59
RESTRUCTURING AMBULATORY SERVICES IN THE ACADEMIC MEDICAL CENTER: ONE APPROACH TO PRIMARY CARE SERVICES FOR THE URBAN POOR* OLIVER FEIN, M.D. Director General Medicine Outpatient Services Columbia-Presbyterian Medical Center New York, New York
D AVID AXELROD, New York State Commissioner of Health, in a recent letter writes, "I never meant to insist that all Primary Care activity be off-site [by which he meant, out of the hospital], but rather that there be a dramatic increase in the availability of off-site services rather than a continued focus on institutional services. "1 Getting primary care into the community is all the rage these days. Little wonder given that virtually no physicians provide primary care from offices in poor communities. The Community Service Society can find only 22 "fully functional" physicians for a population of 1.7 million poor in nine low-income communities in New York City. This study also documents the inadequacy of physician services in poor communities: 40% of physicians are in their offices fewer than 15 hours/week; 66% lack hospital admitting privileges; 75% do not have phone coverage after hours.2 For whatever reasons, the solutions of the past do not appear to have worked. In the 1960s and 1970s we had Community Health Centers, in the 1980s physician homesteading. And in the 1990s fewer and fewer medical students are selecting primary care as a career. The roots of these problems go very deep -to the core of the reward system of our academic medical centers, to the incentives within our government sponsored reimbursement systems, and to priorities within both public and private institutions. I suppose I was invited to address you in part because my institution, the Columbia-Presbyterian Medical Center, is an example of an institution that has responded to the primary care challenge by developing more community*Presented in a panel, Restructuring Health Services in the City: Innovative Approaches to Redirecting Services in the Neighborhood, as part of the Annual Health Conference, The Challenge of Health Care in the Nation's Cities, held by the Committee on Medicine in Society of the New York Academy of Medicine May 16, 1990. Address for reprint requests: 622 West 168th Street, VC-2-205, New York, NY 10032
Vol. 67, No. 1, January-February 1991
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O. FEIN FEIN~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
based services. Columbia-Presbyterian has opened a new 300-bed Community Hospital (the Allen Pavilion) at 225th Street on the northern tip of Manhattan. Columbia-Presbyterian has also sponsored an Ambulatory Care Network Corporation, called the ACNC for short, a separate corporate entity with community board members, which has opened three satellite health centers in the Washington-Heights Community and is presently converting its entire Vanderbilt Clinic into the ACNC. Community activists have criticized Columbia-Presbyterian because the Allen Pavilion is closer to Riverdale than to the poverty pockets of Washington Heights, because only three of the five promised health centers in the ACNC have been opened and because the off-loading of Vanderbilt Clinic into the ACNC is seen as the first step toward removing all of indigent ambulatory care from the medical center. These projects have stimulated as much controversy within the medical center as they have within the community. Opponents inside the medical center blame the community hospital and ACNC for draining scarce resources from the mother institution, thrusting it into budgetary crisis, with rumored losses of as much as $1 million per week in 1989. While I believe there has been considerable stumbling at Columbia-Presbyterian toward Dr. Axelrod's goal of moving primary care services into the community, I also believe there has been considerable movement. There are many positive moments in Columbia-Presbyterian's efforts to establish multidisciplinary Health Centers -including adult medicine, pediatrics, ob-gyn, and dentistry -in the community. This is a model to be watched in terms of its success in recruiting and retaining high quality clinicians for poverty neighborhoods. But Columbia-Presbyterian's efforts to establish off-site health centers and a community hospital are not what I want to call to your attention. In fact, by turning our gaze from the medical center, these developments may lead us to ignore the central resource itself -the hospital. I want to focus your attention back on the institution, the academic medical center, for the following reasons: poor people in New York City rely heavily on hospital-based ambulatory care; the case-mix in hospital-based ambulatory care is sicker and more complex than in community-based care; there is an assumption (poorly proved) that hospital-based ambulatory care costs more than communitybased ambulatory care; much of hospital-based ambulatory care is poorly organized; hospital-based ambulatory care may be our primary means to attract medical students into urban health care; and hospital-based ambulatory care is expanding for the middle class and the wealthy in many parts of the United States. Bull. N.Y. Acad. Med.
