The downstream financial effects of a nursing home practice on an academic medical center

OBJECTIVE: To determine the financial impact of a nursing home practice on an academic medical center. DESIGN: Retrospective cohort design. SETTING: Middle-sized Midwestern community with fee-for-service Medicare population. SAMPLE: One hundred seventy-six nursing home residents followed by faculty and residents of a medical school department of family and community medicine. MEASUREMENTS: Billings and collections for professional and hospital services delivered by the academic medical center during fiscal year 1998. RESULTS: One hundred forty-four patient-years of service resulted in over 1 million dollars in billed charges. For every 1 dollar billed by family medicine, consulting physicians billed 2 dollars and the hospital billed 10 dollars. This amounted to over 4000 dollars per patient per year in reimbursement. This practice generated a wide variety of clinical problems (37 different diagnosis-related groups (DRGs) for the 61 admissions to the hospital). CONCLUSIONS: There is a significant downstream financial effect of a nursing home practice on an academic health center. For this and other reasons, this practice may be worthy of institutional support.     

Preparing for managed care: family practice residents and capitated care in community health centers

This article examines the financial impact on patients of family practice residents when a community health center (CHC) serving as a residency training site is converted to a capitated payment system. The costs in this analysis included using and educating family practice residents at CHCs, the cost of patient encounters at CHCs, and the cost of contracted capitated services. These costs were measured against capitated per member per month (pmpm) payments received by the CHC. If capitated patients were cared for by residents, the CHC would lose $8.42 pmpm. The CHC faced a $5.98 pmpm loss if it used staff physicians rather than residents. This analysis suggests there are educational costs associated with training physicians in capitated health care delivery systems. Family practice residencies and CHCs must prepare for the conversion to capitated systems; academic centers with managed care contracts must control patient encounter costs and utilization to remain competitive.     

La Médecine de Famille (Médecine Générale): Quelles spécificités académiques et professionnelles?

Family Medicine, a true scientific and academic discipline, has been defined by the World Organization of National Colleges, Academies and academic associations of general practitioners / family physicians (WONCA) since 2002, as being a "clinical specialty oriented towards primary care". This paper details the specificities of Family Medicine: a horizontal specialty, primary care, providing comprehensive and continuous care, patient-centered and community-oriented. The promotion of Family Medicine in the Maghreb countries requires a multi-axial strategy based on the social marketing of Family Medicine, the recognition of Family Medicine as a medical specialty and of Family Medicine as a gateway to national health system, the establishment of a quality approach in basic health centers and free practice offices (centers of health centers) and regular validation of the Family Medicine diploma.     

Family practice residencies in community health centers--an approach to cost and access concerns.

An inadequate number of trained primary care clinicians limits access to care at Community Health Centers. If family practice residents working in these centers can provide care to patients at a cost that is comparable to the center''s hiring its own physicians, then expansion of Family Practice Residency Programs into community centers can address both cost and access concerns. A cost-benefit analysis of the Family Practice Residency Program at the Fresno, CA, community center was performed; the community center is affiliated with the University of California at San Francisco. Costs included (a) residents'' salaries, (b) supervision of the family practice residents, (c) family practice program costs for educational activities apart from supervision at the community center, and (d) administrative costs attributable to family practice residents in the community center. Benefits were based on the number of patients that residents saw in the community center. Using this approach, a cost of $7,700 per resident per year was calculated. This cost is modest compared with the cost of training residents in inpatient settings. The added costs attributable to training residents in community health centers can be shared with agencies that are concerned with medical education, providing physicians to underserved communities, and increasing the supply of primary care physicians. Redirecting graduate medical education funding from hospitals to selected ambulatory care training centers of excellence would facilitate placing residents in community centers. This change would have the dual advantage of addressing the current imbalance between training in ambulatory care and hospital sites and increasing the capacity of community health centers to meet the health care needs of underserved populations.     

