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141

P A R T

T H R E E

Providers of Health Services

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CHAPTER TOPICS

Levels of Prevention

Historical Evolution of Health Promotion and Disease Prevention in the United States

The Structure of Organized Public Health Efforts in the United States

The Role of the Private Sector in Health Promotion and Disease Prevention

Public Health in an Era of Terrorism and Emerging Diseases

LEARNING OBJECTIVES

Upon completing this chapter, the reader should be able to

1. Understand the role of public health services in protecting the health of populations.

2. Differentiate the various levels of prevention.

3. Appreciate the history of public health in the United States.

4. Understand the roles and duties of each level of government in providing public health services.

5. Appreciate the increasingly important role of the private sector in public health.

6. View public health services as a collective requirement of all participants in the health care system.

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CHAPTER 6

Public Health: Joint Public-Private Responsibility

in an Era of New Threats

Paul R. Torrens

Lester Breslow contributed to previous editions of this chapter.

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In the past, if one were discussing the organiza- tion of health services in the United States, that dis- cussion would most likely not include a great deal of detail with regard to health promotion or disease prevention. It would probably not cover in very great detail the organization of governmental pub- lic health services either. Health services in the past meant curative and treatment services for the most part, and health promotion or disease prevention services were considered only peripherally, if at all.

This is not to suggest that the providers of health care services in the past were uninterested in keep- ing their patients healthy over a long period of time. Rather, it is meant to suggest that the model of health care in the past was focused around acute treatment of short-term illnesses (with some no- table exceptions). Public health was the job for gov- ernmental agencies and was seen as something quite distinct and very rarely overlapping with cura- tive and treatment services.

In recent years, fortunately, a new paradigm for health promotion and disease prevention has emerged that is based on a public-private part- nership to protect and preserve the health of the American public. The newer challenges of terrorism and emerging diseases have further enhanced the urgency of this relationship. This chapter will exam- ine this new paradigm of health promotion and disease prevention and will provide the modern health care practitioner with a better framework for understanding and dealing with the major health problems of the public.

LEVELS OF PREVENTION

To understand the new framework for health promotion and disease prevention, it is important first to provide background information about the levels of prevention, as included in the terms pri- mary, secondary, and tertiary prevention. Without a clear understanding of the levels of prevention, it would be difficult to understand the relative

roles of the public and the private sectors with regard to the enhancement of the health of the public.

Primary prevention means averting the occur- rence of disease. It includes those measures that are applied or brought into effect before disease is present. These may include general attempts to promote better health by efforts to educate the public, to establish standards of appropriate sani- tation, to apply specific methods of protection such as immunizations, to remove occupational hazards, and to protect from known carcinogens. Primary prevention focuses on the promotion of healthy lifestyles and specific protections from known hazards.

Secondary prevention means halting the progres- sion of disease from its early, unrecognized stage to a more severe one and preventing the complication or sequelae of disease. It focuses on early diagnosis and/or prompt treatment of a health problem that would otherwise have serious impacts on the health of individuals. This means identifying the presence of a problem before it breaks the clinical horizon and before it becomes symptomatic in most cases, although it also includes attempts to discover disease early while it is still effectively treatable. In the case of coronary artery disease, for example, secondary prevention would focus on identifying individuals at high risk for disease— people, for example, who have a strong family his- tory of heart disease, a history of heavy smoking, a lack of exercise, or a blood lipid profile that is ab- normal. These early screening efforts can lead to more specific and focused tests and examinations that might further establish the early diagnosis of potential disease while it can still be constructively handled.

Tertiary prevention involves the prevention (or at least, the limitation) of the effects of disease once it has been identified. This level of prevention oper- ates on the premise that simply because disease is present does not mean that its course should be allowed to run unhindered. In the case of coronary artery disease, for example, tertiary prevention would include efforts at cardiac rehabilitation and

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exercise programs, control of stress, maintenance of optimum weight and diet, and possibly adherence to a medical regimen that might reduce the future risk of further worsening of the disease.

In the new paradigm of public/private partner- ship in health promotion and disease prevention, there is a role for both the public and the private sectors at each level of prevention. Sometimes the roles are quite different and separate; other times the roles are similar, and perhaps overlapping, re- quiring some collaboration and coordination. The important message, however, is that there are sev- eral different levels on which health promotion and disease prevention can focus and a wide variety of interventions that can be sponsored by both public and private sectors.

HISTORICAL EVOLUTION OF HEALTH PROMOTION AND DISEASE PREVENTION IN THE UNITED STATES

To understand the present circumstances in the United States with regard to health promotion and disease prevention, it is important to review the history of public health activities in the United States. Much of our tradition and organizational framework for public health activities in the United States today is the product of the thinking and ac- tions of previous generations (Brockington, 1956; Rosen, 1993). Therefore, it is important to know these developments and to understand how they affect our current thinking.

In the eighteenth century in the United States, public health activities were, for the most part, limited to individual cities and were focused on protection of the public in those cities from dis- eases introduced by travelers arriving from else- where. Early public health efforts in the United States in the eighteenth century focused on inspec- tion of ships arriving in harbors along the eastern sea coast and included laws for the isolation and

quarantine of persons suspected to be carrying diseases that might be spread to the general popu- lation. In some of these cases, local governments established institutions (pest houses) to voluntarily (or involuntarily) contain suspected disease carriers until they either became noninfectious or, more likely, expired from their illness. During this period, the focus of public health activity in the United States was carried out by local governments and was limited to preventing the introduction of dis- ease into the populations of port cities.

The nineteenth century marked a great advance in public health and was described by C.E.A. Winslow as “the great sanitary awakening” (Winslow, 1923). In this period, problems of sanitation were iden- tified as a cause of disease, and public health ef- forts were focused on the improvement of social and environmental conditions. Housing, water sup- ply, and sewage disposal were all the focus of organized public health activities, with the intent of reducing the disease burden on the public by improving the physical environment. As in the eighteenth century, these activities in the nine- teenth century were generally carried out by cities and local governments, with the thrust of orga- nized public health services being carried out on a local level, not necessarily on a state or national one.

In Massachusetts, Lemuel Shattuck published a landmark report in 1850 (Report of the Sanitary Commission of Massachusetts) that, for the first time, collected vital statistics on the population of Massachusetts, pointing out the variable threats to health throughout the state as a result of variable sanitary conditions (Shattuck, 1850). His report recommended, among other things, new census schedules, regular surveys of local health condi- tions, supervision of water supplies and waste dis- posal, and special studies on specific diseases such as tuberculosis and alcoholism. Probably most im- portant was the recommendation of the establish- ment of a State Board of Health to enforce sanitary regulations. Massachusetts did set up such a State Board of Health in 1869, becoming the first state in the United States to do so.

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From the late nineteenth century to the early twentieth century, many of the sanitary threats to public health were brought under control, and em- phasis shifted to the prevention of acute illnesses by use of increasingly available immunizations and vaccinations. This shift of emphasis from sanitary and environmental threats toward individual bacte- riological threats to health signaled a major change in the role of health departments. In previous years, organized public health services focused more on problems that were sanitary and environmental in nature and did not necessarily involve individual people; the efforts were more engineering in nature than they were directly clinical. After the turn of the century, public health activities began to turn more directly toward the prevention of disease in individ- ual people. Organized public health activities moved away from structural protections of food, water, sewage, and housing toward more personal and individual protection through immunization of children. Organized public health activities re- mained largely local government activities, but there now began to be increasing state government activity in public health as well.

As the twentieth century began to progress, fed- eral government activities grew with regard to spe- cific health problems related to children. The United States Children’s Bureau was formed in 1912, and the first White House conference on child health was held in 1919. The Sheppard-Towner Act of 1922 established the federal Board of Maternity and Infant Hygiene; this act provided administra- tive funds to the Children’s Bureau and also pro- vided funds to the states to establish programs in maternal and child health. It also established a pattern of federal-state relationship that was to become standard in later years, with the federal government requiring individual states to develop a plan for providing services, to designate a state agency to administer the program, and to report on operations and expenditures of the program to the federal government. States that did not wish to comply with these regulations were deemed ineligible to receive federal funding, thereby setting the model of the federal practice for establishing

guidelines for public health programs and provid- ing funds to the state to implement programs meet- ing these guidelines.

The Social Security Act of 1935 further ex- panded the federal government’s leadership role in setting national directions for public health; it also further solidified the federal-state partnership with regard to the delivery of public health services in the United States. Under the terms of the Social Security Act of 1935, grants were provided to the states for aiding state and local health departments to provide maternal and child health services as well as the expansion of the work of state and local governments. This marked the first major effort of the federal government to see that a nationwide system of state and local government public health organizations were put into place. By the time that Joseph Moutin issued his landmark report on local public health services in 1946, almost 80 percent of the total United States population had some access to organized local public health services. These services may not have always been of great depth, but at least a national framework of orga- nized local public health services had been estab- lished (Moutin, Hankela, & Druzin, 1947).

The period of the New Deal in the 1930s also had a profound effect on the development of gov- ernmental public health services, but this effect was unfortunately somewhat negative with regard to the leadership of state and federal government activities. During these times, there was consider- able pressure to expand the delivery of personal health services, both curative and preventive, more broadly to the public at large, and there was even some consideration by Franklin Roosevelt’s admin- istration of a mandatory, universal health insurance program that would cover the entire population. Because the role of the federal government in so many other areas was aggressively expanding, it was believed that perhaps there might be a similar expansion of governmental role with regard to the direct provision of health services.

Unfortunately, the political backlash against the expansion of the role of the federal government in the direct provision of health services—led primarily

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by the American Medical Association—was suc- cessful in forcing public health officials to assume a more cautious attitude toward the role of govern- ment assistance. It became quite clear that there was no strong political support for the expansion of governmental health services, at least in the cu- rative area, and many public health officials limited their activities to those programs and functions that were of a more traditional nature (i.e., san- itation, immunization, early detection, and con- finement of communicable diseases) rather than risk the wrath of organized medicine. This did not mean that the organized public health efforts of local, state, and federal government were reduced in volume, but it did mean that the governments were much more cautious in expanding the scope of their services, being careful to keep them within the confines of prevention and not venturing into treatment.

Indeed, it should be pointed out that the feeling in the United States was so conservative with re- gard to the federal government’s role in health care that a cabinet-level department focusing on the health of the United States’ people was not estab- lished until 1953, almost 180 years after the estab- lishment of the republic! Various public health activities had been initiated by the federal govern- ment over the years, but it was not deemed neces- sary, or possibly, politically feasible, to have a federal “department of health,” as health was seen as a personal matter involving private physicians and their patients. It should be pointed out that this same type of thinking governed our nation’s thoughts with regard to education and social wel- fare: these also were seen as local matters in which the federal government should not be involved, at least not directly. The creation in 1953 of a federal Department of Health, Education, and Welfare (HEW) provided a national focus for developing and implementing federal government policy with regard to these three important areas.

In the period of 1953 to the present, there has been a great expansion of governmental activity focused on the public’s health, much of it in the traditional public health areas, but much more in

programs and functions related to the provision of personal health services. The passage of the Medi- care and Medicaid programs in the mid-1960s is generally not seen as an expansion of the federal government’s traditional public health role, but in retrospect, the passage of these financing mecha- nisms for the expansion of personal health services probably has had as major an impact as any of the previous, more traditional public health activities.

One further important development in public health thinking and theory was the passage of the federal Health Planning and Resource Develop- ment Act of 1974 (PL 93-641). Under this law, the federal government provided the funds to individ- ual states for the establishment of a State Health Planning and Development Agency whose purpose was to plan and control the future development of health services—primarily hospitals—in the United States. The thinking behind the passage of this law was that there needed to be a coordinated planning effort to ensure that the proper type and volume of health services were available in equitable fashion throughout the United States, and that this could be carried out only by some type of publicly man- dated planning effort to coordinate and regulate the development of these services. Although this national health planning effort was really a public health effort in the broadest sense, it was never fully connected to the already existing public health structures in the country and was never fully ac- cepted as a legitimate public health activity by many formal public health professionals. The im- plementation of the Health Planning and Resource Development Act of 1974 was complicated and filled with significant controversy throughout the country; the law has since been allowed to lapse on both federal and state levels, and there is presently no direct attempt, by either federal or state govern- ments, to plan the distribution of personal health services.

Lessons from History

What can be learned from this review of the evolu- tion of organized public health efforts in the United

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States? What important political, social, and cul- tural trends can be identified that will tell us more about the current and future status of public health in the United States? There are several major points to emphasize.

First, it should be pointed out that organized public health activities in the United States began in local, seaport communities and only gradually expanded to state and federal government agen- cies. Indeed, the Constitution of the United States reserves to the states all functions (such as health) not specifically earmarked to the federal govern- ment. For most of our country’s history, public health was an activity that was primarily carried out by a local or state governmental agency, and it was only after World War II that it was per- ceived as necessary or appropriate to have a federal cabinet-level Department of Health, Education, and Welfare.

