Ambulatory care healthcare

Before the 1980s, healthcare delivery concentrated

• around the community hospitals because hospitalization costs are very high, healthcare delivery has shifted from expensive inpatient hospital care to less costly care in outpatient settings.  

Ambulatory care

• Defined as “care for an individual presenting for personal health services, who is neither bedridden, nor currently admitted to any health care institution" 

Inpatient:

• patient who stays for one or more nights in a hospital to get a treatment

Outpatient:

• patient who goes to a doctor’s office or hospital for treatment and leaves within the same day

Private practice physicians:

independent doctors running their own business

Physicians affiliated with Managed care organizations (MCOs)

Doctors work as  part of a large, insurance-managed healthcare systems (health maintenance organization HMO, preferred provider organization PPO)

• Managed care organizations (MCOs)

• Decides which providers you can see, how much they get paid, and what services are covered to control and improve quality 

• Use provider networks (ex: Kaiser Permanente, Molina Healthcare, Community Health Plan)

HMO:Network

Must use in network providers (except in emergencies)

HMO:PCP

required

HMO:Referrals

Needed to see specialists

HMO:Cost

Usually lower premiums and lower OOP costs

HMO:Flexibility

Less flexible; must follow network rules

PPO:Network

Can use in network or out of network providers (out of network cost higher)

PPO:PCP

Usually not required; you can see specialists directly

PPO:Referals

not required

PPO:Cost

Usually higher premiums and higher OOP costs

PPO:Flexibility

More flexible, can see any doctor (higher cost if out-of-network)

Ambulatory surgery centers (ASC)

• Hospital based or free standing 

• Surgeries and procedures not requiring admission

• Patients receive surgery and return home the same day

• Preferred by 3rd party payers. 

• Surgeries can be done in less time with lower costs.

• High level of patient satisfaction

Examples of outpatient services

• Services provided by diagnostic imaging centers 

• IV drug therapy (ex: infusion therapy, Abx, chemotherapy)

• Home care services (ex: nursing visits, physical therapy at home)

Hospital emergency services:

• About 90% of community hospitals in the US have ED

Emergent care (5%)

•  requires immediate medical attention; life-threatening conditions (ex: heart attack, stroke, respiratory failure)

Urgent Care (45%) -

• needs prompt medical care within hours but not life threatening (ex: high fever, minor fractures) 

Non urgent care(50%)

• minor or non acute issues that could be handled in a more cost effective setting (ex: minor sprains) 

• Community health centers (CHCs)

• Supported by the federal government 

  • The community health centers (1974) defined the scope of health services that the CHC’s should provide for these centers to get federal grants 

• CHCs serve medically underserved population and those in medically underserved areas

• Over 1500 CHCs serve nearly 34 million patients with limited financial resources

 Indian Health Services (IHS): 

• The U.S. government provides medical and hospital services to Native Americans through IHS

• IHS is managed by the Public Health Service (PHS) within the Department and Human Services (HHS)

School health clinic

• Provide health education for students

• Provide personal health services

• Maintain a safe and healthy school environment

• Voluntary agencies

• American red cross

• Salvation army 

• Church missions 

Prison health services

• Delivered to the inmates in prison through the Federal Bureau of Prisons

• Prisons are linked to hospitals, each of which has a clinic for ambulatory care 

• Free Clinics: 

  • 7 characteristics:

• Have physical facility

• Have trained health staff and volunteers

• Directly provide medical, dental, and psychological services

• Are available to all 

• Have specified hours of operation

• Don’t require set payment; small fees or donations may be requested 

• Major obstacles

• Financially challenged

• Need more voluntary health professionals 

Today

• Many remain under the name of free health clinic or free medical clinic 

• Some have evolved into community health centers or migrant health centers