Pharmaceutique (International Pharmaceutical Federation), (f) Ministry of Health Singapore, (g)

Ministry of Manpower Singapore, (h) National University of Singapore, (i) Organization for

Economic Co-operation and Development, and (j) World Health Organization.


1. Introduction

The growing demand for healthcare and the rising costs for care provide pressing

challenges to public health in many countries. In terms of demographic trends, the baby

boomers have progressed with age and in the U.S., individuals who are over age 65 have now

become the largest consumers of healthcare.1-3 The growth of this population group is

projected to reach 72 million, or nearly 20 percent of the total U.S. population in 2030.2 Like

the U.S., Singapore faces more severe healthcare challenges, with the population group

reaching 1 million, or nearly 25 percent of the total Singapore population by 2030. 4

Several factors contribute to the growing healthcare needs and public health

challenges of aging populations. For example, sedentary lifestyles, unhealthy behaviors (e.g.

tobacco smoking, alcohol drinking etc.), and obesity conspire with chronic diseases and

conditions placing increasing number(s) of middle-age and older adults at risk for health

services.5-9 New medical technologies, early diagnostics, and improved treatments have

improved life expectancy, albeit not necessarily better health. Improving preventive care and

population health represent the challenges to healthcare systems that have been neglected by

most healthcare providers. This paradigm can be accompanied by training non-physician

healthcare professionals with the training and experience to close the gaps in prevention and

population health, and changing the healthcare landscape to promote better health at lower

cost for more people.


Sound national health policies must place a premium on improving functionality and

efficiency of healthcare systems. In the United States (U.S.), the inception of the Patient

Protection and Affordable Care Act (ACA) in 2010 expands existing healthcare schemes to

Americans by exploiting the workforce for primary care and public health to include

prevention and population health as the building blocks to strengthen health quality.10 The

coverage of ACA appeals in providing healthcare providers the opportunities to serve the

needs of the elderly and populations with pre-existing conditions (e.g. cancer).9,10 It

introduces the concept of training non-physician healthcare professionals and engaging them

as members of a team-based healthcare to build the workforce that close the gaps in

prevention and population health.

The Singapore healthcare system is considered a successful model,11 though not

without skepticism.12 The Singapore Healthcare Masterplan 2020 (henceforth referred to as

SHMP-2020) is an ongoing national healthcare strategy to enhance existing healthcare in

Singapore. The SHMP-2020 and ACA both have public health challenges that require

remodeling of their healthcare systems, such as streamlining of healthcare services and

healthcare manpower development supporting primary care, to provide an efficient,

cost-effective care to a growing aging population in Singapore.13

From the healthcare financing perspective, global financial/economic crises have led

to reduced health spending budgets to counter fiscal deficits and government debts.5 In the

U.S., healthcare spending growth was observed at 17.0% in 2013, slightly lower than 17.7%

in 2011.5 The recent revisions to the US healthcare bill also have significant consequences on


the country’s health reform options for improving health insurance coverage, health services

coordination and public health.14 On the contrary, healthcare spending in Singapore has

increased. The government-subsidized healthcare financing (e.g. Medisave, Medishield Life,

Medifund) in Singapore was revamped recently as part of SHMP-2020 to cover patients with

more catastrophic events and extend the scope of severe/chronic conditions.15 Pioneer

Generation Package and ElderShield are two programs designed to extend healthcare

affordability for the elderly and disabled clients.16,17 This means that a higher healthcare

spending is expected to provide extended coverage on larger acute hospital bills and costly

outpatient bills like chemotherapy and kidney dialysis. To date, the Medishield Life scheme

has reported more medical claims in 2016 (47% increase compared to 2015), largely from

patients age 65 and above (73%) and these total claims for senior patients were up 90% from

SGD $181 million to $SGD 343 million.18

To achieve better health system outcomes for Singapore, it is imperative that the

implemented strategies supporting SHMP-2020 can better utilize existing financial and

human resources to assure effective and safe health services, whereby healthcare providers

like pharmacists can improve public health. This paper aims to 1) to review selected concepts

of the ACA, 2) how they served as a template for improving public health in Singapore

through the recent passing of Singapore Healthcare Masterplan 2020 (SHMP-2020), and 3)

demonstrating how the ACA’s emphasis on professional education and the pharmacist

workforce was incorporated into SHMP-2020 to achieve improved access, better quality and


lower costs of healthcare for a nation of over 5.5 million people burdened with a rapidly

aging population.

