Faculty of Medicine University of Jaffna Sri Lanka Policy Work Paper

Policy work requires shared information, knowledge, effective communication, and professionalism. Core competencies for policy professionals include the ability to engage in critical thinking, define problems and communicate findings to a variety of audiences. The purpose of the policy brief is to help you sharpen these skills and methodically apply them to your coursework and class discussions. The length of your brief should not exceed three (4) pages.  Chapter 7
Outpatient and
Primary Care
Services
Learning Objectives
• Outpatient, ambulatory, and primary care
• Principles behind patient-centered medical
homes and community-based primary care
• Reasons for dramatic growth in outpatient
services
• Various types of outpatient settings and services
• Role of complementary and alternative medicine
• Primary care delivery in other countries
• Impact of ACA on primary care
Introduction
• The terms outpatient and ambulatory are
used interchangeably.
• Hospitals provided majority of outpatient
care.
• Independent providers faced capital
constraints.
• Consumer demand fueled growth of
complementary and alternative medicine.
• ACA addresses access for poor and vulnerable.
What Is Outpatient Care?
• Outpatient services or ambulatory care
• Ambulatory care
– Diagnostic and therapeutic services for the
walking patient
– Used synonymously with community medicine
• Outpatient services
– Services not provided with an overnight stay
Scope of Outpatient Services
• Primary care is the foundation for ambulatory
health services.
• Services other than primary care are an
integral part of outpatient services.
• Technological advances allow treatments to
be provided in ambulatory care settings.
Table 7-1: Owners, Providers, and Settings
for Ambulatory Care Services
Data from Barr, K. W., and C. L. Breindel. 2004. Ambulatory care. In: Health care administration: Planning, implementing, and managing organized
delivery systems. L. F. Wolper, ed. 4th ed. Burlington, MA: Jones & Bartlett Learning. pp. 507–546.
Primary Care
• Plays a central role in a health care delivery
system.
• Distinguished from secondary and tertiary
care by duration, frequency, and intensity.
• Secondary and tertiary care are more complex
and specialized.
Secondary Care
• Usually short term
• Sporadic consultation from a specialist
• Includes hospitalization
• Routine surgery
• Specialty consultation
• Rehabilitation
Tertiary Care
• Most complex level of care
• Uncommon conditions
• Institution based
• Highly specialized
• Technology-driven
• Rendered in large teaching hospitals
Health Care Service Frequency
• Primary care
– 75−85% of population requires only primary care
• Secondary care
– 10−12% requires referral to short-term secondary
care
• Tertiary care
– 5−10% require tertiary care
World Health Organization Definition
• World Health Organization (WHO, 1978)
• Three elements for understanding primary
care
1. Point of entry
2. Coordination of care
3. Essential care
Institute of Medicine Definition
• IOM defined primary care
– Comprehensively addresses any health problem at
any stage of patient’s life
– Coordination ensures a combination of health
services to best meet the patient’s needs
– Continuity of care administered over time
– Emphasizes accessibility and accountability
Primary Care and the Affordable Care Act
• Four primary care provisions
– Increased Medicare and Medicaid payments
– New incentives for primary care providers
working in underserved areas
– Expansion of the health center program and
strengthening of the capacity of health centers
– Creation of additional training programs
New Directions in Primary Care
(1 of 2)
• Patient-centered medical homes (PCMH)
– Team-oriented approach for special-needs
children requiring constant care coordination
– Initially consisted of an interdisciplinary team of
physicians and allied health professionals
– Studies demonstrated a positive impact
– PCMH assessment tools
New Directions in Primary Care
(2 of 2)
• Community-oriented primary care elements
– Reducing exclusion and social disparities
– Organizing health services around people’s needs
– Integrating health into all sectors
– Pursuing collaborative models of policy dialogue
– Increasing stakeholder participation
Primary Care Providers
• U.S. primary care practitioners
– Not restricted to physicians trained in general and
family practice
– Includes internal medicine, pediatrics, and
obstetrics and gynecology
• Nonphysician practitioners (NPPs)
– Nurse practitioners (NPs), physician assistants
(PAs), and certified nurse-midwives (CNMs)
Growth in Outpatient Services
• Reimbursement
• Technological factors
• Utilization control factors
• Physician practice factors
• Social factors
Figure 7-2: Percentage of total surgeries
performed in outpatient departments of
U.S. community hospitals, 1980–2013.
