Chapter 5

Ambulatory Care

CHAPTER OBJECTIVES

• Provide familiarity with the major components and functions of the ambulatory care system in the context of the overall delivery system

• Review major developments in the evolving ambulatory care system with respect to physicians, hospitals and consumers

• Highlight ambulatory care initiatives of the ACA

Overview and Trends (1)

• Ambulatory care: medical care not requiring overnight hospitalization

• Continuing volume shift from hospitals began in 1980s–Advanced technology safety improvement–Payer incentives to decrease inpatient stays–Consumer & physician preferences

Overview and Trends (2)

• 1990s: increasing number of facilities owned and operated by hospitals, physicians, independent corporate chains. – Cancer treatment, diagnostic imaging, renal

dialysis, pain management, physical therapy, cardiac & other rehabilitation, eye, plastic and other surgery, etc.

– Physicians and hospitals compete for patient business, altering prior relationships

Components of Ambulatory Care

• Private Medical Office Practice• Other (non-physician) ambulatory care

practitioners• Ambulatory care services of hospitals• Hospital emergency services• Free-standing (non-hospital based) facilities

Private Medical Office Practice

• Predominant mode: 1 billion+ visits/year–586 M visits to primary care physicians–257 M visits to medical specialists–193 M visits to surgical specialists

Transition to Physician Group Practice

• Mayo clinic group practice of salaried MDs in late 1800s; controversial

• Until 1930’s solo practice predominant– 1932 Committee on the Costs of Medical Care*

report recommended group practice as economically efficient, promoted insurance as a means to improve access• *A blue ribbon panel of public health

professionals, academicians and economists

Reactions to Committee Reporton the Costs of Medical Care: 1930s-1950s

• AMA condemned recommendations for group practice and salaried physicians as “unethical” – GHI establishment (1937) erupted legal battle;

AMA expelled GHI-salaried physicians and “blacklisted” them with hospitals

– D.C Medical Society & AMA indicted & found guilty of conspiracy to monopolize medical practice

– Next few decades spawned controversy about MD participation in group health plans

Continuing Opposition to Group Practice

• Physicians sought membership in evolving group health plans as local medical societies attempted and failed at obstructing group practices– Group physicians were ostracized and denied

hospital privileges– Opposition subsided by 1950s due to legal

challenges and physician shortage

Transition from Solo to Group Practice- 1960s

• Social & lifestyle changes • Medical specialization• Medicare & insurance complexities• Office technology costs and overhead

spawned economies of scale opportunities

Group Practice Features

• Single & multi-specialty groups–After hours and vacation coverage– Informal collegial consultation– Informal system of peer review– Shared office overhead (personnel &

technology)

Physician Employment by Hospitals (1)

• Number of physicians employed by hospitals: 32% increase 2000-2012, due to:– Flat/decreasing reimbursement rates– Complex health insurance & technology

requirements– High malpractice premiums– Desire for greater work-life balance

Physician Employment by Hospitals (2)

• Hospital advantages of physician employment:– Gain market share for admissions– Guaranteed use of diagnostic testing, other

outpatient services– Referrals to high-revenue specialty services– Position with physician networks for health plan

negotiations, care coordination, quality monitoring, cost containment

Integrated Ambulatory Care Models (1)

• Patient-Centered Medical Homes• Accountable Care Organizations– Seek remedies for service fragmentation:

piecework reimbursement, no reimbursement for care coordination efforts, ineffective/absent links for patients among/between multiple service providers, service duplications, inadequate aggregation of data on patient outcomes

Integrated Ambulatory Care Models (2)

• Patient-Centered Medical Home (PCMH)– Team-based model of care led by a personal

physician providing continuous and coordinated care throughout a patient’s lifetime including linkages with other professionals for preventive, acute and chronic illness and end-of-life assistance

– Since 2006, Patient-Centered Primary Care Collaborative of 1,000 member organizations e.g. primary care physicians, insurers, government agencies, academia, others

Integrated Ambulatory Care Models (3)

• ACA provisions supporting the PCMH:– Expanded Medicaid eligibility– Medicare & Medicaid payment increases for

primary care and designated preventive services– Funding to place 15,000 primary care providers in

shortage areas– Funding for health professional training and more

primary care residencies– Center for Medicare & Medicaid Innovation

Integrated Ambulatory Care Models (4)

• Transitions to PCMH:– “Wrenching culture and system changes”– Substantial payment reforms– “Highly motivated physicians, redesign of staff

roles and care processes,…health information technology,…other …support”

– NCQA: “Recognition” for adherence to standards; new 2013 certification for “Content Expert”

Integrated Ambulatory Care Models (5)

