Category: Pharmacy

Introduction

Deaths from opioids have increased sharply in the US over the previous couple of decades. The typical elucidation blames prolonged prescription and advertisement of opioids that started in the 1990s. The manufacturers of opioids are giving physicians money to talk and consult about the drug (Nguyen et al., 2019). The affirmations that increased prescription augments deaths have elicited enhanced legal restrictions regarding opioid medications. While supporters are convinced that pharmaceutical payments to doctors affect the extreme opioid prescribing, critics believe that other aspects such as too many restrictions are resulting in the creation of underground markets hence a high probability of overdose. Although a ban on pharmaceutical payments to doctors might seem severe, it is the only suitable solution to the opioid crisis.

Arguments Supporting the Effects of Pharmaceutical Payments on Prescribing

Physician-directed payments from opioid manufacturers have increased the rate of prescribing. From the mid-1990s, remarkable transformations have happened in the field of pain management. For example, the Food and Drug Administration endorsed oxycontin, which led to its being highly marketed since it has minimal chances of abuse, unlike the existing and less effective opioids. This was the beginning of the problem since it created the initial wave of newly self-administered opioids in the market. Hollander et al. (2020) have established that physicians who obtain money from manufacturers of opioids such as oxytocin tend to prescribe the drugs than their counterparts who do not get such direct payments. The connection between payments and prescription is most significant for oxycodone and hydrocodone, the most prescribed opioids amongst Medicare patients. The Medicare populace is believed to have a high and fast-rising frequency of opioid usage problems in the United States.

Pharmaceutical companies make indirect payments to health professionals so that they endorse their drugs. They may not give compensation to doctors to directly recommend their medications since such a form of inducement is unlawful. However, they reward physicians for mentioning their drugs in their speeches, conferences, or consulting services. The companies also send sales agents to physicians workplaces to promote the drugs and perhaps buy lunch or leave samples of the products (Nguyen et al., 2019). Such simple incentives make health professionals either wittingly or unwittingly more likely to prescribe the drug even in greater quantities.

Hadland et al. (2017) affirm that about 50% of all the physicians in the United States receive payments in the form of gifts or money from pharmaceutical companies, totaling more than 2 billion dollars each year. Sometimes the companies offer free meals where physicians are invited to listen to drug representatives, pay for doctors travels, or provide luxurious settings where doctors can operate as paid consultants. Such forms of payments generate an apparent conflict of interest. Nevertheless, medical providers have not stopped these payments since they argue that industry inducements cannot harm patients and might benefit them. Relentless efforts such as a ban on payments to doctors from pharmaceutical companies are vital to resolving the opioid crisis.

Pharmaceutical companies payments to doctors lead to increased care costs by making physicians more likely to prescribe brand-name opioids over inexpensive generics. While uncontrolled prices of drugs are draining the Medicare resources and patients savings, the companies payments are forcing things in the wrong course (Hollander et al., 2020). The governments ban on payments from pharmaceutical companies is vital because the doctors-led initiative is unlikely. Most physicians are convinced that obtaining money or gifts from pharmaceutical companies is acceptable. Moreover, with the continued mounting of evidence concerning the negative impact of industry payments, supporters of this move continue to spread arguments in their favor.

Pharmaceutical companies usually take details about drugs, for example, in the form of slide decks, to hospitals alongside catered lunch or inducement. For busy health facilities, this could be an appropriate means of ensuring that physicians remain up to date. The most substantive affirmation could be that physicians depend on pharmaceutical companies to learn concerning new drugs. Nonetheless, evidence shows that pharmaceutical companies information is biased and, therefore, it makes physicians worse instead of improving their care provision (Nguyen et al., 2019). There are several alternative sources of information, such as communication in medical professional communities, where doctors can acquire enlightenment concerning new drugs and approaches instead of that role being played by pharmaceutical companies. Such medical societies have created dependable, unbiased sources of information for physicians.

There are numerous misconceptions floated to cover up the vice of pharmaceutical payments to physicians to prescribe their drugs. There are assertions that the collaboration of physicians with pharmaceutical companies drives innovation. The argument states that the doctors insights are vital for establishing suitable cures, while paid consultancy services are valuable for patients proper enlightenment. The more than 2 billion dollars used each year are not utilized in research for new drugs (Hollander et al., 2020). Instead, the money is spent on the promotion of medications that are already on the market. Since the money is used after innovation has already succeeded, it is merely meant for persuasion. In other words, it is not entirely by chance that health professionals who obtain the highest amount of money from manufacturers also mainly prescribe drugs from the same companies.

The affirmation that pharmaceutical payments to doctors influence the disproportionate opioid prescribing is not indubitable anymore. Therefore, the argument that such payments do not affect the rate of opioid prescribing is no longer factual considering the existing evidence. Accepting pharmaceutical payments cannot be deemed helpful or even acceptable. Physicians take an oath to continuously operate in patients best interest, which is an obligation that they should honor (Hadland et al., 2017). The most significant problem that should be confronted is that the present situation shows that pharmaceutical payments have been working against the interest of patients.

Payments provided to doctors by drug companies negatively influence the quality of drugs and may lead to the overprescription of such opioids. This translates to diminished quality of care, unwarranted risks to innocent patients, and increased costs attributable to overmedication. Physicians have fallen for the tricks employed by pharmaceutical companies in their efforts to increase their profits. To address this issue, countries around the world should enforce stringent laws that will limit the level of interactions between health professionals and representatives from pharmaceutical companies (Guy Jr et al., 2019). Regular use of some medications in high quantities, for example, vasodilators and benzodiazepines, raises the threat of recognized side effects of such drugs coupled with occasional severe or lethal consequences. Gifts translate to a feeling of indebtedness and eventually sway prescription practices negatively. It is high time that physicians understood that the amount of money or rewards provided accounts for only a small segment of their income. At the same time, they represent an insignificant monetary engagement for drug manufacturers compared to their profits from the sale of opioids.

Medical representatives from drug companies use rewards, compliments, and gifts to create a good rapport with doctors to increase the prescription of their opioids. Such medical representatives receive training to evaluate the personalities and inclinations of doctors. They use knowledge from such physician assessments to manipulate information regarding both themselves and the opioids they sell. Although some doctors believe that promotion and payments from pharmaceutical companies do not influence their personal views, promotion practices sway physicians insights regarding such opioids and the likelihood to prescribe them (Carrico et al., 2018). Constant associations of representatives from drug companies and doctors influence the level of prescriptions and ensuing patients costs.

