UNC Kenan-Flagler Business School

Center for the Business of Health

Global Healthcare
DAY 1
 This course has 2 components, together they make up
the Healthcare Challenge

Healthcare System Disease State Healthcare Challenge

Select a country of interest to Select a disease that has the Develop and propose an
conduct your research and most unmet need, or the innovative business solution
analysis biggest potential for that is sustainable
improvement

Tip: 3 views. (1) look how your country has resolved healthcare issues in other disease states and see what is
‘transferable’ (2) look how your disease has been resolved in other countries and see what is ‘transferable’. (3) Look
outside of healthcare for innovative solutions.

2
 Reflection
State of the world – in the context of healthcare

– Covid-19 / Pandemics/ Mpox - Political Divide - Social Unrest / Underserved

– Homeless / Opioid / Addiction - Inflation - Interest Rates
– Wars - Immigration - Natural Disasters
– Health & Disease - Health Policy - Climate / Sustainability

Hot Spots: US, China, India, Russia/Ukraine, Middle East, Bangladesh, UK, FR, TW, Korea’s, SSA, Latin America

Impact of Covid What ERA are we in?

Health / Death / Fear / Anxiety Since Covid/War: the world has gotten
Shutdown / Travel Restrictions (1) less Global, (2) less Democratic, (3)
Mandates / Trust less Westernized
School / Work / Economy
Relationships / Events / WFH More fragmented, volatile, and more
dangerous
These ‘covid years’ have been a
significant part of YOUR life. Economic Growth, Education and Peace
are the best healthcare
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 Implication
Things to consider and ponder relative to this course

1. Balance between Public Policy and Business; this is a business school class; #1
Public Health school is just down the street. Our job is to run a business within the
context of public health.

2. Sustainability (financial) – There is no pot of gold at the end of the rainbow. How
do you pay for things? Demand for healthcare is unlimited while resources are
finite. How do you ensure that we have healthcare for future generations?

3. Often agreement on the problem, mostly aligned on root causes, but lots of conflict
on the solutions – best to keep the debate on what to do to fix the problem with an
open mind and respect.

4. Despite what you might be hearing and reading, we have made lots of tremendous
progress with regards to healthcare...

Empathy, Communication, Respect, Context, Exercise and Humor

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Some ways to think…

Critical Thinking: The objective analysis and evaluation of an issue in order to form a judgment,
data/fact based.

Contrarian Thinking: Opposing or rejecting popular opinion, going against current practices,
challenging conventional wisdom.

Counterfactual Counter to the facts. How could things have turned out differently? Looking
Thinking: back at past decisions (past tense). Create possible alternatives to what has
already occurred; something that is contrary to what actually happened. As
compared to what? What might have been? “What if?”, “If I had only...”
If I didn’t fire that employee, they’d still be messing up my business.

If I didn’t come to business school, I’d still be in that dead end job

If we didn’t have a stop smoking campaign, then many more people would have
died from lung cancer.

Common Sense: Good sense and sound judgement in practical matters.

 Why Global Healthcare?
Born Blood Lived & Worked Raised

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> 8B people, 2/3rd in China and India Alone

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Countries I have lived or done business in, >58 Countries
Over 80% of the world’s population

Half of your sales will be in the US and the other half will be OUS,
Executive level roles require ISE assignments.
What countries will drive your profits?
What markets do you need to in?
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 Learning Objectives
• Global Healthcare – challenges and opportunities in various countries

• Understand how healthcare systems and healthcare industries work in various countries

• Learn how the healthcare industry partners with public health policy, governments,
agencies, cultures, geography, climate, etc.

• Learn innovative healthcare business strategies that deliver cost effective outcomes.

• Understand the implications of covid-19 around the globe and the role of the healthcare
industry to bring innovative and sustainable solutions.