ACADEMIC MEDICAL MEDICAL CENTER CENTER
ACADEMIC
61
Let me expand on some of these points. First, poor people rely heavily on hospital-based ambulatory care. In New York City 42% of physician visits by those below poverty level are made in hospital ambulatory care settings compared to 14% of physician visits by those earning more than 200% of the poverty level. Blacks make 52% of their physician visits in hospital settings, while whites make only 20%.2 Second, case-mix in hospital-based ambulatory care is sicker and more complex. This is intuitive to many of us who work in these settings because we know how often community practitioners refer, appropriately I would add, complicated cases for work-up and management. But, over the last decade, several investigators have challenged this intuition.3-5 They have used Robert Fetter's (the inventor of DRGs) Ambulatory Visit Groups (AVGs) to compare case-mix between New York city public hospitals and physicians' offices and they find little difference. These results, I believe, are a consequence of a methodology that counts only one diagnosis on each visit and therefore cannot take into account comorbidity and complexity. When we compared our inner-city general medicine practice with internists in the National Ambulatory Care Medical Survey (NAMCS) we found that 25% of our visits were for hypertension compared to 14% in NAMCS. More important, by taking into account multiple diagnoses on each visit we found the staggering statistic that 52% of our patients had hypertension, more than twice the number estimated by counting a single diagnosis on each visit.6 Third, the assumption that hospital-based ambulatory care costs more than community-based ambulatory care is poorly proved. It is based on comparisons of resident performance with community physicians in studies that control inadequately for case-mix. New York State's reimbursement policy belies this assumption: hospitals are paid an all-inclusive fee of $60/visit, while neighborhood health centers with a diagnostic and treatment center designation receive as much as $95/visit. Of course, hospitals protest that they are underpaid, but when their estimates of these costs range from $88/ visit in one institution to $234/visit in another,8 the issue of allocated costs is raised. Just because some hospitals allocate portions of their inpatient costs to ambulatory care should not be taken as proof that hospital-based ambulatory care costs more than community based ambulatory care. Fourth, much hospital-based ambulatory care is poorly organized. The emergency room is overused, the clinic frequently does not offer continuity between visits, hospital-based physicians are dominated by residents-intraining. But it does not have to be that way. More than a decade ago we reorganized our general medical clinic into a faculty group practice, called Associates in Internal Medicine.7 This is not a clinic, although we serve Vol. 67, No. 1, January-February 1991
62
O. FEIN
community patients in a hospital clinic facility. We differ from the clinic because our practitioners are available to their patients by beeper and through on-call coverage systems 24 hours per day, seven days a week. In a clinic most physicians (residents or faculty) are present only half-a-day per week. In the clinic, if you get sick on Tuesday, but have a Monday afternoon doctor, your only source of care is the emergency room. In our group practice, there is continuity at each visit. You always see the same doctor, who knows your case and builds a relationship with you and between visits by phone. This continuity of care saves money by avoiding unnecessary tests and visits. When doctors know a patient well, many problems can be dealt with by phone. When patients are sick and require hospitalization, they want the ambulatory relationship to count for something. But in the clinic this is precisely the moment at which the patient loses his ambulatory care physician and is admitted to a ward resident. In our group practice, patients are admitted as the private patients of their ambulatory care physician and are seen in the hospital daily by their physician who manages their care. Continuity is maintained between inpatient and outpatient care. Coordination of care means that consultations are obtained from a known consultant who provides a direct opinion to the primary care physician. In most clinics consultation is pursued blindly. The patient is sent off to the surgery clinic, and the primary care physician doesn't know if a student, resident, or senior faculty member will see the patient, and the consultant's recommendation may never be sent directly to the primary care physician. There is no opportunity for a discussion between consultant and primary care physician. Our faculty group practice works to promote and deliver a completely different ambulatory care than most hospital-based clinics deliver. Yet, in the discussion of how to increase primary care physicians for poor people, the option of reorganizing hospital-based settings to deliver this kind of care is rarely mentioned. Key to this reorganization strategy is a core faculty whose primary clinical activity is within the group practice. This does not mean that they cannot have other teaching and research activities -but they must have the commitment to be available to their patients at all times. Frequently, it is the mix of activities (patient care, teaching, and research) that sustains these faculty members over many years. Thirteen years ago we started with seven physicians and now have grown to 23. We have nine physicians who have been with us more than 10 years and an additional eight physicians from between five and 10 years. Five physicians are of Hispanic heritage and an additional three physiBull. N.Y. Acad. Med.