Though some doctors depend on sales representatives to correctly inform them concerning opioids, the details are often incorrect. The sales representatives neither have the correct information regarding rival therapies nor accurate data of the opioids they sell. Additionally, medical representatives either overlook or hide specifics concerning adverse drug events. Some physicians feel that they extract helpful information from sales representatives about the drugs (Nguyen et al., 2019). However, doctors cannot differentiate between false and truthful details given by medical representatives. Moreover, exposure to the information provided by drug manufacturers is linked to an increased rate of prescription and high costs.

Arguments Against the Effects of Pharmaceutical Payments on Prescribing

Guy Jr et al. (2019) affirm that it is not pharmaceutical payments to physicians that influence increased prescribing but the existence of too many restrictions on opioid prescription. The threat of opioid overdose from appropriate medication is minimal as doctors only rely on manufacturers to learn about new drugs. Moreover, prescription restrictions compel users to seek diverted or illegal sources, which augments overdose threat since they cannot rigorously evaluate drug potency, efficacy, or quantity in underground markets. On the contrary, from 2011, fast mounting deaths from opioids, for example, fentanyl, resulted in an increased fatality rate irrespective of decreased legal prescriptions.

Pharmaceutical payments to physicians do not influence increased prescribing, but patients needs for the drugs warrant it. Carrico et al. (2018) affirm that pharmaceutical payments to physicians neither cause long-term medical administration of opioids nor pose any significant risk to patients. This proof, in conjunction with the notion of some critics that doctors might be undertreating pain, led to the medical board, non-governmental organizations, and other support groups to recommend opioid treatment for conditions such as chronic aches. Pharmaceutical companies appreciated this occurrence and asserted that opioids such as oxycontin have minimal risks to patients. Quite the reverse, the proponents of the impact of pharmaceutical payments to physicians on prescriptions state that the early optimism emanates from minimal and unconvincing evidence. They affirm that increased opioid prescriptions of the 1990s resulted in increased overdose, dependence, and deaths. Therefore, restriction of pharmaceutical payments to doctors is necessary to reduce unnecessary prescriptions and ultimately the resultant harm.

Lo and Grady (2017) assert that pharmaceutical payments to physicians do not influence increased prescribing as opioids are exclusively availed on prescription and only when doctors find it essential to do so. Consequently, although many forms of opioids are lawfully produced, distributed, and administered within the guidelines of the Controlled Substances Act, they are not as commonly accessible as common legitimate goods. Physicians usually restrict prescriptions to healthcare norms and lawful limitations. Quite the opposite, the increased prescription of opioids happens in health facilities and not only in the underground markets. The effects of opioids from illicit sources are insignificant compared to the ones prescribed by doctors, which necessitates stringent measures such as prohibiting all forms of gifts or payments to physicians by pharmaceutical companies.

Pharmaceutical payments and gifts to doctors do not influence increased prescribing because physicians uphold integrity and the best interest of patients. Physicians are not so crooked or lacking in integrity to the point of auctioning the interests of their patients for a pack of candies, a few donuts, or any amount of money (Lo & Grady, 2017). Health providers resist such temptations and arrive at judgments solely anchored on the welfare of patients. Pharmaceutical companies should not be prohibited from offering gifts and payments to physicians. This is only meant as a token of their appreciation for attending meetings where they are enlightened concerning different medications. Conversely, though doctors are honest and ethical professionals who do everything possible to help patients, they are human beings hence susceptible to external influence. Money is a crucial suspect for undue influence, which is not a surprise as to why pharmaceutical companies use billions of dollars every year to entice doctors into prescribing their drugs.

Conclusion

The more doctors prescribe opioids, the higher the amount of money they receive from the manufacturers. While proponents are convinced that pharmaceutical payments to physicians influence the extreme opioid prescribing, opponents believe that other factors such as many limitations push consumption to underground markets, thereby creating a high possibility of overdose. A prohibition of pharmaceutical payments to doctors may appear severe but is the only appropriate solution to the opioid problem. Despite doctors being honest and ethical professionals, they are human beings thus vulnerable to external influence.

References

Carrico, J. A., Mahoney, K., Raymond, K. M., Mims, L., Smith, P. C., Sakai, J. T., Mikulich-Gilbertson, S. K., Hopfer, C. J., & Bartels, K. (2018). The association of patient satisfaction-based incentives with primary care physician opioid prescribing. The Journal of the American Board of Family Medicine, 31(6), 941-943. Web.

Guy Jr, G. P., Haegerich, T. M., Evans, M. E., Losby, J. L., Young, R., & Jones, C. M. (2019). Vital signs: Pharmacy-based naloxone dispensingUnited States, 20122018. Morbidity and Mortality Weekly Report, 68(31), 679-686. Web.

Hadland, S. E., Krieger, M. S., & Marshall, B. D. (2017). Industry payments to physicians for opioid products, 20132015. American Journal of Public Health, 107(9), 1493-1495. Web.

Hollander, M. A., Donohue, J. M., Stein, B. D., Krans, E. E., & Jarlenski, M. P. (2020). Association between opioid prescribing in Medicare and pharmaceutical company gifts by physician specialty. Journal of General Internal Medicine, 35(8), 2451-2458. Web.

Lo, B., & Grady, D. (2017). Payments to physicians: Does the amount of money make a difference? Jama, 317(17), 1719-1720. Web.

Nguyen, T. D., Bradford, W. D., & Simon, K. I. (2019). Pharmaceutical payments to physicians may increase prescribing for opioids. Addiction, 114(6), 1051-1059. Web.

Introduction: Pathophysiology of Osteoarthritis (OA)

• OA: joint disease, chronic, inflammatory.
• The main cause: unknown (Ashkavand, Malekinejad, & Vishwanath, 2013).
• The most widespread form of arthritis in the USA.
• There is no cure.
• Treatment can relieve the symptoms (Woo, 2016).