Data from National Center for Health Statistics. 2016. Health, United States, 2015. U.S. Department of Health and Human Services. p. 281.
Types of Outpatient Care Settings and
Methods of Delivery (1 of 6)
• Private practice
• Hospital-based services
– Clinical services
– Surgical services
– Emergency services
– Home health care
– Women’s services
Types of Outpatient Care Settings and
Methods of Delivery (2 of 6)
Figure 7-3 Growth in the number of
medical group practices in the
United States.
Data from Medical Group Management Association. Medical group fast
facts. Available at: http://www.mgma.com/uploadedFiles/Store_Content
/Surveys_and_Benchmarking/8523-Table-of-Content-MGMA
-Performance-and-Practices-of-Successful-Medical-Groups.pdf; SK&A
. 2016. Medical group practice list. http://www.skainfo.com/databases
/medical-group-practice-list. Accessed January 2016; VHA Inc. and Deloitte
& Touche. 1997. Environmental assessment: Redesigning health care for the
millennium. Irving, TX: VHA Inc.; SMG Solutions. 2000. Report and directory:
Medical group practices. Chicago, IL: SMG Solutions.
Figure 7-4 Ambulatory care visits in the
United States.
Data from National Center for Health Statistics. 2016. Health, United States, 2015.
U.S. Department of Health and Human Services. p. 265.
Types of Outpatient Care Settings and
Methods of Delivery (3 of 6)
• Freestanding facilities
– Walk-in clinics
– Urgent care centers
– Surgicenters
• Retail clinics
• Mobile medical, diagnostic, and screenings
– EMTs and paramedics
Types of Outpatient Care Settings and
Methods of Delivery (4 of 6)
• Home health care
• Hospice services
– Comprehensive services for terminally ill with life
expectance of 6 months or less
– Palliation with psychosocial and spiritual support
– Specific conditions for Medicare certification
Figure 7-6: Demographic characteristics of
U.S. home health patients, 2013.
Data from Alliance for Home Health Quality and Innovation. 2015. Home Health Chartbook 2015. Available at:
http://ahhqi.org/images/uploads/AHHQI_2015_Chartbook_FINAL_October_Aug2016Update.pdf. Accessed February 2017.
Figure 7-7: Estimated payments for home
care by payment source, 2014.
Data from National Center for Health Statistics. 2016. Health, United
States, 2015. U.S. Department of Health and Human Services. p. 298.
Table 7-4: Home Health and Hospice Care
Patients Served at the Time of the
Interview, by Agency Type and Number of
Patients in the United States, 2007.
Reproduced from Park-Lee E.Y., and F. H. Decker. 2010. Comparison of home and hospice care agencies by organizational characteristics and services provided: United States, 2007.
National Health Statistics Reports no. 30: 1–23.
Types of Outpatient Care Settings and
Methods of Delivery (5 of 6)
• Ambulatory long-term care services
– Nursing homes
– Case management
– Adult day health care
• Public health services
• Community health centers
Types of Outpatient Care Settings and
Methods of Delivery (6 of 6)
• Three characteristics of free clinics
– Services provided at no charge or nominal charge
– Clinic not directly supported or operated by a
government agency
– Services delivered by trained volunteer staff
• Other clinics
• Telephone access
Complementary and Alternative Medicine
(CAM) (1 of 2)
• Reasons for CAM growth
– Most seek CAM therapies following Western
treatments that have not helped
– Want to avoid/delay complex surgeries or toxic
allopathic treatments
– Feel in control when empowered with medical
and health-related information
– Want practitioners to take time to listen to them
Complementary and Alternative Medicine
(CAM) (2 of 2)
• National Center for Complementary and
Alternative Medicine’s (NCCAM) objectives
1. Explore complementary and alternative healing
practices in the context of rigorous science
2. Train complementary and alternative medicine
researchers
3. Disseminate authoritative information to the public
and professionals
Utilization of Outpatient Services
(1 of 3)
• Visits to physicians
– Physicians in general and family practice (22.8%)
– Physicians in internal medicine (13.6%)
– Pediatrics (11.1%)
– Obstetrics and gynecology (6.4%)
– Doctors of osteopathy (6.7%)
Utilization of Outpatient Services
(2 of 3)
Utilization of Outpatient Services
(3 of 3)
Reproduced from Centers for Disease Control and Prevention (CDC). 2013. National Ambulatory Medical Care Survey: 2013 summary tables. Available at:
https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2013_namcs_web_tables.pdf. Accessed April 2017.