A student health HMO as a partnership model within an academic medical center

The Department of Family Practice, College of Medicine, in partnership with the University of Illinois at Chicago, was responsible for the reorganization of the Student Health Service into a health maintenance organization (HMO), Campus Care. Historically, the two campuses of the University of Illinois at Chicago operated student health as an infirmary model. Reorganization of student health into the Campus Care HMO provided expanded health care services to students, preserved more health care dollars in the university system, and provided a nonincremental increase in the size and responsibility of the Department of Family Practice. One year's experience showed that while the capitation was low compared with standard HMOs, the variable and less frequent use of services by the student population resulted in a fiscally viable operation. Numerous transition difficulties were encountered, including the need for rapid systems conversion within a complex university system, reeducation of students as well as traditional university-based practitioners for operation in a managed care system, and the rapid expansion of a small family practice department. The positive experience of the University of Illinois at Chicago supports the notion that family practice is better suited to providing student health care than other primary care disciplines. Three issues are paramount to success: (1) approval, support, and protection by higher level administration from university territorialism, (2) a core family practice faculty with strong leadership and experience in high-volume clinical activity, and (3) a close examination of financial resources in light of expected utilization.     

The Americanization of family medicine: contradictions, challenges, and change, 1969-2000

Family practice became the 20th medical specialty in 1969, identified by its leaders as a harbinger of health care reform, as well as practice excellence, and with expectations of continuing government support of its purpose and role. Since that time, the cultural and political environments have changed significantly in some ways, and not changed in others as initially expected, thus challenging the new specialty with pressures for reinvention with respect to its identity, function, and prestige. The most important impediment to a clear-cut role for family practice has been the lack of a formal administrative structure for primary care practice on a nationwide basis in the United States. Differentiation of the field from all other parts of medicine was also difficult because of the identification of family practice with the professional accoutrements of a specialty, parallel to other specialist fields. Family practice moved from an outsider role in medicine to a position of entrenchment in the medical establishment, including hospitals and academic medical centers. And, family practice became one of several overlapping and competing primary care fields. The role of family practice in US culture is now less clear than the potential role envisioned for it in 1969. Its multiple and not always well-defined roles in medicine may make it difficult to establish a clear identity for the specialty in the future. If it is to be successful, family practice must develop allies and work aggressively to establish its role in primary care. It must also work to institute primary care in the US medical system and act politically (as in the 1960s), taking advantage of current cultural trends, notably the information revolution and the growth of biomedical research.     

Reaching out to those in need: the case for community health science.

The present health care delivery model in the United States does not work; it perpetuates unequal access to care, favors treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are minorities (Native Americans, Hispanics, and African Americans) and those of lower socioeconomic status. Because the nation's poor are most affected by built-in inequities in the health care system and because they have little political power, policy makers have been able to ignore their responsibility to this group. Family medicine leaders have an opportunity to integrate community health science into their academic departments and throughout the specialty in a way that might improve health care for the underserved. The specialty could adapt existing structures to better educate and involve students, residents, and faculty in community health. Family medicine can also involve community practices and respond to community needs through practice based research networks and community based participatory research models. It may also be possible to coordinate the community activities of family medicine organizations to be more responsive to the health crisis of those in need. More emphasis on community health science is consistent with family medicine's roots in social reform, and its historical and philosophical commitment to the principle of uninhibited access to medical care for the underserved.     

Developing a primary care research agenda through collaborative efforts – a proposed “6E” model

The practice of family medicine is not well established in many developing countries including Sri Lanka. The Sri Lankan Government funds and runs the health facilities which cater to the health needs of a majority of the population. Services of a first contact doctor delivered by full time, vocationally trained, Family Physicians is generally overshadowed by outpatient departments of the government hospitals and after hours private practice by the government sector doctors and specialists. This process has changed the concept of the provision of comprehensive primary and continuing care for entire families, which in an ideal situation, should addresses psychosocial problems as well and deliver coordinated health care services in a society. Therefore there is a compelling need to teach Family Medicine concepts to undergraduates in all medical faculties. A similar situation prevails in many countries in the region. Faculty of Medicine Peradeniya embarked on teaching family medicine concepts even before a department of Family Medicine was established. The faculty has recognized CanMed Family Medicine concepts as the guiding principles where being an expert, communicator, collaborator, advocate, manager and professional is considered as core competencies of a doctor. These concepts created the basis to evaluate the existing family medicine curriculum , and the adequacy of teaching knowledge and skills, related to family medicine has been confirmed. However inadequacies of teaching related to communication, collaboration, management, advocacy and professionalism were recognized. Importance of inculcating patient centred attitudes and empathy in patient care was highlighted. Adopting evaluation tools like Patient Practitioner Orientation Scale and Jefferson’s Scale of Empathy was established. Consensus has been developed among all the departments to improve their teaching programmes in order to establish a system of teaching family medicine concepts among students which would lead them to be good Family Physicians in the future. Teaching Family Medicine concepts could be initiated even before establishing departments of family medicine in medical faculties and establishing the practice of family medicine in society. Family medicine competencies could be inculcated among graduates while promoting the establishment of the proper practice of Family Medicine in the society.     

