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Chapter5-AmbulatroyCare5.pptx
Chapter 5
Ambulatory Care
CHAPTER OBJECTIVES
Provide familiarity with the major components and functions of the ambulatory care system in the context of the overall delivery system
Review major developments in the evolving ambulatory care system with respect to physicians, hospitals and consumers
Highlight ambulatory care initiatives of the ACA
Overview and Trends (1)
Ambulatory care: medical care not requiring overnight hospitalization
Continuing volume shift from hospitals began in 1980s
Advanced technology safety improvement
Payer incentives to decrease inpatient stays
Consumer & physician preferences
Overview and Trends (2)
1990s: increasing number of facilities owned and operated by hospitals, physicians, independent corporate chains.
Cancer treatment, diagnostic imaging, renal dialysis, pain management, physical therapy, cardiac & other rehabilitation, eye, plastic and other surgery, etc.
Physicians and hospitals compete for patient business, altering prior relationships
Components of Ambulatory Care
Private Medical Office Practice
Other (non-physician) ambulatory care practitioners
Ambulatory care services of hospitals
Hospital emergency services
Free-standing (non-hospital based) facilities
Private Medical Office Practice
Predominant mode: 1 billion+ visits/year
586 M visits to primary care physicians
257 M visits to medical specialists
193 M visits to surgical specialists
Transition to Physician Group Practice
Mayo clinic group practice of salaried MDs in late 1800s; controversial
Until 1930’s solo practice predominant
1932 Committee on the Costs of Medical Care* report recommended group practice as economically efficient, promoted insurance as a means to improve access
*A blue ribbon panel of public health professionals, academicians and economists
Reactions to Committee Report on the Costs of Medical Care: 1930s-1950s
AMA condemned recommendations for group practice and salaried physicians as “unethical”
GHI establishment (1937) erupted legal battle; AMA expelled GHI-salaried physicians and “blacklisted” them with hospitals
D.C Medical Society & AMA indicted & found guilty of conspiracy to monopolize medical practice
Next few decades spawned controversy about MD participation in group health plans
Continuing Opposition to Group Practice
Physicians sought membership in evolving group health plans as local medical societies attempted and failed at obstructing group practices
Group physicians were ostracized and denied hospital privileges
Opposition subsided by 1950s due to legal challenges and physician shortage
Transition from Solo to Group Practice- 1960s
Social & lifestyle changes
Medical specialization
Medicare & insurance complexities
Office technology costs and overhead spawned economies of scale opportunities
Group Practice Features
Single & multi-specialty groups
After hours and vacation coverage
Informal collegial consultation
Informal system of peer review
Shared office overhead (personnel & technology)
Physician Employment by Hospitals (1)
Number of physicians employed by hospitals: 32% increase 2000-2012, due to:
Flat/decreasing reimbursement rates
Complex health insurance & technology requirements
High malpractice premiums
Desire for greater work-life balance
Physician Employment by Hospitals (2)
Hospital advantages of physician employment:
Gain market share for admissions
Guaranteed use of diagnostic testing, other outpatient services
Referrals to high-revenue specialty services
Position with physician networks for health plan negotiations, care coordination, quality monitoring, cost containment
Integrated Ambulatory Care Models (1)
Patient-Centered Medical Homes
Accountable Care Organizations
Seek remedies for service fragmentation: piecework reimbursement, no reimbursement for care coordination efforts, ineffective/absent links for patients among/between multiple service providers, service duplications, inadequate aggregation of data on patient outcomes
Integrated Ambulatory Care Models (2)
Patient-Centered Medical Home (PCMH)
Team-based model of care led by a personal physician providing continuous and coordinated care throughout a patient’s lifetime including linkages with other professionals for preventive, acute and chronic illness and end-of-life assistance
Since 2006, Patient-Centered Primary Care Collaborative of 1,000 member organizations e.g. primary care physicians, insurers, government agencies, academia, others
Integrated Ambulatory Care Models (3)
ACA provisions supporting the PCMH:
Expanded Medicaid eligibility
Medicare & Medicaid payment increases for primary care and designated preventive services
Funding to place 15,000 primary care providers in shortage areas
Funding for health professional training and more primary care residencies
Center for Medicare & Medicaid Innovation
Integrated Ambulatory Care Models (4)
Transitions to PCMH:
“Wrenching culture and system changes”
Substantial payment reforms