2. Methods

Literature searches were conducted with the key words (Affordable Care Act; Healthcare

2020, Singapore, Healthcare Providers, Pharmacists, Workforce, Elderly) on PubMed®

(2000-2017). Database searches were also performed from AFL-CIOa, AGCb, ASHPc, CDCd,

FIPe, MOHf, MOMg, NUSh, OECDi and WHOj. The literature relevant to the following

thematic discussions was identified.

3. Results and Discussion

3.1 Context of Pharmacist Workforce in ACA & what this means for Singapore

SHMP-2020?

High performing healthcare system must be supported by technically competent staff

that responds to the patients’ needs and can provide effective healthcare.19 It needs adequate

staff and have an equitable distribution of healthcare providers within a country to facilitate

access and provision of care to the patients.19 The WHO also describes a comprehensive

healthcare system to encompass all components of care, including not only the facilities and

the processes of delivery, but also all the relevant stakeholders from the healthcare providers

to the users of care.19 The pharmacist healthcare workforce is a significant component of the

healthcare system. Pharmacists are the drug experts who can advise patients on their

medication use and delivery of patient care services in health management.20 Indeed,


pharmacists are the most prevalently seen healthcare professionals that patients encounter in

the primary care setting.

The policy intervention of ACA does not necessarily contribute to workforce burden

and having inadequate healthcare providers for the growing healthcare needs. Existing U.S.

health policies do not include pharmacists as healthcare providers.20 Under the ACA

definition of healthcare workforce, while pharmacists perform primary care services through

their expanded clinical roles, they are not recognized as non-physician healthcare providers

under the Social Security Act,21 or Centers for Medicare & Medicaid Services (CMS) as

healthcare providers.20 Pharmacists are now enfranchised as healthcare providers with

responsibility for direct patient care and support responsibilities as a result of the ACA.

While this augurs well in providing pharmacists the opportunities in their abilities to improve

healthcare outcomes, the pharmacist professional identity needs further clarification on

existing legal policies and supportive action from the U.S. Surgeon General to close the gaps

in the healthcare workforce and mandate pharmacist’s recognition and empower them in the

team-based healthcare for the growing number of patients.20 This will also have impact on

other healthcare aspects, in terms of providing adequate provision and accessibility to health

services to patients. This will be discussed in the following sections.

The Singapore pharmacists are identified in SHMP-2020 as one of the main

healthcare professionals responsible for health initiatives in this master plan.22 To the best of

knowledge, there is no clear definition as to who constitutes healthcare providers or the

healthcare workforce in the Singapore legislation, although clearly (likewise in the U.S.


ACA) pharmacists are listed as healthcare professionals under the purview of the Singapore

Health Ministry.23 The professional services provided by Singapore pharmacists are part of

their employment and salaried solely through the government funding to hospitals, or the

private employers in the retail/community settings. There are greater recognitions in the

Singapore hospitals and the Health Ministry to expand the clinical roles to provide

patient-care services, including oncology and geriatric care. Importantly, there are no further

fees incurred on these specialized services which is part of the medical coverage and hence

such added services by pharmacists are not expected to bring about a financial burden to the

patients.

The increased healthcare needs by the ageing population on the available resources

makes it timely to consider the approach of ACA’s policy adjustment as a potential

sustainable solution to Singapore healthcare system the way forward. The ACA transforms

healthcare financing from value-based reimbursement for individual healthcare providers, to

a more cost-effective bundled payment model based on health organization responsibility.