ACADEMIC MEDICAL CENTER CENTER
ACADEMIC MEDICAL
63 63
cians are fluently bilingual. We see about 30,000 visits/year and our patients experience 1,000 admissions per year. The added benefit of hospital-based faculty group practices is the role models they provide for medical students and residents. Let me digress for a moment. The cost of teaching in ambulatory care is significant, but not overwhelming. When a medical student or a first-year resident sees a patient, he will be less productive-he cannot see as many patients in a session as a faculty member. So teaching units need more space. In addition, the best supervision for students and residents is a faculty member not distracted by simultaneous patient care obligations. Who pays for this increased space and for the time of faculty supervision? An individual hospital can no longer afford this expense. The medical school cannot cover it through tuition. I believe that the cost of training must be seen as a public responsibility. If government pays for training, it can also set the standards for delivery of care in hospital-based settings. For instance, residents can be required to be in clinic one to three sessions/week, depending on the level of training. Coverage systems utilizing senior residents and faculty can be developed so that patients have access by phone to someone who knows them. Faculty or mid-level practitioners, such as physician assistants and nurse practitioners, can provide urgent/walk-in care when trainees are not in practice. 405 regulations (the "Bell Report") have had a profound impact on inpatient residency training, but outpatient residency training has not been touched. It is crucial that any increased state regulation of standards for ambulatory care training be accompanied by appropriate increases in funding for ambulatory care teaching. Without this, the already underfunded ambulatory care sector for the poor will not be able to comply, driving more and more hospitals to unload their ambulatory care delivery systems for the poor into public hospitals or separate corporations. What are the policy implications of this approach? I believe that city and state policy makers should take the following steps:9 Recognize the importance of hospital-based group practices that reorganize care around the principles of primary care: 24 hour, seven day/week physician availability, continuity between outpatient and inpatient care (patients admitted as the private patients of the attendings), and coordination of care. Provide financial incentives to hospitals that develop such primary care group practices, either on-site or off-site, by reimbursement formulas that increase revenues for such activity. Vol. 67, No. 1, January-February 1991
64
0. FEIN O.
More carefully articulate policy toward specialty clinics-primary care physicians, whether off-site or on-site, need access to specialists for their patients; without this, they feel unsupported in their attempts to provide quality medical care. At Columbia-Presbyterian the state has encouraged reduction in specialty clinic time availability, which is beginning to result in long queues for consultation in some clinics. When this happens, primary care providers feel undermined. Specialty clinics need to be reorganized to serve as efficient consultation services for primary care physicians but not closed down. More carefully examine the issue of allocated costs-as our medical centers hit hard financial times, the deficit in ambulatory care may be exaggerated by allocation of inpatient costs to outpatient areas. State mandated stepdown cost allocation for hospitals should be changed to allow for fairer assessments of ambulatory care costs and the requirement to match ambulatory care revenues with justifiable ambulatory care costs. This reorganization would give our hospital-based activity more independent footing and allow the state to monitor expenditures in these areas more precisely. Primary care is struggling for recognition and a power base in academic medical centers. To insist that all primary care activity take place off-site diminishes our recognition and voice inside the medical center. It is important to build on the beachhead that divisions of general internal medicine and pediatrics have established at the medical center, not to dilute their efforts by insisting that all primary care be off-site. Primary care education is not merely education in ambulatory care sites, but it also represented by penetration of primary care concepts and faculty into the curriculum. At Columbia the Division of General Medicine has worked hard to accomplish this. Our primary care faculty members are now course directors for six major medical school required courses: in the first year, the patient-physician relationship course and biostatistics/epidemiology; in the second year, introduction to the patient; in the fourth year, ambulatory care and public health. Proximity to the campus (our on-site location) makes us more efficient teachers and gives students access to us as faculty advisors, enhancing the students' sense of our discipline as important. Primary care residency training is an extremely important base for our activities as well. At Columbia a superb application for federal funds was turned down this year. Out of 81 applications, only 35-40 will be funded by the federal government. Perhaps the state and city departments of health could establish a program similar to the federal government to provide direct funding to primary care residency training programs. Bull. N.Y. Acad. Med.
