HA 3308 Ch. 5-6

Ambulatory Care

- Outpatient care, not spending 2 nights in the hospital - Ambulation: Walking Trends: - People want fast care, and retail ambulatory care is just that. Physicians are opening up ambulatory care centers, competing with hospitals. - Free-standing ERs are owned by doctors. - Urgent care setters are owned by Hospitals.

Integrated Ambulatory Care Models

- Piecework Reimbursement: Service, rather than patient-focused. (Traditionally used) ACA promoted: -Patient-Centered Medical Homes: Described as the "main policy vehicle to reinvigorate U.S. primary care." Is is a "team-beaded model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes." -Accountable Care Organizations

Clinical Observation Units (COU)

A fix to crowding. COUs use a period of 6-24 hours to triage, diagnose, treat, and monitor patient responses while common complaints such as chest pain, abdominal pain, cardiac arrhythmias, and congestive heart failure are assessed.

ACGME (Accreditation Council for Graduate Medical Education)

Accredits residencies and fellowships

ABMS

American Board of Medical Specialties—certification by passing a board examination.

State Innovative Initiative (SIM)

CPC created this, Under the CPC's State Innovation Models (SIM) Initiative, the Centers for Medicare and Medicaid Services (CMS) awarded nearly $300 million to 25 states to design or test innovative healthcare payment and service delivery models. (Promotes designing and testing healthcare payment and service delivery models)

Urgent Care Association of America (UCAOA)

Describes urgent care as "health care provided on a walk-in, no-appointment basis for acute illness or injury that is not life or limb threatening, and is either beyond the scope or availability of the typical primary care practice or retail clinic."

ED crowding

Due to increased ED use and decrease of EDs.

The "Outcome Project"

Initiated in 1998, the ACGMA made major changes in how the nation's medical residency programs are accredited through an outcomes-based evaluation system. The new system measures medical residents' competencies in performing essential tasks necessary for clinical practice today.

What are retail clinics?

Limited scope healthcare delivery sites located in retail settings and staffed by mid-level providers. (e.i. CVS, Walmart)

Next Generation ACO (NGACO)

Next Generation ACO (NGACO)—includes 21 organizations experienced with care coordination through current and prior ACO initiatives and whose providers are prepared to assume greater financial risks in exchange for higher financial rewards.

Multi-Payer Advanced Primary Care Practice Demonstration (MAPCP)

One of the Center of Medicare and Medicaid Innovation's (CMMI) projects, is a state-led multi-payer collaboration to help primary care practices transform into medical homes. Through MAPCP, Medicare participates in eight existing state multi-payer health reform initiatives that include both Medicaid and private payers. The program pays a monthly care management fee for beneficiaries served by advanced primary care practices to cover costs of care coordination, improved access, patient education, and other services that support chronically ill patients.

Freestanding

Owned, operated by hospitals, physician groups, for-profit, not-for-profit entities, or corporate chains Emergency Centers and Urgent care centers - Retail clinics - Ambulatory surgery centers - Federally qualified health centers - Public health ambulatory services - Not-for-profit agencies • Most free-standing ERs are owned by doctors • Free-standing ERs need 24-7 doctor and equipment, making them hard to make profit. • Many rural/poor have FQHCs

Emergency Severity Index (ESI)

a standardized system for evaluating patient condition upon ED arrival to determine the time frame in which patients require intervention. ◦ (1) immediate, (2) emergent (1-14 minutes), (3) urgent (15-60 minutes), (4) semi-urgent (1-2 hours), (5) non-urgent (2-24 hours).

Maintenance of Certification (MOC)

includes ongoing, required educational programs and recertification examinations every ten years in each of the specialties and subspecialties in which a physician is certified. ABMS ensure performance through this.

Why do hospitals offer emergency services? • What percentage of the visits are clearly inappropriate?

• 8% of ERs visits are inappropriate. • Physician referral: due to their office being closed. "If this is an emergency, go to the ER"

What are not-for-profit agency ambulatory services? What are examples?

