After completing this chapter, the reader should have an understanding of: • The definition of ambulatory care. • The variety of settings for the delivery of ambulatory care. • The importance of ambulatory care services as a part of the U.S. health care system. a number of other ways ambulatory care is delivered, and they are described in this chapter. In recent years the number and type of ambulatory or outpatient facilities have increased to allow more patients to receive treatment outside of the more costly acute care hospitals. Because of advances in technology and technique, many of the procedures formerly done in hospitals can now be performed on an outpatient basis. More familiar ambulatory care facilities, such as hospital outpatient departments and community health centers, have expanded to include surgery centers, diagnostic imaging centers, cardiac catheterization laboratories, and other freestanding facilities. Some facilities are for-profit and are operated by chains, either independently owned or affiliated with a hospital. In other cases, nonprofit health care systems with hospitals have expanded their ambulatory facilities as part of an integrated, cost-efficient way to provide care. When we address health care comprehensively, it is also important to recognize pharmacies, dental care, and “alternative” care such as chiropractic as fitting into what we categorize as ambulatory care. We look now at just a few of the major types of ambulatory care.
Ambulatory care covers a wide range of services for the noninstitutionalized patient and in its most basic description is simply care that does not require an overnight stay by the patient. Office-based physicians provide the majority of ambulatory care. An estimated 787.4 million visits were made to doctors’ offices in 1997, or about 3.0 visits per person (Woodwell, 1999). More than 50 percent of those visits were made to primary care specialists (family practice, pediatrics, and internal medicine). However, there are
100 • CHAPTER 6
Extraordinary changes are taking place in the practice of medicine in the United States. The sheer number of physicians has more than doubled since 1970. Women, who made up only 9.7 percent of the physician population in 1970, now account for 22 percent of all physicians. A larger percentage of female (47.4 percent) than male physicians (31 percent) are in primary care specialties (American Medical Association, 1999). After decades of “business as usual,” physicians are now faced with a decline of professional autonomy, increased competition among themselves, and changes in the methods of payment for their services. Although much of this change can be attributed to cost containment efforts that seek to provide more efficient, effective medical care, and to the alternative delivery systems that have developed, the growing supply of physicians is also a major factor. There were 756,710 physicians in the United States in 1997, or 282 physicians for every 100,000 people— more physicians than ever before (American Medical Association, 1999). While the focus in the 1960s was concern over a shortage of physicians, current discussions focus on whether there is an oversupply of physicians (see Table 6–1). The majority of physicians are in office-based patient care (60.6 percent in 1997). Not everyone agrees that we have an oversupply, but there is general agreement that there is an imbalance in primary care versus specialty care physicians, and a shortage of physicians practicing in certain geo-
graphic areas. Although the sheer numbers of physicians in primary care specialties increased in the 1990s, the overall percentage of physicians in primary care dropped from 36.5 percent in 1980 to 34.6 percent in 1997 (American Medical Association, 1999). The increase in the U.S. physician-population ratio intensifies competition and is one reason...
References: Accreditation Council for Graduate Medical Education (June, 1999). Program requirements for the transitional year [On-line]. Available www.acgme.org/req (Accessed February 28, 2001). American Medical Association. (1982). SMS report, Socioeconomic Monitoring System. Chicago: AMA. American Medical Association. (1996). Nonfederal physicians in the United States and possessions by selected characteristics [On-line]. Available: www.ama-assn.org/physdata (Accessed February 17, 2000). American Medical Association. (1998). Socioeconomic characteristics of medical practice 1997/1998. Chicago: Author. American Medical Association. (1999). Physician characteristics and distribution, 1999. Chicago: Author.
A QUESTION OF ETHICS
• It has been said that an increased number of physicians is related to an increase in the utilization of health care services—a concept known as physicianinduced demand. Is the utilization of health care, in your opinion, related to greater access to care for those who previously could not get care, or do physicians provide unnecessary care in order to maintain their income in a competitive environment?
118 • CHAPTER 6 Ferreter, M. (2000). Taking their cut. Modern Physician, 4(1), 40. Greenfield, S., Nelson, E., Zubkoff, M., Manning, W., Rogers, W., Kravitz, R., Keller, A., Tarlov, A., & Ware, J. (1992, March 25). Variations in resource utilization among medical specialties and systems of care. JAMA, 269(12), 1624–1630. Hall, M., & Lawrence, L. (1998). Advance data: Ambulatory surgery in the United States, 1996 (Vital and Health Statistics, Vol. 300). Hyattsville, Maryland: National Center for Health Statistics. Health Care Financing Administration. (1998, July 23). CLIA: General program description [On-line]. Available: www.hcfa.gov/medicaid/clia/ progdesc.htm (Accessed April 24, 2000). Henderson, J. (1992, May 18). Surgicenters cut further into market. Modern Healthcare, pp. 108–110. MacColl, W. A. (1966). Group practice and prepayment of medical care. Washington, DC: Public Affairs Press. Medical World News. (1973, September 21). Moran, M. (1998, March 9). More physicians are employees. American Medical News, pp. 7–8. Moskowitz, D. (1999). 1999 health care almanac & yearbook. New York: Faulkner & Gray. Patient dumping: Hospitals caught between feds, HMOs. (1999, February 19) American Health Line. Starr, P. (1982). The social transformation of American medicine. New York: Basic Books. U.S. Department of Health, Education, and Welfare. (1970). Medical care for the American people: Final report of the Committee on the Costs of Medical Care. Chicago: University of Chicago Press. Woodwell, D. (1999). National ambulatory medical care survey: 1997 summary. Hyattsville, MD: National Center for Health Statistics.
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