112
THE CURRENT ROLE OF THE HOSPITAL IN AMBULATORY CARE* ERNEST W. SAWARD, M. D. Professor of Social Medicine University of Rochester Rochester, New York
T HE title of this symposium, " The Hospital Reconsidered: A New Perspective," implies that it was earlier considered, and that since then significant change has occurred. But before outlining a new perspective of the hospital, particularly as it applies to ambulatory care, it is, perhaps, useful to recall some general background. A scholarly review of the many viewpoints in the vast literature on ambulatory care of even the last few years is impossible in this short presentation. In examining the hospital and its functions, my starting point is the famous 11th edition of the Encyclopedia Britannica. This pre-World War I edition tells how we were before the many revolutionary changes of this century. The article, by a British hospital administrator, describes not only the history of hospitals, but the problems current at that time. He particularly distinguishes between the problems of administering a private voluntary hospital and a publicly funded one. To those who live in this city his description is all too familiar. I cite this perspective of 70 years ago merely to humble us slightly as to the degree of our progress. Another fundamental examination of the organization of health services was that reported by the committee on the cost of medical care more than 40 years ago.1 The role of organized ambulatory care in relation to the hospital and its financing as described in this report is not only conceptually current, but we have yet to implement its fundamental recommendations. A third perspective of approximately a decade ago was a meeting sponsored by the American Hospital Association in Chicago and chaired by Dr. Peter Rogatz. The substance of this meeting was an advocacy of the hospital's role in providing high-quality, comprehensive ambulatory *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 at the Academy May 1 and 2, 1978.
Bull. N. Y. Acad. Med.
AMBULATORY CARE ~
~
MUATR
113 A
E
1
care in continuity. Challenging concepts expressed by the participants have yet to be carried out by this nation's hospitals. Some of these concepts were embodied in the American Hospital Association's design for national health insurance called Ameriplan.2 But there has been progress. It is evolutionary and not sudden and one can perhaps discern the trends that occur. I shall speak about these trends. The hospital's classic role has gone during this century from a largely caring function with occasional curative episodes to a largely secondary and tertiary curative role with unfortunately a perceived reduction of the caring function. Now I am aware that my nursing colleagues will instantly disagree, but unfortunately I find that not only individual patients but much of society agrees. I am also aware that there are many categories of acute-care general hospitals and that there is no constructive way simultaneously to generalize about major urban voluntary hospitals, major urban public hospitals, suburban community hospitals, and small rural public or private community hospitals.3 They have different roles, different problems, and are all necessary, so their roles must vary with local appropriateness. The question becomes, How does ambulatory care relate itself across this wide spectrum? If the hospital predominantly has secondary and tertiary care functions and most ambulatory care is not, there is an immediate dichotomy of purpose. The same hospital staff is unlikely to perform both functions equally well or with equal desire., Hospitals, particularly those serving the disadvantaged, throughout this century have characteristically maintained some type of ambulatory care services. At a Boston hospital where I trained many years ago it was quaintly called the Outdoor Department. As in many other hospitals, those who visited this department were economically disadvantaged, lived essentially in the immediately surrounding neighborhood, and when they needed inpatient care were admitted to ward service. This clientele differed from that of the private patients of the hospital attending staff, who were almost never seen in the Outdoor Department. It was largely the responsibility of the house staff to care for these ambulatory patients, comprehensively and in continuity to the extent that this could be done with an annually changing house staff, but with general and somewhat diffuse oversight by the attending staff because the latter periodically had to serve in the outpatient department to remain eligible for the attending staff. I cite this historic scene from my personal background because it reasonably respresents a status of ambulatory care attached to hospitals within the Vol. 55, No. 1, January 1979
11411
E. W. SAWARD SWR
E.W
