All five healthcare industry sectors contribute to better
patient.
Who Are the Providers?
- Providers include the people who take care of patients and
the facilities where patients are cared for. People providers are who you think they are—doctors, nurses,
physical therapists, and other clinical staff. These professionals provide
preventive, curative, or rehabilitative healthcare services.
- Provider facilities are things like hospitals, clinics, and
skilled nursing facilities.
Who Are the Payers?
In healthcare, a payer is an entity responsible for covering
the cost of medical services provided to patients by healthcare professionals (known
as providers). They are the ones who pay bills for healthcare. Payers call
their customers “members”. Payers do the following tasks.
- Offer health plans/coverage
- Collect premiums – They receive money from individuals,
employers, or government sources to fund these plans.
- Process claims- When a patient receives care,
the provider sends a claim to the payer, and then reviews and processes.
- Engage members in wellness and care management
programs.
Type of Payer-- Major National Plans
- Regional and Local Plans
- Provider-Led Plans
- Government Plans
What are government payers?Government/Public Payers- These
are the programs funded by federal or state government to provide healthcare
coverage to specific populations:
- Medicare - Primarily for individuals 65 and older
and certain younger people with disability or end-stage renal disease
- Medicaid – Provides health coverage to low-income
individuals and families and those with certain disabilities. It's jointly
funded by the federal and state.
- CHIP (Children’s Health Insurance Program) –
Provides low-cost health coverage to children in families who earn too much to qualify
for Medicaid but cannot afford private insurance.
- TRICARE- Primarily for active-duty and retired uniformed
officers and their families.
- Veterans Health Administration (VA)- Provides coverage to eligible veterans.
Who are the Pharmaceuticals?Pharmaceutical manufacturers belong to a sector of the
healthcare industry known as life sciences. In general, life sciences focus on
research and manufacturing of drugs and devices used in healthcare. Life
sciences include biotechnology experts, medical device developers, and
pharmaceutical manufacturers.
A drug, also called a medication, goes through a long
lifecycle before it gets on the market. Here are the stages it travels
- Research
and Development (R&D): Research is the scientific
investigative undertaking that results in the discovery of a new drug.
Development is when these findings are used to produce the drug, which is
then tested in clinical trials.
- Clinical
trials: Carefully conducted clinical trials are performed on
volunteers to determine if a treatment works, is safe, and is more
effective than an existing treatment.
- Regulatory
review: In the US, findings from clinical trials are submitted
for review by the Food and Drug Administration (FDA) to approve or deny
the drug for sale.
- Commercial
marketing and sales: A new drug launches on the market with
marketing campaigns targeted to physicians and patients, while pharma
sales reps educate physicians on the new drug and how to prescribe it.
Pharmaceutical Products- If we were to list all the drugs on the market today, we’d
need a while, because there are thousands! Instead, let’s talk about the
different drug classifications.
- Generic Vs Brand Name
- Brand Name Drugs -These are original
drugs developed, tested, and marketed by pharmaceutical companies under a
specific trade name. Example: Tylenol is a Brand name that has the Active
Ingredient (Generic Name): Acetaminophen. Protected by patents for several
years, meaning no other company can sell the same drug under a different name.
- Generic Drugs-These are copies of brand
name drugs with the same active ingredients, strength, dosage form, and route
of administration. Approval: Approved by regulatory bodies (like the FDA) only
after the patent of the brand drug expires.
- Small Molecule Vs Biologic
- Small-molecule drugs are those
manufactured in a lab by mixing different chemicals until the right compound is
formed. Small-molecule drugs treat common conditions like infections, high
blood pressure, diabetes, and high cholesterol.
- Biologics, on the other hand, are much
more complex. They’re discovered and manufactured in living organisms, like
plant and animal cells. They’re used for conditions like cancer, multiple
sclerosis (MS), and hepatitis C. There’s more to know, but that’s it for now.
Pharmaceutical Customers-There are four main customers in the pharma sector.
- Physicians prescribe the drugs to
patients.
- Payers pay for most of the prescription
cost—the patient pays the other portion in the form of a co-pay.
- Patients take the drugs or receive the
treatments.
- Distributors store and distribute the
drugs.
Who is the MedTech?
Medical devices and technology (MedTech) fits into the life
sciences sector of the healthcare industry. Life sciences focus on the research
and manufacturing of drugs and devices used in healthcare.
MedTech produces the familiar and the futuristic. MedTech
companies include those that manufacture devices, like bandages or robotics,
and those that provide services, like software to translate x-rays into images.
MedTech Customers
Many of the healthcare sectors serve the same customers, so
you may be familiar with this list. Medtech customers include:
- Payers
- Providers
- Patients
- Distributors
Who is Public Sector Health?
The public sector health system refers to healthcare
services provided, funded, or regulated by the government. It aims to ensure
affordable, accessible, and equitable healthcare for all citizens, especially
the poor and vulnerable.