In addition, we will discuss and debate two epic healthcare questions

1. Which country has the best healthcare?

2. Which country has done the best job managing the Covid-19 pandemic?

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Class Date Topic Reading Material Guest Speakers

TUE 8/20 Introduction – Course Outline, Iron Triangle, Risk Factors, Trends
DAY 1 Chapters 1 and 2

THU 8/22 Models/Systems/Organizations/Metrics Chapters 3 – 5

DAY 2

DAY 3 TUE 8/27 Millions Lives Saved Case Study Millions Lives Saved

THU 8/29
DAY 4 Guest Speaker Sean Sylvia, Professor, Gillings

TUE 9/3 NO CLASS – WELL BEING DAY

THU 9/5 Guest Speaker Edward Lloyd-Evans, World Food Program

DAY 5
(Virtual)

DAY 6 TUE 9/10 HC Systems – Report Outs 10 minutes per country

THU 9/12
HC Systems – Report Outs 10 minutes per country
DAY 7

TUE 9/17
No Class

THU 9/19 NO CLASS – CAREER DAY

HC System – Report Outs

TUE 9/24 10 minutes per country
DAY 8 Doing Healthcare Business In….

THU 9/26 Global Supply – Pricing, Generics and Counterfeit

DAY 9 Drug Importation & Medical Tourism Drug and Tourism Exercise

DAY 10 TUE 10/1 Guest Speaker Peter Hare, Former GSK Executive

THU 10/3 Cost of Healthcare - Pricing Chapter 6 & 7

DAY 11

TUE 10/8 Final Presentation Groups 1 - 3 25 minutes each

DAY 12

DAY 13 THU 10/10 Final Presentation Groups 4 - 6 10 25 minutes each

 Class Material
Two Textbooks are required for this course.

1. Introduction to Global Health 4th edition, Kathryn Jacobsen (Chapters 1 – 7).

2. Case Studies in Global Health Millions Save, Ruth Levine (Cases 1, 3, 9, 11 and 13)

Three purchasing options.

#1 Print Bundle is for print copy of both textbooks with bundled pricing.

#2 Print/eBook Coupon Code is for print or eBook versions, you need to do both independently.

#3 Retail On Your Own, Get used and less expensive version on Amazon and other services.

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 5 Graded Assignments

Assignment Grading Due Date

1 Healthcare System Report 20%, Individual, 3 ppt Slides September 10

2 Business of Healthcare Report 20%, Individual, 2-page October 1

written report
3 Healthcare Challenge 30%, Group Project October 8 or 10

4 Reflection Paper 10%, Individual October 10 EOD

5 Class Participation – prep, attend, engage. 20%, Individual Every Class

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13
 How bad is healthcare around the globe…
• Improvements - Think about the world. War, violence, natural disasters, man-made disasters, corruption, immigration, etc. Things
are bad, and it feels like they are getting worse, right? The rich are getting richer, and the poor are getting poorer; and the number
of poor just keeps increasing; and we will soon run out of resources unless we do something drastic.

At least that’s the picture that most Westerners see in the media and carry around in their heads. The Western world’s
overdramatic worldview. It’s stressful…..and misleading.

• In fact, the vast majority of the world’s population lives somewhere in the middle of the income scale. Perhaps they are not what
we think of as middle class, but they are not living in extreme poverty. Their girls go to school, their children get vaccinated, they
live in two-child families, and they want to go abroad on holiday, not as refugee

• Child Mortality Rate – this measure takes the temperature of a whole society. You won’t find any countries where child mortality
has increased. Because the world in general is getting better. The US is one noticeable exception.

• Developed / Developing – 85% of mankind live inside the developed world. Only 13 countries, representing 6 percent of the world
population, are still in the developing world.

• School: 90% of girls of primary school age attend school. For boys that figure is 92%.

• Paradox: People consistently say that about 20% of people are having their basic needs met. The correct answer in most cases is
close to 80% or even 90%. Proportion of children vaccinated – 88%, proportion of people with electricity – 85%, proportion of girls
in primary school – 90%.

• Pollution: Canada’s per capita CO2 emissions are 2x those of China’s and 8x those of India’s.

• 5 Global Risks: Pandemic, Financial Collapse, World War, Climate Change and Extreme Poverty.

(1st three have all happened before, and the 2 others are happening now.