memory of some of us. This activity was not intended to be financially self-sustaining and was regarded as charity. If we are to discuss trends, such a baseline must be delineated. The great change in technological medicine in America began around World War II. Antimicrobial drugs introduced shortly before the war not only changed the nature of the patient population in hospitals, but they also changed the attitude of the profession. But, perhaps much more important, they changed the attitudes of the public as to what technology could accomplish. The rapid technological developments of the last 30 years, although many are correctly characterized by Dr. Lewis Thomas as "halfway technologies," have profoundly influenced what can be accomplished in the hospital but even more profoundly changed public expectations of what might be accomplished. All of this has affected the hospital's ambulatory care role. The complaint immediately after World War II was basically that the quality of medical care suffered because too few of the physicians then in practice had been properly trained for the rapidly developing medical technology. A surge of specialization occurred so that, from most physicians being generalists, 20 years later most had become specialists. Fewer and fewer attending physicians attached to large general hospitals had a major interest in primary care appropriate to an ambulatory care setting. Many hospital ambulatory care settings had been divided into a multiplicity of specialized services. We all watched this process and felt frustrated by it. The responsive movement from the mid- 1950s to the latter part of the 1960s was to develop comprehensive care clinics. Primary care was not yet a vogue term, but conceptually the ideas differed little from those of today. Starting in the mid-1960s as a reaction against inappropriate subspecialization, both in medical school training and in residency training, emphasis was renewed upon training physicians specifically for ambulatory care and family-medicine programs began not only at medical school-affiliated hospitals but at community hospitals. Concomitant with the development of family-medicine programs, a number of the
leaders of academic internal medicine, having seen their departments fragment into a dozen or more subspecialty units, recognized a need for general internists and recreated programs to train this type of physician. Perhaps before either of these movements, the pediatricians had the foresight to develop strong programs in what was called community pediatrics. Nurse-practitioner programs and physician-assistant programs Bull. N. Y. Acad. Med.
AMBULATORY CARE
AMBULATORY
115
CARE
began and spread rapidly from the mid- 1960s. These last two professional categories find themselves much more at ease and more readily paid in the organized setting of hospital ambulatory care than in the isolation of an individual practitioner's detached offices, and it has been in such settings that many or most seek their careers. Obviously, training programs for family practice, general internal medicine, community pediatrics, and nurse-practitioners and physician assistants required new and expanded settings. These events were only partly a response to professional insight, but mainly responded to social demand. The public found it harder and harder to meet simple health-care needs, and the phenomenal increase in visits to hospital emergency departments was but one reflection of the need then current. Both those involved in medical care administration and the public at large recognized the inappropriateness of this. Therefore, the new manpower developments and the increased difficulty of access to appropriate ambulatory services combined to encourage a proliferation of ambulatory care programs in hospitals across the country. At first, fundamentally reflecting social issues of the late 1960s, these were aimed at the disadvantaged, but it became ever clearer that access to primary care services was a difficult problem for a significant number of the middle class as well. The popular press became full of criticism of the difficulty of obtaining appropriate services for simple illness. Although these needs are felt and expressed differently in central cities, in suburban areas, and in rural towns, they have had much in common. In 1969, in Rochester, N.Y., where I live, the hospitals and the local health-planning agency agreed that each major hospital in the community would provide a general ambulatory service on site, at one detached in a disadvantaged area of the community and, if possible, at one in the rural countryside surrounding the metropolitan area. Some of our local hospitals have accomplished this, and others have accomplished some part of the program. Meanwhile, changes in federal funding (originally through the Office of Economic Opportunity) have intervened and health maintenance organizations have developed, both as free-standing institutions and as part of hospital facilities. I cite these decisions in regard to ambulatory care a decade ago in Rochester as an example of their then current thinking and of the trend which had begun across the country stimulated by grants in some areas, but in many others by the local community itself without outside help. Vol. 55, No. 1, January 1979
11611
E. W. SAWARD E.W SWR
