today’s topic: ambulatory and hospital care. objectives for today be able to describe the...
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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
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
Types of ambulatory care
Physician office or clinic Solo or group
Community health centers Freestanding emergency rooms Freestanding amb care center Clinical labs
Types of ambulatory care (cont.)
Ambulance services Renal dialysis Trauma centers Ambulatory surgery centers Hospital-based
Clinics Freestanding outpatient hospitals
Place / site of utilization
Most persons go to doctor’s office
Among the poor, a higher % go to hospital outpatient dept.
Most frequent reasons for visits
General medical exam Progress visit Routine prenatal examination Cough Postoperative visit Symptoms referable to throat Well-baby examination
Most frequent diagnoses
Essential hypertension Acute upper respiratory infections Routine infant check Normal pregnancy Malignant neoplasm General medical examination Otitis media
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
Hospitals Provide inpatient care
Also the site of some ambulatory care Emergency care Ambulatory surgery center, etc.
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)
Rise of hospitals in the U.SSite of care in 1790s Type of patientAlmshouse (poorhouse) Non-paying, acute
ChronicMental disorders
Jail Mental Disorders
Pest houses Contagious disease
Billeting in private homes Merchant seamen, military
veterans
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
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
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
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
Utilization statistics for Texas
Inpatient 1997 1995 1993beds 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.
Personnel statistics for Texas
Personnel 1997 1995 1993Full 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.
Utilization ratios for Texas (per 1,000 population)
Inpatient 1997 1995 1993beds 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
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
Community hospitals in Texas
Bed size 1997 1995 1993 6-24 48 38 38 25-49 101 112 110 50-99 74 73 79100-199 97 107 92200-299 37 36 48300-399 23 23 19400-499 13 13 10 500+ 14 14 18from AHA Guide, 1999
5 Most Frequent MEDICARE DRGS
from HCFA 1999 Statistical Supplement
0 200 400 600 800
127: Heart failure/shock
089: Pneumonia
014: Cerebro. Vascular dis.
088: COPD
209: Joint/limb reattachment of lowerbody Discharges (1,000s)
5 Most Frequent MEDICARE DRGS
from HCFA 1999 Statistical Supplement
5.0 5.2 5.4 5.6 5.8 6.0 6.2 6.4 6.6 6.8
127: Heart failure/shock
089: Pneumonia
014: Cerebro. Vascular dis.
088: COPD
209: Joint/limb reattachment of lowerbody ALOS
5 Most Frequent MEDICARE DRGS
from HCFA 1999 Statistical Supplement
$0 $5,000 $10,000 $15,000 $20,000 $25,000
127: Heart failure/shock
089: Pneumonia
014: Cerebro. Vascular dis.
088: COPD
209: Joint/limb reattachment of lowerbody
Ave charge per discharge
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)
Teaching & Academic Hospitals
Teaching hospitals Graduate medical education (residency
programs)
Academic medical centers Graduate medical education Supports research
Academic medical centers Tripartite missions of academic
medical centers (AMCs)
1) Teaching
2) Research
3) Patient Care
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
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
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
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
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
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
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
Reasons for rising hospital costs
Aging population General inflation Technology Unnecessary surgery Unnecessary admissions Excess capacity
too many inpatient beds, services
Cost control mechanisms
Government regulation Certificate of need (CON) Rate regulation Peer review organizations (PROs)
Competition Business coalitions Vertical integration Horizontal integration
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
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