104

HOSPITAL INNOVATIONS IN THE COMMUNITY: AMBULATORY CARE* JAMES A. BLOCK, M.D. Director Robert Wood Johnson Foundation Community HospitalMedical Staff Group Practice Program Director Department of Ambulatory Service Genesee Hospital Rochester, New York

T HE last time I was at the New York Academy of Medicine was in 1964. I brought with me the publication from that meeting called Expanding Role of Ambulatory Services in Hospitals and Health Departments, New York Academy of Medicine, 1964.1 At that time I was a medical student at New York University, and had the opportunity to be exposed to some very fine and creative people who have been very influential in health-care developments in New York City. I am greatly indebted to them, and to the Academy. It is important to remember that we stand on the shoulders of a group of people who have been involved with this subject for years. Some of them are here today: Nora Piore, who I first met closeted in a small office of the New York City Department of Health when I was a medical student; Rufus Rorem, who in 1933 participated in the report of the Committee on the Cost of Medical Care; Marvin Lieberman who, with Harry Becker, in 1964 assisted in establishing an Urban Health Institute for students of New York University Medical School; and Harry Becker, Cecil Sheps, Lewis Thomas, and Howard Brown-people for whom I feel a particular warmth and a great deal of gratitude for their vision. I learned many things from them. I hope to share with you today not only what I learned, but what I attempted to build upon as a result of that knowledge and experience. I am in the unenviable position of talking about something which is not new at all, and most of what I shall say today has been said before. *Presented in a panel, Ambulatory Care, as part of the 1978 Annual Health Conference of the New York Academy of Medicine, The Hospital Reconsidered: A New Perspective, held May 1 and 2,

1978.

Address for reprint requests: 220 Alexander Street, Suite 702, Rochester, N.Y. 14607.

Bull. N. Y. Acad. Med.

HOSPITAL INNOVATIONS

105

HOSPITAL INNOVATIONS105

I would like to begin by sharing an experience I had at the Genesee Hospital in Rochester, N.Y. This effort is worth discussing because it embodies many of the issues which we are addressing, and it suggests potential solutions. In 1970 leaders at the Genesee Hospital began to express serious concern about the hospital's outpatient clinic. That concern has moved in and out of focus for hospitals for many years. The Genesee Hospital outpatient clinic was like any other hospital outpatient clinic; it lacked ongoing management attention. It was not primarily organized to serve the needs of the patients, but perhaps more specifically was designed to serve the needs of postgraduate physician education. It was open from 9:00 A.M. to 5:00 P.M. five days a week, and patients turned to the emergency department after 5:00 P. M. or on weekends. There was no appointment system. Patients waited long periods for medical care of varying quality. The sole source of continuity of care was the medical record. Physicians and house staff were frustrated. Patients were used to it. It represented an instance of the "cultural lag" found in so many of our society's institutions. It was, in fact, the only arm of this complex organization whose activities were defined in a socioeconomic context. In a social context in the late 1960s in which the costs of care for the poor and the elderly were largely covered through insurance (Medicaid and Medicare) and in which health care was increasingly defined as an inalienable right of citizenship, hospitals generally regarded outpatient care of dubious quality as a teaching-related charitable endeavor rather than a basic component of their service mission. Outpatient care lagged far behind in the quality of the product it was able to deliver, not only relative to the rest of the institution, but relative to the other activities of the entire medical staff. That cultural lag was perceived, and that cultural lag provided the impetus for re-evaluation of the outpatient function. I was reminded today in listening to the discussions of a comment one of the Genesee Hospital board members made as we described the Genesee Hospital outpatient clinic to him. We reviewed the litany of the problems associated with outpatient clinics and then the financial issues. We indicated that in addition to all the other inadequacies of our outpatient clinic, we were losing $150,000 a year. He shared a perspective with us, which I do not think I shall ever forget. He said, "I thought that the physicians at this hospital were creative people. I would think if we are going to lose $150,000 a year we would at least do it in a way we could be proud of." Vol. 55, No. 1, January 1979