Table 7-6: Principal Reason for Visiting a
Physician
“Modified from Centers for Disease Control and
Prevention (CDC). 2013. National Ambulatory
Medical Care Survey: 2013 summary tables.
Available at:
https://www.cdc.gov/nchs/data/ahcd/namcs_sum
mary/2013_namcs_web_tables.pdf. Accessed April
2017.”
Primary Care in Other Countries
(1 of 2)
• United Kingdom
– Most comprehensive coverage with little or no
patient cost sharing
• Canada
– Covers physician visits but medication coverage
varies
• Australia, New Zealand, and Germany
– Varying degrees of cost sharing
Primary Care in Other Countries
(2 of 2)
• Australia, Canada, France, Germany,
Switzerland, and the U.S.
– Payers typically use fee-for-service payments
– Employ performance incentives
• Mostly privatized in all countries mentioned
except Iceland and Sweden
Summary
• Ambulatory services increased outside the
hospital setting.
• Ambulatory services transcend basic and
routine primary care services.
• Primary care has become specialized.
• Numerous outpatient services have emerged.
• A variety of settings for services have
developed.
Chapter 8
Inpatient Facilities
and Services
Learning Objectives
(1 of 2)
• Perspective on hospital evolution
• Factors contributing to hospital growth prior
to the 1980s
• Reasons for the decline of hospitals and their
utilization
• Measures pertaining to hospital operations
and inpatient utilization
• Compare utilization measures in U.S. hospitals
to other countries
Learning Objectives
(2 of 2)
• Differentiate among various types of hospitals
• How the ACA affected physician-owned
specialty hospitals and nonprofit hospitals
• Basic concepts in hospital governance
• Understand licensure, certification, and
accreditation and the Magnet Recognition
Program
• Get a perspective on ethical issues
Introduction
• Inpatient requires overnight stay in a facility
• Hospital
– Institution with at least six beds
– Delivers services including diagnostics and
treatment
– Evolved from institutions of refuge for homeless
and poor
– Ultramodern facilities providing advanced services
Hospital Transformation in the U.S.
• Five functions in the evolution of hospitals
1. Primitive institutions of social welfare
2. Distinct institutions of care for the sick
3. Organized institutions of medical practice
4. Advanced medical training and research
5. Consolidated systems of health services delivery
Expansion Phase: Late 1800s to Mid-1980s
• Development of professional nursing
• Growth of private health insurance
• Role of government
– Hill-Burton Act
– Public health insurance
Figure 8-1: Trends in the number of U.S.
community hospital beds per 1,000
resident population.
Data from National Center for Health Statistics. 2002. Health, United
States, 2002. Hyattsville, MD: U.S. Department of Health and Human
Services. p. 281; National Center for Health Statistics. 2016. Health, United
States, 2015. Hyattsville, MD: U.S. Department of Health and Human
Services. p. 289.
Downsizing Phase: Mid-1980s Onward
• Average hospital has become smaller.
• Shift from inpatient to outpatient care.
• Changes in reimbursement.
• Impact of managed care.
• Hospital closures
– Since 2000 many government-run hospitals
closed.
Figure 8-3: Ratio of hospital outpatient
visits to inpatient days for all U.S. hospitals,
1980–2013 (selected years).
Data from National Center for Health Statistics. 2002. Health, United
States, 2002. Hyattsville, MD: Department of Health and Human Services.
p. 110; National Center for Health Statistics. 2013. Health, United States,
2012. Hyattsville, MD: Department of Health and Human Services. p. 307;
National Center for Health Statistics. 2016. Health, United States, 2015.
Hyattsville, MD: Department of Health and Human Services. p. 281.
Some Key Utilization Measures and
Operational Concepts
• Discharges
• Inpatient days
• Average length of stay
– Hospital access and utilization: comparative data
• Capacity
• Average daily census
• Occupancy rate
Table 8-2: Ratio of hospital outpatient visits
to inpatient days for all U.S. hospitals,
1980–2013 (selected years).
Modified from Weiss, A. J., and A. Elixhauser. 2014. Overview of hospital stays in the United States, 2012 (Statistical Brief #180). Rockville, MD: Agency
for Healthcare Research and Quality. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb180-Hospitalizations-United-States-2012.pdf.