Source: Hans Rosling, Gapminder Foundation

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https://www.gapminder.org/

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 Most pressing global healthcare issues
• Covid-19 – highlighted many healthcare issues: trust, capability, efficiency,
readiness.
– 14.9M deaths WW in 2020 and 2021, Excess Deaths, Direct and Indirect. 70% are in just 10 countries.
– US, Brazil, Russia and India next largest, deaths/1M pop is a better indicator
– China – lockdowns and transparency
– Boomerang effect – unintended consequences of covid-19, poverty, humanitarian, impact of inflation, etc.
– Mental health crisis

• Migration and War– every day >180,000 people are displaced each day. Record 108m migrants and refugees
– US border / India / China / Southern Europe
– Ukraine / Middle East / Afghanistan / Central Afr

• People – sky rocketing demand

– Ageing
– Obesity: disease of prosperity
– Behavior – tobacco, alcohol, drugs
– NCDs
– Mental Health
– Income Levels
– Environment and Climate

IDMC-GRID-2024-Global-Report-on-Internal-Displacement.pdf
• Dual Burden – Triple Burden
– Chronic - Heart Disease, Diabetes (Obesity), Cancer
– Infectious Disease – Covid-19, Malaria, AIDS, Monkeypox
– Lifestyle/Behavior/Mental Health – Drugs, Alcohol, Traffic, Injury, Tobacco, Unprotected Sex, Social Media
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 This course has 2 components, together they make up
the Healthcare Challenge

Healthcare System Disease State Healthcare Challenge

Select a country of interest to Select a disease that has the Develop and propose an
conduct your research and most unmet need, or the innovative business solution
analysis biggest potential for that is sustainable
improvement

Tip: 3 views. (1) look how your country has resolved healthcare issues in other disease states and see what is
‘transferable’ (2) look how your disease has been resolved in other countries and see what is ‘transferable’. (3) Look
outside of healthcare for innovative solutions.

17
 Business of Healthcare

B2B2C Tradeoffs Sustainable

• Consumer (User) is • Iron Triangle – cost, • Revenue – how much

not the purchaser nor quality, access tax, who to tax, hidden
the payer taxes. Employers,
• Rationing – how is it Individuals, Others.
• Doctor (Purchaser) is done
not the user nor the • Debt – how much debt
payer • Inequities –
underserved • Under water –
• Payer is not the User expenses, waste fraud
nor the Purchaser • Privilege, Right, or and abuse,
Obligation inefficiencies, overuse
• Govt – could be all 3,
often 2

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 Tradeoffs are everywhere and difficult
Healthcare
Outcomes Some examples
• Life Expectancy
• HDHPs –
• Mortality (infant,
• 1/3 of US plans.
maternal)
• 70% of ACA plans, >$2800, Bronze
• Preventable is $8,000.
deaths • Low premium vs higher OOP
Administrative • ACA Silver Premium is $1217/mo.
Efficiency Access
• Paperwork • Rationing Drugs –
• Affordability
• Regulations • UK: non approval
• Timeliness • US: lack of price controls
• Access to data, • Availability – • Emerging: OOP
records, etc. doctor, services
• Time & and product • Access to care
Duplication • Canada: wait time
• Liberia: fewest doctors / capita
• US: cost too much
• Japan: 15 Dr. visits/year/person
• China: All day event

Care Process Equity

• Preventative • Income disparities
• Safe & Accurate • Class NEW INTERNATIONAL STUDY: U.S. Health System
Ranks Last Among 11 Countries; Many Americans
• Coordinated • Race Struggle to Afford Care as Income Inequality Widens |
• Engagement • Gender Commonwealth Fund

Mirror, Mirror 2017: International Comparison Reflects Flaws

and Opportunities for Better U.S. Health Care
Source: The Commonwealth Fund Performance Dimensions (commonwealthfund.org)
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 3 methods to assess a healthcare system
Iron Triangle / Triple Aim / Quadruple Aim of Healthcare

Tradeoffs: Zero sum - you can Harmonization: Mutually obtainable – Provider: addresses the growing
improve 1, or perhaps 2, but it optimizing, integrator, disruption, issue of physician burnout and
comes at the expense of the 3rd. innovation, efficiency, SDOH dissatisfaction

They cannot all 3 be simultaneously Improve Health: Health of populations,

Improved. Improvement in one area outcome measures and disease burden, Are these competing or
results in a decline in at least one of lifestyle and behavior. compatible? Some overlap, some
the other areas. divergence
Lower Costs: better value, reducing the
per capita cost, utilization rates Is one the problem and one the
solution? Pessimistic and optimistic?
Better Care: Improving the patient micro and macro? Historical vs
experience. CAHPS – patient survey Futuristic? Want vs Needs?
Invisible hand and visible hand?
CAHPS – timeliness of appointments,
information, provider communication, Are these achievable? Who would use
coordinated care, courteous office staff, etc.
20 which one?
 Iron Triangle
Cost – how much, healthcare expenditure
per capita, % of GDP, volume versus price,
debt, tax, Fee For Service, premium, co-pay,
coinsurance, free goods

who pays – taxes, individuals, employers,

donations, charity, debt?