In many ways, this development would suggest that our country views public health activities (and perhaps health activities in general) as a local and state matter; federal government involvement devel- oped mostly after World War I, and mostly because of the abundance of federal tax revenues to be re- distributed to states and local governments. The continuing efforts to reduce the size and scope of the federal government and to return basic func- tions (and funds) to local and state governments in recent years may be seen as a continuation of this general idea.

Organized public health activities in the United States began with the quarantine and isolation of potential disease carriers, moved on to the im- provement of sanitation in the environment, then went on to focus on immunization of children and control of individuals with contagious infec- tious disease. Almost all these activities focused on acute infectious diseases, regardless of their origins. This has given rise to an unofficial and generally unspoken agreement that the primary mission of organized public health efforts in the United States should be toward the prevention and control of acute illness rather than chronic disease.

Organized public health efforts in the United States have focused on outbreaks of illnesses such as diphtheria and polio because of the suddenness and the severity of any outbreaks of these illnesses. In reality, however, the much more serious and major public health problems of the United States are no longer acute infectious diseases but rather are chronic long-term degenerative conditions such as heart disease, cancer, and stroke. Organized public health efforts throughout the United States have a well-recognized role in protecting the public from outbreaks of infections, but they spend con- siderably less time and energy on problems of a much more serious and long-term nature, such as cancer, alcoholism, and mental illness. By default, or- ganized public health agencies in the United States have accepted an acute illness prevention role as being appropriate, but they have not accepted a chronic disease prevention role to the same degree of intensity.

Because of the unfortunate political controver- sies of the 1930s around a possible national health insurance program, it would have to be admitted that there has been a relatively guarded relationship between the private medical sector and organized public health agencies throughout the country. As long as the organized public health agencies kept to the more traditional public health roles of sanita- tion, immunization, and infectious disease control, their activities were generally supported by the pri- vate sector. However, whenever the public health sector became more active in the provision of gen- eral health services or in the governance or plan- ning of facilities and personnel in the private sector, considerable opposition arose. As a result of this opposition, organized public health agencies have been rather cautious about expanding their efforts beyond the boundaries of what were perceived as “traditional” public health activities.

This is probably most marked and most obvious in reviewing organized public health’s unwilling- ness or inability to assert any major role in the planning or regulation of the provision of health services in the United States. Although a broad definition of public health would certainly include

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the necessity of ensuring that the public has ade- quate access to personal health services, this plan- ning or regulatory role has not been one that public health agencies have been willing to assume, or been allowed to assume by other forces in society. As a result, the health care system of the United States is a relatively unplanned and poorly coordinated sys- tem compared to most other major industrialized countries throughout the world. In these countries, it is assumed that public health must protect the interest of the public in obtaining access to appro- priate health services of high quality, but that has not been an accepted role for organized public health in the United States until now.

THE STRUCTURE OF ORGANIZED PUBLIC HEALTH EFFORTS IN THE UNITED STATES

The United States utilizes a very intricate combina- tion of local, state, and federal government public health agencies to accomplish the public sector’s re- sponsibilities to the American public (Scutchfield & Keck, 2002). Compared to other countries of the world, the United States has one of the most com- plex sets of relationships between different levels of government of any country in the world, a set of relationships that reflects the unique social and political values of the people of the United States. To understand how public sector activities in health promotion and disease prevention accomplish their objectives, it is important to understand each of the three elements in the public sector—the local, state, and federal government efforts—and then, after un- derstanding how each segment works, understand the relationships between and among them.

In its important 1988 review of public health in the United States, The Future of Public Health, the Institute of Medicine stated that the mission of public health was to assure conditions in which people can be healthy; it further stated that the governmental

role in public health was made up of three func- tions: assessment, policy development, and assur- ance (Institute of Medicine, 1988). Looked at in another way, these functions could be described as identification of the major public health problems, mobilization of necessary effort and resources, and assurance that vital conditions are in place so that crucial services are received.

With regard to assessment, this heading includes all of the activities involved in community diagno- sis, such as surveillance, identifying needs, analyz- ing the causes of problems, collecting and interpret- ing data, case finding, monitoring and forecasting trends, research, and evaluation of outcomes. As- sessment was seen by the Institute of Medicine committee as inherently a public function because policy formation, in order to be legitimate, is ex- pected to take in all relevant information and to be based on neutral and objective factors. Moreover, public decisions take place in the context of limited resources so that a function of government is to provide a central mechanism by means of which competing proposals can be evaluated with only the best interest of society in mind. A fully devel- oped assessment function is absolutely essential for an ideal public health system: without it, a society’s real problems cannot be accurately measured, nor can alternative solutions be objectively evaluated (Fallon & Zgodzinski, 2005).

Policy development is the process by which a so- ciety makes decisions about public health prob- lems, chooses goals and the proper means to reach them, handles conflicting views about what should be done, and allocates resources. The Institute of Medicine asserted that government provides overall guidance in this process, as it alone has the power to give answers that are binding on the entire soci- ety. In order to maintain its credibility in this policy development role, the governmental public health agency must pay attention to the quality of the pol- icy development process itself and must raise cru- cial questions that no one else can raise. To carry out this function effectively, the governmental pub- lic health agency must be equipped for its policy role with technical knowledge and professional

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expertise; this knowledge base of public health can therefore temper the excesses of partisan politics and make for fair social decisions.

The assurance function of governmental public health agencies makes sure that necessary services are provided to reach agreed-upon goals, either by encouraging private sector action, by requiring it, or by providing services directly. The assurance func- tion in public health involves the implementation of legislative mandates as well as the maintenance of statutory responsibilities. It includes regulation of services and products provided in both the pub- lic and private sectors, as well as maintenance of ac- countability to the people by setting objectives and reporting on progress. Carrying out the assurance function requires the exercise of social authority; therefore, this is not a responsibility that can be delegated to the private sector. Members of society expect the government to make certain that they enjoy at least adequate safety and security.

In reviewing the activities of the various govern- mental levels with regard to public health func- tions, it will be clear that some levels carry out more of one function than another. For example, the federal government level of public health in the United States has more of an assessment and policy development function than it does an assur- ance function, whereas state and local government public health activities have more of an assurance and assessment function than they do of policy development.

Federal Government Public Health Activities

The federal government’s role in public health was relatively limited until the passage in 1913 of the Sixteenth Amendment to the United States Consti- tution, which authorized a national income tax. Prior to that time, the federal government’s role in much of public life in the United States was rela- tively limited, particularly with regard to public health because the government had neither statu- tory nor regulatory authority, nor did it have finan- cial resources available to carry out its will. After

the passage of a national income tax in 1913, the resources of the federal government in the United States became so overwhelming that federal gov- ernment authority in all aspects of life, including public health, became the dominant aspect of gov- ernmental activity in the United States. Although local and state governments actually have more for- mal and official responsibilities placed upon them to carry out public health functions than does the federal government, the federal government has by far the greater financial resources and power to make possible implementation of laws and regula- tions throughout the country. The federal govern- ment, therefore, has the predominant role in public health activities in the United States, not necessar- ily because of its explicitly assigned public health functions under the United States Constitution, but rather because it has more financial power and authority available to it because of the national income tax.

The federal government’s activities in public health in the United States are carried out through the Department of Health and Human Services, a cabinet-level department in the federal government. Although the exact internal organization of the De- partment of Health and Human Services varies somewhat from Congress to Congress and presi- dent to president, there is one descriptive character- istic that seems to remain: The Department of Health and Human Services is composed of a se- ries of relatively separate superagencies that have comparatively little interaction with each other and that relate to quite different specialized constituen- cies, both public and professional. The Department of Health and Human Services is not a carefully de- signed and well-integrated organization that was intentionally put together to accomplish very spe- cific functions of the whole organization; rather, it is an historical collection of powerful, individual, specialized agencies that at various times in their history were added into an already-existing federa- tion of superagencies. As a result, the Department of Health and Human Services cannot be seen as functioning as a single, well-coordinated organiza- tion with a clear operating agenda that governs all

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of its parts; rather, the agendas of the individual separate superagencies, taken together, make up the policy of the department itself.

The federal Department of Health and Human Services can most easily be understood as having two major subdivisions, one related to health activ- ities and the other related to human services activi- ties. On the human services side of the department would be organizations such as the Administration on Aging; the Administration for Children, Youth, and Families; and the Social Security Administra- tion (the agency that administers the Social Secu- rity program). On the health services side of the department would be health-related organizations such as the Centers for Disease Control and Pre- vention; the Food and Drug Administration; the Health Resources and Services Administration; the National Institutes of Health; the Alcohol/Drug Abuse/Mental Health Administration; and the Cen- ters for Medicare and Medicaid Services. Approxi- mately two-thirds of the total budget of the entire Department of Health and Human Services is de- voted to human services activities (and the vast bulk of that is specifically devoted to the Social Security Administration), while approximately one- third of the total Department of Health and Human Services budget goes to health-related ac- tivities (and the vast majority of that goes to the Medicare and Medicaid programs).

The major activities of the federal Department of Health and Human Services with regard to public health can be described through its eight primary functions: (1) documenting the health status and health situation in the United States through the gathering and analysis of statistical data; (2) spon- soring research in both basic and applied sciences; (3) formulating national objectives and policy; (4) setting standards for performance of services and protection of the public; (5) providing financial assistance to state and local governments to carry out predetermined programs; (6) ensuring that personnel, facilities, and other technical resources are available to carry out national policies and goals through support for training, construction, and program development; (7) ensuring public ac-

cess to health care services by the provision of spe- cial health insurance programs; and (8) providing limited direct services to certain subgroups of the population.

The major portion of the federal government’s health activities are conducted through contracts and grants to states, localities, and private providers and organizations. The federal govern- ment acts through financing intergovernmental and interorganizational contracts to encourage various public health initiatives, convening participants around an issue, coordinating activities, and devel- oping state and local provider coalitions. In return for federal funds, states, localities, and private orga- nizations must follow the federal standards and policies set in the contract. In most of its activities, the federal government takes an oversight, policy- setting, and technical assistance role, rather than a direct-provider role.

Most contracts to states and localities were initially offered as categorical grants, focusing on particular health issues or populations (such as re- search training grants for education, nutrition infor- mation programs, substance abuse and mental health programs, and family planning programs). In the early 1980s, the federal government grouped numerous categorical grants to states into four major block grants: one in preventive health, one in maternal and child health, one in primary care, and one in alcohol/drug abuse/mental health. The more traditional public health functions of the Department of Health and Human Services have generally been channeled through the Health Resources and Services Administration and the Centers for Disease Control and Prevention, but these are by no means the only channels by which federal public health finances and resources are channeled to state and local governments.

It should be noted that one of the federal govern- ment’s major health activities, the provision of a large volume of direct patient care through the Vet- erans Administration, has no formal or organiza- tional connection with the Department of Health and Human Services. The Veterans Administration and its extensive network of hospitals and clinics

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throughout the United States does not operate under the authority or jurisdiction of the Depart- ment of Health and Human Services at all.

State Government Public Health Activities

States are the principal governmental entity respon- sible for protecting the public’s health in the United States. In the Tenth Amendment to the United States Constitution, states are designated as the repository of all government powers not specifically granted to the federal government. States carry out most of their responsibilities through their police power—the power to enact and enforce laws to protect and promote the health and safety of the people.

There are 55 state health agencies in the United States (the 50 states plus the District of Columbia, Guam, Puerto Rico, American Samoa, and the Virgin Islands). It is probably safe to say that each state agency is somewhat different from all the rest, as there is wide variation in the exact way in which state health agencies are organized. In general, each state agency is directed by a health commissioner or a secretary of health. Each agency also has a state health officer (required to be a licensed physi- cian) who is the top public health medical author- ity in the state; in many states, the state health officer is the director of the state agency, but in some states, the state health officer works for a non- physician director who is the administrator of a larger agency or department. In approximately half the states, there is also some type of state Board of Health or similar appointive body that is charged with the responsibility for approving policy in the public health area and for reviewing the use of pub- lic funds. Approximately half the states do not have Boards of Health and operate their public health agencies as administrative units of state govern- ment without any outside appointive oversight.

Earlier we described the federal Department of Health and Human Services as a somewhat loose collection of superagencies, each of which operated in a semiautonomous fashion from all the rest.

State public health agencies, on the other hand, are relatively compact in the organization of their pub- lic health services and function as a single opera- tional unit that is usually fairly well integrated within itself. The variation among state public health agencies, however, is that the public health function may be gathered together with a wide va- riety of other health-related agencies under some type of superagency or department. In some states, the traditional public health functions, usually gathered together in a single operational unit, are housed in a superagency that also contains organi- zations that deal with environmental issues, mental health services, services for retarded or disabled in- dividuals, as well as the state Medicaid program. There is no uniform arrangement for these state- level superagencies; thus, the public health unit may stand alone as an organizational unit or may be associated with up to four or five other health- related units in a superagency.