ACADEMIC MEDICAL CENTER
65
In conclusion, I do not want to detract from efforts to bring primary care closer to the community, as proposed "homesteading programs" do and as Columbia-Presbyterian's off-site Ambulatory Care Network Corporation does. However, if we want to change the "content" of primary care for the city's poor and we want to change it in the near future, I suggest that we focus on reorganizing hospital-based ambulatory care. It would be a big mistake to emerge from the decade of the 1990s with physicians' private office buildings as the only hospital-based ambulatory care, while the poor and their physicians are separated off into community-based systems. Separate is never equal. The academic medical center must be held accountable. Where is there a better place than on its own turf, in hospital-based ambulatory care? NOTES AND REFERENCES
1. Personal communication to the author January 2, 1990. 2. McKenzie, N. and Conroy, K: Building Primary Health Care Services in Low-Income Communities. New York. Community Service Society of New York, 1990. 3. Lion, J., Malbon, A., and Bergman, A.: Ambulatory visit groups: implications for hospital outpatient departments. J. Ambul. Care Man. 10:56-9, 1987. 4. Lion, J. and Williams, J.L.: Medical and Socioeconomic Case-Mix in Outpatient Departments. In: Ambulatory Care: Problems of Cost and Access, Altman, S., Lion, J., and Williams, J.L., editors. Lexington, MA, Lexington Books, 1983, pp. 161-78. 5. Lion, J.: Case-mix differences among ambulatory patients seen by internists in various settings. Health Serv. Res.
Vol. 67, No. 1, January-February 1991
16:407-13, 1981. 6. Fein, O., Hoffman, S., and Barzel, E.: Looking at the patient in the mix: Is case mix methodology unfair to the hospital outpatient department? J. Gen. Intern. Med. 3:471-75, 1988. 7. Fein, O., Hoffman, S., Goldman, F., et al.: Hospital based group practice: does it change clinic patterns of care? J. Gen. Intern. Med. 2:11-19, 1987. 8. Report by American Practice Management to the Presbyterian Hospital, July, 1989. 9. Many of these points were first raised in a letter dated December 15, 1989, to Commissioner David Axelrod written by Oliver Fein, (CPMC) and Robert Braham (New York Hospital-Cornell Medical Center).
RESTRUCTURING AMBULATORY SERVICES IN THE ACADEMIC MEDICAL CENTER: ONE APPROACH TO PRIMARY CARE SERVICES FOR THE URBAN POOR* OLIVER FEIN, M.D. Director General Medicine Outpatient Services Columbia-Presbyterian Medical Center New York, New York
D AVID AXELROD, New York State Commissioner of Health, in a recent letter writes, "I never meant to insist that all Primary Care activity be off-site [by which he meant, out of the hospital], but rather that there be a dramatic increase in the availability of off-site services rather than a continued focus on institutional services. "1 Getting primary care into the community is all the rage these days. Little wonder given that virtually no physicians provide primary care from offices in poor communities. The Community Service Society can find only 22 "fully functional" physicians for a population of 1.7 million poor in nine low-income communities in New York City. This study also documents the inadequacy of physician services in poor communities: 40% of physicians are in their offices fewer than 15 hours/week; 66% lack hospital admitting privileges; 75% do not have phone coverage after hours.2 For whatever reasons, the solutions of the past do not appear to have worked. In the 1960s and 1970s we had Community Health Centers, in the 1980s physician homesteading. And in the 1990s fewer and fewer medical students are selecting primary care as a career. The roots of these problems go very deep -to the core of the reward system of our academic medical centers, to the incentives within our government sponsored reimbursement systems, and to priorities within both public and private institutions. I suppose I was invited to address you in part because my institution, the Columbia-Presbyterian Medical Center, is an example of an institution that has responded to the primary care challenge by developing more community*Presented in a panel, Restructuring Health Services in the City: Innovative Approaches to Redirecting Services in the Neighborhood, as part of the Annual Health Conference, The Challenge of Health Care in the Nation's Cities, held by the Committee on Medicine in Society of the New York Academy of Medicine May 16, 1990. Address for reprint requests: 622 West 168th Street, VC-2-205, New York, NY 10032
Vol. 67, No. 1, January-February 1991
60
O. FEIN FEIN~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