The main cause of OA is not known, but patients demonstrate such morphological changes as inflammation and cartilage erosion (Ashkavand et al., 2013). The most common signs and symptoms of OA are the stiffness in joints, the weakness in muscles, pain, and the enlargement or swelling of bones. Risk factors for the disease include age, gender, diet, and genetic hormones (Ashkavand et al., 2013). Typically, joint pain gets worse with activity and weight-bearing, whereas the improvement occurs when a patient has enough rest (Woo, 2016). While there is no cure for OA, the appropriately selected treatment can relieve the patients condition by minimizing the functional impairment.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Pharmacodynamics

• The most common over-the-counter drug for OA.
• NSAIDs constitute one of the most common types of treatment of OA.
• NSAIDs help to preserve activity in pain, inflammation, and fever.
• The need for opioid analgesics is reduced.
• NSAIDs help to avoid addiction and chemical dependency (Woo, 2016).

Irrespective of the injury, the inflammatory response is similar. When cell membranes are destroyed, chemical mediators are released, such as prostaglandins, histamine, cytokines, leukotrienes, enzymes, and oxygen radicals (Woo, 2016). Two main enzymes, cyclo-oxygenase and lipo-oxygenase are needed to produce the mentioned mediators. The main mechanism of NSAIDs is considered to be the inhibition of cyclo-oxygenase activity and prostaglandin synthesis (Woo, 2016). Other factors that may be observed include the inhibition of lipo-oxygenase, lysosomal enzyme release, neutrophil aggregation, leukotriene synthesis, and different cell membrane functions (Woo, 2016).

NSAIDs in OA Treatment

• Acetaminophen:
  • tablets, chewable tablets, caplets, gelcaps, elixir, liquid, infant drops;
  • recommended daily dose: not to exceed 3 g;
• Etodolac:
  • capsules (200/300 mg) and tablets (400/500 mg);
  • recommended daily dose: not to exceed 1,200 g;
  • for patients d60 kg, not to exceed 20 mg/kg;
• Diclofenac:
  • tablets (25/50/75 mg) and extended-release (100 mg);
  • recommended daily dose: generally, not to exceed 150 mg;
• Other common OA drugs:
  • Ibuprofen;
  • Indomethacin;
  • Ketoprofen;
  • Meclofenamate;
  • Meloxicam;
  • Naproxen;
  • Oxaprozin;
  • Piroxicam;
  • Sulindac (Woo, 2016).

The initial pharmacological treatment of OA includes 650 mg of acetaminophen four times a day or 1 g three times a day (Woo, 2016). Such an approach allows managing joint pain and relieving other symptoms. However, if this drug cannot produce positive results, NSAIDs are prescribed for the patient. Individuals with poor response to acetaminophen are recommended systemic NSAIDs or intra-articular corticosteroid injections (Woo, 2016). The selection of NSAIDs depends on patient preference, duration and cost f treatment, and adverse reactions.

Aspirin and Nonacetylated Salicylates: Pharmacodynamics

• Actions:
  • oanti-inflammatory;
  • oanalgesic;
  • oantiplatelet;
  • oantipyretic;
• Pharmacological effects: similar to NSAIDs.
• Body temperature is lowered through:
  • othe impact on the hypothalamic thermostat;
  • operipheral vessels vasolidation (Woo, 2016).

Due to their ability to lower patients body temperature, salicylates increase the heat dissipation. Analgesic and anti-inflammatory activities are resolved though the prostaglandin synthesis inhibition in the way similar to NSAIDs (Woo, 2016). It is necessary to note that aspirin has more potency in inhibiting prostaglandin synthesis than NSAIDS. Also, the anti-inflammatory activity of aspirin in higher than that of NSAIDs. The main reason for such a disparity is thought to be the acetyl group of the aspirin molecule (Woo, 2016). Another effect of aspirin is the irreversible inhibition of platelet aggregation. Bleeding times are prolonged through the use of single analgesic-level doses.

Aspirin and Nonacetylated Salicylates in OA Treatment

• Acetylsalicylic acid (aspirin):
  • tablets, chewable tablets, enteric-coated tablets, timed-release tablets, caplets, suppository;
  • cautious use in children is recommended;
  • toxicity risk is increased at high doses;
  • the combination with extended-release dipyridamole is more favorable than aspirin alone;
• Diflunisal:
  • tablets (250/500 mg);
  • recommended dose: 1 g initially, and then 500 mg every 8-12 hours for adults (Woo, 2016).

OA patients may experience acute or subacute painful episodes the major cause of which is inflammation. Whereas there is no effective drug that could change the course of OA, salicylates can be used to treat the pain (Woo, 2016). Aspirin is recommended due to its analgesic effect and anti-inflammatory action. In divided doses (1.2 to 2.4 g daily), this drug is well tolerated. Compared to NSAIDs, aspirin is reported to have fewer side effects (Woo, 2016). Acetaminophen does not have any anti-inflammatory action, but it is helpful for analgesia.

Nursing Implications

• Control over pain.
• Correct intake of drugs.
• No overdose issues.
• Ability to manage ones condition.
• Avoidance of side effects.

The main nurse-related consequence of OA treatment is the patients ability to control his or her life due to the selection of correct drugs and dosage (Woo, 2016). It is necessary to explain the possibility of adverse effects and perform patient education to reach the best outcomes of treatment. Also, the nurse should make sure that the patient is capable of addressing the healthcare facility when he or she notes the deterioration of pain or other uncommon indications. Overall, the nurses role in the pharmacological management of OA is to promote patients well-being and help them to avoid complications.

References

Ashkavand, Z., Malekinejad, H., & Vishwanath, B. S. (2013). The pathophysiology of osteoarthritis. Journal of Pharmacy Research, 7(1), 132-138.

Woo, T. M. (2016). Drugs used in treating inflammatory processes. In T. M. Woo & M. V. Robinson (Eds.), Pharmacotherapeutics for advanced practice nurse prescribers (4th ed.) (pp. 801-836). Philadelphia, PA: F. A. Davis Company.

Introduction

Dementia is a term that is not a particular illness, but it refers to the impaired ability to think, recall, or make decisions that interfere with everyday activities, Alzheimers disease is the most common. Though it mostly impacts older adults, it is not part of normal aging. Due to the general nature of the name, the symptoms can vary from one individual to another. Those with dementia have issues with their memory, communication, attention, and reasoning. Pharmacological approaches consider the use of medicines to treat as well as relieve pain, whereas non-pharmacological methods favor other modalities of care. The aim of this paper is to discuss the non-pharmacological and pharmacological methods of providing care to dementia patients in nursing homes.