10610

A. BLOCK J..A LC

I have never forgotten that observation. Suffice it to say that in the future outpatient clinics will continue to lose money for a variety of reasons.2 But that cannot excuse the quality of care we provide nor a lack of attention to the basic dignity of our patients. The concern regarding the outpatient clinic led to a series of discussions among hospital board members, medical staff members, and community representatives regarding the future of ambulatory care at that institution.3 Critical issues were raised which I would like to share with you. First, with the passage of Medicaid and Medicare in 1965 and with the increase in revenue provided to the institution by the additional governmental activities in the 1960s, with the general climate of the time, and with our capacity to provide a quality product of medical care-was it appropriate in 1970 to offer a hospital service defined whether by design or default in a racial and economic context? Our firm answer was no; it was simply not appropriate. What could we do about it? The answer was very clear. If one wants a single-class system of medical care, one establishes a single-class delivery model. We made the decision to move in that direc-

tion. What were the problems inherent in that decision? There were members of our private medical staff who had serious and appropriate reservations about moving in that direction. Would it now mean that the hospital was going to enter into the practice of medicine in a competitive way with our medical staff? The answer was, yes, that is what it meant, but it was a qualified yes in the context of a real need in the community. That need was not being addressed. We saw evidence of all sorts of patients using the emergency department as their family doctor.4 We saw increasing demand for service from our outpatient clinics as well. It became clear that the only way to meet these needs effectively and efficiently and to meet the need of low-income patients was to create a system of care designed to serve all socioeconomic classes.; Having made that decision-and that resolution involved a long and difficult debate with our medical staff-some related corollary issues surfaced over time. I raise these issues in the context of federal policy, and some concerns I have about some of its directions, results, or both. A question related to the issue of a single-class system of medical care was realization that many others in the past had tried to improve health care for low-income patients only to run into some serious obstacles. Some were resolved and others emerged. Bull. N. Y. Acad. Med.

HOSPITAL INNOVATIONS

-~~~~~~HSIA IlOAIN

107 0

We looked at the major federal health initiatives in ambulatory care, the Community Health Center program and its antecedents, as well as the Children and Youth and Maternal and Infant Care programs. We looked at the Medicaid program. One thing was very clear. Racial and economic segregation continued in all of these programs. Second, particularly in the neighborhood health center programs, a great deal of difficulty was experienced in recruiting and, more important, retaining excellent physicians. It seemed to us that if one were committed to improving health care for low-income patients, unless one created a model that could recruit and retain excellent professional staff it would be a sham. How did one get around that? It seemed to us that the creation, once again, of a single-class system of medical care was the only reasonable means to assure the recruitment and retention of excellent physicians. More important, the hospital provided a very interesting environment to accomplish that. The hospital is an organization in which health professionals feel comfortable. They have been trained in them, they are accustomed to being in them, and they provide an environment where physicians could for the most part consider alternative ways to deliver medical care. For that reason, the idea of a hospital sponsoring, if you will, recruitment and retention of physicians to provide care to patients regardless of income seemed quite likely to succeed. I offer these observations in a context of federal policy to raise some concern I have that some of our federal efforts may be contributing to, in fact exacerbating, both economic and racial segregation in our health-care system. It seems to me that in implementing new ambulatory programs one of the most important criteria we should consider is their capacity ultimately to result in a single-class system of health care. The hospital is in a unique position to do this, and should consider this opportunity very carefully. Hospitals already provide an enormous amount of primary ambulatory care to poor Americans mainly. Private physicians provide primary care to nonpoor patients out of economic necessity. Federal policies which perpetuate this situation or result in further polarization in sources of care between poor and nonpoor Americans must be viewed as contrary to other ideals equally espoused by government at all levels. To return more narrowly to events at Genesee, after this debate we decided to close our outpatient clinic entirely. We would simply lock the doors. To replace the outpatient clinic, the hospital decided to sponsor a primary-care group practice-certainly not a new idea, nor very innovaVol. 55, No. 1, January 1979

