Topics

1. Topics • History of Healthcare • Terminology • Primary Care • Outpatient Services • Other Service Models “Never go to a doctor whose office plants have died.” Erma Bombeck

2. History of Healthcare • Outpatient care must be viewed in the context of the overall healthcare system. • Increased professionalism of medical practitioners over time • Increased role of technologies over time • Increased availability of insurance… • …followed by increased pressure for cost controls • The role of outpatient care mirrors the changing structure of the overall system over time

3. History of Healthcare (cont.) • Earliest healthcare was both outpatient and primary • In providers’ offices or clinics • In patients’ homes • Hospitals were few and did not provide the same types of services we see today

4. History of Healthcare (cont.) • We have seen the increased prominence of hospitals in healthcare delivery • Improved techniques→Improved outcomes→Increased Demand • Hospitals could realize economies of scale for the utilization of increasingly expensive technologies • Increases in financing options supported use of expensive hospital services

5. History of Healthcare (cont.) • Themes to watch for in outpatient/primary care: • Continuation of services traditionally offered on an outpatient basis • Diagnosis • Treating minor injuries • Treating less serious illnesses • Offering entirely new services • Reversing trends to compete for services formerly exclusively offered by hospitals

6. Terminology • Some terms have overlap • Outpatient care: • Essentially no overnight stay • May be provided in a hospital • Primary care: First line of interaction with the healthcare system • Ambulatory care: Patient arrives and leaves • Doesn’t necessarily mean under their own power • Huge overlap with concept of outpatient care

7. Terminology (cont.) • Primary Care marked by • First contact with healthcare system • Typically an ongoing relationship with the provider • PC provider may coordinate other care • Offered by • Family practice • Pediatricians • Internists • Some specialists • Includes non-physician providers • Local to patient • Gatekeeping to advanced care levels

8. Terminology (cont.) • Secondary Care typically involves • Specialists ‒ Hospitalization • Routine surgeries ‒ Rehabilitation • Tertiary Care typically involves • Most complex level of care • High levels of specialization • High levels of technology

9. Primary Care • Primary Care serves massively important roles along several dimensions • Treatment • Economic • Social • Primary care is less expensive than others • Avoids costly and dangerous advanced treatments • Identifies candidates for advanced treatments • Easier to field more widely through society • Helps to keep population healthy

10. Primary Care (cont.) • Many other countries formalize the role of PC in the array of healthcare services • In the U.S. • Managed Care Organizations emphasize PC • In other environments the patient can often drive treatment mix between • PC in a comprehensive and referral role • Direct access to specialists • Advantage of PC emphasis depends on • Timely access to advanced care when needed • Adequate numbers of PC providers

11. Primary Care (cont.) • Other roles of primary care • Preventive care • Examinations • Immunizations • Continuity of care • Population health • Reporting • Preventive care

12. Outpatient Care • Most Primary Care is also Outpatient Care • Explosive growth illustrated in Table 7-1 of • Distinct types of outpatient care facilities • Ownership models for outpatient care

13. Outpatient Care (cont.) • Demand for OP driven by several factors • Shifting of hospital services to outpatient basis • Less invasive procedures • Ambulatory centers economize capital equipment without entire hospital • Cost pressures decrease “elective” or “just-in-case” hospitalizations • See Table 7-2 list of declining inpatient services • Huge percentage shifted to outpatient basis

14. Outpatient Care (cont.) • Outpatient Demand Shifts (cont.) • New technologies enabled non-hospital facilities to realize economies for certain capital investments without need for the entire hospital infrastructure • Ambulatory surgery centers • Imaging centers • Rehab facilities • Laboratories

15. Outpatient Care (cont.) • Outpatient Demand Shifts (cont.) • New practice models developed to provide services formerly provided by hospitals • Mobile services • Hospice services • Home health care • Telemedicine services • Alternative medical practices • Some changes were driven by change in reimbursement policies

16. Outpatient Care (cont.) • Hospital Outpatient Services • Hospitals realized significant demand and revenue losses from shift to OP delivery • Many hospitals increasing their own outpatient services delivery • In the hospital • Further leverages capital investments • Ownership of specialty satellite facilities • Ownership of physician practice groups

17. Outpatient Care (cont.) • Hospital Outpatient Services (cont.) • Hospital Emergency Rooms are traditional providers of OP services • Less than half of visits are emergencies • Routine care for uninsured • Night/weekend care • Highly specialized ED staff/facilities not well used for non-urgent care • Many hospitals are owning walk-in clinics

18. Outpatient Services (cont.) • Hospital Outpatient Services (cont.) • Women’s Health Centers are a growing outpatient specialty practice that are often operated by hospitals • Women are a the major users of healthcare and also have higher annual charges for services • Women therefore form a customer base that can be catered to • Social pressures call for increased attention to women’s issues

19. Outpatient Services (cont.) • Freestanding Facilities—what are the goals and economic justifications for… • Walk-in clinics • Surgical centers • Rehab centers • Why are dental, chiropractic, and vision providers almost always freestanding facilities with no hospital affiliation?

20. Other Service Models • Mobile Services • Emergency treatment and transportation services • Most widely known • Other mobile units make sense to… • Deliver care to groups of patients for whom mobility is difficult

21. Other Service Models (cont.) • Home Health Care • Millions of patients fit two criteria • Have limited mobility due to age or physical condition • Require care that does not need on-site facilities of a hospital or clinic • These patients can often be treated at home and avoid institutionalization • Changes in Medicare and Medicaid funding have supported home treatment • Private payers recognize cost savings as well

22. Other Service Models (cont.) • Home Health Care (cont.) • HHC includes a wide variety of services • Short term treatment, including recovery • Medication monitoring • Medication administration, including IVs • Daily living task assistance

23. Other Service Models (cont.) • Hospice Care • Services for patients with less than six month life expectancies • Services may be delivered in a variety of settings • Including home care • Provide distinctive services • Palliative care • Emotional and spiritual needs • Include family in treatment plan • Requires specialty training • Covered by Medicare

24. Other Service Models (cont.) • Ambulatory Long-Term Care • Services for long-term needs without institutionalization • Case management • Views holistic patient circumstances • Coordinates multiple providers • Adult day care • Allows relief for unpaid LTC providers • Not residential

25. Other Service Models (cont.) • Public Clinics • Public health services • Focus on population health • Provide some treatments as a policy decision • Indigent patients • Control disease • Services vary widely geographically • Community health centers • Federal program for underserved populations • Preventive, primary, and dental care

26. Other Service Models (cont.) • Public Clinics (cont.) • Free clinics • Not government supported • Focus on underserved populations • Significant volunteer labor • Telephone access or triage • Consultations for a wide variety of services • Patient monitoring • Triage (many ER visits not needed) • Operate under various organizational models

27. Other Service Models (cont.) • Alternative and Complimentary Medicine • Chiropractic care considered complimentary • Covered by some insurance • Often with limits • Wide range of “nontraditional” treatments • (May be traditional elsewhere) • Explosive growth in demand (Why?) • Typically not covered by insurance • But some are!!! • Significant government research