Pharmacological Methods

Cholinesterase inhibitors are medications that work by improving the levels of a chemical messenger involved in judgment and memory, including donepezil, galantamine, and rivastigmine. Although mainly utilized in cases of treating Alzheimers disease, they can be provided to patients suffering from other illnesses such as Parkinsons disease dementia, vascular dementia, and Lewy body dementia (Marazziti et al., 2021). Side effects can consist of vomiting, diarrhea, and nausea. Other likely side effects comprise fainting, slowed heart rate, and sleep disturbances.

Another medication is memantine which works by controlling the glutamates activity, another chemical messenger involved in brain functions such as memory and learning. In some instances, it is prescribed with a cholinesterase inhibitor (Marazziti et al., 2021). A common side effect is a dizziness, as suggested by Marazziti et al. (2021). Other medicines that can be used in the treatment of dementia depend on the physician and the symptoms someone is experiencing.

Non-Pharmacological Methods

Symptoms of cognitive impairment, as well as behavioral and psychological symptoms in dementia, may be treated with various non-pharmacological interventions that span behavioral, psychological, and environmental fields. As a health professional, one can obtain advice concerning the availability of these activities and training sessions for the patients and their families and caregivers at the Dementia Behavior Management Advisory Service (Yorozuya et al., 2019). The first method to apply is cognitive behavioral therapy, which may offer assistance with adjusting to the initial diagnostic examination, and forward planning, as well as treating depression in the early stages of dementia. Individuals who get the most out of this mechanism are those in their early days after discovery.

Another method is psychotherapy and psycho-educational intervention, which may aid caregivers in dealing with helping people with dementia and maintain their well-being. The third technique is behavioral management therapy, which is used to target challenging behavioral trends in dementia patients (Varkonyi-Sepp et al., 2022). Such behaviors comprise agitation, wandering, and repetitive questioning. The fourth approach is environmental or modification, where creative solutions to the symptoms are encouraged, targeting the surroundings of the impacted people (Sousa et al., 2021). The ideal environment for someone is that which is familiar, constant, and non-stressful.

Conclusion

The paper has discussed the non-pharmacological and pharmacological methods of providing care to dementia patients in the nursing home. While pharmacological methods employ the use of medicines to treat the sick, non-pharmacological utilize other modalities of care, such as therapy. For instance, use of cholinesterase inhibitors are medications that work by improving the levels of a chemical messenger involved in judgment and memory, including donepezil, galantamine, and rivastigmine. Additionally, it has shown an intervention, such as an environmental approach, which focuses on the surroundings of the patient. It is stated that an ideal environment for someone is that which is familiar, constant, and non-stressful.

References

Marazziti, D., Avella, M. T., Ivaldi, T., Palermo, S., Massa, L., Vecchia, A. D., Basile, L., & Mucci, F. (2021). Neuroenhancement: State of the art and future perspectives. Clinical Neuropsychiatry, 18(3), 137169.

Sousa, L., Neves, M. J., Moura, B., Schneider, J., & Fernandes, L. (2021). Musicbased interventions for people living with dementia, targeting behavioral and psychological symptoms: A scoping review. International Journal of Geriatric Psychiatry, 36(11), 1664-1690.

Varkonyi-Sepp, J., Freeman, A., Ainsworth, B., Kadalayil, L. P., Haitchi, H. M., & Kurukulaaratchy, R. J. (2022). Multimorbidity in difficult asthma: The need for personalized and non-pharmacological approaches to address a difficult breathing syndrome. Journal of Personalized Medicine, 12(9), 1435.

Yorozuya, K., Kubo, Y., Tomiyama, N., Yamane, S., & Hanaoka, H. (2019). A systematic review of multimodal non-pharmacological interventions for cognitive function in older people with dementia in nursing homes. Dementia and Geriatric Cognitive Disorders, 48(12), 116.

Patients diagnosed with dementia experience impaired abilities to memorize events and past encounters with various activities. Dementia also exposes patients to decision-making challenges that occur from psychological interferences. The analysis of the importance of non-pharmacological versus pharmacological methods in providing care for individuals living with dementia formulates the objectives of the health policy. Assessing non-pharmacological health policy prompt readers to master the agencies, target audience, and health outcomes involved in the nursing practice.

Non-Pharmacological Health Policy

The health policy of non-pharmacological versus pharmacological methods concentrates on the remedies for supporting dementia patients. Yorozuya et al. (2019) argue that the policys non-pharmacological perspectives aim at improving and maintaining the cognitive functioning of individuals. The policy stresses that memory training can maximize the cognitive functioning of individuals diagnosed with mild dementia (Yorozuya et al., 2019). Music and dance, multi-sensory, light massage, and animal-assisted therapies can work with the policy of non-pharmacological care.

Legislators and Agencies Involved in Non-Pharmacological Health Policy

The non-pharmacological health policy adopts numerous legislators or agencies to improve health care practices and outcomes. Yorozuya et al. (2019) highlight that the Dementia Bill of Rights and the CARE Act include the primary legislation protecting patients with dementia in America. The CARE Act provides relief funds to specialists handling dementia patients; the health policy gets its finances from the government and well-wishers. In addition, the Dementia Behavior Management Advisory Service and Rural Caregivers to Cognitive Behavior interventions involve active agencies linked to non-pharmacological home care.

Influence of the Policy Among the Targeted Populations

Behavioral interventions incorporated in non-pharmacological health policy influence the management of memory loss and judgment among affected populations. However, the policy best works for mild cases, especially individuals recently diagnosed with Alzheimers and mixed dementia. The non-pharmacological health policy will increase self-awareness and encourage mood changes among the targeted groups. Furthermore, the health framework will reduce depression and stress and manage pains for individuals with severe cases.

Importance of the Health Policy

The non-pharmacological health policy topic is essential and needed in practice because it exposes affected families to the best remedies for behavioral control and symptom eradication among dementia patients. Secondly, the topic is relevant since it enables individuals to understand cognitive functioning. Thirdly, knowledge of the management of patients in Nursing Homes is simplified by implementing a non-pharmacological health policy. Finally, the policy boosts the moods of patients and the outcomes of treatment of people diagnosed with dementia.

Reference

Yorozuya, K., Kubo, Y., Tomiyama, N., Yamane, S., & Hanaoka, H. (2019). A systematic review of multimodal non-pharmacological interventions for cognitive function in older people with dementia in nursing homes. Dementia and Geriatric Cognitive Disorders, 48(12), 116.