• Most of healthcare is non-profit, their mission is to provide service. • Planned Parenthood • Alzheimer's association.

By 2012, almost 2/3 of physicians in practice? group practices, ranging from 2-11 members, what are the advantages to a group practice?

- Reduced overhead cost, and shared responsibility.

Comprehensive Primary Care (CPC)

Another CMMI project, its a multi-player initiative which promotes collaboration Between public and private healthcare payers to strengthen primary care.

The agency for Health Care Policy and Research (Now the Agency for Healthcare Research and Quality (AHRQ)

Congress created this in 1989, The agency was directed to fund outcomes and health services research to start developing practice guidelines. After a slow start, the agency began releasing practice guidelines for specific conditions. For a clinical practice guideline to be considered for AHRQ approval it must meet these criteria: ◦ The guideline must contain systematically developed recommendations, strategies, or other information to assist healthcare decision-making in specific clinical circumstances. ◦ The guideline must have been produced under the auspices of a relevant professional organization (e.g., medical specialty society, government agency, healthcare organization, or health plan). ◦ The guideline development process must have included a verifiable, systematic literature search and review of existing evidence published in peer-reviewed journals. ◦ The guideline must be current and the most recent version (i.e., developed, reviewed, or revised within the last five years).

Patient-Centered Primary Care Collaborative (PCPCC)

Created to advocate for improvement in the primary care delivery model. The 2012 PCPCC report notes that 30 publications indicate that medical home drives reductions in healthcare costs and/or unnecessary utilization such as ED visits, hospitalizations, and readmissions. (AAFP says we need more info to come to a conclusion)

What is the "safety-net" in medical care?

For those who cant afford health insurance, the ER is used as primary care.

What's Newday?

In December 1991, the publication Newsday reported the first information regarding physician performance ever made public.

What had a powerful influence in the movement toward ambulatory?

Managed care

Accreditation vs. Certification

Organizations: are accredited (voluntary) and licensed (regulated by state) Individuals: Are certified (voluntary, employers use this to see if you;be learned) and licensed.

What are Public Health Ambulatory Services?

Outpatient preventative services facility. • 90% do immunizations (primary role) • 83% to TB screening • 64% do STD screening ect.

Association of American Medical Colleges (AAMC)

The organization established in 1876 to standardize the curriculum for medical schools in the United States and to promote the licensure of physicians. (Accredits medical schools)

ACA budget-authorized primary care objectives

This allocates money to three initiatives: National Health Service Corps (support providers with scholarships and loan repayments if they agree to work in underserved areas), Targets Graduate Medical Education (GME) to support training for medical residents. And increases reimbursements for Medicaid primary care.

What are Federally Qualified Health Centers?

a community-based organization that provides comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay or health insurance status. • 1,300 in the U.S. • 22 million patients a year

clinical practice guidelines

systematically developed protocols used to assist practitioner and patient decisions about appropriate health care by defining the roles of specific diagnostic and treatment modalities in patient diagnosis and management.

What is the history of ambulatory services of hospitals? • What is the trend of ambulatory services of hospitals?

• 1900, dispensary serving the poor. • Hospital outpatient has been most predominant for poor people. • Hospital ERs contribute 45% of revenues, because they are a way to get them in. • Outpatient has been going up, except for the last two years due to retail medicine. • ERs are: community safety nets • Texas requires every hospital to have an ER

What has led to hospitals wanting to buy physician practices? What are the problems associated with this?

• 1990s: Hospitals went through a phase of buying practices. The hospitals would buy a building, doctors retire, and patients scatter. Left with an empty building you paid too much for. • Now: you have to sign a non-compete clause and that you have to stay in practice for how long I say. • PRIVIA: management group, helps manage practices with a fee, doctors only practice medicine.

What is an Accountable Care Organization ( ACO)?