Regardless of the organizational arrangement, there are certain functions and activities that seem to be common throughout the 55 state public health agencies in the United States. These include the following general functions: (1) collect and an- alyze health statistics to determine the health status and general health situation of the public; (2) pro- vide general education to the public on matters of public health importance; (3) maintain state labo- ratories to conduct certain specialized tests that are required by state public health law; (4) establish and police public health standards for the state as a whole; (5) grant licenses to health care profession- als and institutions throughout the state and moni- tor and inspect the performance of personnel and institutions as appropriate; and (6) establish gen- eral policy for local government public health units and provide them with financial support as may be appropriate.

In general, state public health agencies nation- wide receive half of their financial resources from state taxes, approximately one-third from federal government grants and contracts, and the remain- der from special sources such as licensing fees and reimbursements. In discussing federal public

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health agencies, we pointed out that the financial resources of the federal public health activities draw on the very large national income tax for the financ- ing of their operations, and at the same time, the federal government agencies have relatively few mandated responsibilities that must be carried out. By contrast, state governments must depend on a less robust (as evidenced by the 2000–2003 fiscal era) state income tax for approximately half of their funding and, at the same time, have many more mandated services that they must provide. In gen- eral, state health departments are moderately well funded for the services that they are required to provide but considerably underfunded in terms of the potential health promotion and disease preven- tion services that they could provide.

If it can be said that the federal government pub- lic health agencies focus their energies on the iden- tification of major health problems in the country and the establishment of national policies to attack these problems, state public health departments concentrate their energies on translating national health goals and objectives into state policy and spend a considerable bit of their time seeing that that policy is carried out. Many of these policies are carried out by the state public health agencies themselves, and many of them are carried out by local public health agencies under the direction and supervision of state health departments.

Local Government Public Health Activities

Local health departments are the front line of pub- lic health services in the United States. It is here in the local government agencies that the actual daily work of public health takes place, and it is here that the policies and strategies decided upon by federal and state public health agencies must be carried out. It is here where the stress of meeting public health challenges is greatest and where deficiencies or shortfalls are most visible and obvious (Levy & Sidel, 2005).

Local health departments carry out their activi- ties under the authority delegated by either their state or their local jurisdictions. Depending upon

the interests and the resources of the local govern- ment, the local government public health function may either be very broad and energetic or very narrow and restricted. Some local health depart- ments serve a single city or county, while others cover a group of counties. In about one-third of the states, the local health units are actually dis- trict offices of state health agencies, and in another one-third, the local health agencies are responsible to both local governments and the state public health agency.

The organization of the local public health agency is generally relatively simple, with the local public health agency responding directly to the local elected authority—either a mayor, county administrator, or board of supervisors. In its opera- tions, however, the local public health authority must depend on state or federal funds for approxi- mately half of its operating budget, so the leaders of the local public health agencies must continuously maintain a dual reporting function, one to their local government and the other to the state and/or federal government that provides them with the bulk of their operating revenues.

A special committee of the American Public Health Association, chaired by Haven Emerson in 1945, defined the six basic functions of a local health department as follows (Emerson, 1945):

1. Vital statistics—recording, tabulating, inter- preting, and publishing of essential facts of births, deaths, and reportable diseases

2. Communicable disease control—tuberculosis, venereal disease, measles, hepatitis, and AIDS

3. Sanitation—supervision of milk, water, and eating places

4. Laboratory services

5. Maternal and child health services, including supervision of the health of children in schools

6. Health education of the public

For the most part, local public health departments continue to carry out the vital statistics, communi- cable disease control, environmental sanitation, and

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maternal and child health functions even up to the present time. They also, for the most part, maintain active public health education programs, although these efforts have become increasingly endangered by budgetary deficiencies. For the most part, labo- ratory services are no longer provided by local pub- lic health departments but are now provided by state health departments. And for the most part, the local public health department’s functions are very immediate and in direct contact with the public: recording births and deaths, trying to maintain con- trol or contact of individual people with serious communicable diseases, inspecting restaurants and other public gathering places to identify sanitary problems, and making sure that newborn infants receive their immunizations for infectious diseases and that children in school have some degree of health supervision. If the federal government’s functions can be described as distant, nationwide, impersonal, and related to policy, the local govern- ment’s public health function can be described as immediate, individual, pragmatic, and personal. The basic operating unit of local government public health only serves to enhance this sense of immediate contact with the public because it is usu- ally represented by the local health center or local public health office; this is usually situated in areas of the greatest public health problems and at loca- tions that provide the easiest access to the most susceptible segments of the population.

Unfortunately, the disconnection between man- dated required services and financial resources be- comes most apparent at the local public health level. In the United States, local governments are usually the least well financed of the three levels of government, and it is no different for local public health agencies.

Integrating Public Health Services

From this description, it can be seen that the public portion of our nation’s health promotion and dis- ease prevention activities depends on an intricate collaboration and cooperation between three levels of governmental agencies: federal, state, and local.

It involves elaborate transfer of financial resources from the federal government (where the resources are most abundant) to state governments (where resources are less abundant but still sufficient) and through to local public health agencies (where re- sources are scarcest and responsibilities most in- tense). The public portion of our nation’s health promotion and disease prevention activities is, for the most part, focused first on the protection of the public from potential threats to health and only secondarily on the active promotion of healthier lifestyles (Novick & Mays, 2001).

Although the public health professionals in gov- ernmental health agencies know very well that the greatest long-term impact on the health of our nation’s people probably depends on changes in styles of living, those same public health profes- sionals very often find themselves limited in their ability to engage in activities that are directly fo- cused on lifestyle change. Federal, state, and local government public health agencies can create poli- cies and goals to encourage individual personal lifestyle change, but for the most part, the actual implementation of those changes probably rests with the private sector, with the providers of medi- cal care. Governmental public health agencies can go only so far with the resources available to them in creating an atmosphere for major lifestyle change and improvement and, therefore, must de- pend upon their private-sector colleagues to carry the effort more directly into the homes of individual people. Nevertheless, governmental public health agencies have played a vital role in the protection of the public, in setting strategies and goals for the im- provement of the health status of the public, and in motivating the public to move to an even higher level of healthful living.

For that next level of health promotion and dis- ease prevention, however, the full involvement and participation of the private sector is necessary. The importance of the private-sector clinical role was originally stressed in the United States Preventive Services Task Force Report in 1989 and was rein- forced by the United States Public Health Service’s major reports, Healthy People 2000 and Healthy People 2010, which set national health promotion

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and disease prevention objectives for the country (U.S. Department of Health and Human Services, 2000; U.S. Preventive Services Task Force, 1989; U.S. Public Health Service, 1990).

THE ROLE OF THE PRIVATE SECTOR IN HEALTH PROMOTION AND DISEASE PREVENTION

It is comparatively easy to discuss the role of govern- mental public health agencies: usually they have been in existence for some time, have clearly defined roles, and have well-documented track records ex- tending over many years. When one approaches the role of the private sector in health promotion and disease prevention, however, discussion be- comes more difficult and more diffuse, if no less im- portant. Indeed, in the minds of many individuals, the role of the private sector, particularly the physi- cian in private practice, is increasingly central in creating the major lifestyle changes that are viewed as being so important to the prevention of disease over the long term.

Many deaths in the United States are attri- butable to lifestyle and personal actions on the part of individuals, such as tobacco use, improper diet and activity patterns, overuse of alcohol and firearms, unsafe sexual behavior, and vehicular accidents while under the influence of alcohol. Most of these causes of death are only partially amenable to change by broad social or legislative actions, and only individual behavior change will really affect many of them. The physician in medical practice is in a key position to influence behavior change because research has shown that individ- uals are more likely to follow improved health habits if they are encouraged to do so by their usual medical practitioner. The central role of the practicing physician in encouraging and enhancing improved personal life habits has long been acknowledged and must be central to any future

national plan of health promotion and disease prevention.

There are two major barriers to the individual physician’s assuming the central role in health pro- motion and disease prevention: (1) the individual physician’s willingness and ability to perform these health promotion and disease prevention activities, and (2) the ability of the population to access the services of a private physician.

With regard to the physician’s interest in, and ability to perform, health promotion and disease prevention activities, it has long been noted that physicians are generally more interested and more competent in matters related to curative and treat- ment activities than they are in matters related to health promotion and disease prevention. This may be a reflection of their early medical training, which may have lacked emphasis on health promotion and disease prevention, or it may be related to the physician’s natural human tendency to see curative treatment as “doing something” while seeing health promotion and disease prevention as “not doing something.” Physicians are by nature activists and are more naturally drawn to the interventions where they are likely to see results in a relatively short period of time as opposed to events where the consequences of their actions will be known only, if at all, many years later.

It should also be pointed out that in the previous era of fee-for-service medicine, physicians were only reimbursed for treatment activities and were usu- ally not reimbursed, either by insurance companies or by individuals paying their own bills, for preven- tion services. The former methods of payment for medical services encouraged increased active treat- ment of illness but did not encourage its active pre- vention. It is only natural, therefore, that physicians in the past should have responded to obvious incentives by spending more of their time and ener- gies on treatment and less on prevention.

Probably a greater barrier to enhancing the role of the private physician in health promotion and disease prevention is the limited access that a signif- icant portion of our population has to medical care. A significant portion of the United States

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population is uninsured or has very limited insur- ance, with relatively large financial burdens still resting with the individual patient who is unlikely to visit a physician on a regular basis. If individual people in the United States discover that their insurance plans do not cover health promotion and disease prevention and that they must pay for such tests themselves, they are less likely to use such tests and procedures and to visit a physician on a regular basis to obtain the counseling and encouragement that might be possible there.

It would seem natural to suggest, therefore, that if our nation wishes to involve the private sector in extensive health promotion and disease preven- tion activities that reach our entire population, it must be arranged in some fashion for the entire population to have health insurance coverage that ensures adequate access to medical care (Levy & Sidel, 2005). Without universal health insurance coverage of some kind, it is an illusion to talk about a nationwide health promotion and disease prevention effort, as a significant percentage of the population (and, perhaps, those at highest risk) cannot access the one place where the most influ- ential health promotion and disease prevention counseling might take place—the office of a pri- vate medical practitioner. Universal health insur- ance coverage, therefore, is central to any nation- wide effort of health promotion and disease prevention.

Merely having universal health insurance cover- age, however, is not enough if that health insurance coverage does not include financing for health pro- motion and disease prevention tests, procedures, and counseling. Many of the health insurance plans issued at the present time do not include reimburse- ment for health promotion and disease prevention, and as a result, individuals who may actually have health insurance coverage of a general nature are not covered for health promotion and disease preven- tion services. Therefore, it is essential that the de- sign of future health insurance packages include financing for these services. Without such financ- ing, individuals may be actively discouraged from seeking health promotion and disease prevention

tests and procedures, as well as advice and counsel- ing, from their primary physician.

The Role of Managed Care in Health Promotion and Disease Prevention

The advent of managed-care health insurance cov- erage around the United States may present an opportunity to accomplish some of these health promotion and disease prevention objectives, par- ticularly if the specific managed-care plans are those of the health maintenance organization (HMO) type, which reimburse physician groups on a per capita basis. The advent of managed care of the HMO type presents opportunities for the ex- pansion of health promotion and disease preven- tion in ways that have not been previously available (Breslow, 1996; Koplan & Harris, 2000).

It is important to note two essential elements of the HMO type of managed-care plan: (1) the offi- cial assignment of the long-term responsibility for supervising all aspects of an individual’s care to a specific physician or medical group, and (2) the re- imbursement of that physician or medical group on a per capita basis. Each of these specific aspects of HMO managed care is very supportive of the gen- eral long-term thrust in health promotion and disease prevention.

With regard to the first (i.e., the assignment of long-term responsibility for an individual’s care to a specific physician), HMO managed-care plans require the identification of a specific primary care physician for each person covered by that type of insurance. This puts a particular physician on no- tice that this individual patient (or family unit) is his or her long-term responsibility. This identifica- tion of the individual physician as having an official long-term and continuing responsibility for an indi- vidual or a family changes the perspective of the individual physician away from the provision of spe- cific individual services and toward the long-term health of the individual or the family. The designa- tion of an individual physician as a patient’s pri- mary care doctor further solidifies the long-term

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role of that physician in managing the entire health- related set of activities in the minds of both the physician and the patient.

The use of per capita reimbursement to the pri- mary care physician further reinforces the long- term nature of the relationship and particularly emphasizes the long-term role of attempting to reach maximum health outcomes, not just provid- ing individual fee-for-service interactions. The HMO per capita reimbursement method serves as a reminder to the physician that his or her financial rewards are dependent upon keeping the individ- ual patient as healthy as possible, rather than sim- ply providing a series of individual services to a sick person. The dynamics in the HMO managed- care plan thereby provide more incentives for keep- ing people healthy.