La medicina familiar y comunitaria y la universidad. Informe SESPAS 2012

Family and community medicine is an academic subject, a medical specialty and a health profession with distinct dimensions: healthcare, teaching, research and management. In this discipline, the object of knowledge is the person, understood as a whole. Family medicine, as an academic subject, and primary care, as a health education setting, should be incorporated into the core graduate and postgraduate curricula. The absence of these elements leads to training bias and has major repercussions on quality, coordination and patient safety. The development of the Health Professions Act and the construction of the European Higher Education Area (EHEA) have created a favorable climate for the presence of this discipline in the university.Since the 1960s, family medicine has been consolidated as an academic subject with its own departments in almost all European universities, and a significant number of family physicians are teachers. A balance has been achieved between the hospital-based system (based on theory, disease, and the biological model) and the patient-centred model (based on problem solving, community-oriented and the bio-psycho-social model). The introduction of family and community medicine as a specific subject, and as a transverse subject and as an option in practicals, represents the adaptation of the educational system to social needs. This adaptation also represents a convergence with other European countries and the various legal requirements protecting this convergence. However, this new situation requires a new structure (departments) and faculty (professors and associate and assistant professors).     

Family and community medicine and the university. SESPAS report 2010

Family and community medicine is an academic subject, a medical specialty and a health profession with distinct dimensions: healthcare, teaching, research and management. In this discipline, the object of knowledge is the person, understood as a whole. Family medicine, as an academic subject, and primary care, as a health education setting, should be incorporated into the core graduate and postgraduate curricula. The absence of these elements leads to training bias and has major repercussions on quality, coordination and patient safety. The development of the Health Professions Act and the construction of the European Higher Education Area (EHEA) have created a favorable climate for the presence of this discipline in the university. Since the 1960s, family medicine has been consolidated as an academic subject with its own departments in almost all European universities, and a significant number of family physicians are teachers. A balance has been achieved between the hospital-based system (based on theory, disease, and the biological model) and the patient-centred model (based on problem solving, community-oriented and the bio-psycho-social model). The introduction of family and community medicine as a specific subject, and as a transverse subject and as an option in practicals, represents the adaptation of the educational system to social needs. This adaptation also represents a convergence with other European countries and the various legal requirements protecting this convergence. However, this new situation requires a new structure (departments) and faculty (professors and associate and assistant professors).     

China's new cooperative medical scheme improved finances of township health centers but not the number of patients served

China's New Cooperative Medical Scheme, launched in 2003, was designed to protect rural households from the financial risk posed by health care costs and to increase the use of health care services. This article reports on findings from a longitudinal study of how the program affected the use of health care services, out-of-pocket spending on medical care, and the operations and financial viability of China's township health centers, which constitute a middle tier of care in between village clinics and county hospitals. We found that between 2005 and 2008 the program provided some risk protection and increased the intensity of inpatient care at township health centers. Importantly, the program appears to have improved the centers' financial status. At the same time, the program did not increase the overall number of patients served or the likelihood that a sick person would seek care at a township center. These findings serve as a benchmark of the program's early impact. The results also suggest that the composition of health care use in China has changed, with people increasingly seeking outpatient care at village clinics and inpatient care at township health centers.     

