Today’s Topic: Ambulatory and Hospital Care

1. Today’s Topic:Ambulatory andHospital Care

2. Objectives for Today • Be able to describe the organization and types of ambulatory care • Be able to describe the organization and types of hospital care

3. Ambulatory Care • Care for the walking patient • Primary source of contact with health system

4. Rise of ambulatory care • Before WWII, most care provided in the home • medicine not technical • docs could carry most equipment • After WWII, care moved to the physician’s office • incredible advances in technology • increased demand for medical care

5. Types of ambulatory care • Physician office or clinic • Solo or group • Community health centers • Freestanding emergency rooms • Freestanding amb care center • Clinical labs

6. Types of ambulatory care (cont.) • Ambulance services • Renal dialysis • Trauma centers • Ambulatory surgery centers • Hospital-based • Clinics • Freestanding outpatient hospitals

7. Utilization stats: # phys. contacts Total 6.0 per year Males 5.2 per year Females 6.7 per year

8. Place / site of utilization • Most persons go to doctor’s office • Among the poor, a higher % go to hospital outpatient dept.

9. Most frequent reasons for visits • General medical exam • Progress visit • Routine prenatal examination • Cough • Postoperative visit • Symptoms referable to throat • Well-baby examination

10. Most frequent diagnoses • Essential hypertension • Acute upper respiratory infections • Routine infant check • Normal pregnancy • Malignant neoplasm • General medical examination • Otitis media

11. Other reasons for visits • Major psychiatric disorders • Major depression, anxiety • Often undetected, undiagnosed • If diagnosed, often inappropriately treated • Borderline psychiatric disorders • Mild depression, anxiety • The worried well

12. Hospitals • Provide inpatient care • Also the site of some ambulatory care • Emergency care • Ambulatory surgery center, etc.

13. Types of hospitals • Government • Local, state, government • UMC is a county owned hospital • Not-for-profit • Owned by private non-government groups • Religious hospitals, such as Covenant • University hospitals, such as Duke • For-profit • Hospital Corporation of American (HCA)

14. Rise of hospitals in the U.S Site of care in 1790s Type of patient Almshouse (poorhouse) Non-paying, acute Chronic Mental disorders Jail Mental Disorders Pest houses Contagious disease Billeting in private homes Merchant seamen, military veterans

15. Rise of hospitals in the U.S.:the 18th and 19th centuries • Medical care was secondary to housing • First voluntary (community) hospitals in late 1700s, early 1800s • European trained physicians led the way for voluntary hospitals

16. Rise of hospitals in the U.S.:the 19th and early 20th centuries • Advances in medical science • Anesthesia (Ether used by Long in 1842) • Germ theory • Steam sterilization in 1886 • Antibiotics in 1940’s • X-rays in 1896 • Blood types in 1901 • Nursing care

17. Rise of hospitals in the U.S.:the early twentieth century • Role of the social elite • Role of physicians • Promoted voluntary, community hospitals because feared gov’t. regulation • Led to fragmentation of hospital system • Religion, race, income • Four types of hospitals in early 20th c.: proprietary, private, charitable, religious, and government

18. Rise of hospitals in the U.S.:the mid 20th century • Hospital Survey & Construction Act • Referred to as Hill-Burton Act, 1946 • Between 1947 and 1971, government paid $3.7 billion to expand community and regional hospitals (Levey, 1996) • Medicare and Medicaid, 1965 • Increased demand for hospital care

19. Utilization statistics for Texas Inpatient 1997 1995 1993 beds 55,759 57,178 58,157 admissions 2,126,610 2,029,050 1,963,869 days 11,355,612 11,366,956 11,811,104 alos 5.3 5.6 6.0 from AHA Guide, 1999. Includes nursing home units.