Current pharmaceutical pricing creates obstacles for a number of patients, healthcare facilities, and for the overall progress of medical science. The modern landscape of policies regarding pharmaceutical pricing is unable to mediate adequate strategies to benefit clients, producers, and healthcare professionals. However, there are three actions that can be utilized by congress in order to improve the pricing factors of medicine to make it more available to those that require it.

The practice of drug development is incredibly time and capital consuming. As such, it motivates pharmaceutical companies to often set unbelievably large prices. In order to combat this issue, the implementation of innovation-friendly policies is essential. Essentially, such policies attempt to distribute costs of drug development through a number of routes such as taxes, regulations regarding reviews process, and through other means (Morgan et al., 2020). This lifts a portion of the economic burden of the manufacturing firm.

Currently, companies enjoy market monopolies through either patented goods or FDA-granted exclusivity. However, this causes them to be the sole price-setters of certain medicine and pharmaceuticals. As such, modern policies should analyse and offer more reasonable monopoly protections to such firms (Beall et al., 2020). This policy can be observed through limiting patent varieties and the time they can be viable for. Certain drugs that have common uses may even be required to be non-monopolized.

While competition is a useful tool within economics, it has failed the pharmaceutical market in the past few decades. This is largely because it is often used as a tool to inhibit the production of generic medication by smaller firms. Contention in which one firm has more capital and influential power ultimately limits the introduction of new products (Lakdawalla et al., 2018). As such, policies should observe changes in products that influence prices more closely with producers needing to exhibit more transparency when presenting such alterations.

References

Beall, R. F., Hollis, A., Kesselheim, A. S., & Spackman, E. (2021). Reimagining Pharmaceutical Market Exclusivities: Should the Duration of Guaranteed Monopoly Periods Be Value Based?Value in Health, 24(9), 1328-1334. Web.

Lakdawalla, D. N. (2018). Economics of the Pharmaceutical Industry.Journal of Economic Literature, 56(2), 397-449. Web.

Morgan, S. G., Bathula, H. S., & Moon, S. (2020). Pricing of pharmaceuticals is becoming a major challenge for health systems. BMJ, 368(1). Web.

Pharmaceuticals are crucial to the system of healthcare across the world; therefore, the United Nations proclaimed that every state should provide universal and equal access to it. To fulfill this objective, every country accepted global coverage for pharmaceutical services  except for Canada. In Canada, universal insurance expires as soon as the patient has received the prescription and is out of the doctors cabinet. Disregarding the national pharmacare program leads to inequities, financial losses, and weakens Canadas purchasing influence on the global pharmaceutic market. The latest report on the program implementation was documented in 2019; however, no explicit decision was made. Even though Canada considers the pharmacare plan as unbearably expensive, some critics believe it is crucial to let the government pay off high-cost medicines prescribed to the countrys citizens.

Medical prescriptions allow millions of Canadians to fight severe diseases, ease pain, and prevent the occurrence of symptoms  in other words, to lead a healthy lifestyle and live longer. However, the healthcare system of this state is flawed by the fact that there is no universal drug coverage program. Today, the drug costs take the second place for expenses in Canadian healthcare system. As a result, many Canadians are devoid of the possibility of acquiring expensive drugs and are literally left to die. Drug prices have significantly grown since the last decade. In Canada, drug spending has risen from $2.6 billion in 1985 to $33.7 billion in 2018 (Wudrick 7). There are, however, governmental organizations that provide pharmaceutic coverage for vulnerable groups such as seniors or invalids, but other people are to buy drugs themselves. The number of those who do not have private insurance is around 10% of the entire population (Koch 15). As a result, thousands of surveys reported that Canadians could not resort to the pharmacy due to their inability to pay for the prescribed medication (Wudrick 6)

The Proponents Opinion

The idea of issuing a national pharmacare program is not a novice to the Canadian government. It has been suggested in every study of Canadas healthcare structure from the 1964 Hall Commission report to the Pharmacare Now report. This act proclaimed that all the healthcare services should be accessible, understandable, and equal to anybody. Medicare was first introduced in the 1960s; prescription medicines were essential but did not present a significant element in a healthcare system. Moreover, there was a limited range of inexpensive drugs available to citizens. The government decided to focus on physician services and hospitals, as they were considered the main components of the healthcare system. The pharmacys services were supposed to be added later; however, they were disregarded due to other state problems. Therefore, the provinces and regions developed their own plans to sustain the well-being of the locals, and some employers accepted a policy of supplying their workers with health benefits. However, such programs were supposed to attract the workforce to the regions and maintain workplace productivity rather than serve as a safety net.

Typically, a wealthy country tries to establish complete insurance coverage to express commitment to its residents. However, the current situation concerning universal coverage makes no sense. Therefore, this occurrence led to the Advisory Councils announcement on the Implementation of National Pharmacare in February 2018 (Wudrick 2). The council conducted the financial, social, and economic assessment of other countries pharmacy plans and consulted with the healthcare professionals, patients, and others to evaluate the states position. The councils chair, Dr. Eric Hoskins, proclaimed that people should not be stolen thousands of dollars for the medications. According to the source, the council believes, correctly, that a national program with bulk purchasing would drive down costs countrywide (Koch 6). He introduces some alterations to the Ontarios insurance plan available to everyone under 25, even though the majority of this age group already had coverage from their workplaces or private ones. Moreover, he spent the money of the taxpayers to subsidize those who did not need it. Hoskins also claimed that Canada urgently needed a precise strategy that would rein in medical costs. The New Democratic Party (NDP) proclaimed the pharmacare program as their foundation for the next election, promising to issue adequate medical coverage.

In addition to this, the implementation of such a program would help to collect data and report it to improve a general health situation in the state, speed up the decision-making process, and reduce inequities. By developing drug data records, health care professionals can follow the operation of a patients treatment and see if their health gets better or worse. The drug data will be connected to the patients personal data such as age, sex, race, and others to make this policy better for Canadas diverse populations. As a result, the diversification gaps will be filled in.

Canada cannot implement this program on its own, but the country could propose other states to join the multinational program of drug coverage based on a fair return. The source claimed that certainly, it would be a program welcomed by many in the United States where drug costs, generally far higher than here, are a political issue. Drug companies would scream foul if a policy of fair return were implemented (Koch 12). As a result, if Canada is unable to make a program on its own, it needs to resort to at least the nearest provinces and territories of the indigenous population.