• A group of providers that are accountable for your care. Rooted in a hospital. • Seton in Austin was the pioneer ACO • ACO will receive a check form Medicare every month for all of your healthcare needs. • 1/3 are ran by physicians, 2/3 ran by hospital administrators. • Most ACOs are given incentives for doing a good job. (One sided risk) • Two-sided risks are an award for doing it right and a punishment for doing it wrong.

What is a Patient-Centered Medical Home?

• A team-based care model lead by the physician • Focuses on the family along with patient (social determinants of disease) • Treating the entire family. • Associated with doctors office.

What was the reaction to the Committee Report on the Costs of Medical Care: 1930s- 1950s

• AMA report condemned group practice, and that salaried physicians were unethical. The group practice gets between the doctor and their patient. • The Practice Act: Doesn't allow a practicing physician to be employed • AMA is against employment of doctors • Older doctors would not like being employed. • Most young/female doctors want to be employed.

What was medical education like during colonial America or the 19th century?

• Before the 1850s, we didn't even have med schools. • It was originally an apprenticeship • Early docs were those who had sharp objects and alcohol. • Mentors are meant to criticize and protect you. • Formal physicians came from Europe • Harvard was the first to provide a 4 year medical degree • JAMA started publishing for doctors

What are other examples of ambulatory care practitioners?

• Dentists • Physical therapists • Nutritionists • Nurse Practitioners

What are the typical ambulatory care settings?

• Doctor's office (trillion visits a year, 70% are unnecessary) • ER • Free-standing facilities

• In recent years, physicians chose employment by hospitals over private practice: - What is employment? - What is the advantage of employment to the physician? - What is the advantage of employment to the hospital?

• Employment: Employers are responsible for taxes, but doctors are independent contractors. - Being employed provides stability for the physician • Hospitals would better be able to control the doctors if they are employed. • States can change their practice act • MD practice act dictates the rest of the acts (it is at the top) • Every 2 years, labs techs are credited instead of licensed. (So doctors dont have to pay more)

Public Health Ambulatory Services

• Focus on prenventative health, family planning, and controlling substances. • Historically, support for ambulatory public health services has included combinations of city, county, and state funding, plus federal and state disease-specific or block grant funds. • Public health ambulatory services staff may include physicians, nurses, aides, social workers, public health educators, community health workers, and clerical and administrative staff, who function under the overall administrative direction of a local health officer. • Usually connected to LHDs

What are the problems associated with traditional ambulatory care models?

• How do we reimburse them? Historically piecemeal (fee for service) • Repeat visits • Payment and provision of service: Getting paid for the correct delivery of service.

When did prospective payment come about?

• In 1983, prospective hospital reimbursement replaced retrospective payment via Medicare's initiation of the diagnosis-related group system (DRG).

In 1991, what did Pew Charitable Trusts predict?

• In 1991, Pew Charitable Trusts predicted that disease prevention would characterize future healthcare systems.

When did physicians start transitioning from solo practice to group practice? Why?

• Late 1800s, accelerated in the 1960s— • Wanted better quality of life

There are two types of physicians: what are they?

• MDs and DOs. DOs have the same kind of training, but emphasize prevention.

The 1991 Pew Charitable Trust reports predicted that disease prevention would drive future healthcare. Why have physicians resisted prevention in their education and practice?

• MDs treat you after getting sick, but never really done much for prevention. • Sick people means profit. • We have never reimbursed doctors for preventing sickness, only after. We need incentive (capitation: only receive $50 monthly per patient—more appointments = loss of more cash)

What are ambulatory surgery centers?

• Mainly driven by surgeons, they have moved their practice outside the hospital. • Higher patients satisfaction, and physicians are paid more. • In Ambulatory centers, the co-pay is collected the then and there. (It directly affects the salary of the surgeon) • Do it better than hospitals

What are evidence-based clinical practice guidelines and why are they important?

• Making decisions based on the evidence. • Doctors and managers are becoming researchers. • Protocols: The researched way to treat a patient. what makes patients healthier? • Without protocols, comes customization, and is therefore more expensive. • Helps prevent malpractice if you practice protocol.

When did physicians start moving from solo practice to group practice?