“Highly motivated physicians, redesign of staff roles and care processes,…health information technology,…other …support”
NCQA: “Recognition” for adherence to standards; new 2013 certification for “Content Expert”
Integrated Ambulatory Care Models (5)
Accountable Care Organization (ACO)
ACA adopted model: groups of providers, suppliers of health care, health-related services, others involved in patient care to coordinate care for Medicare patients (PCMHs are ideal primary care component)
Goals: timely, appropriate care; avoid duplications, medical emergencies and hospitalizations
Integrated Ambulatory Care Models (6)
ACO definition- legally constituted entity within its state including providers, suppliers, Medicare beneficiaries on governing board
Responsible for 5,000 Medicare beneficiaries for 3 years
Meet Medicare-established quality measures
Payments combine fee-for-service w/shared savings, bonuses linked with quality standards applicable to all providers
Integrated Ambulatory Care Models (7)
ACO providers and suppliers
ACO Physicians, hospitals in practice arrangements
Networks of individual practices of ACO professionals
Partnerships or joint ventures between hospitals, ACO professionals, or hospitals employing ACO professionals
Other DHHS-approved providers, suppliers
Other Ambulatory Care Practitioners
Licensed professionals in independent practice: solo or group, single or multidisciplinary practices
Dentists, podiatrists, psychologists, optometrists, physical therapists, social workers, nutritionists
Early Hospital Ambulatory Care
19th century: clinics poorly equipped & staffed, often remote “dispensaries”
Served community’s poorest; charitable Mission
Teaching sites for medical students
Staffed by low-ranking physicians, often to earn admitting privileges
Traditional Teaching Hospital Clinics
Organized into specialty areas for teaching & research purposes; “anatomic” orientation
Patients benefit from sophisticated care
Specialty orientation causes fragmentation, challenges in coordinating care across multiple clinics
Hospital Clinic Evolution-1980s
Primary care as “core” with salaried, not volunteer, physicians
Improved care coordination
Specialty (boutique) services to attract paying patients
Hospital Ambulatory Care-Today
Continue “safety-net: functions
Teaching sites for primary & specialty care
Well-equipped and staffed
Profitable referral centers: acute care and ancillary services; 42% total hospital revenue
Continuing challenges for providers and patients in coordinating care across multiple clinics will be aided by EHR use
Hospital Emergency Services (1)
Staffed and equipped for life-threatening illness and injury; physician & nurse specialists
136 million annual visits- 259/minute
Community “safety nets”-2008-2009: 10% upsurge in usage, the highest increase on record
1990-2009: total number of urban EDs declined 27%, from 2446 to 1779 due to for-profit ownership, market competition, low profit margins
Hospital Emergency Services (2)
Visit payment status: 19% uninsured; 39% privately insured
Inappropriate use: 8%, ~ 10M “non-urgent,”
Patient self-determination of symptoms
Physician referrals (off-hours, office scheduling issues)
One-third of visits: injuries, poisonings, adverse effects of prior treatment
Freestanding Facilities
“Freestanding” = non-hospital based facilities: owned, operated by hospitals, physician groups, for-profit, not-for-profit entities, corporate chains
Urgent care
Retail clinics
Ambulatory surgery centers
Federally qualified health centers
Public health ambulatory services
Not-for-profit agencies
Urgent Care Centers (1)
First in 1970s
UCAOA: “Provide walk-in, extended hour access for acute illness and injury care that is either beyond the scope or availability of typical primary care practice or retail clinic”
Operate under licensed physician auspices
8,700+, 150 million visits annually
Ownership: for-profit, physician groups, managed care organizations
Primary care physicians, nurses, ancillary services, e.g. lab & radiology
Urgent Care Centers (2)
Primary care physicians, nurses, ancillary services, e.g. lab & radiology
After hours, non-emergency; 55% suburban; 25% urban; 20% rural
Episodic care w/emphasis on primary care physician relationship
Since 1997, American Board of Urgent Care Medicine certifies, following exam, primary care specialists in the field of urgent care
Contentious Issues
Hospitals: Cull paying patients, leave the poorest for hospital emergency departments and clinics
Physicians: Discourage/impede relationship with primary physician and continuity of care
Consumers: Urgent care responds quickly, efficiently, effectively w/lowest costs
Retail Clinics (1)
First in 2000; Minneapolis/St. Paul grocery stores; ~ 1,200 retail sites by 2010
Operated in pharmacies & supermarkets (CVS, Walgreens, Wal-Mart, Target, others )
2007-2009- number of retail clinics quadrupled: visits exploded from 1.5 M to 6.0M
Entrepreneurial response to consumers
Retail Clinics (2)
Strong insurer & employer acceptance; some insurers waive/lower co-pays