The council also thought it would be efficient to impose a multi-payer system. It means that an average Canadian resident will have to pay one-third of the total insurance cost. Several countries already utilize such a system as it proves to meet national standards. Therefore, Canada could use this method as well as it is financed through payroll taxes and other premiums. The problem is that Canadian residents who do not have private employment plans are forced to resort to the provincial medicine plans. The council also viewed the catastrophic model plan, which could be the basis of universal insurance.

The Opponents Position

The opponents, however, claim that the average cost of issuing such a program would cost a dozen millions of dollars annually, which would devastate Canadas economy. The amount of money spent on implementing the application on the federal level will be enormous. Around $25.5 billion will be shifted from the provinces, and the private sector to the national budges, causing much damage to the economics as $4.1 billion will be added annually to the expenses on the program (Wudrick 14). Moreover, the insurers claim the program implementation would ruin the coverage of those residents who purchase secondary insurance. As a result, the insurers will not be accessible anymore as the newly issued universal coverage will include every medical service. However, they managed to survive in 1984 when the Canada Health Act was first passed.

Moreover, there is such an opinion that once every citizen under the universal coverage will have access to all the medications, people having private insurances will not be able to get those. Around 24 million of those who have individual plans will no longer access the medicines they were prescribed. The opponents believe that there is no need to wipe out the systems that efficiently works now.

Furthermore, the national pharmacare program will demand substantial tax increases that citizens will not be able to pay off. Around 12.3$ billion will be the taxpayer cost annually (Wudrick 16). Thus, the government monopoly believes it is necessary to accept this program. They consider such money is not a deal when it comes to coverage. In addition to this, they allude to the catastrophic insurance that can cover high medication expenses. As a result, they suggest that the existing employment-related and provincial plans are enough to sustain the populations health.

Conclusion

In conclusion, it is relevant to say that Canada urgently needs a national pharmacare program because of several reasons. First, many residents cannot acquire drugs they need for their treatment as those drugs cost much. Second, such a program would prove the states commitment to society and its needs. Finally, health professionals will be able to collect their patients data to improve the well-being of a nation. The opposite view assumes that the program is costly and will be beneficial neither to the taxpayers nor to the government. Consequently, the pharmacare plan is urgently needed to be implemented due to the high demand for drugs.

Works Cited

Koch, Tom. Yes to the National Pharmacare  Because We Already Paid for It.The Globe and Mail, 2019,

Wudrick, Aaron. Canada Cant Afford National Pharmacare Program.The Hamilton Spectator, 2019.

Introduction

Pharmacologic treatment and patient management are crucial among registered nurses (RNs). Therefore, the knowledge gained in this course is important for my future endeavors. During the classes, I was taught the laws and regulations of prescribing drugs, the ethical issues associated with drug administration, and the components of a correctly written prescription. Additionally, therapeutic communication helped me understand various relationships with different healthcare stakeholders. Understanding the different drugs that affect different body organs will help me avoid cases of misdiagnosis in the future. Therefore, the knowledge gained from this course will play a significant role in making me a compliant and competitive nurse.

Knowledge of Pharmacology

I knew little about drugs and medication prescriptions before taking the course in pharmacology. I could only prescribe common drugs such as painkillers that do not need a professional opinion. However, the course expanded my knowledge of medical prescriptions, non-medical prescriptions, healthcare costs, insurance, and complementary alternative treatments. Prescription medication involves pharmaceutical drugs that legally require a prescription for them to be dispensed. Such drugs are prescribed because of various reasons including the potential scope of misuse and the high possibility of side effects on the patients. As an RN I have to be very cautious when prescribing and dispensing such drugs to patients.

Meanwhile, non-medical prescriptions are those drugs that do not need expert knowledge and advice before dispensing. The non-prescriptive drugs are administered to treat minor health problems such as headaches, stomachaches, and fever. Over-the-counter drugs such as acetaminophen, aspirin, and antacids are non-medical prescriptions (Greenfield, 2022). Moreover, I learned about the concepts of healthcare costs and various factors that are taken into account. Healthcare costs include the amount spent on renting hospital buildings, securing drugs, and paying practitioners, among others. Therefore, various factors are included in estimating the amount that patients pay for medical services.

The knowledge of insurance and complementary alternative treatments helped me understand how patients can relieve themselves from the burden of healthcare costs. Medical insurance policies allow employers and contracted third parties to take care of medical expenses for patients. Insurance companies require individuals to subscribe to various plans that cover different types of medical care (Greenfield, 2022). Meanwhile, organizations pay for their employees medical care for their business success. Patients can take complementary alternative treatments to avoid the side effects of drugs and increased healthcare costs. The alternative treatments include yoga, tai chi, massage therapy, and acupuncture. The expanded pharmacological knowledge gained will help me understand patients situations and appropriately manage them.

Medication Use

Medication use is significant in alleviating patients conditions and relieving their pains. However, inappropriate medication use can lead to patient complications and consequent problems such as potential lawsuits against the nurses. Accordingly, as an RN I think of medication used differently because of the potential consequences. I believe that every drug must be dispensed and taken as prescribed by a medical expert. Consequently, I am always careful when dispensing drugs to patients, and where I doubt my knowledge in prescribing a specific drug, I consult other experts in the field. Unlike nurse practitioners (NPs), RNs are not permitted to prescribe drugs, order tests, diagnose patients, or perform any duty that is normally performed by physicians. Therefore, my responsibilities of educating patients are limited when compared to an NP. As an RN I can only observe, offer minor treatments, and educate patients, under strict supervision.

Advanced Practice Appreciation

Advanced nursing practice requires cutting-edge educational and clinician knowledge that proves professional competency. My knowledge of pharmacology has made me appreciate the role of advanced practice in nursing. The practice equips RNs and NPs with unconventional knowledge of helping patients and avoiding potential legal liabilities. I was encouraged to specialize in various nursing areas and take more courses on the same. However, my belief that the roles of advanced registered nurses (APRNs) and RNs are not significantly different was not changed. Although APRNs are more effective than RNs, they both perform similar functions. Therefore, advanced practice is only met to improve RNs effectiveness in a healthcare organization, offering more opportunities.

Course Knowledge and Future Practice

The knowledge gained in this course will be beneficial to my future advanced practice. I will use the knowledge of ethical medical practice in taking care of my patients within the legal requirements. Avoiding unethical medical practices such as giving wrong drug prescriptions and disrespecting patients privacy, will allow me to gain the trust of my patients. Moreover, having understood pharmacokinetics and dynamics, I shall assess the patients body biochemical reactions to drugs before dispensing them. Consequently, my patients will have minimum cases of drug-related body reactions. Furthermore, the knowledge of drug effects on different body parts encourages me to further my studies in pharmacology in the future. Therefore, this course is beneficial for my future patients and career development in advanced nursing practice.

