Population Health Initiative - Case Study Example

Population Health Initiative: Policy Initiative Paper Introduction Ambulatory primary care initiatives in the health care sector has been mooted from time to time as one of the most comprehensive models for the development and augmentation of the existing system of health care on a reformatory basis. While the already existing centers of ambulatory primary care have evolved through a checkered process of ‘forwards and backwards’, the potential for new ones to grow in an environment of uneven competition and partial regulation is underlined by the ever growing gap between government and private budgeted health care expenditures and the demand for health care services. In this light the Governing Board’s plan to launch an ambulatory primary care unit has to be critically assessed by using market-based metrics of evaluation so that parametric growth areas of importance can be individually analyzed and presented. There is also the need for an analysis of the probabilities related to decision making and operational parameters of management. In other words the effective management of such a service unit with attendant logistical problems requires far more critical planning and design. Analytical presentation of the plan The existing literature on ambulatory primary care as a dynamic complement to residential care in the health sector has been heavily biased in favor of policy perspectives along with a marked emphasis on regulatory mechanisms. While such literature ignores the strategic importance of its potential as a viable complement with a lot of attendant benefits, the hospital-based care system gets preference in a majority of assessments for the latter’s quality and administrative practicability. This discrepancy is basically due to the fact that monitoring and follow up procedures adopted under the ambulatory-based primary care system could be minimal and sparse while any hospital-based system would have a more detailed set of procedures in monitoring and follow-up work. Thus a very attractive growth area in the ambulatory primary care sector is the continuous monitoring procedures. For example palliative care is carried out at ambulatory primary care clinics with a view to reducing the relative severity and symptoms of diseases but the patient is not cured of the disease completely. This quality-of-life improving auxiliary service has been in greater demand from a variety of patients suffering from chronic illnesses such as cancer and eating disorders. While such patients might seek hospice-based care at a cost as a last resort, there is little need for most of such patients to be continuously hospitalized till the disease is cured (Haas, 2004). This organization has particular potential to design and deliver such palliative care to patients in niche market segments such as those who need health care but not able to afford hospice-based care. There are patients with terminal illnesses such as cancer and then there are patients with disorders that do not require hospital-based care. For instance pre-natal care can be delivered through ambulatory primary care clinics. Next potential growth area for ambulatory primary care is the consultation for psychological disorders which require little or no residential care. For instance eating disorders and mild depression need advice but hospital-based care is not necessary. Quality of life improving ambulatory primary care techniques go a long way in that they have been utilized as the potential alternative to hospice-based treatment. However at Blackwell (Ref. the case study), there have been a series of anomalous failures in both the residential primary care and the hospital-based ambulatory care. While these shortcomings have been attributed basically to inefficient work practices and a lack of facilities, there is also a total neglect of efficient management practices at Blackwell. Dr. Winters’ efforts to reorganize the faculty and residents in the hospital and the ambulatory care facility have had the desired impact, though outcomes cannot be determined under highly uncertain circumstances (McQueen and Jones, Editors, 2007). Despite a persistent effort to revitalize the non-functional residential primary care unit of the Hospital there had been some hitches before Dr. Card was brought on the scene. Texoma Medical Center (TMC) in Texas, Saint Barnabas Ambulatory Care Center in New Jersey, University of North Carolina (UNC) Ambulatory Care Center, Ambulatory Care Centers of Children’s Hospital of Pittsburgh and Los Angeles Ambulatory Care Center are few centers that are being managed excellently well right now. While most of these well managed centers depend on consultancy services in planning and execution of ambulatory care activities, the most sought after services include strategic management, clinical operations, HRM, facility design & planning and information systems management (Tan, Editor, 2005). These centers have successfully put in place patients’ care programs that can be applied across a broader cross section of ownership and leadership structures and styles. For instance LA Ambulatory Care Center has adopted a series of management techniques that have surpassed in performance comparatively well than those adopted by ordinary centers. As demonstrated by the Blackwell experience, residents’ productivity rates have very little parallel elsewhere in the