based services. Columbia-Presbyterian has opened a new 300-bed Community Hospital (the Allen Pavilion) at 225th Street on the northern tip of Manhattan. Columbia-Presbyterian has also sponsored an Ambulatory Care Network Corporation, called the ACNC for short, a separate corporate entity with community board members, which has opened three satellite health centers in the Washington-Heights Community and is presently converting its entire Vanderbilt Clinic into the ACNC. Community activists have criticized Columbia-Presbyterian because the Allen Pavilion is closer to Riverdale than to the poverty pockets of Washington Heights, because only three of the five promised health centers in the ACNC have been opened and because the off-loading of Vanderbilt Clinic into the ACNC is seen as the first step toward removing all of indigent ambulatory care from the medical center. These projects have stimulated as much controversy within the medical center as they have within the community. Opponents inside the medical center blame the community hospital and ACNC for draining scarce resources from the mother institution, thrusting it into budgetary crisis, with rumored losses of as much as $1 million per week in 1989. While I believe there has been considerable stumbling at Columbia-Presbyterian toward Dr. Axelrod's goal of moving primary care services into the community, I also believe there has been considerable movement. There are many positive moments in Columbia-Presbyterian's efforts to establish multidisciplinary Health Centers -including adult medicine, pediatrics, ob-gyn, and dentistry -in the community. This is a model to be watched in terms of its success in recruiting and retaining high quality clinicians for poverty neighborhoods. But Columbia-Presbyterian's efforts to establish off-site health centers and a community hospital are not what I want to call to your attention. In fact, by turning our gaze from the medical center, these developments may lead us to ignore the central resource itself -the hospital. I want to focus your attention back on the institution, the academic medical center, for the following reasons: poor people in New York City rely heavily on hospital-based ambulatory care; the case-mix in hospital-based ambulatory care is sicker and more complex than in community-based care; there is an assumption (poorly proved) that hospital-based ambulatory care costs more than communitybased ambulatory care; much of hospital-based ambulatory care is poorly organized; hospital-based ambulatory care may be our primary means to attract medical students into urban health care; and hospital-based ambulatory care is expanding for the middle class and the wealthy in many parts of the United States. Bull. N.Y. Acad. Med.
ACADEMIC MEDICAL MEDICAL CENTER CENTER
ACADEMIC
61
Let me expand on some of these points. First, poor people rely heavily on hospital-based ambulatory care. In New York City 42% of physician visits by those below poverty level are made in hospital ambulatory care settings compared to 14% of physician visits by those earning more than 200% of the poverty level. Blacks make 52% of their physician visits in hospital settings, while whites make only 20%.2 Second, case-mix in hospital-based ambulatory care is sicker and more complex. This is intuitive to many of us who work in these settings because we know how often community practitioners refer, appropriately I would add, complicated cases for work-up and management. But, over the last decade, several investigators have challenged this intuition.3-5 They have used Robert Fetter's (the inventor of DRGs) Ambulatory Visit Groups (AVGs) to compare case-mix between New York city public hospitals and physicians' offices and they find little difference. These results, I believe, are a consequence of a methodology that counts only one diagnosis on each visit and therefore cannot take into account comorbidity and complexity. When we compared our inner-city general medicine practice with internists in the National Ambulatory Care Medical Survey (NAMCS) we found that 25% of our visits were for hypertension compared to 14% in NAMCS. More important, by taking into account multiple diagnoses on each visit we found the staggering statistic that 52% of our patients had hypertension, more than twice the number estimated by counting a single diagnosis on each visit.6 Third, the assumption that hospital-based ambulatory care costs more than community-based ambulatory care is poorly proved. It is based on comparisons of resident performance with community physicians in studies that control inadequately for case-mix. New York State's reimbursement policy belies this assumption: hospitals are paid an all-inclusive fee of $60/visit, while neighborhood health centers with a diagnostic and treatment center designation receive as much as $95/visit. Of course, hospitals protest that they are underpaid, but when their estimates of these costs range from $88/ visit in one institution to $234/visit in another,8 the issue of allocated costs is raised. Just because some hospitals allocate portions of their inpatient costs to ambulatory care should not be taken as proof that hospital-based ambulatory care costs more than community based ambulatory care. Fourth, much hospital-based ambulatory care is poorly organized. The emergency room is overused, the clinic frequently does not offer continuity between visits, hospital-based physicians are dominated by residents-intraining. But it does not have to be that way. More than a decade ago we reorganized our general medical clinic into a faculty group practice, called Associates in Internal Medicine.7 This is not a clinic, although we serve Vol. 67, No. 1, January-February 1991
62
O. FEIN
