Outpatient Services andOutpatient Services andPrimary Health CarePrimary Health Care

Heidi KinsellMaster of Health Administration (MHA)Health Services Research, Management and Policy

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Overview for TodayOverview for Today

Outpatient CarePrimary CareKey Issues

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DefinitionsDefinitionsOutpatient = Do Not require

overnight hospital stay.Ambulatory Services = services

provided to the “walking” patient.Community Medicine = services

provided in the immediate “community” where patients live.

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WhereWhere is Outpatient Care is Outpatient Care Provided?Provided?

Physician officesHospital outpatient departments

◦Diagnostic (e.g. lab, radiology)◦Therapeutic (e.g. PT, chemotherapy)

Hospital EDsNursing homes, Home health,

HospiceAmbulatory Surgery CentersPublic Health CentersRetail Clinic/Convenient Care Clinic

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Outpatient Care = Outpatient Care = Growth!Growth!All trend lines are up, up, upReimbursement changes

◦Payments◦Utilization controls

New technologiesPatient preferences

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Important ConsiderationsImportant ConsiderationsOutpatient services are

delivered….◦In a variety of settings◦By various types of providers◦For various conditions Acute Chronic Preventive Primary, secondary, tertiary

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The Health Services The Health Services SystemSystemPreventive CarePrimary CareSecondary CareTertiary CareRestorative CareContinuing Care

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Understanding Primary Understanding Primary CareCare

Primary Care◦ Main health care provider in non-emergency

situationsSecondary Care

◦ Specialist for expert opinion or surgical/other intervention

◦ May include hospitalization, surgery, rehabilitation

Tertiary Care◦ Complex care for relatively uncommon conditions

(usually institution-based and technology-driven)

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Two Dimensions to Two Dimensions to ConsiderConsiderType of Care

◦Preventive --Coordination--- Continuing

Location of Care◦Inpatient --- Outpatient◦With various inpatient sites (e.g.

hospital, nursing home) and outpatient locations (e.g. physician office, surgery center, home)

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Primary CarePrimary CareThree key elements

◦Point of Entry◦Coordination of Care◦Essential Care

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Point of EntryPoint of EntryFirst contact with health care

systemGatekeepers

◦Patients come “through” primary care physicians to hospitals and specialists Con: Limits care? Pro: Prevents unnecessary care?

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Coordination of CareCoordination of CarePCPs coordinate delivery of care

from many sourcesPatient advisors, patient

advocatesEnsure continuity and

comprehensivenessThe Evidence

◦this works (better health outcomes)◦people prefer it (patient satisfaction)

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IdealIdeal Attributes of Primary Attributes of Primary CareCare

IntegratedCoordinating Continuity of careAccessibilityAccountability

◦For both patients and providers

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Primary Care ToolsPrimary Care Tools

Clinical guidelinesDisease managementCase managementPharmacy care managementOthers

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Who Provides Primary Who Provides Primary Care?Care?PhysiciansExtendersNursesAncillaryAlternative providers

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PhysiciansPhysicians

PCPs (Primary Care Physicians)Typically…

◦Family Practice◦General Internal Medicine◦General Pediatrics◦Obstetrics & Gynecology

Controversy◦Who?◦Specialized primary care training?

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Extenders & Non-physician Extenders & Non-physician Practitioners Practitioners

Nurse PractitionersPhysician AssistantsNurse Midwives Other Health Care

Providers

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TrendsTrendsHistorically

◦Over-supply of specialists◦Bias towards specialists and sub-specialists◦Follow the money

Now/Future◦Growing demand for PCPs◦Income still lower◦New organizational and financial structures promoting use of primary care physicians

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HC Reform & Primary CareHC Reform & Primary CarePatient Centered Medical Home

(PCMH)Community Health FocusMore grant funding & payments

for PC trainingIncreased Medicare

reimbursements for PCPs

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ConclusionConclusionWill the system “adjust” to

appropriate mix of primary & specialty care?

Primary care is a fundamental component of the health care system today and tomorrow.◦UnitedHealthcare, RI Foundation offer

$250K for primary care docs◦CA’s Eisenhower Medical Center gets

teaching approval for primary care ◦1 in 4 New Docs Regret Career Path

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Master of Health Administration, MHA

Health Management & Policy Concentration of MPH

PhD in Health Services Researchhttp://hsrmp.phhp.ufl.edu

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