country in comparison what has been achieved at the above centers. Especially centers at the Children’s Hospital of Pittsburg have remarkably well achieved higher productivity growth rates among their residents and the faculty. As borne out by the same case study, residents were demoralized in the past due to poor HRM practices, especially poor motivation. Subsequent changes at Blackwell served as the harbinger of a qualitative shift (Galea, Editor, 2007). The same trend could be attributed to some of the above centers. For example UNC center had been faced with similar situations. Now the center’s overall performance in critical criteria like finance, outpatient turnout, residents’ productivity rates, sustainability goals, faculty involvement and organizational learning outcomes, is excellent. This strategic reorientation has come about as a result of internal and external organizational revamping. Hospital-based outpatient primary care programs necessitate additional arrangements that are specifically designed to effect qualitative changes in ambulatory programs. Coordination between the faculty and resident staff is one such fundamental determinant of quality. Quality improvement programs initiated at the hospital level cannot be totally failure-proof devices to initiate action programs to achieve positive organizational outcomes though because quality improvement requires constant reviewing and updating of existing programs (Mayer and Villaire, 2007).Very few current programs at the organizational level could be described as feasible to continue with. Procedural changes could be the next best area for improvement in this organization’s efforts to establish an ambulatory primary care service. Organizational procedures and practices at the individual unit level need prioritizing and reorienting to align such procedures and practices with ongoing programs (Friedman and Petersen, 2003). Sudden variations in program-specific procedures might require a total refocus of resources as well. Such drastic changes lead to very difficult strategic choices that may compel the management to exercise caution and reprioritize procedures. One of the most critically important areas in the functional domain of the hospital-based ambulatory care system is the supply chain management. Thus this requires much greater attention in the planning process as one where continuous improvement could produce highly positive outcomes. For instance supply chain management involving hospital equipment and material such as pharmaceuticals plays a pivotal role in the whole process of management. Therefore mostly the organizational outcomes such as profit margins, efficiency and market share growth depend to a greater extent on supply chain management abilities. The potential growth strategies of this approach are determined by the capacity utilization and rationalization efforts of the organization. While the existing capacities of the faculty and the resident staff will have to be enhanced through learning and training programs along with research, there must also be a dynamic component of recruitment and replacement. New staff has to be recruited while the existing staff is moved up to more responsible positions. Projected revenue for this current ambulatory primary care system can be worked out on the following basis. Given the budgetary constraints (i.e. costs and revenues) and cash flow forecasts there could be no better evaluation of its financial success other than through a comparative statistical analysis of similar operations in the country. In the first instance Medicare and Medicaid work together to ensure a qualitative service for the final consumer, i.e. the patient. In this backdrop medical insurance plays a very decisive role in determining demand for the service. Current diversification plans of the hospital management to start an ambulatory primary care service would definitely be influenced by the likely cash flows through this system. Many centers throughout the country are faced with the reality that they cannot even breakeven. This is due to the constantly rising operational costs and industry-specific factors such as persistently soaring economic rents of specialist medical staff. Currently many hospitals have a habit of hiring faculty on the basis of piecemeal pay or per assignment. However even the faculty members with specialties in geriatrics, pediatrics and so on need to be permanently employed due to the greater demand for their service. Residents cannot be hired for temporary employment. These factors contribute to rising costs. However there are equally well revenue generating activities as well. The projected revenue for ambulatory care can be approximately US$ 5 million given an operational capacity of handling 50,000 visits by patients on a monthly basis. This is an oversimplification of the otherwise complex scenario of revenue flow. This is for the first year of operations. Subsequently the number of visits by patients would increase, thus adding more to the projected revenue as shown by the following table. Patient care and related organizational performance parameters on operational variables could be established with a degree of certainty given the strategic orientation of ambulatory primary care in a highly insurance-based health care market. The organization needs not only the techniques for quantifying highly abstract operational concepts but also the