community patients in a hospital clinic facility. We differ from the clinic because our practitioners are available to their patients by beeper and through on-call coverage systems 24 hours per day, seven days a week. In a clinic most physicians (residents or faculty) are present only half-a-day per week. In the clinic, if you get sick on Tuesday, but have a Monday afternoon doctor, your only source of care is the emergency room. In our group practice, there is continuity at each visit. You always see the same doctor, who knows your case and builds a relationship with you and between visits by phone. This continuity of care saves money by avoiding unnecessary tests and visits. When doctors know a patient well, many problems can be dealt with by phone. When patients are sick and require hospitalization, they want the ambulatory relationship to count for something. But in the clinic this is precisely the moment at which the patient loses his ambulatory care physician and is admitted to a ward resident. In our group practice, patients are admitted as the private patients of their ambulatory care physician and are seen in the hospital daily by their physician who manages their care. Continuity is maintained between inpatient and outpatient care. Coordination of care means that consultations are obtained from a known consultant who provides a direct opinion to the primary care physician. In most clinics consultation is pursued blindly. The patient is sent off to the surgery clinic, and the primary care physician doesn't know if a student, resident, or senior faculty member will see the patient, and the consultant's recommendation may never be sent directly to the primary care physician. There is no opportunity for a discussion between consultant and primary care physician. Our faculty group practice works to promote and deliver a completely different ambulatory care than most hospital-based clinics deliver. Yet, in the discussion of how to increase primary care physicians for poor people, the option of reorganizing hospital-based settings to deliver this kind of care is rarely mentioned. Key to this reorganization strategy is a core faculty whose primary clinical activity is within the group practice. This does not mean that they cannot have other teaching and research activities -but they must have the commitment to be available to their patients at all times. Frequently, it is the mix of activities (patient care, teaching, and research) that sustains these faculty members over many years. Thirteen years ago we started with seven physicians and now have grown to 23. We have nine physicians who have been with us more than 10 years and an additional eight physicians from between five and 10 years. Five physicians are of Hispanic heritage and an additional three physiBull. N.Y. Acad. Med.
ACADEMIC MEDICAL CENTER CENTER
ACADEMIC MEDICAL
63 63
cians are fluently bilingual. We see about 30,000 visits/year and our patients experience 1,000 admissions per year. The added benefit of hospital-based faculty group practices is the role models they provide for medical students and residents. Let me digress for a moment. The cost of teaching in ambulatory care is significant, but not overwhelming. When a medical student or a first-year resident sees a patient, he will be less productive-he cannot see as many patients in a session as a faculty member. So teaching units need more space. In addition, the best supervision for students and residents is a faculty member not distracted by simultaneous patient care obligations. Who pays for this increased space and for the time of faculty supervision? An individual hospital can no longer afford this expense. The medical school cannot cover it through tuition. I believe that the cost of training must be seen as a public responsibility. If government pays for training, it can also set the standards for delivery of care in hospital-based settings. For instance, residents can be required to be in clinic one to three sessions/week, depending on the level of training. Coverage systems utilizing senior residents and faculty can be developed so that patients have access by phone to someone who knows them. Faculty or mid-level practitioners, such as physician assistants and nurse practitioners, can provide urgent/walk-in care when trainees are not in practice. 405 regulations (the "Bell Report") have had a profound impact on inpatient residency training, but outpatient residency training has not been touched. It is crucial that any increased state regulation of standards for ambulatory care training be accompanied by appropriate increases in funding for ambulatory care teaching. Without this, the already underfunded ambulatory care sector for the poor will not be able to comply, driving more and more hospitals to unload their ambulatory care delivery systems for the poor into public hospitals or separate corporations. What are the policy implications of this approach? I believe that city and state policy makers should take the following steps:9 Recognize the importance of hospital-based group practices that reorganize care around the principles of primary care: 24 hour, seven day/week physician availability, continuity between outpatient and inpatient care (patients admitted as the private patients of the attendings), and coordination of care. Provide financial incentives to hospitals that develop such primary care group practices, either on-site or off-site, by reimbursement formulas that increase revenues for such activity. Vol. 67, No. 1, January-February 1991