Managed-care insurance coverage of the HMO type also has a great advantage over the previous fee-for-service type of coverage in that it not only assigns official responsibility to an individual phy- sician or medical group, but it also holds that physician or medical group accountable for what happens to the patient. In the past, no physician or medical group was responsible for reporting to any insurance plan or purchaser of health care about the long-term pattern of services and their results. The individual physician merely provided one ser- vice after another on an individual and relatively unconnected basis, and no accountability was ever really required as to how the pattern of individual services eventually affected the overall health of an individual patient.

Under the new forms of HMO managed care, not only is it possible to assign individual long- term responsibility to a specific physician or medi- cal group, but it is also possible, and, indeed, in- creasingly the rule, to designate specific actions that the physician or group must take during the course of a particular year. It is increasingly common for HMO managed-care plans to outline certain specific services or practices that a physician must follow and also to require documentation of the completion of those services.

For example, many HMO managed-care plans require that physicians provide certain health promotion and disease prevention services (such as immunizations for children, provision of mammo- grams for women over a certain age, blood choles- terol measurements, and the like). Not only are the HMO managed-care plans able to require physi- cians to provide these services, but they are also able to require the physicians to report that these services have actually been completed.

What this means for the encouragement of health promotion and disease prevention activities on the part of the physician should be obvious. In the future, if it is judged that a certain pattern of health promotion and disease prevention ser- vices or activities should be provided to an individ- ual patient during the course of a particular year, that requirement can be written into the contract with the individual physician before he or she is allowed to assume long-term responsibility for the patient. Unwillingness to perform these health promotion and disease prevention actions would bar the physician from being able to contract with the HMO managed-care plan in the first place. The contract language can also ensure that the physi- cian agrees to provide information that will allow the plan to determine whether the services have actually been delivered to the patient as agreed upon.

Many aspects of managed care are cause for con- cern among thoughtful observers of health care in the United States, but the enhancement of health promotion and disease prevention activities is not one of them. Indeed, one of the major positive as- pects of managed care is its potential ability to install an organized, well-financed, and well- documented system of care that emphasizes health promotion and disease prevention. Despite what- ever other concerns may exist about managed care, it is clear that the growth of managed-care health insurance coverage offers an opportunity for an en- tirely new era with regard to the promotion of bet- ter health and prevention of future disease in the United States.

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PUBLIC HEALTH IN AN ERA OF TERRORISM AND EMERGING DISEASES

Public health services received tremendous new at- tention following September 11, 2001, from both the increased threat of terrorist attacks and the emergence of new diseases (Table 6.1) (Shadel et al., 2004). Preparation for potential terror events has been funded in varying degrees by federal and state sources. The focus on such preparation has en- compassed a wide range of public health activities including monitoring, planning, mobilization, co- ordination with other entities, and prepared re- sponse. Public health services are integral to any response to external attack, and the expertise of public health agencies and officials has been ex- panded through training, expansion of capabilities, acquisition of equipment, and a more prepared workforce.

As with terror threats, in recent years the advent of emerging new disease challenges, including SARS, hemorrhagic fevers, avian flu, and other po- tential illnesses, has led to increased surveillance and preparation. The potential impact of these threats could be huge in the United States and internationally, such that public health agencies are expected to be prepared to respond, and indeed, to anticipate potential threats (Merson, Black, & Mills, 2005). Combined with possible terrorist use of infectious agents such as anthrax, reliance on public health agencies may be greater than funding and staffing would suggest is realistic.

Finally, of course, natural disasters also pose tremendous challenges for public health agencies. Hurricanes, earthquakes, fires, and floods have all demonstrated their impact on human popula- tions nationally and internationally. The prospec- tive preparation for these events has clearly been grossly inadequate. Most local public health agencies remain underfunded and understaffed if the expectation is that they will be capable of mounting a full and appropriate response (Rowitz, 2003).

In addition to natural disaster and terrorism, ac- cidents, the impact of crowding, certain effects of population aging, chemical infringements, drug misuse, and many other concerns affect the public health arena as well. And public health-related events can lead to other complications such as dis- placement of people, disruptions in the food and water supplies, lack of access to health care, im- pacts on utilities, and separation of family mem- bers. The scope of direct and indirect effects of many events on the public’s health is huge, perhaps much greater today than in past years.

Clearly the role of public health in protecting our nation has greatly expanded over the past few years. The traditional threats facing the nation’s public health are now clearly augmented by expec- tations for a broader array of capabilities to re- spond to newly strengthen challenges on many more fronts. Recognizing the importance of public health services to the nation, further development

CHAPTER 6 Public Health: Joint Public-Private Responsibility in an Era of New Threats 157

Table 6.1. Illustrative Twenty-First Century Emerging Public Health Threats

Terror Natural Disasters Disease

Active attacks on commerce

Economic attacks including those on banking

Interference with food, water, utilities, supplies

Internet attacks

Earthquakes Extreme heat Floods Hurricanes Landslides and

mudslides Power outages Tornadoes Tsunamis Volcanoes Wildfires Winter weather

Anthrax Avian influenza Botulism Ebola hemorrhagic

fever Hantavirus Lassa fever Plague Ricin toxin Viral encephalitis

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of this capability is not only essential, but it is also cost effective and beneficial to our nation’s future survival.

SUMMARY

It should be clear from this discussion of health promotion and disease prevention in the United States that this is a shared responsibility between the public (governmental) and the private sectors of health care (Institute of Medicine, 2003). Neither sector can do what the other can do, and neither sector can do it alone. For the people of this coun- try to reach their maximum health status, it will be necessary to forge an even stronger public-private partnership that allows both sectors to use their unique roles and advantages to advance the health of the public in ways that have never before been possible.

REVIEW QUESTIONS

1. What are the various levels of prevention? 2. Discuss the historical evolution of health

promotion and disease prevention in the United States.

3. What are the lessons from history of public health development in the United States?

4. Describe and discuss the structure of orga- nized public health in the United States.

5. Discuss the role of the private sector in health promotion and disease prevention in the United States.

6. Discuss the role of managed care in health promotion and disease prevention in the United States.

7. List some of the major public health threats that have recently emerged in the twenty-first century.

8. Summarize the future of public health in the United States.

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Brockington, C. (1956). A short history of public health. London: J & A Churchill.

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CHAPTER TOPICS

Historical Perspectives and Types of Care

Use of Ambulatory Care Services

Ambulatory Practice Settings

Institutionally Based Ambulatory Services

Government Programs

Noninstitutional and Public Health Services

The Role of Ambulatory Services

Managing a Medical Practice

Professional Practice Organizations

LEARNING OBJECTIVES

Upon completing this chapter, the reader should be able to

1. Understand the role of ambulatory care services.

2. Appreciate the evolution of ambulatory care as a distribution system.

3. Review the primary ambulatory care providers.

4. Outline the organizational role and control mechanisms of ambulatory care services.

5. Assess the allocation of responsibility for coordination, integration, appropriateness, and rationalization between ambulatory care and other sectors.

6. Understand how practices are managed.

CHAPTER 7

Ambulatory Health Care Services and

Organizations

Stephen J. Williams

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CHAPTER 7 Ambulatory Health Care Services and Organizations 161

This chapter addresses the array of services that provide care in communities to noninsti- tutionalized patients. The chapter addresses the multitude of service distribution channels, prac- tices, and patterns utilized in the provision of physician, dental, and other professional services. Some services related to institutionalized patients such as those admitted to hospitals or nursing homes are also mentioned as they pertain to am- bulatory care, recognizing the increasing connec- tion between various types and levels of health care services.

Ambulatory care has increased dramatically in status in the health care system over the past three decades as the system has moved toward increas- ingly integrated and, ultimately ideally, seamless provision of care. The trend toward providing services in less expensive and less intensive sur- roundings and facilities, encouraged by the march of technology and by pricing and reimbursement pressures, is further accelerating these trends.

The ambulatory arena, which encompasses a very broad array of services as exemplified by the partial listing in Table 7.1, serves two principal roles in the health care system. First, these services provide an increasingly greater percentage of all direct patient care in the form of personal and pre- ventive health services. Second, ambulatory care is increasingly serving the role of care manager in al- locating resources to meet patient needs in clinical decision making. Because of the increasingly com- plex nature of ambulatory care services, this chap- ter will discuss the historical and current nature of these services but will also delve into the manage- rial considerations involved in organizing, develop- ing, and controlling this segment of the health care system.

The role of ambulatory care services in organiz- ing and delivering physician, dental, and other pro- fessional services is continuing to evolve. But the fundamental realignment of the nation’s health care system, driven by technology, quality con- cerns, cost and reimbursement imperatives, and by the desires of consumers, is now set in place and is irreversible.

HISTORICAL PERSPECTIVES AND TYPES OF CARE

Traditionally, ambulatory care services have been viewed as the primary source of contact that most people have with the health care system. Although there are few concise definitions of ambulatory care, these services can be defined as care provided to noninstitutionalized patients. Sometimes ambu- latory care is termed care for the “walking patient.” Ambulatory care includes a wide range of services, from simple, routine treatment to surprisingly com- plex tests and therapies.

Table 7.1. Illustrative Ambulatory Care Services

Solo practice Group practice Hospital clinics Hospital emergency rooms Ambulatory surgery centers (hospital-based and

freestanding) Community-wide emergency medical systems Poison control centers Community hotlines Neighborhood (community) health centers Migrant health centers Community mental health centers Federal systems—Veterans Administration, Indian Health

Service, military health services Home health services School health services Prison health services Public health services and clinics Family planning and other specialized clinics Industrial clinics Pharmacies Vision care Medical laboratories Indigenous practitioners

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Ambulatory care originated with the healing arts themselves. In primitive societies and for many years thereafter, until the advent of institutional care, all care was provided on what might today be referred to as an ambulatory care basis. Of course, the types of care given then bear little resemblance to today’s health care, but the history of civilization demonstrates a consistent commitment to caring for the sick using whatever knowledge had been available at the time. Remarkable forms of medical practice occurred in Greece, Rome, and other rela- tively sophisticated societies. In fact, many primitive societies even had their own indigenous practition- ers such as religious healers and medicine men.

In more recent times, ambulatory care was pro- vided in many new settings by a variety of more ad- vanced practitioners. In Europe, and later in the United Sates, many of these services were given to wealthy patients in their homes; poor people were cared for in dispensaries and public clinics. With improvements in hospital care, more patients of all social classes received both inpatient and outpa- tient care in hospital settings. In the United States, the poor have always been more likely than the wealthy to obtain care from the hospital than from private physicians.

In the United States, ambulatory care services were traditionally provided by individual medical practitioners working in their offices and in pa- tients’ homes and by public clinics operating pri- marily for poor and indigent patients. The limited technological armament that physicians required allowed them to travel easily, carrying with them their principal equipment and supplies. Thus, home care was common, especially among wealthier pa- tients. Physicians’ offices were frequently located in their homes or in other small buildings, as op- posed to today’s medical office buildings or large medical centers. The general practitioner who made house calls, provided guidance, and offered available treatments was typical of the primary care provided before and somewhat after World War II.

For the poor in both Europe and the Untied States, care—when available—was often limited to

public or philanthropic clinics or dispensaries. Private practitioners may have given their time to serve the poor, but their devotion to the patient was probably limited, as was the availability of care and the facilities in which services were provided.

Early efforts to link ambulatory care services and integrate them formally with inpatient care were promoted in this country and in Europe, in part, through the concept of regionalization. In Great Britain, the concept was presented in the Dawson Report, which eventually led to the National Health Service (United Kingdom Ministry of Health, 1920).

Since World War II, an explosion of medical knowledge has led to increasing specialization, more complex technology, and rapid changes in the settings and nature of services. Fewer physi- cians are able or willing to travel to the patient’s home, and many can no longer carry with them either the equipment and supplies or the special- ized personnel available in an office. The growth of technical specialization, in particular, has led to the rapid expansion of new settings for providing care, such as group practices and, more recently, a profusion of specialized facilities. Increased knowl- edge has also led to the partial phasing out of the traditional general practitioner, replaced by the broadly trained family practitioner, a specialty whose development was encouraged by managed care and by concerns over the comprehensiveness of care.

The increasing sophistication of insurance mech- anisms and the use of ambulatory care services as a control mechanism on the use of all services have led to an increase in the degree of structure of the health care system. This increasing structure has primarily occurred in the private, nongovernmental sector. The concept of social and economic regula- tion of the system through governmental interven- tion, carried to a high level of sophistication in the Dawson Report, has largely been abandoned, at least for the foreseeable future. Integration of ser- vices now focuses largely on multiple, independently organized systems of care that are competitive with one another.

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CHAPTER 7 Ambulatory Health Care Services and Organizations 163

Levels of Ambulatory Care Services

The diversity of services, providers, and facilities in- volved in ambulatory care today is truly amazing and growing all the time. Ambulatory care services can be differentiated by, as contrasted to public health, discussed in the previous chapters, levels of care. Primary prevention reduces the risks of mor- bidity by removing or reducing disease-causing agents and opportunities from our society. These activities include efforts to eliminate environmental pollutants that are suspected of causing diseases such as cancer. Other examples of primary preven- tion include encouraging people to use automobile seat belts, treatment of water and sewage, and san- itation inspections in restaurants. Preventive health services are more direct personal interventions to de- tect and prevent disease. Examples of these services include hypertension, diabetes, and cancer-screening and immunization programs. The combination of primary prevention and preventive services is our first line of defense against disease.

