hsa 3111: outpatient and primary care services 1 dr. lawrence west, health management and...

HSA 3111: Outpatient and Primary Care Services

1Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest

Topics

• History of Healthcare• Terminology• Primary Care• Outpatient Services• Other Service Models

“Never go to a doctor whose office plants have died.”Erma Bombeck



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



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




• 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




• 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



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



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



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



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



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



Primary Care (cont.)

• Other roles of primary care– Preventive care

• Examinations• Immunizations

– Continuity of care– Population health

• Reporting• Preventive care



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



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




• 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




• 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




• 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




• 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



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



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?



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



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




• 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




• 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




• 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




• 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




• 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




• 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

hsa 3111: outpatient and primary care services 1 dr. lawrence west, health management and...

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