Outpatient Services and Primary Health Care Heidi Kinsell Master of Health Administration (MHA) Health Services Research, Management and Policy 1

Overview for Today Outpatient Care Primary Care Key Issues 2

Definitions Outpatient = 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. 3

Where is Outpatient Care Provided? Physician offices Hospital outpatient departments ◦ Diagnostic (e.g. lab, radiology) ◦ Therapeutic (e.g. PT, chemotherapy) Hospital EDs Nursing homes, Home health, Hospice Ambulatory Surgery Centers Public Health Centers Retail Clinic/Convenient Care Clinic 4

Outpatient Care = Growth! All trend lines are up, up, up Reimbursement changes ◦ Payments ◦ Utilization controls New technologies Patient preferences 5

Important Considerations Outpatient services are delivered…. ◦ In a variety of settings ◦ By various types of providers ◦ For various conditions  Acute  Chronic  Preventive  Primary, secondary, tertiary 6

The Health Services System Preventive Care Primary Care Secondary Care Tertiary Care Restorative Care Continuing Care 7

Understanding Primary Care Understanding Primary Care Primary Care ◦ Main health care provider in non-emergency situations Secondary 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) 8

Two Dimensions to Consider Type 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) 9

Primary Care Three key elements ◦ Point of Entry ◦ Coordination of Care ◦ Essential Care 10

Point of Entry First contact with health care system Gatekeepers ◦ Patients come “through” primary care physicians to hospitals and specialists  Con: Limits care?  Pro: Prevents unnecessary care? 11

Coordination of Care PCPs coordinate delivery of care from many sources Patient advisors, patient advocates Ensure continuity and comprehensiveness The Evidence ◦ this works (better health outcomes) ◦ people prefer it (patient satisfaction) 12

Ideal Attributes of Primary Care Integrated Coordinating Continuity of care Accessibility Accountability ◦ For both patients and providers 13

Primary Care Tools Clinical guidelines Disease management Case management Pharmacy care management Others 14

Who Provides Primary Care? Physicians Extenders Nurses Ancillary Alternative providers 15

Physicians PCPs (Primary Care Physicians) Typically… ◦ Family Practice ◦ General Internal Medicine ◦ General Pediatrics ◦ Obstetrics & Gynecology Controversy ◦ Who? ◦ Specialized primary care training? 16

Extenders & Non-physician Practitioners Nurse Practitioners Physician Assistants Nurse Midwives Other Health Care Providers 17

Trends Historically ◦ 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 18

HC Reform & Primary Care Patient Centered Medical Home (PCMH) Community Health Focus More grant funding & payments for PC training Increased Medicare reimbursements for PCPs 19

Conclusion Will 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 20

Master of Health Administration, MHA Health Management & Policy Concentration of MPH PhD in Health Services Research 21