Medical care that is oriented toward the daily, rou- tine needs of patients, such as initial diagnosis and continuing treatment of common illness, is termed primary care. This care is not necessarily highly com- plex and does not generally require sophisticated technology and personnel. The vision of the general practitioner of bygone days, traveling from house to house ministering to the sick, represents the tradi- tional role of primary care, which is replaced in today’s society by considerably more skilled practi- tioners in relatively more complex facilities.

In addition to providing services directly, the primary care professional should serve the role of patient advisor, advocate, and system gatekeeper. In this coordinating role, the provider refers patients to sources of specialized care, gives advice regarding various diagnoses and therapies, and provides continuing care for chronic conditions. In many organized systems of care, such as managed- care programs, this role is also very important in controlling costs, utilization, and the rational allo- cation of resources.

The evolution of technology and medicine’s in- creasing ability to intervene in illness have led to greater specialization of health care services. These more specialized services, termed secondary and tertiary care, are provided in both ambulatory and inpatient settings. The content of secondary and ter- tiary care practices is usually more narrowly defined than that of the primary care provider. Subspecial- ists, who provide the bulk of secondary and tertiary care, also often require more complex equipment and more highly trained support personnel than do primary care providers.

In recent years, the evolution of health care services has led to greatly expanded provision of secondary care on an outpatient, or ambulatory care, basis. Numerous diagnostic and surgical ser- vices of increasing complexity have been shifted to the ambulatory arena. Recent advances in the use of fiber optics and other technologies suggest that this trend will continue.

There are no clear dividing lines for primary ver- sus secondary and secondary versus tertiary care. Secondary services include routine hospitalization and specialized outpatient care. These services are more complex than those of primary care and in- clude many diagnostic procedures as well as more complex therapies. Tertiary care includes the most complex services, such as open-heart surgery, burn treatment, and transplantation, and is provided in inpatient hospital facilities.

USE OF AMBULATORY CARE SERVICES

Historically, and at the present time, most ambula- tory care services are provided in solo and group practice office-based settings. Institutional settings for care, primarily the hospital, although an impor- tant component of the health care system, remain less prominent. Overlap between office-based prac- tice and institutional settings is increasingly com- mon, however, as the dividing lines between various

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components of the health care system continue to blur. Managed-care programs especially tend to integrate these services. The development of in- creasingly sophisticated information systems and reimbursement mechanisms increasingly facilitate the integration of services across all levels of care.

Measures of the use of ambulatory care services are contained in Tables 7.2, and 7.3, which present survey results on utilization patterns based on national data that are representative of the entire United States population. These data are taken from the National Health Interview Survey (Adams, Dey, & Vickerie, 2007), a national survey of Americans’ use of health care services, and they

complement the utilization data presented in other chapters.

Tables 7.2 and 7.3 describe doctor visits experi- enced by Americans in various demographic cate- gories. The very young and the very old report higher utilization of ambulatory services, and females generally experience higher utilization than males. The lowest income groups in our popula- tion, not coincidentally those of lower health status as well, experience the highest utilization of ambu- latory services when the data are examined by in- come groups. In examining the data by health status, ambulatory services utilization is highest for the less healthy, as would be expected.

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Table 7.2. Health Care Visits to Doctors’ Offices, Emergency Departments, and Home Visits within the Past 12 Months: United States, 2003

Number of Health Care Visits

Characteristic None 1–3 Visits 4–9 Visits 10 or More Visits

Percent Distribution All persons 15.8 45.8 24.8 13.6

Age Under 18 years 11.3 54.5 26.7 7.5 18–44 years 22.4 46.7 19.1 11.8 45–64 years 14.7 42.2 26.6 16.5 65 years and over 6.3 31.5 35.8 26.4

Sex Male 20.6 46.8 21.9 10.7 Female 11.1 44.9 27.7 16.3

Race White only 15.7 45.6 25.1 13.6 Black or African

American only 14.7 45.8 25.2 14.3 Hispanic or Latino 25.3 42.9 20.3 11.5

Poverty status Poor 20.9 37.8 23.7 17.6 Near poor 19.8 41.5 23.6 15.1 Nonpoor 13.7 48.4 25.4 12.6

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Table 7.4, also based on data from the National Health Interview Survey, indicates dental visit use. Such use is more dependent on financial access and the data clearly show lower use by lower income people and by the older popula- tion. Dental use would seem to fall short of pre- ventive recommendations for various population groups also.

Use of Office Setting Services

Most utilization data are available from survey re- search results. To obtain more detailed information on health care use in physician office settings, the federal government has conducted periodic surveys of private, office-based physicians—the National Ambulatory Medical Care Survey (Hing, Cherry, & Woodwell, 2006). The National Ambulatory Medi- cal Care Survey (NAMCS) is based on a sampling of visits to nonfederal office-based physicians. The survey has been performed annually since 1989.

Table 7.4. Dental Visits During the Prior Year According to Selected Characteristics: United States, 2003

Characteristic 2 Years of Age 2–17 Years of 18–64 Years of 65 Years of Age

and Over Age Age and Over

Percent of persons with a dental visit in the prior year Total 66.3 75.0 64.8 58.0

Sex Male 63.6 74.1 60.9 58.4 Female 68.9 75.9 68.6 57.7

Race White only 67.5 76.0 65.9 59.8 Black or African American only 58.4 70.5 58.1 38.7 Hispanic or Latino 52.4 64.5 48.3 46.0

Poverty Status Poor 48.2 65.8 44.5 37.1 Near poor 52.3 66.6 49.1 43.6 Nonpoor 73.4 80.8 72.0 67.8

Table 7.3. Visits to Physician Offices and Hospital Outpatient and Emergency Departments by Selected Characteristics: United States, 2003

Age, Sex, All Physician and Race Places Offices

Number of visits in thousands Total 1,114,504 906,023

Number of visits per 100 persons Under 18 years 307 232 18–44 years 300 229 45–64 years 442 377 65 years and over 754 664

Sex Male, age adjusted 338 273 Female, age adjusted 442 360

Race and age White, age adjusted 399 332 Black or African American,

age adjusted 391 261

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Data collection is based on the physician, who is randomly assigned to a one-week reporting period during which an encounter form is used to record symptoms.

Table 7.5 lists the most common reasons for all office visits. The relative prominence of routine care, of follow-up or ongoing care, and of relatively simple primary care is striking and reflects the predominance of the routine, day-to-day needs of patients seeking ambulatory care services.

Further understanding of the nature of the visits is obtainable from additional data regarding the services provided to patients and the interactions shared between patients and physicians. The princi- pal sources of payment for patient office visits are private and commercial insurance, Medicare, HMOs, and other managed-care arrangements. The percentage of visits included in this last category likely will increase in future years while managed care grows in popularity.

The most common drug categories prescribed during the physician office visits are classified in Table 7.6. The most prevalent categories of drugs

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Table 7.5. Number and Percent Distribution by Sex of Office Visits for the Top 10 Principal Reasons for Visits: United States, 2004

Number of Visits Patient's Sex Principal Reason for Visit in Thousands Female Male

All visits 910,857 100.0 100.0 General medical examination 56,703 5.2 7.7 Progress visit, not otherwise specified 48,302 5.3 5.3 Postoperative visit 26,299 2.9 2.8 Cough 25,951 2.5 3.3 Prenatal examination, routine 24,816 4.6 — Medication, other and unspecified kinds 16,483 1.7 2.0 Hypertension 14,510 1.4 1.8 Symptoms referable to throat 14,470 1.7 1.5 Knee symptoms 14,241 1.5 1.7 Well-baby examination 11,023 1.0 1.6

SOURCE: From National Ambulatory Medical Care Survey: 2004 Summary. Advance Data from Vital and Health Statistics, no. 374, by E. Hing, D. K. Cherry, and D. A. Woodwell, 2006, Hyattsville, MD: National Center for Health Statistics.

Table 7.6. Therapeutic Classification for the 10 Drugs Most Frequently Prescribed at Office Visits: United States, 2004

Therapeutic Classification Number of

Prescriptions

Antidepressants 81,185 NSAID 73,737 Antiasthmatics/bronchodilators 69,507 Antihypertensive agents 69,113 Hyperlipidemia 63,996 Antihistamines 58,163 Acid or peptic disorders 56,906 Antiarthritics 54,783 Blood glucose regulators 53,069 Nonnarcotic analgesics 51,918

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CHAPTER 7 Ambulatory Health Care Services and Organizations 167

include cardiovascular and renal, antimicrobial, and pain-relief agents. As technology changes, the classification distribution of various drug cate- gories will likely change in prevalence as well.

The distribution of office visits by the duration of the visit (Table 7.7) indicates that relatively few visits require either very short or very long physi- cian contacts. The typical physician office visit requires only about 5 to 15 minutes of time; nearly three-fourths of all visits require 15 minutes or less. A high percentage of visits conclude with the rec- ommendation that the patient return at a specified time interval for a follow-up visit. An interesting issue in resource utilization is the impact of physi- cian assistants, nurse practitioners, and other pro- fessionals on the time allocation of physicians in clinical care.

The National Ambulatory Medical Care Survey provides some insight into the nature of office- based ambulatory care. Much more extensive docu- mentation of the survey and results for various types of services, providers, and patient characteris- tics is available from the federal government.

The survey data are an aid to planning health ser- vices in the ambulatory care setting and provide perspectives on national patterns of utilization. The applicability of the data to setting standards of performance in managed-care settings or under contracted agreements for service, however, is lim- ited because of the many variables that could not be adequately measured.

AMBULATORY PRACTICE SETTINGS

Significant differences exist among physician prac- tice settings. The two primary noninstitutional set- tings for the provision of ambulatory care are solo and group practice. Each of these settings may be a component of larger systems of care through such integrating mechanisms as referral arrangements, insurance contracts, and direct ownership of prac- tices, especially in vertically integrated health care delivery systems.

Although the solo practice of medicine has tra- ditionally attracted the greatest number of practi- tioners, group practice and institutionally based services have expanded dramatically, continuing a trend that has been building over the past 30 years. Changing lifestyles, the cost of establishing a prac- tice, personal financial pressures on practitioners, contracting and affiliation opportunities under managed care, and the burdens of running a busi- ness have enhanced the attractiveness of group practice for many physicians. With sharp increases in the number of physicians beginning practice, the growth of alternative settings, and especially of group practice, has been dramatic. Although solo practice remains a viable avenue for providing ambulatory care services, these other settings have rapidly assumed a more prominent and visible role in the health care system, particularly as they provide a further mechanism for the inte- gration, management, and control of health care services.

Table 7.7. Percent Distribution of Office Visits, by Time Spent with Physicians: United States, 2004

Time Spent with Physician Percent Distribution

All visits 100.0 Visits at which no physician

was seen 4.9 Visits at which a physician

was seen 95.1 Time (with a physician) 100.0

1–5 minutes 3.6 6–10 minutes 18.7 11–15 minutes 40.1 16–30 minutes 31.2 31 minutes and over 6.4

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Solo Practice

Solo practitioners are difficult to uniformly charac- terize. Early sociological studies focused on specific questions, such as referral patterns or quality of care, and they did not provide a comprehensive pic- ture of what the solo practitioner did. Studies that did contribute to a more complete understanding of the activities of solo practitioners were based on physicians in one geographic area or a particular specialty, and the results of these studies, although interesting and useful, may not be applicable to other practices or areas. In addition, solo practi- tioners are heterogeneous; they include many types of health care professionals who provide an im- mense array of services.

Most solo practitioners perform a number of functions in the office, including patient care, consultations, and administration and supervi- sion of office staff. The requirements for adminis- tration, for supervision of personnel and for insurance paperwork have been increasing in re- cent years. Solo practitioners are also affiliating with managed-care networks that help ensure a viable patient population.

Solo practice is often associated with an increased feeling that the provider cares about the welfare of the patient, possibly resulting in a stronger patient- provider relationship that occurs in other settings. There is some evidence that this situation, where it occurs, is a result of the lower level of bureaucracy or organizational complexity in solo practice. Because there is also some evidence that the relationship be- tween patient and physician is related to patient com- pliance with medical regimens, patients who perceive that they are receiving more personalized care may respond to the care process more positively.

Solo practitioners may not be as restricted in re- ferrals to specialists as providers in some other set- tings, such as group practice, where organizational loyalties intervene. Managed-care contracts, how- ever, may limit referral options.

From the provider’s perspective, solo practice of- fers an opportunity to avoid organizational depen- dence and to be self-employed; there is also no

need to share resources or income with other providers. Philosophically, solo practice is most closely aligned with the traditional economic and political organizations that used to characterize medicine; younger physicians faced with discount- ing, contracting, and networks for care, however, may no longer identify with the more traditional perspectives.