This integrates non-physician providers as members of the healthcare team to improve

delivery of healthcare. A less ambiguous policy needs to ensure healthcare sustainability,

where the Singapore pharmacists are empowered in the roles and responsibilities to improve

delivery of healthcare.

3.2 Providing Adequate Healthcare: How pharmacist workforce impacts manpower issues in ACA? What this implies for SHMP-2020?


The density of healthcare providers affects the scope and quality of healthcare

services.19 Healthcare shortages could have existed before a policy change, just as in the case

of the ACA in the U.S., but strong critics were directed at workforce shortfalls arising from

understaffing physicians to cope with the growing patient need for care.24,25 There are also the

possibility that shortfalls in the primary care workforce is due to merely a primary care

demand-capacity mismatch period. The pharmacists can improve the delivery of care and

provide a logical solution to this urgent workforce need.24 Indeed, the following perspectives

have supported the ACA’s concept that engaging non-physician healthcare professionals as

members of a team-based healthcare can build the workforce that close the gaps in the

healthcare workforce to improve the delivery of care to the growing number of patients.

Firstly, when compared with physicians and nurses, the overall pharmacist shortage in

the U.S. has generally stabilized,26,27 and the workforce supply is generally available to take

on this role. A useful and known indicator, the Aggregate Demand Index (ADI) tabulates the

feedback from employers on their experiences in hiring pharmacists to project the current

U.S. pharmacist’s workforce market trends of surplus and deficits. The scales of 1 to 5

indicates as the workforce situation with high demand, difficulty filling openings; and 5 as

having much less demand than the supply of pharmacists available.28 The supply and demand

of pharmacists in the U.S. is in equilibrium. According to the April 2014 statistics, the

national Aggregate Demand Index (ADI) was 3.30.28 The ADI was only 0.30 points above the

equilibrium point of 3, and a decimal 0.09 increment from 2013. Also, the ADI of 2.93 for

community pharmacist demands suggests a general adequacy in pharmacists in the


community sectors of independent, chain, supermarket pharmacies.28 Comparing the ADI

trends in the past decade, the employer’s indication on pharmacists’ high demand shortage

continued on a consistent downward trend from a high from 4.33 in 2000, dwindling rapidly

to 3.98 by 2005 and steady decreases annually.29 There was an incidental spike to 4.31 in

2006, which the demand was believed to be attributed to unanticipated events such as the

introduction of the Medicare Part D outpatient pharmacy benefit (i.e. more prescription filling

and pharmacy services) and aftermaths of hurricanes Rita and Katrina.28 Apart from existing

spatial use geographic in place of spatial) mismatches (e.g. pharmacist’s demands across

urban and rural areas) that could not be ascertained by ADI, closer evaluation on the 2014

data (taking into consideration the expected surge in ACA enrollments and services in the

year) appears to suggest that the current healthy, stable U.S. pharmacist workforce is not

likely to be significantly or affected negatively by the growing healthcare demands resulting

from ACA.27

Secondly, the ACA needs to reconcile with the current pharmacist workforce

situation.30 Factors that contribute to the drastic shortage of pharmacists in the 1990s include

the demands from increased filling of prescriptions and the preferred shorter working hours

in a predominantly female-based pharmacist workforce setting.31,32 In 2012, about 53.7% of

the pharmacists were female.26 Prescription drug use continues to increase in recent years.32

Incidentally, the ageing population also affects the pharmacist workforce itself, where more

than 27 % of the U.S. pharmacists were at least age 55 years in May 2013, and with a mean


average age of 45 years old.27 These issues remain and have implications as ACA

implementation takes place since 2014.

