1. Outpatient Services and Primary Health Care
Heidi Kinsell
Manager, Academic Programs
Health Services Administration

2. Overview for Today
Outpatient Care
Primary Care
What are key issues?

3. Some Key Terms
Outpatient Services
Ambulatory Care
Primary Care

4. Definitions
Outpatient Services = Do Not require overnight hospital stay.
Ambulatory Services = services provided to the “walking” patient.
Community Medicine = services provided in the immediate “community” where patients live
OP-With room & board charges Ex: 23 hour units
Ambulatory-many pts are not walking ambulance at home very sick

5. Where is Outpatient Care Provided?
Physician offices
Hospital outpatient departments
Diagnostic (e.g. lab, radiology)
Therapeutic (e.g. PT, chemotherapy)
Hospital emergency departments
Home health agencies
Ambulatory clinics and surgery centers
Chiropractors, other types of providers
Neighborhood health centers
Public health centers/services
Hospice
Groups & individual docs
Nursing homes

6. Outpatient Care = Growth!
All trend lines are up, up, up
Why?
Reimbursement changes
Payments
Utilization controls
New technologies
Patient preferences
Reimbursement Changes: 1. Favor least invasive, least costly alternatives
2. PPS-PROSPECTIVE PAYMENT SYSTEM A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, DRGs for inpatient hospital services).
Capitation-$ per life per month
Utilization Controls: Limit LOS so some no longer IP & others now IP & OP components
Technologies: home IVS, laser surgery, laproscopic surgery, home/video monitoring
Patient prefs: why stay overnight?, big hospitals many times in urban/undesirable locations, far etc.
So….Increased entrepreneurs changes in hospitals strategy

7. Important Considerations
Outpatient services are delivered….
In a variety of settings
By various types of providers
For various conditions
Acute
Chronic
Preventive
Primary, secondary, tertiary
Etc.
Physicians, PTs, lab techs, physician extenders (ARNPs, Pas)
Come back to various conditions

8. Some Trends to Watch Telephone and Email visits Group visits
Use of the Internet in various ways
Information (general, specific)
Tracking care (conditions, progress)
Finding providers
Finding support groups, “community”
Increased role of the consumer/patient
Trends to watch for both OP & Primary Care
Group visits: California –people with same condition (eg, asthma) meet together with doc.
Tracking care esp. for chronic conditions
Consumers/Patients driving hc- choices of health plans, providers, procedure/care

9. The Health Services System
Preventive Care
Primary Care
Secondary Care
Tertiary Care
Restorative Care
Continuing Care
Prev-education & prevention: well-baby, screenings/mammograms, vaccines
Prim-Early detection & routine care, coordinating
Second-ER, Critical Care
Tertiary-highly specialized & highly technical
Restorative-Immediate follow up, Rehab, Home Care, Step down
Contin-LT Care, Chronic care, Hospice/Palliative

10. The Health Services System
Preventive Care
Primary Care
Secondary Care
Tertiary Care
Restorative Care
Continuing Care

11. Understanding Primary Care
Secondary Care
Short-term, sporadic consultation from a specialist for expert opinion or surgical/other intervention
Typically includes hospitalization, surgery, rehabilitation
Tertiary Care
Complex care for conditions that are relatively uncommon (usually institution-based and technology-driven)
Can be long-term
Quaternary Care

12. Two Dimensions to Consider
Type of Care
Preventive Continuing
Location of Care
Inpatient --- Outpatient
With various inpatient sites (e.g. hospital, nursing home) and outpatient locations (e.g. physician office, surgery center, home)

13. Primary Care Three key elements Point of Entry Coordination of Care
Essential Care

14. Point of Entry First contact with health care system Gatekeepers
Patients come “through” primary care physicians to hospitals and specialists
Con: Limits care?
Pro: Prevents unnecessary care?
1-Clarify problem
2-Serve as patient advocates
Evidence: dec. specialists, dec. $$
PRIMARY CARE A basic level of care usually given by doctors who work with general and family medicine, internal medicine (internists), pregnant women (obstetricians), and children (pediatricians). A nurse practitioner (NP), a State licensed registered nurse with special training, can also provide this basic level of health care.
PRIMARY CARE DOCTOR A doctor who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems. He or she makes sure that you get the care that you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them. In many managed care plans, you must see your primary care doctor before you see any other health care provider.