Accessed May 2017.
Figure 8-5: Average lengths of stay by U.S.
hospital ownership (selected years).
Data from National Center for Health Statistics. 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 307;
National Center for Health Statistics. 2016. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 281.
Figure 8-6: Breakdown of U.S. community
hospitals by size, 2013.
Data from National Center for Health Statistics. 2016. Health, United States,
2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
Figure 8-7: Change in occupancy rates in
U.S. community hospitals, 1960–2013
(selected years).
Data from National Center for Health Statistics. 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 314;
National Center for Health Statistics. 2016. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
Factors That Affect Hospital Employment
• Hospitals accounted for largest number of jobs in
the health care industry in 2013.
– Workforce represented roughly 39% of total health
care employment.
– More than 6 million people are employed by U.S.
hospitals.
• Changes in reimbursement policy can affect
employment.
• Cannot outsource health care jobs because they
generally require personal interaction.
Hospital Costs
• Inpatient hospital services are the largest
share of total U.S. health care expenditures.
• Medicare and Medicaid payments.
• Rise in bad debts.
• International cost comparisons.
Figure 8-8 Proportion of total U.S. hospitals
by type of hospital, 2014.
Data from Health Forum. 2016. Fast facts on U.S. hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed October 30, 2016.
Types of Hospitals
(1 of 4)
• Classification by ownership
– Public hospitals
– Private nonprofit hospitals
– Private for-profit hospitals
• Classification by public access
• Classification by multiunit affiliation
Figure 8-9: Breakdown of U.S. community
hospitals by types of ownership, 2013.
Data from National Center for Health Statistics. 2016. Health, United States,
2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
Table 8-6: The Largest U.S. Multihospital
Chains, 2014
Data from Sanofi-Aventis. 2016. Managed care digest series: Hospital/systems digest, 2016. Bridgewater, NJ: Author.
Types of Hospitals
(2 of 4)
• Classification by type of service
– General hospitals
– Specialty hospitals
– Physician-owned specialty hospitals
– Psychiatric hospitals
– Rehabilitation hospitals
– Children’s hospitals
Types of Hospitals
(3 of 4)
• Classification by length of stay
– Short-stay hospitals
– Long-term care hospitals
• Classification by location
– Swing-bed hospitals
– Critical access hospitals
– Other rural designations
Types of Hospitals
(4 of 4)
• Classification by size
• Other types of
hospitals
Figure 8-6 Breakdown of U.S.
community hospitals by size, 2013.
– Teaching hospitals
– Church-affiliated
hospitals
– Osteopathic hospitals
Data from National Center for Health Statistics. 2016. Health, United States,
2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
Expectations for Nonprofit Hospitals
(1 of 2)
• Internal Revenue Code, Section 501(c)(3)
– Grants tax-exempt status to nonprofit
organizations
– Institutions are exempt from federal, state, and
local taxes
• Nonprofit organizations
– Provide some defined public good
– Do not distribute any profits to any individuals
Expectations for Nonprofit Hospitals
(2 of 2)
• Nonprofit institutions face new ACA demands
1. Establish written financial assistance and
emergency care policies.
2. Limit charges for those eligible for assistance
under hospital’s financial assistance policy.
3. Limit billing and collection actions against those
within the guidelines of financial assistance.
4. Conduct a community health needs assessment.
Some Management Concepts
• Hospital’s organizational structure differs from
other large business organizations.
• Hospital governance
– See Figure 8-10
– Board of trustees
– Chief executive officer
– Medical staff
Licensure, Certification, and Accreditation
• State governments oversee the licensure of
health care facilities.
• Certification allows a hospital to participate in
Medicare and Medicaid programs.
• Accreditation is designed to ensure facilities
meet certain basic standards.
Magnet Recognition Program
• Designation conferred by the American Nurses
Credentialing Center
– Affiliate of the American Nurses Association
• Recognizes
– Quality patient care
– Nursing excellence
– Innovations in professional nursing practice in
hospitals
Ethical and Legal Issues in Patient Care
• Principles of ethics
• Legal rights
– Bill of rights and informed consent
– Advance directives
• DNR
• Living will
• Durable power of attorney
• Mechanisms for ethical decision making
Summary
• Almshouses and pesthouses evolved into
public hospitals to serve the poor.