• Mayo and Cleveland Clinic in the late 1800s. • Started to accelerate in the 1960s—now. • Advantages: Dont have to do everything themselves, share responsibility, indirect expenses, and flexible scheduling.

Two major physician concerns in the changing healthcare system cause ethical issues. What are they?

• Medical care use: how much authority should an insurance company have in purchasing for things? • Technology advancement: To what extent should we use it?

International Medical Graduates (IMGs)

• More hospitals depend on International Medical Graduates (IMGs) to help fill their residency positions, now, only 25% of residences are filled by IMGs. • Most foreign physicians gain entry to U.S. Healthcare by attending residency here. • IMGs must pass a clinical skill assesment before being accepted into residency. (This dropped the #)

What is the predominant ambulatory care setting?

• Physician office visits (trending down) • 56% are primary care visits

Why are malpractice costs escalating and what care America do about it?

• Protocols • Tort law (is civil law): someone else comes agianst you, malpractice is this. • Tort reform: Limits the amount of peunitive costs (charging for mistake itself, punishment) Texas limited cost to $600,000. • Compensatory costs: cost to fix the problem. (I.e. Prostatic, hospital stay) • Some states have aggressive tort reform, due to this, Texas has lower malpractice insurance because they are sued for only a limited amount.

What is telehealth? While efficient, why has adoption been slow?

• Telehealth, enhancing healthcare using telecommunication strategies. • Not everyone has broad band access and reimbursement is poor.

Accountable Care Organization (ACO)

• The ACA adopted the ACO model, which is a group of providers and suppliers involved in patient care that work together to coordinate care for the patients they serve under the traditional Medicare fee-for-service program. • ACOs are designed to ensure care coordination so that all patients receive timely and appropriate care and avoid unnecessary duplication of services.

Patient-Centered Medical Homes (PCMHs)

• The PCMH embodies a philosophy of advanced primary care (APC) based on the 5 core principles below, which address the Institute for Healthcare Improvement "Triple Aim" of improved population health, improved patient experience of care, and reductions in per-capita costs: ◦ The PCMH supports patients leaning to manage their care and to participate in quality-improvement research, and helath policy efforts. ◦ Comprehensive: The PCMH offers holistic care from a team of providers that are responsible for all of the patients' health needs. ◦ Coordinated: The PCMH ensures that care is organized across all elements of the broader healthcare system. (Elements of the broader healthcare system are referred to as the "medical neighborhood.") ◦ Accessible: The PCMH delivers accessible service with shorter waiting times, 27/7 telephone access, and alternative methods of communication through HIT. ◦ Committed to Quality and Safety: The PCMH demonstrates commitment to quality improvement and the use of data and health information technology and other tools to assist patients and families making informed decisions about their health.

What was the first law concerning medicine?

• The first law concerning medicine was enacted in Virginia in 1639 to control physician fees.

The Primary Care Incentive Payment Program

• Through The Primary Care Incentive Payment Program, the ACA provided a 10% Medicare payment bonus from 2011 to 2015 for physicians, nurse practitioners, clinical nurse specialists, and physician assistants for whom primary care services account for at least 60 percent of their Medicare charges.

What are urgent care centers?

• Urgent care (Not 'as serious' cases) vs. free-standing ER (Just like a hospital-based ER) • Urgent care centers may go down once doctors expand their hours. • After hours office

Physicians get their information about new medical findings through?

• physicians often rely on what is termed "point of care knowledge resources" or expert summaries of the latest medical evidence, indexed by topical area and targeted for clinicians caring for patients. • Ironically, the vast majority of peer-reviewed biomedical journals are not freely available on the Internet and require subscription fees for access. • The 2009 NIH Public Access Policy requires authors of all scientific papers on NIH-funded research that are published in the peer-reviewed biomedical journals to deposit their accepted manuscripts in a repository maintained by the National Library of Medicine that is freely searchable on the Internet. • The repository, PubMed Central, is distinct from PubMed that only indexes the articles and does not contain the full articles.