Health System Organization

1. Health System Organization Session 3: January 20, 2011 Defining and Re-designing Primary Care Group presentation #1: Lewis, Ch. 1

2. Ambulatory/Outpatient Services:Scope and Definition • By service: • preventive, diagnostic, therapeutic, emergent • By location: • rural/urban, community clinic, hospital • By discipline: • medicine, nursing, dental, vision, complementary • By setting: • office, surgi-center, clinics, dialysis, psychiatric • By level: • primary, secondary, tertiary

3. Primary Care • WHO Definition (p. 247) • Point of Entry • Coordination of Care • Essential Care • IOM Definition (p. 250) • Comprehensive • Coordinated • Continuity • Accessibility • Accountability

4. Chapter 4 of the 2008 WHO Report • Why is policy important? • What are the three policy areas considered? • What are the barriers? • What is the key point?

5. Neighborhood Social Cohesion • There is a positive relationship between how people perceive their connections to their neighbors and their reported health and well-being. • People who are non-Hispanic, older, married, and of higher socioeconomic position are more likely to perceive their communities as being socially cohesive. • While communities with higher socioeconomic status are more likely to be socially cohesive, neighborhood connectedness plays a larger role in self-reported health status among people with lower socioeconomic status.

6. Neighborhood Social Cohesion • There is a strong relationship between culture and neighborhood connectedness. Neighborhoods that are more ethnically homogeneous are more likely to trust and feel connected to their neighbors, benefiting their overall health and well-being. • People are more likely to consider feeling connected to their neighbors if they live in a community where residents have higher education levels. • Factors such as the number of neighbors moving in or out of a community, the median income of households, and the percentage of owner-occupied housing were not predictive of neighborhood connectedness (when other factors were taken into account).

7. Growth and Re-design in Primary Care • Technology • Reimbursement • Scope of Services in Physician Office Practices • Social Factors • Settings and Overall Increase in Demand • Patient Protection and Affordable Care Act (health reform)

8. Sources of Primary Care • The 32 million Americans receiving health coverage under the Health Care Reform Act of 2010 mostly will be treated by: • 47 respondents also agreed on a write-in answer, indicating that ER physicians will see significantly increased traffic based on the PPACA.

9. S.M. , Family Practice; CA - Because many specialists are clueless about the long-standing close relationships between Primary Care Physicians and their patients. Unless reimbursement is reduced significantly, this relationship will continue. R. A., Family Practice; C T - Specialists will push for this to happen. They make their money predominantly by doing procedures. The physician extenders can take care of the majority of the problems seen in the office. B.D., Internal Medicine; OH - ….Specialists tend to devalue the role of generalists. The model they would like to see operative is one where “PCPs” update shot records and screening protocols…be responsible for completing FMLA paperwork, signing home health care orders, taking off-hour calls, and other uncompensated work. They would limit their medical care to self-limited conditions like colds and minor trauma… Generalists see a model where they manage all aspects of the patient care. They actively treat all their patients’ conditions to the degree that their training and experience allows them meet the standard of care. They determine not only when a consult or referral is needed but also when it is not and when routine specialty follow-up no longer adds significantly to the patients care. These are competing visions….The first model prevails in major American metro areas with teaching hospitals. The second prevails in most western democracies.…Frankly I’m not sure which will prevail under health care reform. I believe that a comparative analysis would clearly show improved patient satisfaction improved outcomes and most of all reduced cost with a greater role for generalists but I’m not optimistic that reason will win out over the lobbying power of the specialists.

10. The Issue of Access • E.D. Use by Patient Flow • E.D. Use by Frequency and Payer

11. Reasons for Seeking Care in the ED • Medical • 33% - fever, flu, cough, etc. • 19% - pain • 11% - injury • 8% - gastro-intestinal • 28% - other • Duration of Medical Problem • 21% - a few hours • 23% - one day • 21% - two or three days • 19% - four to seven days • 9% - more than a week • 7% - more than a month • Contact with Medical Personnel Prior to Coming to ED • 35% - yes • 63% - no • 2% - Tried, but unable • Reason for Not Going to Usual Source of Care* • 51% - Prefer ED because no appointment required, don’t have to wait • 31% - Office/clinic closed • 14% - Told to go to ED • 4% - Financial/insurance reasons *Does not include those without a usual source of care.

12. Primary Care: Quality & Cost Effects • What were key points? • What was missing? • What are proposed solutions and how do they differ? • What are common challenges? • Friedberg, Hussey & Schneider? • Kilo & Wasson? • Margolius & Bodenheimer? • Bodenheimer & Pham? • Grundy, et al?

13. Break When You Return: Group 1 Presentation