• Accountable Care Organization (ACO)– ACA adopted model: groups of providers, suppliers

of health care, health-related services, others involved in patient care to coordinate care for Medicare patients (PCMHs are ideal primary care component)

– Goals: timely, appropriate care; avoid duplications, medical emergencies and hospitalizations

Integrated Ambulatory Care Models (6)

• ACO definition- legally constituted entity within its state including providers, suppliers, Medicare beneficiaries on governing board– Responsible for 5,000 Medicare beneficiaries for 3

years– Meet Medicare-established quality measures– Payments combine fee-for-service w/shared

savings, bonuses linked with quality standards applicable to all providers

Integrated Ambulatory Care Models (7)

• ACO providers and suppliers– ACO Physicians, hospitals in practice arrangements– Networks of individual practices of ACO

professionals– Partnerships or joint ventures between hospitals,

ACO professionals, or hospitals employing ACO professionals

– Other DHHS-approved providers, suppliers

Other Ambulatory Care Practitioners

• Licensed professionals in independent practice: solo or group, single or multidisciplinary practices

• Dentists, podiatrists, psychologists, optometrists, physical therapists, social workers, nutritionists

Early Hospital Ambulatory Care

• 19th century: clinics poorly equipped & staffed, often remote “dispensaries”

• Served community’s poorest; charitable Mission

• Teaching sites for medical students• Staffed by low-ranking physicians, often to

earn admitting privileges

Traditional Teaching Hospital Clinics

• Organized into specialty areas for teaching & research purposes; “anatomic” orientation–Patients benefit from sophisticated care– Specialty orientation causes fragmentation,

challenges in coordinating care across multiple clinics

Hospital Clinic Evolution-1980s

• Primary care as “core” with salaried, not volunteer, physicians

• Improved care coordination• Specialty (boutique) services to attract paying

patients

Hospital Ambulatory Care-Today

• Continue “safety-net: functions• Teaching sites for primary & specialty care• Well-equipped and staffed• Profitable referral centers: acute care and

ancillary services; 42% total hospital revenue• Continuing challenges for providers and

patients in coordinating care across multiple clinics will be aided by EHR use

Hospital Emergency Services (1)

• Staffed and equipped for life-threatening illness and injury; physician & nurse specialists

• 136 million annual visits- 259/minute• Community “safety nets”-2008-2009: 10% upsurge in

usage, the highest increase on record• 1990-2009: total number of urban EDs declined 27%,

from 2446 to 1779 due to for-profit ownership, market competition, low profit margins

Hospital Emergency Services (2)

• Visit payment status: 19% uninsured; 39% privately insured

• Inappropriate use: 8%, ~ 10M “non-urgent,”– Patient self-determination of symptoms– Physician referrals (off-hours, office scheduling

issues)• One-third of visits: injuries, poisonings,

adverse effects of prior treatment

Freestanding Facilities

• “Freestanding” = non-hospital based facilities: owned, operated by hospitals, physician groups, for-profit, not-for-profit entities, corporate chains– Urgent care – Retail clinics– Ambulatory surgery centers– Federally qualified health centers– Public health ambulatory services– Not-for-profit agencies

Urgent Care Centers (1)• First in 1970s– UCAOA: “Provide walk-in, extended hour access

for acute illness and injury care that is either beyond the scope or availability of typical primary care practice or retail clinic”

– Operate under licensed physician auspices• 8,700+, 150 million visits annually• Ownership: for-profit, physician groups, managed

care organizations• Primary care physicians, nurses, ancillary services,

e.g. lab & radiology

Urgent Care Centers (2)• Primary care physicians, nurses, ancillary

services, e.g. lab & radiology• After hours, non-emergency; 55% suburban;

25% urban; 20% rural• Episodic care w/emphasis on primary care

physician relationship• Since 1997, American Board of Urgent Care

Medicine certifies, following exam, primary care specialists in the field of urgent care

Contentious Issues

• Hospitals: Cull paying patients, leave the poorest for hospital emergency departments and clinics

• Physicians: Discourage/impede relationship with primary physician and continuity of care

• Consumers: Urgent care responds quickly, efficiently, effectively w/lowest costs

Retail Clinics (1)

• First in 2000; Minneapolis/St. Paul grocery stores; ~ 1,200 retail sites by 2010–Operated in pharmacies & supermarkets

(CVS, Walgreens, Wal-Mart, Target, others )–2007-2009- number of retail clinics

quadrupled: visits exploded from 1.5 M to 6.0M– Entrepreneurial response to consumers

Retail Clinics (2)