108'O

J..A A. BLOCK LC

tive. In fact, we emphasized the fact that we were noninnovative. We were not doing anything new. We were simply trying to get an excellent group of doctors to participate in the group practice of medicine, to serve all patients. We set about that, and I would like to tell what happened over the last seven years. We began with an outpatient clinic that was providing care to approximately 80% Medicaid patients. Remaining patients were for the most part medically indigent. A few Medicare patients were included in the mix, and the population was predominantly black. The outpatient clinic, as I indicated before, like so many other outpatient clinics, had a serious financial deficit. Seven years later we have a primary-care group practice made up of 17 full-time physicians in pediatrics, internal medicine, and obstetrics and gynecology. Approximately 35% of the patients are Medicaid recipients. However, we quadrupled the number of Medicaid recipients for whom we provide outpatient care as an institution.6 We have each year consistently reduced the cost to the Medicaid program for the care of those patients. The practice is racially and economically balanced, and incorporates house-staff education in the primary-care specialties.7 Specialty clinics have, with one exception, been fully integrated into the faculty and private practices of the appropriate specialties within the hospital. The practice functions as an organized medical group. Physicians are on call in each specialty, seven days a week, 24 hours a day. The physicians, however, are not a private medical group. I would like to discuss some other ideas that are not at all new. Some are ideas that I thought Dr. Frist covered very eloquently in the early afternoon. Those ideas concern management. The fact is that not only do outpatient clinics generally provide very poor medical care but they have been poorly managed. Some results of the lack of management have been interesting. We have come to believe that outpatient clinics lose money because the patients cannot pay. I would like to question that for a moment, and to suggest that low-income patients have had a bum rap. It is true that many patients cannot afford fully to pay for services received. But it is also true that definitions of deficit as it relates to hospital outpatient care to a great degree result from management decisions we have or have not made, depending on one's perspective. We allocate costs and use personnel in a most interesting way. Our decisions have resulted in inappropriate use of resources of every variety-space, manpower, time, Bull. N. Y. Acad. Med.

HOSPITAL INNOVATIONS

HOSPITAL

109 109

etc. All these have contributed to the financial burden of the outpatient

clinic. At Genesee we tried to address this in organizing our group practice by a formal management structure to administer both the business arm of the medical practice and its professional arm. We felt it was essential to introduce management into the group practice which had now replaced the outpatient clinic. Hence, although I have suggested that the group practice functions as a private medical group, it is not a private medical group. The physicians are salaried by the hospital and the group practice falls within a hospital department. Nonetheless, within that department the physicians who comprise the medical group exercise considerable authority over the management of their practice and implementation of basic policies within that practice. They function as though they were a private corporation. They have a full-time medical group manager, from the hospital's perspective a fulltime administrator who works with their group. We are very pleased, needless to say, with the experiment. We have accomplished a lot. There is a lot we have not accomplished, but we are addressing some relevant issues with which all of us wrestle. I would add one other dimension of the group that interests me. The group also offers prepaid medical care and participates in a health maintenance organization arrangement. We do this for several reasons. We think that prepayment is extremely important. We believe that Dr. Saward and others have made an enormous contribution to this country in advocating that approach. We think that we must learn how to function in a budgeted health-care system, and that this provides a means to accomplish this. Second, prepayment offers something else which is extremely important to many who are concerned about the care of low-income patients. It is an opportunity to bring low-income patients and others together in an excellent medical-care system. Another interesting thing it offers, from the point of view of a hospital or from the point of view of those responsible for large numbers of low-income patients, is that it offers an opportunity to integrate our environment racially and economically by attracting patients through employer group offerings of prepaid insurance. So one might think for a moment of prepayment as a form of busing. Prepayment can, if structured properly, bring middle-class people and low-income people together to provide excellent medical care. Once again, I am concerned about government policy. It is not clear to me, in looking Vol. 55, No. 1, January 1979