All the increasingly complex problems of admin- istering a practice must be dealt with in solo prac- tice unless a professional manager is hired. Further- more, competitive pressures in the health care industry are leading many practitioners to question the feasibility and desirability of going it alone. Many solo practitioners are now affiliated with larger entities such as independent practice associa- tions, practice management companies, and other organizations. Thus, solo practice offers distinct opportunities and has philosophical and emotional appeal but is far from devoid of problems and con- straints, especially in light of the realities of medical practice today.

Group Practice

Office-based practice includes, in addition to solo practice, group practice. This form of practice has been growing in popularity in recent years, espe- cially as the increasing pressures of practice have led many providers to seek alternative settings in which to work.

Group practice is an affiliation of three or more providers, usually physicians, who share income, expenses, facilities, equipment, medical records, and support personnel in the provision of services through a formal, legally constituted organization. The definition of group practice, developed by the American Medical Association and the Medical Group Management Association, is three or more physicians formally organized to provide medical care, consultation, diagnosis, and/or treatment through the joint use of equipment and personnel, and with income from medical practice distributed in accordance with methods previously determined by members of the group. Although definitions of a

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group practice vary somewhat, the essential element is formal sharing of resources and income.

History of Group Practice

Some of the earliest group practices in the United States were started by companies that needed to pro- vide care to employees in rural sites where medical care was unobtainable. For example, the Northern Pacific Railroad organized a practice in 1883 to pro- vide care to employees building the transcontinental railroad. This industrial clinic was one of a number of such clinics founded in the nineteenth century.

Even more significant, however, was the establish- ment of the Mayo Clinic in Rochester, Minnesota— the first successful nonindustrial group practice. The Mayo Clinic, originally organized as a single- specialty group practice in 1887 and later broad- ened into a multispecialty group, demonstrated that group practice was feasible in the private sec- tor. The Mayo Clinic also represented a reputable model for group practice in a national atmosphere of fierce independence where group practice was viewed with skepticism and distrust. By the early 1930s, there were about 150 medical groups throughout the country, many of which were lo- cated in the Midwest (Rorem, 1931). Most included or were started by someone who had practiced or trained at the Mayo Clinic.

In 1932, the Committee on the Costs of Medical Care was established to assess health care needs for the nation. It issued a report that suggested a major role for group practice in the provision of medical care. The committee recommended that these groups be associated with hospitals to provide comprehensive care and that there be prepayment for all services. The report strongly supported the concept of regionalization that eventually gained wide recognition in the establishment of the British National Health Service, our own military health care systems, and other national models of orga- nized health service systems.

Other constituencies, including some unions, also developed group practices. After World War II, a number of pioneering groups were established. In

New York City, the Health Insurance Plan of New York was organized to provide prepaid medical care to the employees of the city—an idea pro- moted by Mayor Fiorello LaGuardia. On the West Coast, the Kaiser Foundation Health Plan was es- tablished to provide health care to employees of Kaiser Industries; Kaiser is an affiliation of plans and providers that is now serving millions of Amer- icans across the nation. In Seattle, a revolutionary development was the establishment of the Group Health Cooperative of Puget Sound, a consumer- owned cooperative prepaid group practice. It was founded by progressive individuals who were dis- satisfied with the private medical care available to them in the late 1940s.

Developments in medical practice also spurred the group practice movement. Perhaps most no- table was the increasing specialization of medicine and the rapid expansion of technology. This in- creasing sophistication meant that no individual practitioner could provide all the expertise that pa- tients would require. It also meant that more com- plex and expensive facilities, equipment, and per- sonnel were needed to care for patients. Group practice provided a formal structure for sharing these costs among providers. Many people believed that resources would be used more efficiently in groups. In addition, multispecialty groups, encom- passing more than one specialty, could provide patients with more of their health care under one roof and, hence, reduce problems of physical access to care and coordination of services.

Group practice was also thought to promote higher quality care. Most of the different specialists that a person required would be practicing together and would thus have the opportunity to discuss pa- tient problems among themselves, share a common medical record, and be more able to ensure the quality and continuity of care. Therefore, group practice was viewed by many as being advanta- geous for the physician—offering opportunities such as easily developed referral arrangements, sharing of after-hours coverage, greater flexibility in working hours, and less financial risk—while also benefiting the patient.

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Opposition to group practice occurred mostly for political and philosophical reasons. The American Medical Association and local medical societies have, at times, opposed group practice. Many early group practices had difficulties when physicians were denied admitting privileges in local hospitals. Community-based specialists sometimes refused to treat patients referred by group-practice physicians. In more recent years, however, opposition to group practice has disappeared, and restrictive laws no longer exist. The need to form affiliations for con- tracting under reimbursement programs and for achieving efficiencies in organizing health services more generally has also driven the growth of group practice.

The American Medical Association has con- ducted surveys of physician-oriented medical group practices in the United States on a periodic basis (Havlicek, 1999). The dramatic increase in popular- ity of practices is reflected in Table 7.8. The number of reporting group practices has more than doubled since 1975. There are more than 20,000 group practices in the United States, the majority of which are single-specialty groups. Even more dramatic is the growth in the number of physicians in a group-

practice setting. The average size of all group prac- tices in the United States is about nine physicians. Most group practices are professional corporations or partnerships. Managed care has led to group practices in contracting arrangements such as the independent practice associations (IPAs).

Group practices may be formed by, or affiliated with, larger organizations such as hospitals or health systems. The larger entity may provide capital, man- agement services, patient flows, and contracting as- sistance to the smaller group. Groups may be affili- ated with one another through various mechanisms that may provide management services and contract- ing potential for solo and smaller group practition- ers while preserving a degree of independence for these practitioners. A group practice without walls has been another avenue utilized to affiliate practi- tioners. In essence, practices are merged but are able to maintain their existing locations with administra- tive services carried out in a central office or through a contract with a management services organization. There are for-profit management companies and some not-for-profit entities providing these services to physician groups and, in some instances, actually purchasing groups outright, as well. In the past, some of these companies collapsed due to overpay- ing for groups and other financial miscues.

A critical assessment of group practice yields distinct advantages and disadvantages for both patients and providers as compared to other modalities for providing ambulatory services. Some of these are summarized in Table 7.9. Some of the topics listed under patient or provider perspectives could readily pertain to both.

Advantages of Group Practice

The advantages of group practice from the perspec- tive of the provider include shared operation of the practice, joint ownership of facilities and equipment, centralized administrative functions, and, in larger groups, a professional manager. The professional manager can provide expertise in areas often lack- ing among the providers such as billing, personnel management, patient scheduling, ordering of sup- plies, negotiating, and contracting.

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Table 7.8. Number of Medical Groups and Number of Physicians in Group Practice, United States, Selected Years

Year Total Number

Number of Physician

of Groups Positions in Group

Practice

1969 6,371 40,093 1975 8,488 66,842 1980 10,762 88,290 1984 15,186 139,127 1988 16,495 155,628 1991 16,576 184,358 1996 19,820 206,557 2006 (est.) 25,000 300,000

Adapted from Medical Groups in the U.S., 1999 Edition. A Survey of Practice Considerations by P. L. Havlicek, 1999, Chicago: American Medical Association.

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Financially, the group relieves the provider of the heavy initial investment often required to establish a practice. In most groups, however, co-ownership requires that new members buy into the group through the purchase of a share of the group’s capital assets over a period of time. Rather than having to independently absorb the ups and downs of a practice, as solo practitioners do, those involved in a group practice share income and expenses

within the group, allowing for moderation of those fluctuations experienced in individual practices.

The participation of physicians in group practice has also a significant advantage in facilitating the development of arrangements for contracting and negotiating. The group can support increased levels of participation, has a knowledgeable group- practice administrator to manage the contracts, and can respond to the market with a wider range of

Table 7.9. Some Advantages and Disadvantages of Group Practice

Advantages Disadvantages

From perspective of the provider Availability of professional manager Less individual freedom Organizational responsibility for patient Possible excessive use of specialists Less physician administrative time Fewer outside consultants Shared capital expense Possible reduced identity with patient and community Shared financial risk Group rather than individual decision making Improved contracting and negotiating ability Sharing of all problems Better coverage and shared on-call shifts Necessity of working with others More flexible working hours Less individual incentive and more orientation toward security More peer interaction Income limitations Increased access to specialists Income distribution arguments Broader array of ancillary services Stable income for providers No direct financial concerns with patient Lower initial investment More time for continuing education More flexible vacation time Generally excellent benefits Possible efficiencies of scale Use of nonphysician practitioners

From perspective of the patient Care under one roof Possible lessening of provider-patient relationship Availability of specialists, laboratories, and so on Possible overuse of ancillary services Improved coverage and emergency care Possible high provider turnover Central location of medical and administrative records Heavy patient loads and possible increase in waiting time Simplified referrals Less provider incentive for care Peer interaction among providers More bureaucracy Better administration of group Possible promotion of efficiency in patient care

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services. Having a professional manager to negoti- ate on behalf of the group further enhances the relative attractiveness of group practice, particularly for physicians who lack experience in interpreting and negotiating contracts.

Patient-care responsibilities are also shared in group practice. This sharing results in greater flexi- bility of working hours for the provider, as well as more time for vacation and continuing education, without sacrificing the quality of care for the patient. For example, providers cover for each other during vacations and after normal working hours. Although most practitioners in solo practice ar- range for patient-care coverage, the continuity of care and the extent of coverage are probably greater in group practice, as patients’ medical records and the full resources of the group are always available, even if specific providers are not working.

The use of certain personnel may be more ad- vantageous in group than solo practice. Reception- ists, medical records and information systems specialists, laboratory and radiology technicians, and nurses may be used more efficiently and in the specialized areas of their training in many medium- and larger-sized groups. In addition, there is some question about whether any savings that are achieved will be returned to payors or simply repre- sent higher incomes for providers.

The effect of groups on patient care, especially on the quality of care, is an important issue. Sharing of medical records, computer-assisted quality assurance, peer interaction, easy referrals and consultations with specialists, more sophisticated and accessible ancil- lary services, and more skilled and diversified support personnel are all arguments suggested in support of higher-quality care in group practice. For the patient, the group offers a wide range of services under one roof so that travel between providers is reduced and access increased. A unified computerized medical record can contribute to continuity of care and less duplication in diagnosis and treatment. Managed- care contracts in groups can be more comprehensive and promote integrated care.

Group practices usually offer more accessible care after normal working hours. Some groups also

offer emergency services through their own emer- gency rooms or clinics. Groups with a broader community perspective may even be involved in programs such as school health services and community immunization efforts, and the use of a professional manager should benefit the patient through more efficient scheduling and patient flow and improved overall management of the practice.

There are also some distinct disadvantages to group practice for providers, patients, and commu- nities. From the perspective of the provider, practic- ing in a group implies less individual freedom, with a variety of restrictions imposed through the shar- ing of a practice. Managed-care contracts may re- quire a higher level of monitoring of clinical care as well. In addition to reduced freedom, group prac- tice entails sharing responsibilities and problems with others. The interpersonal requirements for working out these responsibilities may not appeal to all practitioners. Older individuals who have been working in solo practice may especially be unlikely to adapt readily to group practice.

The financial advantages for group practice are a trade-off against some restrictions on income gener- ation and the necessity of complying with the group’s income distribution and practice pattern re- quirements. Thus, there is often more security and fewer risks, but also less incentive and reward for individual initiative and production.

INSTITUTIONALLY BASED AMBULATORY SERVICES

In addition to solo and group practice in the tradi- tional private sector, many institutions have ex- panded their involvement in ambulatory care. These institutionally based settings, especially those associated with hospitals, are discussed next.

The hospital has evolved from an institution for poor people who could not be cared for at home to a provider of a full range of health services from primary to tertiary care. As technological advances

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have brought more services into the hospital and expanded the scope of care provided, the hospital has assumed an especially important role in the provision of highly complex health services. At the same time, an increasing number of people have sought primary care from hospitals, some- times as a result of the lack of access to other sources of care. Most hospitals now operate out- patient services.

Traditional hospital outpatient services have been provided in clinics and emergency rooms. In many hospitals, clinics used to have second-class status as compared to complex and expensive inpa- tient services. However, as hospitals have recog- nized the important role of primary care, especially in managed-care contracting and are seeking to ex- pand the base of patients who are potential users of inpatient and ancillary services, more attention has been directed toward improving clinic operations and services.

Hospital clinics include both primary care and specialty clinics. Many hospitals differentiate be- tween clinics for walk-in patients without appoint- ments and those for scheduled visits. Triage is an important function of hospital clinics and emer- gency services. Specialty clinics are usually orga- nized by department and provide services such as ophthalmology, neurology, and allergy care. In teaching hospitals, and especially academic medi- cal centers, clinics serve as important settings in which house staff members provide ongoing care to patients and follow-up after hospitalization. Clinics also provide an opportunity to expose medical stu- dents and house staff to ambulatory care services in order to complement the traditionally more exten- sive experience with inpatient care.