• Key measures of inpatient utilization.
• Hospitals are classified in numerous ways.
• ACA restrictions.
• Ethical decision making has been a special
area of concern for hospitals.
Chapter 7
Outpatient and
Primary Care
Services
Learning Objectives
• Outpatient, ambulatory, and primary care
• Principles behind patient-centered medical
homes and community-based primary care
• Reasons for dramatic growth in outpatient
services
• Various types of outpatient settings and services
• Role of complementary and alternative medicine
• Primary care delivery in other countries
• Impact of ACA on primary care
Introduction
• The terms outpatient and ambulatory are
used interchangeably.
• Hospitals provided majority of outpatient
care.
• Independent providers faced capital
constraints.
• Consumer demand fueled growth of
complementary and alternative medicine.
• ACA addresses access for poor and vulnerable.
What Is Outpatient Care?
• Outpatient services or ambulatory care
• Ambulatory care
– Diagnostic and therapeutic services for the
walking patient
– Used synonymously with community medicine
• Outpatient services
– Services not provided with an overnight stay
Scope of Outpatient Services
• Primary care is the foundation for ambulatory
health services.
• Services other than primary care are an
integral part of outpatient services.
• Technological advances allow treatments to
be provided in ambulatory care settings.
Table 7-1: Owners, Providers, and Settings
for Ambulatory Care Services
Data from Barr, K. W., and C. L. Breindel. 2004. Ambulatory care. In: Health care administration: Planning, implementing, and managing organized
delivery systems. L. F. Wolper, ed. 4th ed. Burlington, MA: Jones & Bartlett Learning. pp. 507–546.
Primary Care
• Plays a central role in a health care delivery
system.
• Distinguished from secondary and tertiary
care by duration, frequency, and intensity.
• Secondary and tertiary care are more complex
and specialized.
Secondary Care
• Usually short term
• Sporadic consultation from a specialist
• Includes hospitalization
• Routine surgery
• Specialty consultation
• Rehabilitation
Tertiary Care
• Most complex level of care
• Uncommon conditions
• Institution based
• Highly specialized
• Technology-driven
• Rendered in large teaching hospitals
Health Care Service Frequency
• Primary care
– 75−85% of population requires only primary care
• Secondary care
– 10−12% requires referral to short-term secondary
care
• Tertiary care
– 5−10% require tertiary care
World Health Organization Definition
• World Health Organization (WHO, 1978)
• Three elements for understanding primary
care
1. Point of entry
2. Coordination of care
3. Essential care
Institute of Medicine Definition
• IOM defined primary care
– Comprehensively addresses any health problem at
any stage of patient’s life
– Coordination ensures a combination of health
services to best meet the patient’s needs
– Continuity of care administered over time
– Emphasizes accessibility and accountability
Primary Care and the Affordable Care Act
• Four primary care provisions
– Increased Medicare and Medicaid payments
– New incentives for primary care providers
working in underserved areas
– Expansion of the health center program and
strengthening of the capacity of health centers
– Creation of additional training programs
New Directions in Primary Care
(1 of 2)
• Patient-centered medical homes (PCMH)
– Team-oriented approach for special-needs
children requiring constant care coordination
– Initially consisted of an interdisciplinary team of
physicians and allied health professionals
– Studies demonstrated a positive impact
– PCMH assessment tools
New Directions in Primary Care
(2 of 2)
• Community-oriented primary care elements
– Reducing exclusion and social disparities
– Organizing health services around people’s needs
– Integrating health into all sectors
– Pursuing collaborative models of policy dialogue
– Increasing stakeholder participation
Primary Care Providers
• U.S. primary care practitioners
– Not restricted to physicians trained in general and
family practice
– Includes internal medicine, pediatrics, and
obstetrics and gynecology
• Nonphysician practitioners (NPPs)
– Nurse practitioners (NPs), physician assistants
(PAs), and certified nurse-midwives (CNMs)
Growth in Outpatient Services
• Reimbursement
• Technological factors
• Utilization control factors
• Physician practice factors
• Social factors
Figure 7-2: Percentage of total surgeries
performed in outpatient departments of
U.S. community hospitals, 1980–2013.
Data from National Center for Health Statistics. 2016. Health, United States, 2015. U.S. Department of Health and Human Services. p. 281.