64
0. FEIN O.
More carefully articulate policy toward specialty clinics-primary care physicians, whether off-site or on-site, need access to specialists for their patients; without this, they feel unsupported in their attempts to provide quality medical care. At Columbia-Presbyterian the state has encouraged reduction in specialty clinic time availability, which is beginning to result in long queues for consultation in some clinics. When this happens, primary care providers feel undermined. Specialty clinics need to be reorganized to serve as efficient consultation services for primary care physicians but not closed down. More carefully examine the issue of allocated costs-as our medical centers hit hard financial times, the deficit in ambulatory care may be exaggerated by allocation of inpatient costs to outpatient areas. State mandated stepdown cost allocation for hospitals should be changed to allow for fairer assessments of ambulatory care costs and the requirement to match ambulatory care revenues with justifiable ambulatory care costs. This reorganization would give our hospital-based activity more independent footing and allow the state to monitor expenditures in these areas more precisely. Primary care is struggling for recognition and a power base in academic medical centers. To insist that all primary care activity take place off-site diminishes our recognition and voice inside the medical center. It is important to build on the beachhead that divisions of general internal medicine and pediatrics have established at the medical center, not to dilute their efforts by insisting that all primary care be off-site. Primary care education is not merely education in ambulatory care sites, but it also represented by penetration of primary care concepts and faculty into the curriculum. At Columbia the Division of General Medicine has worked hard to accomplish this. Our primary care faculty members are now course directors for six major medical school required courses: in the first year, the patient-physician relationship course and biostatistics/epidemiology; in the second year, introduction to the patient; in the fourth year, ambulatory care and public health. Proximity to the campus (our on-site location) makes us more efficient teachers and gives students access to us as faculty advisors, enhancing the students' sense of our discipline as important. Primary care residency training is an extremely important base for our activities as well. At Columbia a superb application for federal funds was turned down this year. Out of 81 applications, only 35-40 will be funded by the federal government. Perhaps the state and city departments of health could establish a program similar to the federal government to provide direct funding to primary care residency training programs. Bull. N.Y. Acad. Med.
ACADEMIC MEDICAL CENTER
65
In conclusion, I do not want to detract from efforts to bring primary care closer to the community, as proposed "homesteading programs" do and as Columbia-Presbyterian's off-site Ambulatory Care Network Corporation does. However, if we want to change the "content" of primary care for the city's poor and we want to change it in the near future, I suggest that we focus on reorganizing hospital-based ambulatory care. It would be a big mistake to emerge from the decade of the 1990s with physicians' private office buildings as the only hospital-based ambulatory care, while the poor and their physicians are separated off into community-based systems. Separate is never equal. The academic medical center must be held accountable. Where is there a better place than on its own turf, in hospital-based ambulatory care? NOTES AND REFERENCES
1. Personal communication to the author January 2, 1990. 2. McKenzie, N. and Conroy, K: Building Primary Health Care Services in Low-Income Communities. New York. Community Service Society of New York, 1990. 3. Lion, J., Malbon, A., and Bergman, A.: Ambulatory visit groups: implications for hospital outpatient departments. J. Ambul. Care Man. 10:56-9, 1987. 4. Lion, J. and Williams, J.L.: Medical and Socioeconomic Case-Mix in Outpatient Departments. In: Ambulatory Care: Problems of Cost and Access, Altman, S., Lion, J., and Williams, J.L., editors. Lexington, MA, Lexington Books, 1983, pp. 161-78. 5. Lion, J.: Case-mix differences among ambulatory patients seen by internists in various settings. Health Serv. Res.
Vol. 67, No. 1, January-February 1991
16:407-13, 1981. 6. Fein, O., Hoffman, S., and Barzel, E.: Looking at the patient in the mix: Is case mix methodology unfair to the hospital outpatient department? J. Gen. Intern. Med. 3:471-75, 1988. 7. Fein, O., Hoffman, S., Goldman, F., et al.: Hospital based group practice: does it change clinic patterns of care? J. Gen. Intern. Med. 2:11-19, 1987. 8. Report by American Practice Management to the Presbyterian Hospital, July, 1989. 9. Many of these points were first raised in a letter dated December 15, 1989, to Commissioner David Axelrod written by Oliver Fein, (CPMC) and Robert Braham (New York Hospital-Cornell Medical Center).
