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
The US Affordable Care Act Provides a Model to Improve Public Health in Singapore Through Professional Education and the Pharmacist Workforce Page | 2
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.
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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.
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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
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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
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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,
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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.
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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?
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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
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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
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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
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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
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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.
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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
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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
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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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