HCA 701: Survey of the U.S. Healthcare System

Physicians and Ambulatory Care

RESOURCES NEEDED TO MAINTAIN A HEALTH CARE DELIVERY SYSTEM

Financing

Healthcare Professionals

Technology & Supplies

Health Care Delivery System

FacilitiesSource: Williams and Torrens, Introduction to Health Services, 2002

Healthcare Professionals

Healthcare is a major employer It has a rapidly growing labor sector

Professionals Non-professionals and technicians Non-institutional workers

Rapid growth due to: Technology growth and specialization Health insurance coverage Aging population Emergence of hospitals

Types of Healthcare Worker Certification

Licensure – state or legal designationCertification and registrationIndependent and dependent professions

Independents practice without physician supervision (e.g., doctors, dentists)

Dependents need physician supervision (most nurses, CNAs)

Ambulatory Care

Personal health care given to the patient in an non-hospital or institutional setting

Types of settings: Physician owned private practice Managed care clinic settings Community health care settings “Urgent care” facilities

Shift to ambulatory care due to several factors: Medicare PPS Managed care Improved technology

Patient Visits per 100 persons by Ambulatory Service Type, 1993-94 and 1999-2000

0

20

40

60

80

100

120

140

160

180

Primary CareVisit

SurgicalSpecialty

MedicalSpecialtyPractice

OutpatientDept.

EmergencyDept.

1993-94

1999-2000

Physician Authority

Based on modern science and scientific knowledge. Physicians become the intermediaries between

science and private experience Authority signifies the presence of status and quality Requires legitimacy and dependence.

Legitimacy – acceptance by subordinates Dependence – bad things can happen if we don’t obey

Types of Physician Authority Social Authority Cultural Authority Professional Authority

The Evolution of the Physician in the U.S.

AllopathicHomeopathyOsteopathicChiropractic

Physicians

Comprised of two types by practicePrimary care physicians – short supply in

U.S.Family Practice, Internal medicine, OB/GYN,

PediatriciansSpecialists – Surplus in U.S.

Specialize in specific areas

Physician Surplus or Shortage?

Rapid growth of physicians, esp. specialists, during 1980-95 due to: Massive federal outlays Influx of International Medical Graduates (IMGs)

Distribution of physicians gives appearance of shortage Not enough primary care providers Medical underserved areas in rural communities

and inner cities Malpractice and the impact on physicians

Physicians: NV vs. US

Physicians Type Nevada U.S.

Physician generalists per 100,000 population

21 30

Physician specialists per 100,000

142 206

Changing Role of the Physician

More employed physiciansBy managed care organizations and

hospitals (the emergence of the “Hospitalist”)

Large group practices emerged with the growth of managed care

Emphasis away from specialty areas to managed care

More female physicians

Physicians who would recommend the practice of medicine

48%

41%

11%

Yes

No

Don't know

46%

31%

20.0%

31%

22%

16%

15%

1%

8%

0% 10% 20% 30% 40% 50%

Loss of autonomy

Excessive professional demands

Less respect for the medical profession

Inadequate financial rewards

Difficulty operating practice

Education process to long/expensive

Not Satisying

Liability

Other

For physicians who wouldn’t recommend medical profession

Distribution of Physicians by Specialty: 1980, 1986, 1995, 2000 (In thousands

1980 1986 1995 2000 Pct. Change

Specialty No./% No./% No./% No./% 1986-2000

All specialties414/100 521/100 630/100 684/100 31.4

Primary Care 159/38.5 179/34.4 205/32.5 219/32.0 22.2

Other Medical

Specialties 25/6.2 62/12.0 83/13.2 94/13.7 50.2

Surgical Specialties 110/26.7 134/25.7 158/25.2 170/24.9 27.0

All other specialties 118/28.5 144/27.8 183/29.1 201/29.4 38.9

Physician Medical Education

Undergraduate medical curriculum Most emphasize the acute care setting Increase in women and minorities

Graduate medical education Major increases in residencies Shifts in the organization of medical schools

Must compete for patients Shift to managed care by med school hospitals Trends medical education in for-profit hospitals

Flexnor Report

Will doctors meet demand in a bio-terror event

Nurses

Typifies the concern of healthcare: “nursing is concerned with human response to health problems”

Historic factors that shaped nursing as a career: Occupation to support physicians Emergence of hospitals as community institutions Acceptable female occupations, primarily white

females Linked to religious orders

Understanding the Nursing Shortage

Changes in occupational opportunities for women since 1970s

Majority of RNs are 50+ years of age or married with children at home

Low salaries – pay compression Burnout Lack of clinical career ladder Active vs. Inactive – about 1/3 of nurses not

working fulltime