Types of Outpatient Care Settings and
Methods of Delivery (1 of 6)
• Private practice
• Hospital-based services
– Clinical services
– Surgical services
– Emergency services
– Home health care
– Women’s services
Types of Outpatient Care Settings and
Methods of Delivery (2 of 6)
Figure 7-3 Growth in the number of
medical group practices in the
United States.
Data from Medical Group Management Association. Medical group fast
facts. Available at: http://www.mgma.com/uploadedFiles/Store_Content
/Surveys_and_Benchmarking/8523-Table-of-Content-MGMA
-Performance-and-Practices-of-Successful-Medical-Groups.pdf; SK&A
. 2016. Medical group practice list. http://www.skainfo.com/databases
/medical-group-practice-list. Accessed January 2016; VHA Inc. and Deloitte
& Touche. 1997. Environmental assessment: Redesigning health care for the
millennium. Irving, TX: VHA Inc.; SMG Solutions. 2000. Report and directory:
Medical group practices. Chicago, IL: SMG Solutions.
Figure 7-4 Ambulatory care visits in the
United States.
Data from National Center for Health Statistics. 2016. Health, United States, 2015.
U.S. Department of Health and Human Services. p. 265.
Types of Outpatient Care Settings and
Methods of Delivery (3 of 6)
• Freestanding facilities
– Walk-in clinics
– Urgent care centers
– Surgicenters
• Retail clinics
• Mobile medical, diagnostic, and screenings
– EMTs and paramedics
Types of Outpatient Care Settings and
Methods of Delivery (4 of 6)
• Home health care
• Hospice services
– Comprehensive services for terminally ill with life
expectance of 6 months or less
– Palliation with psychosocial and spiritual support
– Specific conditions for Medicare certification
Figure 7-6: Demographic characteristics of
U.S. home health patients, 2013.
Data from Alliance for Home Health Quality and Innovation. 2015. Home Health Chartbook 2015. Available at:
http://ahhqi.org/images/uploads/AHHQI_2015_Chartbook_FINAL_October_Aug2016Update.pdf. Accessed February 2017.
Figure 7-7: Estimated payments for home
care by payment source, 2014.
Data from National Center for Health Statistics. 2016. Health, United
States, 2015. U.S. Department of Health and Human Services. p. 298.
Table 7-4: Home Health and Hospice Care
Patients Served at the Time of the
Interview, by Agency Type and Number of
Patients in the United States, 2007.
Reproduced from Park-Lee E.Y., and F. H. Decker. 2010. Comparison of home and hospice care agencies by organizational characteristics and services provided: United States, 2007.
National Health Statistics Reports no. 30: 1–23.
Types of Outpatient Care Settings and
Methods of Delivery (5 of 6)
• Ambulatory long-term care services
– Nursing homes
– Case management
– Adult day health care
• Public health services
• Community health centers
Types of Outpatient Care Settings and
Methods of Delivery (6 of 6)
• Three characteristics of free clinics
– Services provided at no charge or nominal charge
– Clinic not directly supported or operated by a
government agency
– Services delivered by trained volunteer staff
• Other clinics
• Telephone access
Complementary and Alternative Medicine
(CAM) (1 of 2)
• Reasons for CAM growth
– Most seek CAM therapies following Western
treatments that have not helped
– Want to avoid/delay complex surgeries or toxic
allopathic treatments
– Feel in control when empowered with medical
and health-related information
– Want practitioners to take time to listen to them
Complementary and Alternative Medicine
(CAM) (2 of 2)
• National Center for Complementary and
Alternative Medicine’s (NCCAM) objectives
1. Explore complementary and alternative healing
practices in the context of rigorous science
2. Train complementary and alternative medicine
researchers
3. Disseminate authoritative information to the public
and professionals
Utilization of Outpatient Services
(1 of 3)
• Visits to physicians
– Physicians in general and family practice (22.8%)
– Physicians in internal medicine (13.6%)
– Pediatrics (11.1%)
– Obstetrics and gynecology (6.4%)
– Doctors of osteopathy (6.7%)
Utilization of Outpatient Services
(2 of 3)
Utilization of Outpatient Services
(3 of 3)
Reproduced from Centers for Disease Control and Prevention (CDC). 2013. National Ambulatory Medical Care Survey: 2013 summary tables. Available at:
https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2013_namcs_web_tables.pdf. Accessed April 2017.