Implementation of the health center concept in a rural community: A case study

A comprehensive health center integrates inpatient, outpatient, and public health services within the same medical and administrative structure. While health centers have been widely delveloped in other countries, only limited implementation has occured in the United States. This case study documents the successful implementation of the health center concept in a sparsely populated area of northwestern New Mexico. This remote geographic setting and the socioeconomic characteristics of the area's tricultural population are described. The evolution of the delivery system with its network of satelite clinics predominantly staffed by mid-level primary care providers is presented. Program development and funding for the provision of a wide range of preventive and curative health services supported by communication, transportation, outreach, educatioon, public health, and administration components are analyzed. Problems purported to hinder the implementation of comprehensive health centers in the United Styates are discussed from an experimental perspective.Dr. Reid, is with the Department of Family, Community, and Emergency Medicine, Anderson Schools of Management, University of New Mexico, Albuquerque, New Mexico 87131. Dr. Bartlett, is with the Department of Family medicine, University of Alabama, Birmingham, Alabama. Dr. Kozoll is Director, Checkerboard Area Health System, Cuba, New Mexico 87013. This study was supported by HURA Grant No. 06-D-000495-02 with the Bureau of Community Health Services, DHEW. The authors wish to acknowledge the assistance and valuable support of Robert Clements, PMS president, in the design of this investigation. This study would not have been possible without the excellent cooperation of the CAHS administrator, James Reibsomer, and his entire medical and administrative staff.     

The research environment in family practice

Both the place of family practice in academic medicine and the intellectual underpinning of the specialty itself are thought by many to depend on the development of successful research programs in academic departments of family medicine. Yet many believe less research than desired is being done in such departments, even by faculty trained in research. To gain additional information on this important subject, a survey was conducted of the departmental research experiences of 42 graduates of the several Robert Wood Johnson Foundation Family Practice Academic Fellowship Programs who had had the opportunity for at least one year of faculty experience. The responses indicate that the majority of such graduates spend 20 percent or less of their time in research, that most perceive administrative duties as interfering with research, that a minority have budgeted research time, and few have departmental research funds. Despite these obstacles, those who do research publish with surprising frequency, about one paper per fellow per year. Several ways are presented to improve the research environment in departments of family practice and to lead to even more productive, secure research activities of these and other family practice faculty.     

Gender differences in the utilization of health care services

BACKGROUND: Studies have shown that women use more health care services than men. We used important independent variables, such as patient sociodemographics and health status, to investigate gender differences in the use and costs of these services. METHODS: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of health care services and associated charges were monitored for 1 year of care. Self-reported health status was measured using the Medical Outcomes Study Short Form-36 (SF-36). We controlled for health status, sociodemographic information, and primary care physician specialty in the statistical analyses. RESULTS: Women had significantly lower self-reported health status and lower mean education and income than men. Women had a significantly higher mean number of visits to their primary care clinic and diagnostic services than men. Mean charges for primary care, specialty care, emergency treatment, diagnostic services, and annual total charges were all significantly higher for women than men; however, there were no differences for mean hospitalizations or hospital charges. After controlling for health status, sociodemographics, and clinic assignment, women still had higher medical charges for all categories of charges except hospitalizations. CONCLUSIONS: Women have higher medical care service utilization and higher associated charges than men. Although the appropriateness of these differences was not determined, these findings have implications for health care.     

Family medicine as an academic discipline: progress, challenges, and opportunities

Family practice as a specialty, now just over 20 years of age, arose in response to increasing public pressure and societal needs, not primarily from a breakthrough in new clinical knowledge or technology advances. Its academic discipline of family medicine is necessarily derived more from its clinical principles and functions in practice than from a unique body of knowledge and skills. Nevertheless, the mixture of knowledge, skills, and attitudes are collectively unique as applied by the family physician, and are teachable, learnable, and subject to critical inquiry and research. This paper presents an overview of the progress, present challenges, and future opportunities of family medicine as an academic discipline. A comparative analysis of the literature in the three primary care specialties reveals more commonalities than differences. Family practice has much to contribute to needed reforms in medical education and the health care system. The field is ideally positioned to be an active part of future resolutions to today's problems in both arenas.     

Shaping the future of academic health centers: the potential contributions of departments of family medicine

Academic health centers (AHCs) must change dramatically to meet the changing needs of patients and society, but how to do this remains unclear. The purpose of this supplement is to describe ways in which departments of family medicine can play leadership roles in helping AHCs evolve. This overview provides background for case studies and commentaries about the contribution of departments of family medicine in 5 areas: (1) ambulatory and primary care, (2) indigent care, (3) education in community and international settings, (4) workforce policy and practice, and (5) translational research. The common theme is a revitalization of the relationship between AHCs and the communities they serve across all missions. Family medicine leadership can provide dramatic organizational improvement in primary and ambulatory care networks and foster opportunities for leadership by AHCs in improving the health of the population. Departments of family medicine can also play a leading role in developing new partnerships with community-based organizations, managing the care of the indigent, and developing new curricula in community and international settings. Finally, family medicine departments and their faculty have a central role in helping AHCs respond to workforce needs and in developing translational research that emphasizes the health of the population and effectiveness of care. AHCs are a public good that must now evolve substantially to meet the needs of patients and society. By pushing for substantial change, by helping to reinvigorate the relationship between AHCs and the communities they serve, and by emphasizing fundamental innovation in clinical care, teaching, and research, family medicine can help lead the renewal of the AHC.     

