Today’s Topic:

Ambulatory and

Hospital Care

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

Ambulatory Care

Care for the walking patient

Primary source of contact with health system

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

Utilization stats: # phys. contacts

Total 6.0 per year

Males 5.2 per year

Females 6.7 per year

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

Physician-Hospital Organizations (PHOs)

Corporations formed to contract with managed care plans