15. Coordination of Care
PCPs coordinate delivery of care from many sources
Patient advisors, patient advocates
Ensure continuity and comprehensiveness
The Evidence
this works (better health outcomes)
people prefer it (patient satisfaction)
Key: IHI big push
“Sustained partnership” between patients & physicians
PCPs cooridnate as you move along the continuum among the sites
When used- dec. hospitalizations, dec. ED use, better compliance with meds

16. Essential Care Meeting needs to optimize population health
What is population health?
Why do we care?
Pop. Health- Needs of the “group”/ community 2) “Covered lives” in a health plan
Why care?-
Use limited resources appropriately
public/society/greater good i.e. better health for all examples: polio, measles, small pox
Private managed care plans fundamental to the mc philosophy

17. Ideal Attributes of Primary Care
Integrated
Coordinating
Continuity of care
Accessibility
Remove barriers of geography, financing, race, language, culture
Accountability
For both patients and providers
Continuity- not just numbers
Accessibility issues: geog- travel time?, where is prim care?, how long wait for 1st appt., Fin-take your insurance, language/culture-get appt speak language?
What happens here?- many use hospital EDs as primary care
How do we achieve accountability?
Numbers
Training
Social change norms
Acute Care Services/ or potentially preventable hospitalizations
Conditions/hospitalizations:
prevent disease
treat disease that lead to rapid onset (pneumonia)
Manage chronic conditions
Therefore- timely & effective primary prevents ACSH

18. Who Provides Primary Care?
Physicians/Doctors
Extenders
Nurses
Ancillary
Alternative

19. Physicians PCPs (Primary Care Physicians) Typically… Controversy
Family Practice
General Internal Medicine
Pediatrics
Obstetrics & Gynecology
Others
Controversy
Who?
Specialized primary care training?
Think/Remember- Primary Care as an “approach”
Others-opthamologists, cardiologists
Who? E.g. OB?, infectious disease for HIV patient?
Spec. PC training?- a requirement e.g. consider med school & training for specialists

20. PCP Trends Historically Future Over-supply of specialists
Bias towards specialists and sub-specialists
Follow the money
Future
Growing demand for PCPs
Income still lower
New organizational and financial structures promoting use of primary care physicians
How to “share” the patient
When to refer? Who gets credit i.e. $, esteem
Follow the money & Future: 9/16/2008 Article
“Just 2 % of nearly 1,200 fourth-year students surveyed planned to work in primary care internal medicine, according to results published in the Journal of the American Medical Association. In a similar survey in 1990, the figure was 9%.”
The salary gap may be another reason. Family medicine had the lowest average salary last year, $186,000, and the lowest share of residency slots filled by U.S. students, 42 %. Orthopedic surgery paid $436,000, and 94 % of residency slots were filled by U.S. students.
The Web-based survey was done at 11 medical schools with demographics and training choices similar to all U.S. medical students.

21. Doctors Allopathy Osteopathy Optometry Psychology Podiatry Pharmacy
Teacher, skilled in a profession, licensed to practice “medicine”
Allopathy-M.Ds combat disease by use of remedies “ordinary” medicine (vs. alternative)
Osteopathy-D.O. normal body is a vital mechanical organism own remedies
Optometry-eyes
Psychology-mental health, no meds vs psychiatry
Podiatry-medical treatment of foot disorders
Pharmacy-medications

22. Physician Extenders or Nonphysician Practitioners
Nurse Practitioners
Physician Assistants
Nurse Midwives
Social Workers
Nutritionist
90% work in primary care
Use on routine care
Spend more time w/pts
cheaper
Some say better care
Do more prevention
NPs-GP,FP,IM,peds, GYN/OB ARNPs
Some practice independently
PAs-all require physician supervisors

23. Alternative Medicine Providers
Also known as “complementary medicine”
Examples include…
Chiropractic
Homeopathy, herbal formulas
Acupuncture
Meditation, biofeedback
Spiritual guidance
Others
Trends:
Growth!
Growing acceptance by traditional health care systems
Issues:
1- when pts don’t explain this to primary care docs
2- can they effectively coordinate traditional care?

24. Primary Care Tools Clinical guidelines Disease management
Case management
Pharmacy care management
Others
Clinical: set of algorithms on how to treat routine conditions (procedure)
What to order, when to see again
DZ mgmt: goes beyond guidelines measuring progress of managing the disease
Asthma, diabetes, etc.
Case Mgmt: not specific to disease, help with coordination and continuity of care
Pharmacy care mgmt: started to dec. $ but now expanded to track, follow patients or specific medication

25. Future Trends/Issues
Will the system “adjust” to appropriate mix of primary & specialty care?
Enough primary care physicians in the right places? (Rural, Urban)
National Health System?
The aftermath of September 11, 2001
Mental health needs
Potential for bioterrorism

26. Conclusions
Primary care is a fundamental component of the health care system today and tomorrow.