Quality – structure (physical, material

and human), process (prevention,
screening, treatment, adherence) and Access – 5 A’s: Availability, Accessibility,
outcomes and results.
Sustainability Accommodation, Affordability,
Acceptability.
Efficacy, compliance, and adherence to
treatments. Infant Mortality, Life Disparities, coverage, wait times,
Expectancy and Immunizations. formularies, utilization of services, step
edits, prior authorization, gatekeepers,
ability to pay for care, distance, travel,
location, distribution, delivery

Measures of a healthcare system: Infant/Maternal Mortality, Life Expectancy, Immunization Rates.

New Metrics: Patient Experience, Timeliness, Readmissions, DALYs

Sustainability
3Es: Ethics, Environment, Economics
5Ps: People, Planet, Prosperity, Peace and Partnership
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 Healthcare Framework

Healthcare System Healthcare Industry

Iron Triangle Healthcare Sectors

Provider Payer
Hospital Administration Private Insurance
Hospitals Public
Clinics Tenders
Doctors and Nurses Grants & Donations

Producers Services
Sustainability
Pharma Wearables / Apps / AI
Biotech Digital Services and
Devices Therapeutics
Equipment and Supply Health Information
Services

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 Healthcare System Report - Premise
• Your company’s President of International is heading to Country X for an affiliate visit
and has asked you to come along and to prepare a ‘country briefing’.

• As a hot shot MBA fresh out b school, you have put together a few slides. You settle
into your business class seat and hand the deck to the President. These are the slides
you will flip through on your flight over some ocean just before you node off and try to
get some sleep prior to your day of meetings.

• You need to explain how the health system operates, is organized, how it is funded,
what are the challenges and opportunities, what is the industry environment and
the business profile outlook.

• Needs to be BLUF (bottom line up front), brief, relevant. The 3 slides are:
– Healthcare Analysis,
– Healthcare Ecosystem,
– Industry Profile

https://databank.worldbank.org/reports.aspx?source=world-development-indicators#
To create a table you can export as an excel file, you select the series (various development indicators such as vax rates, infant mortality, etc.), countries of
interest, and years from which data was collected. Data from every series does not exist for every country at every year, but if you try enough series and wide
enough time span, you can find enough solid data to analyze and narrow down your time span to make a compelling argument with the data.

https://www.commonwealthfund.org/international-health-policy-center/countries

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 Healthcare Analysis

Structure – type of model/system

Iron Triangle
Beveridge to Bismarck to Private to OOP. (what mix)

Role of Government and Policy

Cost – how much, healthcare expenditure per
Who and What is covered: prevention, inpatient, capita, volume versus price, % of GDP, debt
outpatient, mental health, drug coverage, long term
care, SDOH

Major Challenges and Issues – what is broken?

Quality – outcomes and results.
Strengths and Solutions – done well, best practice.
Measures of a healthcare system:
Infant/Maternal Mortality, Life Expectancy,
Immunization Rates.
Patients New Metrics: Patient Experience,
Timeliness, Readmissions, DALYs
Disease Burden: QALY’s, DALYs, mortality, etc.

Demographics: Size, population, age, life expectancy, Access – disparities, coverage, wait times,
major health issues, leading causes of death, health availability of services and products, utilization of
risk factors, incidence and prevalence rates, toilets, services, various ways to ration care.
sanitation, electricity, transportation, etc.