Many hospital primary-care clinics evolved from an orientation of service to the poor and were staffed by physicians who served without reim- bursement in exchange for staff privileges. The level of commitment to the patient under such circum- stances was—not surprisingly—less than desirable. Many hospitals now employ physicians and other practitioners as full-time clinic staff. Some hospitals have established primary-care group practices to com-

plement other outpatient services and to assume the burden of providing primary care to patients who seek most of their care from the hospital or as a component of a vertically integrated health care delivery system. Hospitals are also increasingly em- ploying hospitalists and intensivists physicians who are stationed at a hospital full time to care for inpa- tient and sometimes critical clients. Hospitals with ambulatory care resources can negotiate contracts for providing a wide range of both inpatient and outpatient services. Enhanced preparation for cop- ing with major community emergencies such as ter- rorism and natural disasters is another expanded function of hospital-based ambulatory care.

Ambulatory Surgery Centers

A further innovation in hospital-based care has been the development of ambulatory surgery cen- ters. Originating in hospitals in Washington, D.C., Los Angeles, and elsewhere, these organized hospi- tal units provide one-day surgical care. Patients are usually screened for acceptability by their per- sonal surgeons and then report at an assigned date and time for surgery. The surgeon is supported by the unit’s facilities, equipment, and personnel, and the patient is discharged 1 to 3 hours after surgery when recovery from anesthesia is suffi- ciently complete.

In the early 1970s, freestanding ambulatory surgery centers were opened; one of the first was in Phoenix, Arizona. These facilities are independent of hospitals and usually provide a full range of services for the types of surgery that can be per- formed on an outpatient basis. Community surgeons are granted operating privileges and can perform surgery in these facilities when the patient agrees and when there are no medical contraindications.

Other facilities are also used for ambulatory or outpatient surgery. Many physicians informally per- formed surgery in their offices, although this prac- tice has declined in some specialties as a result of malpractice concerns and the increasing availability of better-equipped and -staffed alternative facilities. Some specialties, such as oral surgery, plastic surgery,

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and ophthalmology extensively use formal office- based surgical facilities.

Emergency Medical Services

The emergency room, like other hospital depart- ments, has undergone transformation in recent years. The emergency room has expanded in the range of services offered and in complexity. Prepa- ration for possible terrorist attacks and for discus- sion has also increased. An especially important long-term trend has been the increasing use of the emergency room for primary care. Because the emergency room requires sophisticated facilities and highly trained personnel and must be accessi- ble 24 hours a day, costs are high and services are not designed for nonurgent care. To reduce the burden on the emergency room and to meet patient need more effectively, many hospitals treat patients on a triage basis. In this process, often performed by a nurse, the patient’s health care needs are determined and the patient is referred to a more appropriate source of care within the hospital.

Emergency medical services have also been in- creasingly integrated with other community re- sources. Included are drug and alcohol treatment programs, mental health centers, and voluntary agencies. Most major urban centers have devel- oped formal emergency medical systems that in- corporate hospital emergency rooms as well as transportation (ambulance and possibly aircraft) and communication systems (landline and cell phones).

GOVERNMENT PROGRAMS

In addition to private-sector and institutionally ini- tiated efforts, government programs have been used to increase the availability of health care resources in many communities. These programs have adapted

some of the concepts of private institutional settings, especially those of group practice.

Neighborhood health centers were funded start- ing in 1965. Originally intended to serve approxi- mately 25 million people, this federal program never reached its initial objectives. The program was designed to provide primary medical care with a family orientation. It was targeted for population groups in need of services, as reflected by such indi- cators as disease prevalence and income level. At the same time, the centers were intended to employ people from the communities they served in posi- tions that would offer opportunities for training and advancement.

Although these health centers were originally in- tended to serve the poor, changes in federal policy that encouraged them to collect fees from patients and from third-party insurers have broadened the socioeconomic mixture of patients obtaining care. A related category of provider, the free clinic, evolved from a strong social commitment but has had to face similar financial realities. In some com- munities, the combination of former free clinics, neighborhood health centers, public agency clinics, and some hospital clinics and groups now forms an informal safety net of providers for individuals who lack private insurance or access to other sources of care, or who simply need care from an available, sympathetic provider.

Other community health centers that have been funded by the federal government include migrant health centers serving transient farm workers in agricultural areas and rural health centers. The National Health Service Corps has supported prac- titioners who were placed in urban and rural areas with shortages of medical resources. The Commu- nity Mental Health Center program was estab- lished to provide ambulatory mental health services in underserved areas.

The federal government directly operates many health facilities. The Veterans Administration in- cludes the largest health services system under a unified management structure in the United States. The Indian Health Service is charged with ensuring

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access to medical care on Indian reservations and in certain other locations.

NONINSTITUTIONAL AND PUBLIC HEALTH SERVICES

As noted in the introduction to this chapter, there are many ways in which ambulatory and commu- nity health services are provided. Home health services are provided by visiting nurse asso- ciations, proprietary companies, some hospitals (especially those in vertically integrated systems), public health departments, and other agencies. These services allow people to remain in their homes and yet receive essential health services, thereby reducing costs and increasing the quality of life for many.

Rural health care has required unique and inno- vative solutions in many communities, especially in the absence of adequate supplies of physicians and facilities. In rural Alaska, many towns are served by physicians and other professionals who regularly fly in to treat patients. Satellites and the Internet are used to facilitate communications with subspecial- ists in urban medical centers.

Other community health services not discussed in detail here include, but are not limited to, school health services; prison health services; vision care; dental care provided by solo, group, and institution- ally based practitioners; foot care from podiatrists; and drug dispensing from pharmacists, who often also extensively advise and educate consumers—a mandate now under many state laws. Voluntary agencies also provide health care services such as cancer screening clinics and health education. Fi- nally, many indigenous health practitioners offer their services in this country and abroad. These practitioners include chiropractors, “medicine men,” naturopaths, and others. The supportive and some- times curative role of these individuals is often underestimated.

THE ROLE OF AMBULATORY SERVICES

Ambulatory care services, and particularly physician- related care, provide a service distribution network for most noninstitutional health care services. How that network distributes services throughout the community and to various population groups is of critical importance to ensuring access and availabil- ity of services in the community. In many contexts, the distribution network serves as the delivery vehi- cle for specific insurance products, particularly under managed-care plans. This distribution system is typically tied into other related care such as inpa- tient and laboratory services.

The distribution network is critical to ensuring the availability of services for at-risk population groups such as traditionally underserved minority populations, the poor, and individuals with unique needs such as pregnant women, children, and the elderly. Distribution networks must be energized by appropriate management structures and by the availability of adequate funding to assure that they deliver needed care. These services may be funded, or provided directly, by government programs for certain populations.

The distribution network is further defined by the composition of primary and specialty providers and services, supportive technology such as imaging ca- pacity and laboratory services, and other needed health care resources. The management, monitoring, and evaluation of these distribution networks is typically the principle function of health care managers in delivery organizations, increasingly influenced by contractual demands from insurers, employers, and other payors and influenced by patient expectations and attitudes.

The delivery network can be evaluated by measures of effectiveness and efficiency, quality of care, and services provided. The satisfaction of payors, patients, and providers is also integral to

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assessing the success of the networks and delivery mechanisms.

Many complex factors affect the success of deliv- ery systems in providing the care needed by popu- lations. Patient, provider, payor, and system issues must be carefully weighed in assessing how all ser- vices are delivered to the client population and po- tential areas for improving this effort. For example, patients need the appropriate mix of primary care and specialty services, access to appropriate tech- nology, and, at the same time, need to be treated ethically, humanely, and in a manner that promotes patient compliance and satisfaction.

Patients are the clients and in a typical retail set- ting would be respected as such. In the health care system, provider organizations and individual pro- fessionals do not always adapt to the service model embodied by the retail sector of the economy. Over- all, however, the nation’s health care system has greatly improved its customer perspective during the past couple of decades. The interjection of third- party payors into the transaction process leads some to adopt the philosophy that the payor rather than the patient is the true customer, leading to dis- tortions in the patient-provider relationship. This is a particularly significant problem when the payor is a government program, especially Medicaid or other safety net programs. It is imperative for the nation’s health care delivery network to view each patient as a valued customer regardless of source of payment, racial or ethnic group, age, or other inter- vening characteristic.

The management of these complex enterprises requires sophisticated business skills and the avail- ability of adequate information. Increasingly so- phisticated management practices and the develop- ment of state-of-the-art management information systems are now enhancing the capability of health services administrators to run the health care system and its component organizations. Medical practices have generally not reached the level of sophistication seen in the institutional set- ting except that many larger groups have signifi- cant resources available for sophisticated manage- ment capabilities.

MANAGING A MEDICAL PRACTICE

This section of the chapter is designed to convey the flavor of managing medical practices in the highly competitive environment within which the nation’s health care system operates today. The professional manager in the ambulatory care arena must be a jack-of-all-trades with extensive skill capabilities in a variety of technical areas (Keagy & Thomas, 2004).

The Medical Group Management Association, the national organization of group-practice administrators, has outlined the technical areas of professional knowledge that convey the broad array of expertise and skills required in this arena today. These areas include financial management, human resource management, planning and mar- keting, information systems, risk management, governance and organizational dynamics, business and clinical operations, and professional respon- sibility. Each of these skill and expertise domains encompasses a broad array of topics and specific technical capabilities.

Today’s manager must be knowledgeable and adept at a huge range of activities from strategic planning to contract negotiations to the expanse of personnel management. In addition, professional managers in this arena, unlike many other institu- tional settings, typically deal with not only strategic concepts and issues, but also the minutia of day- to-day management. Interacting with various con- stituencies including payors, physicians and other providers, and patients is a daily requirement.

Administrators in ambulatory care are now ex- pected to provide organizational leadership and direction to a much greater extent than in the past. Strategic planning, budgeting, financial decision making, physician and staff recruitment, retention, evaluation, cash-flow analysis, capital expense plan- ning, development and application of information systems for financial reporting, quality evaluation,

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and legal compliance are other examples of the broad spectrum of responsibilities and duties.

Managed-care contracts, the lifeblood of many medical practices today, have become increasingly complex and demanding. Administrators in many regions of the country must negotiate sophisticated contractual arrangements with various managed- care payors. These contracts often contain stipula- tions with regard to practice patterns, fee discounts, reporting requirements, quality assessment and cre- dentialing, dispute resolution through arbitration, and many other complex provisions. Contracting with multiple payors, each with its own set of con- tract requirements, further complicates the adminis- trative role. And, of course, many of the insurance provisions discussed elsewhere in this book apply to these contracts and are subject to interpretation and negotiation.

The increasing array of interdependencies be- tween the ambulatory care arena and inpatient and other services must also be considered, particularly in contract arrangements where the group is assum- ing a broad array of risks. For example, groups that are moving to employ hospitalists will need to clar- ify work assignments for physicians serving in this role versus other members of the group and will have to coordinate care for patients who are in an inpatient setting being treated by the physicians within the group. The increased role of such quality and utilization-related mechanisms as utilization management, clinical protocols, disease manage- ment, and various contracting arrangements for selective subspecialty contracts must all be consid- ered as well.

PROFESSIONAL PRACTICE ORGANIZATIONS

Medical practices can be organized from a variety of legal perspectives. Determination of the appro- priate structure in an individual group will be deter- mined by tax, organizational and governance, and

liability issues. Groups can be organized as for- profit or non-profit entities depending on owner- ship considerations. For-profit entities can include traditional for-profit corporations, partnerships, or limited liability companies. In certain instances, the physician practice and the operational and physical assets of the group may be organized separately, depending on state physician practice acts.

Compliance with a variety of state and federal laws, particularly regulations related to Medicare, Medicaid, and Health Insurance Portability and Accountability Act (HIPAA), as well as the Stark law provisions and various other practice parame- ters must also be considered in organizing and operating medical groups. Tax law is a further important consideration, particularly as it pertains to control over physician after-tax income and the ability to maximize, where appropriate, retirement plan funding. Tax-exempt practices must comply with a variety of federal and state legal and tax considerations as well and will have certain income tax and charitable donation advantages.

In most instances, physician compensation and other payment arrangements must be carefully de- signed to comply with federal and state laws, espe- cially those related to Medicare fraud and abuse. Payments between groups and other organizations such as hospitals or ambulatory surgery centers and laboratories must be designed to strictly adhere to these regulations to avoid conflicts of interest and other illegal arrangements.

Physician practices can be organized as a com- ponent of physician-hospital relationships under various forms of vertical integration. Physicians practicing in these arrangements sell their practices to hospital entities as a means to access capital and clinical distribution networks. The hospital network then invests in computerized information systems, marketing, and managed-care contracting to utilize the distribution networks created as a mechanism for providing services to patients under managed- care contracts. However, under these arrangements, physicians lose control and are subject to clinical monitoring and accountability. The substantial capital investments required from hospital systems

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also sometimes result in unprofitable arrange- ments, particularly when managed-care contracts pressure payment levels. Managing hospitals and managing physician practices also requires vastly different skills and approaches that some hospital administrators lack awareness of.