psychometrics to determine patient care dynamics. Such operationalization data would help the organization to evaluate organizational outcomes with a degree of success. However they are related to abstract concepts such as patients’ attitudes towards ambulatory primary care, organizational approaches to managing outpatient visits and psychometrics related to changing assessments of health care programs. The diversity and complexity of operational challenges faced by ambulatory care organizations are basically connected with quality, treatment regimes and service metrics. Even when the hospital operates from a single site resource constraints and logistical problems would compel the management to put into operation a diverse amount of care delivery systems that in turn exact a heavy toll on the physician. In the USA currently the Health Plan Employer Data and Information Set (HEDIS) is the most widely used performance metric. This metric is extensively utilized to assess preventive and chronic health care programs at ambulatory primary care units (Roski and Gregory, 2001). The existing sample datasets are frequently used by statisticians to assess the cumulative growth projections though. The time frame within which the ambulatory primary care service can be established and operationalized depends on a number of other factors. For instance performance related programs seek to identify and measure ambulatory care services rendered on scheduled timelines which signify both the time-centric nature of the service delivery and follow-up (Magnus, 2007). While the ambulatory primary care might be fully operational in 6 months to 8 months from now, there can be unforeseen delays arising from logistics related bottlenecks. However, the timeline for fully-fledged operations need not be extended beyond this period for both the faculty and resident staff are available right now. Only the equipment and other logistics have to be brought in to existence. Critical success measures include financial measures of performance as against those metrics of abstract performance criteria discussed above. Such performance measures as market share, share price, market share growth, gross and net revenues, profit ratio, capital ratios and so on would determine the ambulatory primary care service’s success or failure. Though many such measures cannot be performed right now due to the lack of data, budgetary and cash flow forecasts can be made to a certain extent by focusing attention on planned expenditures and revenues (Spark, 2007). The cash flows can be tentatively forecast in accordance with the information provided in the above table. A breakeven analysis would do the rest. Naturally there would be a higher level of return for ambulatory primary care operations as the current market trends show. Conclusion As Kovner and Neuhauser (2004) point out in their introduction to this edition, ambulatory medical practices with their satellite pinpoints of operations have made a telling impact on the overall health care system to such an extent that there is very little by way of divergence of opinion on the subject. This policy initiative paper is based on this particular premise of future possibilities. The ambulatory primary care sector has been growing at a rapid rate from year to year. Its current growth phase rests on the intervening forces of government regulations and inherent growth-related constraints. Finally hospital-based ambulatory primary care as against mobile service centers at outdoor stations has such potentialities for growth in the coming years because the present US government’s commitment to provide child health care insurance at multiple levels. Insurance-based medical care has its advantages when it comes to billing formalities. Individuals seeking medical attention are not constrained by total cost though they are constrained by the relative cost of each system – hospital-based inpatient primary care and hospital-based outpatient care. Thus ambulatory care plays a pivotal role in the sphere of health care and it has such good future prospects too. REFERENCES 1. Haas, L.J. (2004). Handbook of Primary Care Psychology. New York: Oxford University Press. 2. Friedman, C. and Petersen, K.H. (2003). Infection Control in Ambulatory Care. New York: Aspen Publishers. 3. Galea, S. (Ed.). (2007). Macrosocial Determinants of Population Health. New York: Springer Publishing Company. 4. Kovner, A.R. and Neuhauser, D. (Eds.). (1978). Health Services Management: Readings, Cases, and Commentary, Eighth Edition. Chicago: Health Administration Press. 5. Magnus, M. (2007). Essentials of Infectious Disease Epidemiology (Essential Public Health). Massachusetts: Jones & Bartlett Publishers. 6. Mayer, G.G., and Villaire, M. (2007). Health Literacy in Primary Care: A Clinicians Guide. New York: Springer Publishing Company 7. McQueen, D. and Jones, C. (Eds.). (2007). Global Perspectives on Health Promotion Effectiveness. New York: Springer. 8. Roski, J .and Gregory, R. (2001). Performance measurement for ambulatory care: Moving towards a new agenda. International Journal for Quality in Health Care, Vol. 13(6) pp.447-453. 9. Spark, A. (2007). Nutrition in Public Health: Principles, Policies, and Practice. Florida: CRC Press. 10. Tan, J.(Ed.). (2005). E-Health Care Information Systems: an Introduction for Systems: An Introduction for Students and Professionals. California: Jossey-Bass. Read More