Social, Cultural, Religious

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 Healthcare Ecosystem

Provider Payer:
• Government or Private Government/Insurer/Employer/
• Hospitals, Clinics, Retail, other means/ways Private/Individual/Organizations
• Pharmacies
• What roles do they play
• Who pays and how much?
• Doctor and nursing staffing
• How is it funded?
• Hospital administration
• What is tax vs fees vs OOP?
• Doctors and Nurses / 1000 people
• Other funds – organization, donations, charity,
• EHR
• How do they cover those who cannot afford
• Managed Care
healthcare?
• Cost Sharing – Copays, discounts, etc.

Producers Services:
• Pharma, Biotech, Devices, Equipment, Suppliers, • Organizations
Distributors • Foundations
• Who are major players
• Non-Profits
• Business outlook
• Digital/Wearables/AI/Apps
• Ease of doing business
• Protection of Intellectual Property • HIT – Health Information Services
• Ability to set prices • Digital Therapeutics
• R&D Capabilities

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 Industry Profile – Sector or Entity

Major Players Impact of Covid-19

• What Sectors • Policies and Actions – masks, lockdowns,

• What role, relative to public health vaccines, testing and tracing, enforcement
• Competitors • Cultural Norms – trust, media, adherence
• Partnerships • Politics
• Local vs Global • Costs and Payments
• Strengths and Weaknesses • Impact on infrastructure and debt
• Non-profit, Agencies, Organizations, and • Results – infections rates, hospitalization,
Advocacy impact death/fatality rates
• Unintended consequences

Business Environment Outlook

• Integration – vertical and/or horizontal • Trends

• PPP • Growth
• Fraud • Regulations
• Innovation • Policy
• Business ‘Friendly’ • Initiatives
• Import vs Export • Priorities and focus
• Image and perception of industry

Tip: PPPs, Alliances, Licensing, key competitors, attractive markets, market growths, business environment,
headwinds, unmet needs, innovations.
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 Covid-19 Status and Implications

Policy and Actions Role of Industry

• Masks • Provider
• Lockdowns • Payer
• Travel restrictions • Producer
• Treatment • Services
• Cost of care and treatment
• Penalties
• Enforcement

Culture Results

• Testing
• Social norms
• Infection rates
• Behavior
• Hospitalization
• Communication
• ICU capacity
• Media
• Death / Fatality Rates
• Politics
• Vaccination rate
• Realistic Goals

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 HC System report should answer
1. Is your country’s healthcare system sustainable? What is the financial health of your
country?

2. How much does someone have to pay for Healthcare (actual/real costs)? (tax, fees, OOP,
foundations, charity, donatins, etc). What is actually covered and what is NOT covered?

3. What element of the Iron Triangle (Cost, Quality, or Access) is the most critical and urgent
element to improve and why?

4. What business sector of healthcare needs to be ‘revamped’ – provider, payer, pharma,

services, other? (Not policy, that is fixed) and how?
Considerations:

• What current initiatives are already underway and are they working or not?

• You may choose to select a specific disease state within your country in order to streamline your analysis. Pick the one that
is killing the most people.

• Cost – Does your country spend too much or too little on healthcare? Who is financing / funding healthcare?

• Access – Are all people really covered? ‘We cover everybody, but we don’t cover everything’. What means of rationing care
are being employed?

• Quality – What metrics and outcomes are being used? How accurate is the reporting?

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 Countries for Healthcare Systems Report
Country / Student Country / Student Country / Student

Kenya / UK / Mexico /

S. Africa / Germany / Brazil /

Morocco / France / Cuba /

China / Italy / Argentina /

Japan / Spain / Peru /

Singapore / Sweden / Costa Rica /

Thailand / Switzerland / Saudi Arabia /

S. Korea / Greece / Egypt /

India / Estonia / Turkey /

New Zealand / Canada / Israel /

Australia Romania / UAE /

Country Profiles | Commonwealth Fund

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 This course has 2 components, together they make up
the Healthcare Challenge

Healthcare System Disease State Healthcare Challenge

Select a country of interest to Select a disease that has the Develop and propose an
conduct your research and most unmet need, or the innovative business solution
analysis biggest potential for that is sustainable
improvement

Tip: 3 views. (1) look how your country has resolved healthcare issues in other disease states and see what is
‘transferable’ (2) look how your disease has been resolved in other countries and see what is ‘transferable’. (3) Look
outside of healthcare for innovative solutions.