Conclusion

As an RN I will interact with drugs and various medications daily. Although my role in nursing is to observe and educate patients, I can be instructed to administer drugs for minor health problems. Understanding the prescriptive and non-prescriptive medications will help me administer appropriate drugs to patients. The knowledge of medical costs and health insurance will help me in assessing a patients economic situation and suggesting alternative medications that are affordable and effective. Pharmacological concepts are crucial for my patients and advanced career development.

References

Greenfield, D. P. (2022). Psychopharmacology for Nonpsychiatrists: A Primer. Springer Nature.

The case under analysis focuses on the provision of generic drugs to African countries suffering from AIDS pandemic. Despite the fact that the company has acquired the pharmaceutical plant in Ghana and reconstructed the facility to increase its capacity. However, despite the increase in financing the project, it still meets opposition and controversy on the part of certain organizations who take control of the health standards in the world.

There are a number of objections to the AIDS treatment due to several reasons. To begin with, the drug companies lack appropriate facilities that would promote adequate treatment. Further, the companies have problems with adherence to complicated medical procedures and standards.

Third, some of the drugs are too expensive to supply them to African countries. Finally, lack of commitment of political leaders to the project also poses threats to the program implementation. Although the project has a number of controversies, the prevention programs proposed by Phyto-Riker Pharmaceutical can significantly improve the situation in Ghana and in Africa.

While establishing compliance with the world accepted healthcare and drug standards, it is highly important for the company to estimate the economic and social context in which this regulation should be implemented. At this point, the laws should be reconsidered with regard to the AIDS crisis because some of the regions require immediate drug intervention to cease the high rates of pandemic.

The companys U.S. roots are beneficial in this situation because CEO can attract investors, such as U.S. Export-Import Bank, that can take an active part in financing export of generic drugs and dealing with patent issues. Lowering prices is another beneficial strategy that can help the companies deal with the disease prevention.

In addition to economic strategies introduced by the U.S. based company, Phyto-Riker Pharmaceuticals have developed new herbal products in collaboration with Ghanaian researchers who are assisted by the leading American specialists. The deep and valid research provided by western physicians has been of great value to the scientific studies introduced by African professors.

Hence, the costs spent on delivery and supply could have been cut to promote further integration of medical intervention. Due to the fact that the United States is considered to be the leading producers of antiretroviral drugs, the company can also provide complications in terms of patent and licensing procedures.

As soon as these barriers are eliminated, the African countries can be provided with sufficient therapeutic intervention. Finally, the generic drugs produced by the company could also be applied for releasing pain or treating common bacterial infections. It can also contribute to defining systems and suspending the rise of opportunistic diseases for people with HIV.

In conclusion, although the provision of generic drugs produced by Phyto-Riker Pharmaceuticals imply a number of contradictions in terms of compliance with medical standards, their actions toward the prevention of AIDS ratio in African countries are justified. Specifically, the company has managed to introduce constant investment into the poorest regions in Ghana through funding proposed by U.S. Export-Import Bank.

Second, American physicians have managed to establish fruitful cooperation with Ghanaian researchers and develop new alternative solutions to the drug manufacturing. This is of particular concern to herbal products which could be developed through supply of local raw materials. As a result, the costs on delivery will be compensated and the companies can lower the prices for their products.

Abstract

Teva is a leading player in the global pharmaceutical industry. The multinational company has continued to acquire new businesses and firms. This paper analyzes Tevas competitive advantages and strengths. The discussion also evaluates the companys resources and opportunities. The article also explains how Teva should move forward in order to remain a leading competitor in the industry.

How Teva Competes in the Generic Pharmaceutical Industry

According to the case study, Teva has continued to compete against different pharmaceutical companies across the world. The company uses its strengths to compete in the generic pharmaceutical industry. By 2006, Teva had executed over 14 transactions with different companies. The company also established new mergers and acquisitions in order to increase its bargaining power (Pearce & Robinson, 2013).

The company also acquired Ivax in 2005. This decision led to the introduction of two blockbusters called Zocor and Zoloft (Khanna, Palepu, & Madras, 2010, p. 17). The company has also maintained an effective supply chain. The approach has made the company competitive in the generic pharmaceutical industry. Teva has also instituted new centers of excellence (CoE) in different parts of the world.

The approach has made it easier for the company to control labor skills, business costs, intellectual property issues, and tax provisions (Khanna et al., 2010, p. 18). The company has also continued to target the most profitable markets such as Europe, the U.S., and Japan. The company also produces quality generic drugs that can compete successfully in the global market.

The company has a unique innovative strategy or business (Khanna et al., 2010, p. 6). The firm has always cooperates with different academic institutions in Israel. This approach has resulted in quality drugs. Such competitive advantages have made Teva a leading player in the industry.

Evaluating Tevas Valuable Resources

Teva has many resources. Most of these resources play a significant role towards the success of the pharmaceutical company. The first valuable resource is Tevas research and development (R&D) strategy. Teva collaborates with different researchers and experts in order to produce quality drugs. The companys financial strength is also a valuable resource.

This strength makes it easier for Teva to acquire new companies and business partners. The resource has also made the company competitive and profitable. The company has also employed the best leaders and managers. Such managers understand the threats and obstacles affecting the company. This practice makes it possible for Teva to engage in profitable business practices.

Tevas competitive advantage is another valuable resource. The above resources determine the best practices and activities in a market dominated by many global players (Khanna et al., 2010, p. 18). The companys factories and plants are relevant towards effective business performance. The firm uses these factories to produce the best drugs for its clients.

Teva uses its efficient supply chain to get raw materials and deliver quality products to different customers (Khanna et al., 2010, p. 18). Teva has also produced many innovative drugs and biosimilars. These resources will always support the companys business strategy.

Opportunities for Teva in Biosimilars and Innovative Pharmaceuticals

The case study explains why the global market for biosimilars might grow within the next eight years. Teva can produce more biosimilars in order to compete in the worldwide market. The rewards for such generic drugs can be very high. Such generics are cheaper and easier to produce compared to innovative drugs (Khanna et al., 2010, p. 22). The market for such biosimilars is also underdeveloped.