Market forecasts doubling numbers to 2,800 by 2018
American Academy of Family Practice Physicians recognizes need and physician opportunities; opposes expansion beyond minor illnesses; clinics can be a component of the PCMH
Retail Clinic Issues
AMA 2007: urged investigation for conflicts of interest (RX, other sales), disruption of physician/patient relationships, co-pay waiver unfair to physicians still required to collect
Ambulatory Surgery Centers (1)
Established in 1970s
Anesthesia advances: primary drivers
New operative technologies
34.7 M annual visits
2008: 5,149 Medicare-certified centers; 2000-2007: 7.3% increase in numbers
Ambulatory Surgery Centers (2)
96% full or partial physician-ownership; 25% have hospital ownership interest; 2% entirely hospital-owned
Medicare & private insurer mandates pushed development
Hospital opportunities for profitable space conversions
Benefits of Ambulatory Surgery & Quality
Patients: access, fewer complications, quicker recovery
Physicians: convenient staffing and scheduling, less competition for facilities
Accreditation: Medicare, Joint Commission, Accreditation Association for Ambulatory Health Care, American Association for the Accreditation of Ambulatory Surgery Facilities; 43 states require licensure
Federally Qualified Community Health Centers (FQHCs) (1)
1960s: U.S. Office of Economic Opportunity; both urban and rural locations
2008: $ 1.9 billion grant, HRSA Bureau of Primary Care, Dept. of HHS
2011: Served 20.2 million patients in 1,200 centers with 8,500 sites in all states, D.C., Puerto Rico, U.S. Virgin Islands
Federally Qualified Community Health Centers (2)
Multidisciplinary teams; education, translation, pharmacy, transportation, etc.
Link, refer: WIC, social work, public assistance, legal services
2/3 patients uninsured or Medicaid
Revenue: Medicare, Medicaid, private insurance, sliding fee payments; Medicaid patients increased 39% 2007-2011 while Medicaid reimbursement declined
Federal Community Health Centers (3)
Administering organizations: local government health departments, units of community organizations, stand-alone not-for-profit agencies
2009: $ 600 M ARRA Funds to expand 85 centers; support EHR, other technology
2010: ACA funds expansions, new sites, 3-year PCMH pilot for Medicare beneficiaries
Public Health Ambulatory Services: History
Originated in charitable tradition of community responsibility by municipalities & states, colonial period-1800s almshouses and “poor houses”
State & local governments’ roles & public health developments led to tax-supported departments of health in late 19th, early 20th centuries
Public Health Ambulatory Services: History
Public health success in controlling childhood & other communicable diseases gave way to medical cares focus on chronic illness with resource shift from prevention to treatment
New public health demands to promote lifestyles, provide safety-net services, expand regulatory oversight to medical industries
Public Health Ambulatory Services (3)
Current public health services range across a spectrum of city, county, state: immunizations, well-baby care; tobacco control; disease screenings, education, personal services through health centers; infectious disease case-finding and control.
Staffing: physicians, nurses, aides, social workers, sanitarians, educators, community health workers, support staff
Public Health Ambulatory Services (4)
2010 NACCHO, National Survey of Local Health Departments (2,107/2,565 responses)
Most common ambulatory services
92%: childhood immunizations
75%: tuberculosis treatment
59%: treatments for STIs
55%: family planning
Public Health Ambulatory Services: Emergency Preparedness
2001 terrorist attacks
$ 5 billion to states to strengthen infrastructure accompanied by many new demands amid state budget crises; did little but fill gaps
2009 H1N1 threat
Public health response of states variable; suggests reports identify Internet access, staffing constraints, media use patterns as causes.
Not-for-Profit Agencies (1)
Not-for-profit organizations, governed by volunteer boards of directors
Cause- related, often grass-roots origins
Disease and/or cause specific Missions
Usually tax-exempt, 501(c) 3
Education, counseling, medical care, advocacy
Examples: Planned Parenthood, Alzheimer’s Association
Not-for-Profit Agencies (2)
Single corporations or affiliates of national organizations
Funding: government & private foundation grants, private donations, Medicare, Medicaid, private insurance, sliding fee scale
Repositories of community values & charity, fill gaps for special need populations and cause advocacy
Continued Future Expansion and Experimentation
Shift from hospitals to freestanding facilities will continue with medical care advances, cost-reduction initiatives, consumer demands; ambulatory surgery, urgent care and retail clinic use will grow
PCMH, ACO models’ study findings will inform practitioners & policymakers about future refinements to improve quality and reduce costs