30
Global Perspectives

Immunity Charm (youtube.com)

Immunity Charm - Making Immunization into a

tradition | Campaigns of the World

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 Healthcare Challenge
This group project will result in a global health case study report. Each team of 3 to 5 students will identify one healthcare issue related to a
disease/illness in a country and develop a business solution for that problem. For the disease/illness in the specific country, students will
complete an analysis and develop a sustainable solution.

• Challenge: Essentially identifying a gap or unmet need and find a sustainable business solution. Make an improvement on 2 or more
points of the iron triangle. Build a business case – how much $, how many lives saved, who pays for it and how does the entity stay in
business.
• Industry Perspective: Balance working within the existing healthcare system and public policy, establishing public private
partnerships (PPP) if appropriate, bringing innovations and business solutions. Solutions should be designed for Provider, Payer,
Pharma/Device or Tech/Digital. Or any combination.
• Hint: Consider various analogues. Either how has your country solved similar problems in other disease states and can the learnings
be applied. And/Or, how has your disease issues’ been resolved in other countries and can the learnings be applied.

Follow the suggested outline below to articulate the challenges/issues, the opportunity and the strategies and solutions. Groups will have 20-
25 minutes to present 5 to 10 slides. Presentations will be to an executive board seeking support and financial backing to resolve the
challenge. Support could come in the form of sponsorship, activity, financial, resources or knowledge and expertise.

• Slide 1 - The disease in your country (refer to the million lives saved case studies). Provide some stats, trends, comparison, magnitude
of disease burden (prevalence, incidence, DALY's, mortality, etc.). What are the Covid-19 implications?
• Slide 2 – 3 - How does the HC system in the country work and how does it manage the disease (refer to the HC systems reports).
What are the Covid-19 implications? Hint: highlight only the elements that are relevant to your HC Challenge.
• Slide 4 – 5 - What are the major challenges, issues, disparities? Is the system sustainable? What is broken? What is the current
strategy in place and what is wrong with it? What are the drivers of costs, quality and/or access? What are the financials?
• Slides 6 - 10 - Solution. What can you do to improve the system, impact on the iron triangle? Is your solution designed for Provider,
Payer, Pharma/Device or Tech/Digital health. Or is it a combination? Provide analysis, such as how much would it cost? How many
people would it help? How would you fund it? How would it work? What is your strategy and why will it work? Do you have any
analogues to back up your plan? Is it scalable? How would your plan be implemented considering Covid-19?

VMLY&R COMMERCE | Our Work | Lifebuoy's Roti Reminder (vmlyrcommerce.com)

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 Business of Healthcare Report
For the country you have done your Healthcare Systems report on, pick a company to analyze.
Could be provider, payer, producer, services, organization, non-profit or advocacy.

1. Company Strategy: Mission, Purpose, Core Business, Leadership, Role in Healthcare system

2. Financials: Analyze the financial health of that company – Revenue, Profit, Debt, Cash Flow.

3. Brands: What are the products or services? How are they doing? Growth, Innovation,

4. MarketPlace: Who is the competition? Is the market growing or satisfied?

5. Opportunities: What does the future look like? Should we buy shares or not?

What is the business model – the product of value, does it improve health, who pays for it, how much, who are
the key decision makers,

2-page written report due Oct 1

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 Questions
• What % of the population should be covered with free health insurance
• How much health coverage should be free?
• What % of GDP should healthcare be?
• What % of healthcare should be public? private? Is it a public good?
• What % is the right amount of tax to pay for Healthcare?
• What role does Business play in healthcare?
• How much profit should a business make on health?

Health and Human Rights – the ‘Right to Health’

1. What are the services and goods guaranteed to every person under the human rights to health?

2. What responsibilities do states have for the health of their own populations?

3. What duties do states owe to people beyond their borders in securing the right to health?

4. What kind of global governance for health is needed to ensure that all states live up to their mutual responsibilities?

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BACKUPS

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Grading Scale for BUSI 625

Grade 100 Point Scale

A 93-100
A- 90-92
B+ 87-89
B 83-86
B- 80-82
C+ 77-79
C 73-76
C- 70-72
D+ 67-69
D 64-66
F 50-63

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Kenan-Flagler Business School
The University of North Carolina at Chapel Hill
Chapel Hill, NC 27599-3445
www.kenan-flagler.unc.edu