The academic health center and the healthy community.

US medical care reflects the priorities and influence of academic health centers. This paper describes the leadership role assumed by one academic health center, the State University at Buffalo's School of Medicine and Biomedical Sciences and its eight affiliated hospitals, to serve its region by promoting shared governance in educating graduate physicians and in influencing the cost and quality of patient care. Cooperation among hospitals, health insurance payers, the business community, state government, and physicians helped establish priorities to meet community needs and reduce duplication of resources and services; to train more primary care physicians; to introduce shared governance into rural health care delivery; to develop a regional management information system; and to implement health policy. This approach, spearheaded by an academic health center without walls, may serve as a model for other academic health centers as they adapt to health care reform.     

Whither primary care in the academic health science center?

Five forces that shape the form and function of the future academic health center are a mandate to decrease health care costs, a surplus of physicians, intense competition for the provision of tertiary medical care, a suboptimal diagnosis-related group (DRG) case mix, and decreasing funding for manpower training and research. All five forces cause the academic health center to be much more in need of strong primary medical care services. This article describes the current relationship between primary care and the academic medical center, new contributions that primary care can make to the academic medical center, and the benefits that would accrue to both the academic medical center and primary care should a closer working relationship develop. These benefits include increased outpatient volume and revenue, a more balanced inpatient case mix, better primary medical care education, an enhanced community reputation, and greater influence by primary care on academic medical center policies. Published and personal case study experiences that show some of the potential problems with a closer working relationship between primary care and the academic medical center are described.     

The Organization and Delivery of Family Planning Services in Community Health Centers

BackgroundFamily planning and related reproductive health services are essential primary care services for women. Access is limited for women with low incomes and those living in medically underserved areas. Little information is available on how federally funded health centers organize and provide family planning services.MethodsThis was a mixed methods study of the organization and delivery of family planning services in federally funded health centers across the United States. A national survey was developed and administered (n = 423) and in-depth case studies were conducted of nine health centers to obtain detailed information on their approach to family planning.FindingsStudy findings indicate that health centers utilize a variety of organizational models and staffing arrangements to deliver family planning services. Health centers' family planning offerings are organized in one of two ways, either a separate service with specific providers and clinic times or fully integrated with primary care. Health centers experience difficulties in providing a full range of family planning services.Major ChallengesMajor challenges include funding limitations; hiring obstetricians/gynecologists, counselors, and advanced practice clinicians; and connecting patients to specialized services not offered by the health center.ConclusionsHealth centers play an integral role in delivering primary care and family planning services to women in medically underserved communities. Improving the accessibility and comprehensiveness of family planning services will require a combination of additional direct funding, technical assistance, and policies that emphasize how health centers can incorporate quality family planning as a fundamental element of primary care.     

The 21st century: the age of family medicine research?

Family medicine has matured as an academic and scientific discipline with its own core concepts, knowledge, skills, and research domains. It has acquired much expertise in studying common illnesses; the integration of medical, psychological, social, and behavioral sciences; patient-centered care; and health services delivery. Many health care challenges in the 21st century will place a great demand on primary care, which can serve its purpose only if it is of high quality and evidence based. Family medicine research can contribute to many areas of primary care, ranging from the early diagnosis to equitable health care. Stakeholders, such as the World Health Organization, governments, and funding agencies, are becoming more supportive to family medicine research because they recognize its key importance in improving the quality of primary care and bridging the gap between biomedical research and clinical practice. Family medicine can play a leading role in shifting the paradigm of medical research from the laboratory to the person. The 21st century should be a golden age of family medicine research because the time is right for the discipline, the health care environment is most suitable, and stakeholders are supportive. Family medicine must prepare for it by building up its research track record and capacity.