20. Personnel statistics for Texas Personnel 1997 1995 1993 Full time RNs 49,680 48,011 45,854 Full time LPNs 12,574 12,702 13,471 Total full time 220,417 214,986 206,291 Total part time 54,459 54,011 50,266 from AHA Guide, 1999. Includes nursing home units.

21. Utilization ratios for Texas (per 1,000 population) Inpatient 1997 1995 1993 beds 2.9 3.1 3.2 admission 109.3 109.1 109.5 inpatient days 584.2 611.1 658.7 from AHA Guide, 1999

22. Community hospitals in Texas Inpatient 1997 1995 1993 Total hosp 407 416 414 Urban 244 251 247 Rural 163 165 167 from AHA Guide, 1999

23. Community hospitals in Texas Bed size 1997 1995 1993 6-24 48 38 38 25-49 101 112 110 50-99 74 73 79 100-199 97 107 92 200-299 37 36 48 300-399 23 23 19 400-499 13 13 10 500+ 14 14 18 from AHA Guide, 1999

24. 5 Most Frequent MEDICARE DRGS from HCFA 1999 Statistical Supplement

25. 5 Most Frequent MEDICARE DRGS from HCFA 1999 Statistical Supplement

26. 5 Most Frequent MEDICARE DRGS from HCFA 1999 Statistical Supplement

27. Regulation • Without gov’t. control, hospitals had to self-regulate • American College of Surgeons the 1st • American Hospital Association 2nd • Comprised to form JCAHO • Self-regulation may have led to higher quality (Stevens)

28. Teaching & Academic Hospitals • Teaching hospitals • Graduate medical education (residency programs) • Academic medical centers • Graduate medical education • Supports research

29. Academic medical centers • Tripartite missions of academic medical centers (AMCs) 1) Teaching 2) Research 3) Patient Care

30. Academic medical centers • What factors influence which missions receive most attention? • Defining characteristics of AMC organizaiton • University owned vs. affiliated • Governance • Public vs. private • Not for profit / For profit

31. Academic medical centers • Patient care mission • Only about 118 of 6,500 hospitals are AMCs (Levey, 1996) • Provide about 75% of residency training • 60% of regional trauma care • 50% of organ tranplantations • 25% of open heart surgery

32. Organization of AMCs • University owned, university or state governed,NFP • Duke University Hospital • University of Iowa Hospitals & Clinics • University affiliated, NFP • Mass General and Brigham & Women’s / Harvard University • UMC / Texas Tech University HSC

33. Organization of AMCs (cont.) • University affiliated, private, for profit • Tulane University sold most of its hospital to Columbia/ HCA • University of Minnesota sold it’s hospital to Fairview Health System

34. Organization of AMCs (cont.) • “…public universities should divest themselves of their hospitals, or at the very least, find mechanisms to put them at arms’ length from the parent universities.” Robert Petersdorf President-Emeritus of AAMC

35. Organization of AMCs (cont.) • An alternative • University owned, NFP, but not university governed • University of Kansas Med. Ctr. • University of Wisconsin Med. Ctr. • Governed by a state appointed board, not the University nor the state itself

36. Critical Access Hospitals • In response to BBA of 1997 • Limited to max. 15 beds, additional 10 swing beds • Patient stay limited to 96 hours • 24 hr. emergency care required • Cost-based reimbursement

37. Reasons for rising hospital costs • Aging population • General inflation • Technology • Unnecessary surgery • Unnecessary admissions • Excess capacity • too many inpatient beds, services

38. Cost control mechanisms • Government regulation • Certificate of need (CON) • Rate regulation • Peer review organizations (PROs) • Competition • Business coalitions • Vertical integration • Horizontal integration

39. Health Systems • Horizontal integration/chains or regional systems • increase purchasing power, scale economies • Vertical integration • Expansion of organization into new fields • e.g. Hospitals expanding into primary care, nursing home care, insurance, etc. • Control cost of inputs, improve coordination

40. Physician-Hospital Organizations (PHOs) • Corporations formed to contract with managed care plans