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

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 1930s 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 Report

on 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 patients 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

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 communitys 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 Evolution1980s

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 nonurgent,
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

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 physicianownership; 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%:
75%:
59%:
55%:

childhood immunizations
tuberculosis treatment
treatments for STIs
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, Alzheimers
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