Table 7-6: Principal Reason for Visiting a
Physician
“Modified from Centers for Disease Control and
Prevention (CDC). 2013. National Ambulatory
Medical Care Survey: 2013 summary tables.
Available at:
https://www.cdc.gov/nchs/data/ahcd/namcs_sum
mary/2013_namcs_web_tables.pdf. Accessed April
2017.”
Primary Care in Other Countries
(1 of 2)
• United Kingdom
– Most comprehensive coverage with little or no
patient cost sharing
• Canada
– Covers physician visits but medication coverage
varies
• Australia, New Zealand, and Germany
– Varying degrees of cost sharing
Primary Care in Other Countries
(2 of 2)
• Australia, Canada, France, Germany,
Switzerland, and the U.S.
– Payers typically use fee-for-service payments
– Employ performance incentives
• Mostly privatized in all countries mentioned
except Iceland and Sweden
Summary
• Ambulatory services increased outside the
hospital setting.
• Ambulatory services transcend basic and
routine primary care services.
• Primary care has become specialized.
• Numerous outpatient services have emerged.
• A variety of settings for services have
developed.
Chapter 8
Inpatient Facilities
and Services
Learning Objectives
(1 of 2)
• Perspective on hospital evolution
• Factors contributing to hospital growth prior
to the 1980s
• Reasons for the decline of hospitals and their
utilization
• Measures pertaining to hospital operations
and inpatient utilization
• Compare utilization measures in U.S. hospitals
to other countries
Learning Objectives
(2 of 2)
• Differentiate among various types of hospitals
• How the ACA affected physician-owned
specialty hospitals and nonprofit hospitals
• Basic concepts in hospital governance
• Understand licensure, certification, and
accreditation and the Magnet Recognition
Program
• Get a perspective on ethical issues
Introduction
• Inpatient requires overnight stay in a facility
• Hospital
– Institution with at least six beds
– Delivers services including diagnostics and
treatment
– Evolved from institutions of refuge for homeless
and poor
– Ultramodern facilities providing advanced services
Hospital Transformation in the U.S.
• Five functions in the evolution of hospitals
1. Primitive institutions of social welfare
2. Distinct institutions of care for the sick
3. Organized institutions of medical practice
4. Advanced medical training and research
5. Consolidated systems of health services delivery
Expansion Phase: Late 1800s to Mid-1980s
• Development of professional nursing
• Growth of private health insurance
• Role of government
– Hill-Burton Act
– Public health insurance
Figure 8-1: Trends in the number of U.S.
community hospital beds per 1,000
resident population.
Data from National Center for Health Statistics. 2002. Health, United
States, 2002. Hyattsville, MD: U.S. Department of Health and Human
Services. p. 281; National Center for Health Statistics. 2016. Health, United
States, 2015. Hyattsville, MD: U.S. Department of Health and Human
Services. p. 289.
Downsizing Phase: Mid-1980s Onward
• Average hospital has become smaller.
• Shift from inpatient to outpatient care.
• Changes in reimbursement.
• Impact of managed care.
• Hospital closures
– Since 2000 many government-run hospitals
closed.
Figure 8-3: Ratio of hospital outpatient
visits to inpatient days for all U.S. hospitals,
1980–2013 (selected years).
Data from National Center for Health Statistics. 2002. Health, United
States, 2002. Hyattsville, MD: Department of Health and Human Services.
p. 110; National Center for Health Statistics. 2013. Health, United States,
2012. Hyattsville, MD: Department of Health and Human Services. p. 307;
National Center for Health Statistics. 2016. Health, United States, 2015.
Hyattsville, MD: Department of Health and Human Services. p. 281.
Some Key Utilization Measures and
Operational Concepts
• Discharges
• Inpatient days
• Average length of stay
– Hospital access and utilization: comparative data
• Capacity
• Average daily census
• Occupancy rate
Table 8-2: Ratio of hospital outpatient visits
to inpatient days for all U.S. hospitals,
1980–2013 (selected years).
Modified from Weiss, A. J., and A. Elixhauser. 2014. Overview of hospital stays in the United States, 2012 (Statistical Brief #180). Rockville, MD: Agency
for Healthcare Research and Quality. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb180-Hospitalizations-United-States-2012.pdf.
Accessed May 2017.
Figure 8-5: Average lengths of stay by U.S.
hospital ownership (selected years).