The decision to produce more biosimilars can make Teva a leading competitor in the pharmaceutical industry. Innovative drugs are complex and expensive to produce (Khanna et al., 2010). According to Khanna et al. (2010, p. 22), the period for developing an innovative drug is between 10 and 15 years. The drugs also require the best skill, dedication, and information.

This case study explains why the corporation should strike a balance between its biosimilars and innovative drugs. Teva can use the approach to identify the best competitive advantages and opportunities. The companys R&D team should address the challenges affecting its practices. Teva can also form partnerships with different research institutions in order to produce quality innovative drugs (Melicher & Norton, 2014, p. 58).

How Teva Should Move Forward

Teva has maintained an annual growth rate of over 30 per cent. The biggest question is how Teva can keep its current pace (Khanna et al., 2010, p. 22). I am encouraging the company to focus on every emerging global market. This strategy will ensure the company markets its biosimilars to different consumers across the globe. Some countries such as Japan, France, and Germany have also opened up their markets.

This situation makes it easier for Teva to market its products to more customers across the globe. It will also be appropriate for the company to target new markets such as Latin America, Africa, and Asia. These two approaches will ensure the company is on the right track. Teva can also produce new innovative drugs in order to become a market leader (Pearce & Robinson, 2013).

This approach will ensure its innovative drugs are competitive and profitable. The managers should also be ready to analyze every change in the global market. This practice will address every challenge affecting Tevas performance. The company should also support its research and development (R&D) team. The strategy will ensure the company remains profitable across the globe.

Reference List

Khanna, T., Palepu, K., & Madras, C. (2010). Case 21: Teva Pharmaceutical Industries, Ltd. Harvard Business School, 1(1), 1-25.

Melicher, R., & Norton, E. (2014). Introduction to Finance: Markets, Investments, and Financial Management. New York, NY: Wiley.

Pearce, J., & Robinson, R. (2013). Strategic Management: Planning for Domestic and Global Competition. New York, NY: McGraw Hill.

Process map

The paper will attempt to explain the issues that are faced by Health Management Organization (HMO) pharmacy and come up with possible solutions to the problems. In order to identify the problems at a pharmacy, it is important to first come up with the process map of the prescription filing process (Snee & Hoerl, 2005). The process map is presented below.

The map above is categorized into four parts, that is, ordering, transliterating, allotting and administering. In each of the four stages, there are potential areas for errors to occur. A closer review of the entire process shows that the most profound errors are incorrect drug, dose, patient, time, route, labelling, and drug interaction (Snee & Hoerl, 2005). In summary, it can be noted that the entire process lacks quality control checks that ensures that patients receive the correct medication.

SIPOC Model

At this point, the SIPOC model will be used to analyze the HMOs pharmacy business process. This model will assist in finding all important elements of the prescription filling process. SIPOC is an abbreviation for suppliers, input, process, output, and customer (Britz et al., 2000). The SIPOC model is presented below.

Root causes of problems

The first main cause is unreadable handwriting. This arises when the handwriting of the doctor cannot be understood clearly by the pharmacy clerk. The second cause is the lack of efficient and effective quality control checks. It can be observed that the process lacks a third party who reviews the prescriptions against the medication before being issued to the patients (James et al., 2009). Therefore, errors committed by one person cannot be noticed on time. The third root cause is interruptions.

This can be attributed to the fact that the clerk handles many patients and can make mistakes. Interruptions are also caused by few clerks handling numerous patients. This is likely to cause fatigue at work and increase chances of errors. Another cause is customer related problems. This arises from customers with numerous prescriptions, noisy customers, and customers in a rush. The final cause that can be identified in the process are traps. These are medications that sound or look like the prescribed medicines (Snee & Hoerl, 2005).

Special or common causes

A review of the root causes shows that they are common causes. They are not specific to the HMOs pharmacy. They are common across various hospitals. For instance, a study conducted in the UK in 2007 showed that most hospitals experienced these problems (Anecleto, Perini, Rosa & Cesar, 2007).

Tools

The first tool that can be used to evaluate the cause of errors is carrying out root cause analysis. The analysis is important because it gives information on the reality of the causes of the errors. It also suggests possible ways of improving the process. The second tool is carrying out a survey. A survey is aimed at measuring the opinions and perceptions of the pharmacists. This tool is effective in establishing self-reported errors. Therefore, a combination of these two tools can be help in establishing errors in the HMOs pharmacy business process (Snee & Hoerl, 2005).

Solution

The HMOs pharmacy should introduce an automated pharmacy carousel system. Other items that can work together with the carousel system are printers, bar-code scanners, and a bar-coded medication bins. Also, it should have software that allows the carousel system to interact with the HMOs system. Studies have shown that this system has significantly reduced errors in the business process of a process (Peck et al., 2006).

Strategy to measure the aforementioned solution

The solution above can be measured by calculating the rate of incorrectly filled prescriptions (error rate). This should be calculated before the system is implemented. After implementation of the system, the error rate should be calculated at an interval of one week. This rate should be monitored to ascertain whether there is a reduction in error rate or not. If there is a significant reduction of the error rate, then it implies that the system is effective (Cheung, Bouvy & Smet, 2009).

References

Anecleto, T. A., Perini, E., Rosa, M. B., & Cesar, C. C. (2007). Drug-dispensing errors in the hospital pharmacy. Clinics (Sao Paulo), 62(3), 243  250.

Britz, G.C., Emerling, D.W., Hare, L.B., Hoerl, R.W., Janis, S. J., & Shade, J.E. (2000). Improving performance through statistical thinking, Milwaukee, WI. Quality Press.

Cheung, K., Bouvy, M., & Smet, P. (2009). Medication errors: the importance of safe dispensing. British Journal of Clinical Pharmacology, 67(6), 676-680.

James, K. L., Barlow, D., McArtney, R., Hiom, S., Roberts, D., & Whittlesea, C. (2009). Incidence, type, and causes of dispensing errors: a review of the literature. International Journal of Pharmacy Practice, 17(1), 9-30.

Peck, R., Casella, G., Cobb, G., Hoerl, R., Nolan, D, Starbuck, R., & Stern, H. (2006). Statistics: A Guide to the unknown, Pacific Grove, CA: Duxbury Press.

Snee, R.D., & Hoerl, R.W. (2005). Six sigma beyond the factory floor; deployment strategies for financial services, health care, and the rest of the real economy, Upper Saddle River, NJ: Financial Times/Prentice Hall.