110

110

J. A. BLOCK

at major federal programs, including the health maintenance organization program, that we have given serious enough attention to the importance of prepayment and other federal efforts toward a single-class system of medical care. I would like to describe another opportunity in which I participated over the last several years. In 1975 the Robert Wood Johnson Foundation began a program to assist community hospitals in sponsoring primary care group practices. This program has now been under way for three years, and we are working with hospitals throughout the United States.8 These hospitals encourage the development of primary care medical group practices in areas of need. Some of these practices are moving in the direction I described earlier, the direction the Genesee Hospital took in 1970. Others may establish group practices 30 miles from the hospital in rural areas where there may not be a physician. Some are going into newly developing suburban communities without adequate numbers of primary care physicians. In all cases, the hospitals are moving toward the establishment of organized medical-care delivery systems in areas of need. This is a very important evolution in the hospital's role because I perceive the hospital as a very exciting and very complex institution. When I talk about hospitals, I have much more in mind than inpatient beds. I have in mind a very important community resource that can address community problems and is a very important community educational resource as well. The community hospital in many ways is uniquely situated to address the problems of primary care in its community. It has management expertise, it has medical staff leadership, and it has trustees who are part of that community. All of these can mobilize to address a problem. Our experience with the Robert Wood Johnson Foundation has been exciting. We have seen a great variety of experiments throughout the country. One interesting and unique program is in Richmond, Va. The Richmond Memorial Hospital has participated in the Robert Wood Johnson Foundation program for almost three years. In Richmond all but one of the city's nonprofit community hospitals were purchased by proprietary interests and moved to new suburban locations. Richmond Memorial Hospital found itself the only downtown nonprofit community hospital, with the exception of the Medical College of Virginia Hospital. They wanted to stay downtown. They felt committed to the city Bull. N. Y. Acad. Med.

HOSPITAL INNOVATIONS

III

and to the patients who turned to it for care. It is also interesting that historically Richmond Memorial Hospital was also the hospital that had provided privileges to the active black practitioners in that community although they made up only about 15% of the medical staff. What did Richmond Memorial Hospital decide to do? Their solutions were very innovative. They decided to seek to meet the primary ambulatory care needs of developing rural and suburban fringe areas by sponsoring a group practice. Clearly, these practices feed that institution. Clearly, this group practice will assure the hospital's long-term financial viability. They have now opened offices in four different settings, surrounding the entire southwestern quadrant of Richmond. They have 16 physicians in their hospital-sponsored primary-care group practice. These physicians are both salaried employees of the Richmond Memorial Hospital and participants in a highly organized medical group. They provide improved access to general medical care and a very interesting solution to a problem Richmond Memorial Hospital and urban Richmond faced. One of the things in the Richmond example that is very important to me, and which I want to emphasize in closing, is that the decisions that we make in health care as hospitals and as physicians are decisions with a ripple effect upon the entire social fabric of our community. Urban hospitals are in a unique position within their communities. If we are farsighted and continue to contribute to the social structure of our cities we shall retain the confidence of the American people.

1.

2. 3

4.

REFERENCES Expanding Role of Ambulatory Services 5. Ball, R. M.: National health insurance: in Hospitals and Health Departments. Comments on selected issues. Science New York, the New York Academy of 200: 1978. Medicine, 1964. 6. Ullman, R., Kotok, D., and Tobin, J. R.: Blendon, R. J.: Reform of ambulatory Hospital-based group practice and comcare: A financial paradox. Med. Care 14: prehensive care for children of indigent 526-34, 1976. families. Pediatrics 60: 873-80, 1977. Regenstreif, D. I.: Innovation in hospi- 7. Tatelbaum, R. C. and Regenstreif, D. I.: tal-based ambulatory care: Some sources, An ambulatory training model for an patterns, and implications of change. obstetrics and gynecology residency proHum. Organ. 36: 43-49, 1977. gram. J. Med. Educ. 53: 1978. Ullman, R., Block, J. A., Stratman, W. C., 8. Block, J. A., Bourque, D. P., Froh, R. et al.: Impact of a primary care group practice B., et al.: Physicians and hospitals: Proon emergency room utilization at a commuviding primary care. Med. Group Man. nity hospital. Med. Care. In press. 25: 1978.

Vol. 55, No. 1, January 1979

Hospital innovations in the community: ambulatory care.

104 HOSPITAL INNOVATIONS IN THE COMMUNITY: AMBULATORY CARE* JAMES A. BLOCK, M.D. Director Robert Wood Johnson Foundation Community HospitalMedical St...
805KB Sizes 0 Downloads 0 Views