• Strong insurer & employer acceptance; some insurers waive/lower co-pays

• Market forecasts doubling numbers to 2,800 by 2018

• American Academy of Family Practice Physicians recognizes need and physician opportunities; opposes expansion beyond minor illnesses; clinics can be a component of the PCMH

Retail Clinic Issues

• AMA 2007: urged investigation for conflicts of interest (RX, other sales), disruption of physician/patient relationships, co-pay waiver unfair to physicians still required to collect

Ambulatory Surgery Centers (1)

• Established in 1970s• Anesthesia advances: primary drivers• New operative technologies• 34.7 M annual visits• 2008: 5,149 Medicare-certified centers; 2000-

2007: 7.3% increase in numbers

Ambulatory Surgery Centers (2)

• 96% full or partial physician-ownership; 25% have hospital ownership interest; 2% entirely hospital-owned

• Medicare & private insurer mandates pushed development

• Hospital opportunities for profitable space conversions

Benefits of Ambulatory Surgery & Quality

• Patients: access, fewer complications, quicker recovery

• Physicians: convenient staffing and scheduling, less competition for facilities

• Accreditation: Medicare, Joint Commission, Accreditation Association for Ambulatory Health Care, American Association for the Accreditation of Ambulatory Surgery Facilities; 43 states require licensure

Federally Qualified Community Health Centers (FQHCs) (1)

• 1960s: U.S. Office of Economic Opportunity; both urban and rural locations

• 2008: $ 1.9 billion grant, HRSA Bureau of Primary Care, Dept. of HHS

• 2011: Served 20.2 million patients in 1,200 centers with 8,500 sites in all states, D.C., Puerto Rico, U.S. Virgin Islands

Federally Qualified Community Health Centers (2)

• Multidisciplinary teams; education, translation, pharmacy, transportation, etc.

• Link, refer: WIC, social work, public assistance, legal services

• 2/3 patients uninsured or Medicaid• Revenue: Medicare, Medicaid, private

insurance, sliding fee payments; Medicaid patients increased 39% 2007-2011 while Medicaid reimbursement declined

Federal Community Health Centers (3)

• Administering organizations: local government health departments, units of community organizations, stand-alone not-for-profit agencies

• 2009: $ 600 M ARRA Funds to expand 85 centers; support EHR, other technology

• 2010: ACA funds expansions, new sites, 3-year PCMH pilot for Medicare beneficiaries

Public Health Ambulatory Services: History

• Originated in charitable tradition of community responsibility by municipalities & states, colonial period-1800s almshouses and “poor houses”

• State & local governments’ roles & public health developments led to tax-supported departments of health in late 19th, early 20th centuries

Public Health Ambulatory Services: History

• Public health success in controlling childhood & other communicable diseases gave way to medical cares focus on chronic illness with resource shift from prevention to treatment– New public health demands to promote lifestyles,

provide safety-net services, expand regulatory oversight to medical industries

Public Health Ambulatory Services (3)

• Current public health services range across a spectrum of city, county, state: immunizations, well-baby care; tobacco control; disease screenings, education, personal services through health centers; infectious disease case-finding and control.

• Staffing: physicians, nurses, aides, social workers, sanitarians, educators, community health workers, support staff

Public Health Ambulatory Services (4)

• 2010 NACCHO, National Survey of Local Health Departments (2,107/2,565 responses)

• Most common ambulatory services– 92%: childhood immunizations– 75%: tuberculosis treatment– 59%: treatments for STIs– 55%: family planning

Public Health Ambulatory Services: Emergency Preparedness

• 2001 terrorist attacks– $ 5 billion to states to strengthen infrastructure

accompanied by many new demands amid state budget crises; did little but fill gaps

• 2009 H1N1 threat– Public health response of states variable; suggests

reports identify Internet access, staffing constraints, media use patterns as causes.

Not-for-Profit Agencies (1)

• Not-for-profit organizations, governed by volunteer boards of directors

• Cause- related, often grass-roots origins• Disease and/or cause specific Missions• Usually tax-exempt, 501(c) 3• Education, counseling, medical care, advocacy– Examples: Planned Parenthood, Alzheimer’s

Association

Not-for-Profit Agencies (2)

• Single corporations or affiliates of national organizations

• Funding: government & private foundation grants, private donations, Medicare, Medicaid, private insurance, sliding fee scale

• Repositories of community values & charity, fill gaps for special need populations and cause advocacy

Continued Future Expansion and Experimentation

• Shift from hospitals to freestanding facilities will continue with medical care advances, cost-reduction initiatives, consumer demands; ambulatory surgery, urgent care and retail clinic use will grow

• PCMH, ACO models’ study findings will inform practitioners & policymakers about future refinements to improve quality and reduce costs