The U.S. and Singapore pharmacist workforce are confronted with public health

challenges of an increased medication use and gender-related work practices. In 2012, about

76% of the 2013 licensed pharmacists in Singapore were females and approximately 70% of

the establishments are community pharmacies.33 The community pharmacies are the main

providers of primary care services, hence the urgency to explore recruitment of suitable

foreign pharmacists to ensure workforce equilibrium in Singapore. Currently, only degrees

from 138 approved foreign pharmacy schools are recognized by the Singapore Pharmacy

Council.33 It is estimated that Singapore needs about 50% more pharmacists by the year

2020.33 As of June 2017, there are 3026 registered pharmacists in Singapore, or about 52.3

pharmacists per 100,000 population ratio.34 This means that the pharmacist workforce has

almost doubled over the past decade and is closing in to the statistics of developed OECD

countries.34 As discussed in the preceding section, the policy adjustment in ACA itself does

not necessarily adversely impact public health through worsening workforce deficits. In fact,

sound policy interventions can bring about adequate realistic workforce in Singapore to

improve delivery of healthcare.

3.3 Providing effective healthcare - ACA on pharmacist workforce in quality of health services? What this implies for SHMP-2020?

Accountable care organizations (ACO) is another feature of the ACA model that can

be used to achieve cost-effective healthcare. ACO model works as a bundled payment


scheme for service provider to make reimbursements in terms of how they have improved the

overall health status of patients, the care efficiency, and healthcare experience.35 With the

strong patient-care infrastructure in ACOs to bring about cost-effectiveness in healthcare, the

ACA has created greater opportunities for different healthcare providers (including

physicians and pharmacists) to streamline work processes and work collaboratively as a team,

in order to fulfill the required responsibility of providing comprehensive quality healthcare

services for the patients.35,36 Pharmacists work collaboratively in a team-based care approach

in different settings,20,37,38 by collaborating with physicians and other health providers to

provide effective patient-centered care. The new Advanced Practice Pharmacist model in

California is one recent initiative that positively demonstrates how medication therapy

management (MTM) programs can be achieved through collaboration between physicians

and pharmacists.37

The primary healthcare in Singapore healthcare system are provided by the

community sector providers (of some 2000 private general practitioners and 18 public

outpatient polyclinics), while government-funded voluntary welfare organizations will be

involved in the step-down care sector for nursing homes, community hospitals and

hospices.33,39 With the goals of SHMP-2020 in mind, the enhancement of Singapore’s existing

healthcare financing should assure a more comprehensive coverage on more chronic ailments

expected in the elderly and based on a combination of government subsidies and

interventions. The timely policy intervention and closer oversights have led to financial

commitments and national strategies enabling Singapore pharmacists in building the quality


of healthcare workforce and capacity building.15,22 For example, specialist pharmacists can

actively contribute in the new opened Centre of Geriatric Medicine for geriatric care and

patients with dementia.40 Recently, there are more government-led efforts, such as the

reorganization of health system clusters to streamline services, introduction of team-based

care programs and the proposed collaborative prescribing rights for pharmacists to directly

manage the patients.41-44 The Chief Pharmacist’s Office at MOH also spearheaded a 10-year

National Pharmacy Strategy with pharmacy initiatives for healthcare transformation towards

supporting healthy living and active living, enabling delivery of care at the community level

and ensuring value-adding healthcare.4 These ongoing developments echoes the ACA’s ACO

model to future-proof Singapore’s health system for a growing number of patients. It is clear

that there are merits of involving pharmacists in the team-based healthcare collaboration to

bring about cost-effective healthcare.

3.4 Growing Capacity of healthcare providers: ACA on Pharmacist Training, and impact for SHMP-2020?

Professional education provides the mechanism to enhance the capacity of

pharmacists to improve the delivery of high quality healthcare. Based on needs projection by

the Pharmacy Manpower Project in 2001, an increase in a need for 417,000 pharmacist

full-time equivalents (FTEs) would be expected for primary healthcare services in the U.S. by

2020.45 The U.S. PharmD training of new pharmacists to be fully competent practicing

professionals may takes 6-7 years, or longer.45 In this regard, it is not evident if the current

education syllabus and pharmacy enrollments align well with the requirements of ACA.45 The

ACA encourages more uptake of pharmacists through scholarships as stipulated in the U.S.


healthcare bill to pursue specialist training in relevant areas of primary care. However, the

strategy of leveling up specialized skills for existing pharmacists may fall short of the

immediate healthcare needs and demands.