Data from National Center for Health Statistics. 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 307;
National Center for Health Statistics. 2016. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 281.
Figure 8-6: Breakdown of U.S. community
hospitals by size, 2013.
Data from National Center for Health Statistics. 2016. Health, United States,
2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
Figure 8-7: Change in occupancy rates in
U.S. community hospitals, 1960–2013
(selected years).
Data from National Center for Health Statistics. 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 314;
National Center for Health Statistics. 2016. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
Factors That Affect Hospital Employment
• Hospitals accounted for largest number of jobs in
the health care industry in 2013.
– Workforce represented roughly 39% of total health
care employment.
– More than 6 million people are employed by U.S.
hospitals.
• Changes in reimbursement policy can affect
employment.
• Cannot outsource health care jobs because they
generally require personal interaction.
Hospital Costs
• Inpatient hospital services are the largest
share of total U.S. health care expenditures.
• Medicare and Medicaid payments.
• Rise in bad debts.
• International cost comparisons.
Figure 8-8 Proportion of total U.S. hospitals
by type of hospital, 2014.
Data from Health Forum. 2016. Fast facts on U.S. hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed October 30, 2016.
Types of Hospitals
(1 of 4)
• Classification by ownership
– Public hospitals
– Private nonprofit hospitals
– Private for-profit hospitals
• Classification by public access
• Classification by multiunit affiliation
Figure 8-9: Breakdown of U.S. community
hospitals by types of ownership, 2013.
Data from National Center for Health Statistics. 2016. Health, United States,
2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
Table 8-6: The Largest U.S. Multihospital
Chains, 2014
Data from Sanofi-Aventis. 2016. Managed care digest series: Hospital/systems digest, 2016. Bridgewater, NJ: Author.
Types of Hospitals
(2 of 4)
• Classification by type of service
– General hospitals
– Specialty hospitals
– Physician-owned specialty hospitals
– Psychiatric hospitals
– Rehabilitation hospitals
– Children’s hospitals
Types of Hospitals
(3 of 4)
• Classification by length of stay
– Short-stay hospitals
– Long-term care hospitals
• Classification by location
– Swing-bed hospitals
– Critical access hospitals
– Other rural designations
Types of Hospitals
(4 of 4)
• Classification by size
• Other types of
hospitals
Figure 8-6 Breakdown of U.S.
community hospitals by size, 2013.
– Teaching hospitals
– Church-affiliated
hospitals
– Osteopathic hospitals
Data from National Center for Health Statistics. 2016. Health, United States,
2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
Expectations for Nonprofit Hospitals
(1 of 2)
• Internal Revenue Code, Section 501(c)(3)
– Grants tax-exempt status to nonprofit
organizations
– Institutions are exempt from federal, state, and
local taxes
• Nonprofit organizations
– Provide some defined public good
– Do not distribute any profits to any individuals
Expectations for Nonprofit Hospitals
(2 of 2)
• Nonprofit institutions face new ACA demands
1. Establish written financial assistance and
emergency care policies.
2. Limit charges for those eligible for assistance
under hospital’s financial assistance policy.
3. Limit billing and collection actions against those
within the guidelines of financial assistance.
4. Conduct a community health needs assessment.
Some Management Concepts
• Hospital’s organizational structure differs from
other large business organizations.
• Hospital governance
– See Figure 8-10
– Board of trustees
– Chief executive officer
– Medical staff
Licensure, Certification, and Accreditation
• State governments oversee the licensure of
health care facilities.
• Certification allows a hospital to participate in
Medicare and Medicaid programs.
• Accreditation is designed to ensure facilities
meet certain basic standards.
Magnet Recognition Program
• Designation conferred by the American Nurses
Credentialing Center
– Affiliate of the American Nurses Association
• Recognizes
– Quality patient care
– Nursing excellence
– Innovations in professional nursing practice in
hospitals
Ethical and Legal Issues in Patient Care
• Principles of ethics
• Legal rights
– Bill of rights and informed consent
– Advance directives
• DNR
• Living will
• Durable power of attorney
• Mechanisms for ethical decision making
Summary
• Almshouses and pesthouses evolved into
public hospitals to serve the poor.
• Key measures of inpatient utilization.
• Hospitals are classified in numerous ways.
• ACA restrictions.
• Ethical decision making has been a special
area of concern for hospitals.