Many other hospital-physician relationships have been developed or are currently under development. Joint ventures such as for imaging centers or other services that allow physician participation in eco- nomic product development with associated finan- cial rewards are popular in some areas of the country. These arrangements can present a minefield with regard to compliance with federal and state reg- ulations such as those mentioned previously.

A variety of other contractual relationships and organizational forms can be used to relate physi- cian practices with other components of the health care system and to organize physician delivery systems themselves. As discussed else- where in this book, a number of these contractual arrangements form portions of managed-care sys- tems. For example, independent practice associa- tions, or IPAs, are a form of health maintenance organization utilizing community-based physician practices as contractual organizations to provide managed-care physician services. The IPA allows for independent physician practice while provid- ing a mechanism to form a health maintenance or- ganization and to offer a contracting approach to such organizations.

The physician-hospital organization, or PHO, is another arrangement based on contracts between hospitals and medical staffs that allow for a health care delivery and distribution system that integrates a range of health services. As with all other contrac- tual relationships in the health care environment, there are numerous legal and regulatory issues as- sociated with all of these arrangements. In addi- tion, complex financial concerns are also faced by participants in these systems. Many of the newer forms of organizing ambulatory services have had difficulty in many parts of the country for a variety of reasons, some of which relate to financial, gover- nance, and control factors.

Another organizational and contractual develop- ment in the industry, alluded to previously, relating physician practices to hospital organizations and systems has been the management services organi- zation, or MSO, and the related physician practice management company, or PPMC. These organiza- tions perform a management function organizing and managing services and may be a joint venture between physician practices and hospitals. Other forms of contractual relationships and manage- ment arrangements, such as physician-hospital organizations or PHOs and medical foundations, also exist in various locations throughout the country.

Especially complex are arrangements that may infer physician financial gain as a result of various incentive or contractual arrangements that could potentially be interpreted as violations of federal (Stark) Medicare law or other potentially prohibited situations. Particularly complex are arrangements that involve physician equity ownership in joint ven- tures or ancillary services and other arrangements that could represent a conflict of interest, potentially in violation of federal law. Physician practices need to be particularly careful in structuring arrange- ments such as physician payments for hospital administrative services, hospital or other entity re- imbursement of practice expenses, physician pay for performance, quality of care, and productivity in- centives, contracting-related bonuses and incentives, compensation schemes, and payments for participa- tion in marketing and other auxiliary services.

Physician Practice Management

Medical practices are complex organisms that require an array of management skills. Among the most important of these skills is financial management.

Financial Management

Financial management of medical practices and especially larger physician practices requires corporate-style accounting and financial systems including, but not limited to, balance sheet and

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income and revenue statements, flow of funds anal- ysis, capital budgeting for major expenditures, and cash management (Wolper, 2005). Monitoring and controlling the flow of funds within a practice is particularly important for providers involved in managed-care contractural arrangements, espe- cially those involving capitation payments where budgeting and control of expenditures can be criti- cal to profitability. The development of a business plan using financial models allows practices to de- termine in advance which services are appropriate to provide from a financial perspective. Overall control of financial parameters is a key function of the management staff.

Another critical concern in the area of financial management for most medical practices is taxation. Because most practices are for-profit entities, the taxes accrued at the practice or individual provider level can be an important determinant of the amount of profit taken home by the owners of the practice, typically physicians. Federal and some state tax changes since the mid-1980s have reduced the flexibility of many individuals and entities in controlling the amount of taxes paid. Therefore, it is important for medical groups to determine those areas of their operations that have a linkage to taxation. For example, where appropriate, tax advan- taged corporate retirement plans may offer an un- usual ability to reduce current taxation. The legal structure of the practices and many other complex considerations will impinge on the exact nature of such a plan.

Ultimately, as for any other business entity, in- creasing revenue and decreasing expenses is the key to profitability. For practices that are in a non- profit or not-for-profit setting, these issues are still critical to ensuring financial viability and to gen- erating excess revenues over expenses that can be invested into the practice. Controlling expendi- tures is often integrally tied to capital investment decisions and to personnel issues and staffing. Effective negotiation of managed-care contracts and, where appropriate, budgeting, especially for managed care and nonprofit entities, are also vital considerations.

Reimbursement and Other Issues

Another interesting aspect of practice management involves provider reimbursement issues, particu- larly those pertaining to physicians. Physician prac- tices, and especially group practices, use a variety of models for distributing income to physicians who are, in many instances, the owners of the practice. Physician reimbursement and income distribution formulas can affect or, in turn, be affected by productivity, specialty, reputation, and many other factors. Physician reimbursement is generally de- signed to incentivize providers in a variety of ways depending on the ownership and nature of the practice.

Practices often will incentivize providers to pro- mote productivity as measured by revenue gener- ated or services provided. In some practices, physi- cians and other professional providers may be paid a straight salary although this is not typical. Salary plus incentive compensation based on such factors as productivity is more common, where the under- lying salary is a guaranteed minimum income level. Some practices have quite complex reimbursement formulas considering such factors as specialty dif- ferentials, research activities, involvement in mar- keting, tenure in the group, hours worked, adminis- trative duties assumed, and so forth. Compensation is a complex and typically proprietary issue that is the subject of considerable discussion and some- times intense debate in many practices.

Sometimes reimbursement issues in multispecialty groups are a focal point for internal medicine and family practice specialists who argue that they bring in the patients, use the laboratory, and gen- erate demand for other referral services. Surgeons, on the other hand, claim that they generate a greater percentage of total revenue and place less of a burden on some of the physical facilities and staff. Providers under managed-care contracts may value their ability to control utilization and costs, while providers under preferred provider plans and fee- for-service arrangements may argue that they bring in more revenue for their efforts. Blending the diversity of providers, patient payment sources, and services offered in a practice and implementing a

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reimbursement structure that appropriately incen- tivizes the providers while ensuring good quality care, is a continuing struggle in the ambulatory care arena.

Other complex responsibilities for managers in medical practices include a broad range of issues re- lated to human resources. Personnel costs represent the largest single expenditure in many medical set- tings and managing that resource is extremely im- portant to the financial viability of a practice. In addition, numerous and complex federal and state regulations impinge on employment in any setting. Maintaining appropriate personnel, recruiting, hir- ing, evaluation, promotion, and termination poli- cies and procedures requires an increasingly high level of sophistication. Individuals working within a medical practice typically experience workplace stress and require sensitive supervision. Employee compensation and incentives are other areas of complexity as well.

No practice would be successful without solid leadership by both the practice manager and the medical staff. Practice management requires rally- ing all the employees around the goals and objec- tives of the practice and constantly assuring a high level of enthusiasm, consumer sensitivity, aware- ness of privacy, and many other considerations on the part of the employees. Federal law now requires compliance with a variety of rules and regulations pertaining to patient privacy and all payors now expect practices to comply with contractual agree- ments and claims reimbursement procedures.

A revolution in management of medical prac- tices is under way with the implementation of new information systems technology. The holy grail of the application of computer systems in health care practices is the computerized medical record. Many larger and some medium- and smaller-sized prac- tices are in the process of implementing a partially or completely automated computerized medical record. Although the technology has taken an un- usually long time to be developed and prepared for implementation, the hardware and software capa- bility for automated medical records now appears to be available.

Automated medical records allow for many ad- vances in managing clinical care and the practices themselves. By capturing the details of interac- tions between patients and health care providers in an increasingly cost-effective manner, computer- ized medical records are paving the way for a revolution in health care management and quality assurance.

Automated medical records are also being im- plemented with associated technologies such as computerized drug and laboratory test ordering. Increasingly, integrated components of information technologies not only allow for such valuable qual- ity checks as drug interactions but also provide for a more comprehensive collection of clinical and managerial data overall.

The traditional applications of automated infor- mation technologies have long included numerous administrative functions including determination of eligibility under insurance plans, billing (including credit and collections), insurance billing, appoint- ment scheduling, and physician and other resource monitoring. The integration of computerized medi- cal records into legacy systems has tremendous implications for much more comprehensive and interaction-specific tracking of patient resource use, quality assessment, referral and follow-up tracking, and other more advanced applications. Among other applications for computerized medical records are the use of patient-specific clinical protocols and guidelines and other clinical decision support systems; tracking patients to ensure appropriate- ness of care and to reduce duplication of services; automated quality reporting; advanced decision support information for management of practices, including provider-specific utilization data, revenue and expense accounting, and other management relevant information.

Of considerable concern in the application of many of these automated and computerized sys- tems is patient privacy. Federal privacy laws, partic- ularly under recently implemented requirements, complicate the collection, dissemination, and anal- ysis of information where patient identifiers are still attached and available. In addition, interchange of

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data among providers, provider organizations, insurers, and other entities requires sophisticated protection for assuring patient privacy.

SUMMARY

Ultimately, the costs and quality of health care services are directly related to the success of the system’s management. In ambulatory care, where resources are often stretched thin, this concept is even more valid. The ability to provide more and better care to more people will depend on im- proved management, integrated information sys- tems, more efficient services, and a commitment to enhancing the operations side of delivery organiza- tions. This is no small task and is the challenge for the future in ambulatory and community health care.

REVIEW QUESTIONS

1. What services are incorporated within ambu- latory care services?

2. Describe the evolution of ambulatory care in terms or its role in the operation and ratio- nalization of the health care system.

3. How has the organization of ambulatory care been changed by the development and growth of managed care?

4. Describe the most prominent settings for ambulatory practice in the United States.

5. Describe the general types of institutionally based ambulatory health care services.

6. What managerial attributes enhance ambula- tory care organizations?

7. Describe the challenges ambulatory care will encounter in the future and its role in the U.S. health care system.

REFERENCES & ADDITIONAL READINGS

Adams, P. F., Dey, A. N., & Vickerie, J. L. (2007). Summary health statistics for the U.S. population: National Health Interview Survey, 2005. National Center for Health Statistics. Vital Health Stat. 10(233). Washington, DC: U.S. Government Printing Office.

Havlicek, P. L. (1999). Medical groups in the U.S., 1999 edition. A survey of practice characteristics. Chicago: American Medical Association.

Hing E., Cherry D. K., & Woodwell, D. A. (2006). National ambulatory medical care survey: 2004 summary. Advance data from vital and health statis- tics. No. 374. Hyattsville, MD: National Center for Health Statistics.

Keagy, B. A., & Thomas, M. S. (Eds.). (2004). Essentials of physician practice management. San Francisco: Jossey-Bass.

Rorem, R. (1931). Private group clinics. Chicago: University of Chicago Press.

United Kingdom Ministry of Health. (1920). Dawson report, interim report on the future provision of medical and allied services. London: His Majesty’s Stationery Office.

Wolper, L. F. (2005). Physician practice management. Essential operational and financial knowledge. Sudbury, MA: Jones and Bartlett.

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PART THREE: Providers of Health Services

CHAPTER 6: Public Health: Joint Public-Private Responsibility in an Era of New Threats

LEVELS OF PREVENTION
HISTORICAL EVOLUTION OF HEALTH PROMOTION AND DISEASE PREVENTION IN THE UNITED STATES
THE STRUCTURE OF ORGANIZED PUBLIC HEALTH EFFORTS IN THE UNITED STATES
THE ROLE OF THE PRIVATE SECTOR IN HEALTH PROMOTION AND DISEASE PREVENTION
PUBLIC HEALTH IN AN ERA OF TERRORISM AND EMERGING DISEASES
SUMMARY
REVIEW QUESTIONS
REFERENCES & ADDITIONAL READINGS

williams12890_1418012890_00.08_chapter07.pdf

CHAPTER 7: Ambulatory Health Care Services and Organizations

HISTORICAL PERSPECTIVES AND TYPES OF CARE
USE OF AMBULATORY CARE SERVICES
AMBULATORY PRACTICE SETTINGS
INSTITUTIONALLY BASED AMBULATORY SERVICES
GOVERNMENT PROGRAMS
NONINSTITUTIONAL AND PUBLIC HEALTH SERVICES
THE ROLE OF AMBULATORY SERVICES
MANAGING A MEDICAL PRACTICE
PROFESSIONAL PRACTICE ORGANIZATIONS
SUMMARY
REVIEW QUESTIONS
REFERENCES & ADDITIONAL READINGS

williams12890_1418012890_00.09_chapter08.pdf

CHAPTER 8: Hospitals and Health Systems

HISTORY OF THE HOSPITAL
THE SCOPE OF THE INDUSTRY
STRUCTURE OF HOSPITAL AND HEALTH SYSTEMS
HOSPITAL ORGANIZATION
THE HOSPITAL AND MEDICAL STAFF
KEY ISSUES FACING THE HOSPITAL INDUSTRY
SUMMARY
REVIEW QUESTIONS
REFERENCES & ADDITIONAL READINGS