The growing aging population has also created challenges for Singapore pharmacists

in practice. In Singapore, chronic conditions and increased reliance on lipid-lowering and

anti-hypertensive medications have become more prevalent in older population.46 In order to

build capacity, there are strategy based on phased approach policy interventions supporting

the SHMP-2020 roadmap to encourage pharmacist specialization and competency in primary

care. Before the introduction of SHMP-2020, the pharmacist specialization was first enacted

in legislation under the Pharmacist Registration 2007.47 In 2009, a new career framework was

established to allow practicing pharmacists to pursue professional, clinical, or research career

tracks.32 A new Doctor of Pharmacy (PharmD) Program was also introduced in the pharmacy

school curriculum.48 It consists of didactic and clerkship components that enhance the

pharmacist’s clinical knowledge and specialized patient care.48 In tandem with SHMP-2020,

the establishment of the Pharmacy Specialist Accreditation Board (PSAB) in 2012 formalized

pharmacy specialization to include disciplines like oncology, geriatric care, cardiology,

psychiatry and infectious diseases.33 In terms of education, the Department of Pharmacy (the

only pharmacy school in Singapore) has recently revamped the 4 year pharmacy training

curriculum, incorporating both experiential clinical training and inter-professional education

training components and use of innovative simulation technologies/virtual reality learning to

ensure that the pharmacy graduates will meet the SHMP-2020 workforce objectives.49-51 The


school has increased it’s enrollment, from 150 in 2014, towards 240 pharmacy students to

support the projected 3000 pharmacists for SHMP-2020.33,52 The Singapore government has

also continued to provide funding for specialist training scholarships and support of higher

degrees (masters and doctoral training), as well as study awards (e.g. Healthcare Skills Future

Study Awards under the national SkillsFuture initiative) to support skills upgrading.33,53

Besides having a mandatory Continuing Professional Education (CPE) system for pharmacist

licence renewal, the recently implemented Advanced Practice Competency Framework and

running of accredited national pharmacy residency programs also provide a systematic

approach to encourage practicing Singapore pharmacists in lifelong professional development

and acquisition of new competencies to advance their clinical skills.4 The above underscores

the extensive multi-prong approach in Singapore of integrating professional education and

specialization over time. The ACA’s limitations in the pharmacist’s capacity building has

also been a learning model for Singapore to consider the need for more adequate timeframe to

effect a policy change in healthcare.

4. Conclusion

Remodeling health policies such as ACA and SHMP-2020 provide opportunities to improve

on existing limitations in access to care, cost of care, and improved quality of care. Achieving

these new goals also present(s) challenges. The pharmacist workforce, for example, must be

trained to acquire new skills and learn to work in collaboration with other members of

healthcare teams rather than continue to behave as a solo operator to deliver effective health

services in an increasingly complex healthcare setting. While both frameworks show


common convergence focusing on expanded services and primary healthcare for the growing

and ageing populations, healthcare outcomes may differ due to the influence of governmental

interventions and existing context of healthcare frameworks. Building capacity and expertise

through education and professional training is essentially a long-term approach towards

workforce equilibrium, cost reduction and quality of care. The ambiguous status of the

pharmacist as a healthcare provider has limited the potential of pharmacists to lower overall

healthcare costs. The Singapore pharmacists can work collaboratively with other healthcare

providers to provide efficient team-based healthcare that achieves improved access, better

quality and lower costs of healthcare for a burdened with a rapidly aging population.

Achieving this goal requires sound and timely adjustments in health policy to improvements

in healthcare outcomes.

5. Acknowledgments

The author wishes to thank Professor Claude Desjardins for his invaluable comments and

suggestions on the manuscript.


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