Hospitals' current problems in meeting community responsibilities simultaneously with elaborate constraints on reimbursement for their services have produced a particular turbulence readily visible in New York and elsewhere. A recent opinion states: "There is a growing, unfounded consensus among health professionals, government officials, and members of the public that ambulatory care is simply too much of a drain on our teaching hospitals' shrinking financial resources to be continued."4 But in this regard there is wide diversity in our large country. Ambulatory care services, whether attached to a hospital or at a detached site but related to the hospital, improve the occupancy of the hospital in a symbiotic relation. By usual hospital-accounting methods, the ambulatory services by themselves are seldom financially self-sustaining and they typically strain hospital finances. Whether the increase in hospital occupancy arising from ambulatory services yields an adequate offset has had much discussion. But there is no longer much discussion that appropriate primary care ambulatory services have become an accepted responsibility of the leading hospitals in most metropolitan areas and in many smaller communities as well. Although health-care planning for comprehensive services has been on the American agenda for half a century, rising and falling in interest at different times, Public Law 93-641 in 1974 and its gradual implementation in the last few years certainly has received renewed interest. High on the list of national priorities and in the priorities now expressed in the healthsystems plans of various health-systems agencies is access to appropriate ambulatory health-care services for the entire population. Unevenness of this access, geographically and by socioeconomic class, is an unfortunate but acknowledged fact of American health care. As a society we have attempted many devices to provide it. The main institutional sponsor, quite naturally considering its historic role, has been the hospital. Independently sponsored neighborhood health centers have been viable only by the use of federal funds. Prepaid group practice health maintenance organizations have successfully accomplished these goals for working populations by organizing a structured program for exactly this purpose. Not only have some of these programs been highly successful, but their cost effectiveness once again appeals strongly to the administration and forms a prominent part of current federal health policy. Such plans have widely diverse forms of sponsorship by consumer groups, professional groups, hospitals, medical schools, and universities, to mention but a few. Bull. N. Y. Acad. Med.
AMBULATORY CARE
AMBULATORY
CARE
117
In summary, the present status of hospital-related ambulatory care is that the concepts present for at least half a century have gradually been implemented in a widespread manner by a much greater variety of institutions, largely in response to fundamental developments in medical care itself. Technology has forced specialization of the health professions and, in turn, changed the hospital into an instrument of this technology and specialization. But, beginning over a decade ago, specialization of the profession, particularly as epitomized by the intensity of contemporary hospital care, created a gap for many in society, particularly the disadvantaged, in access for ordinary health needs. The result has been a demand both in many state legislatures and in the Congress to recreate the role of general physician as now embodied in training programs labeled family medicine, general internal medicine, and community pediatrics. These training programs relate to hospitals in their contemporary expanded role, and hence provide progressive amounts of ambulatory care. In many instances, previously specialized compartmented ambulatory clinics have been reorganized to take in broader comprehensive functions. The community perceives its hospital as by far the strongest institutional provider of health care, and therefore calls upon it not only to provide ambulatory services on site at the hospital, but often at detached areas of particular need in the community. A few communities of the United States have further developed peripheral outreach sites in the surrounding rural areas. Other institutional forms have developed from similar stimuli, as freestanding neighborhood health centers and health maintenance organizations as well as many less clearly defined forms. American health delivery is characteristically pluralistic in its devices and forms. It is the strength of the American hospital system, however regulated, however harassed by regulation, to be flexible enough to cope with community desires to fulfill locally perceived health needs. I hope I have made clear that there is no single way to do this, but multiple approaches are required. I have looked at the delivery of health services in many different parts of the United States. Problems are diverse and the outcomes of programs to cope with them are equally diverse. Surely, one cannot think of a single model solution for all of them. This diversity, through its many resultant innovations, gives us strength. Everywhere, the hospital, as a community institution, is looked to as having a responsible role, a role greatly expanded from the central role of inpatient care of a decade ago. Ten years ago fewer than one in 10 patient visits were to Vol. 55, No. 1, January 1979
118
E. W. SAWARD
outpatient departments or large group practices. Today, one of four visits is to such institutions.5 This trend is reason enough to consider what it may be 10 years from now. REFERENCES 1. Committee on the Costs of Medical Care: 3. Hospital Research and Educational Trust: The Future of the Public General HospiMedical Care for the American People: tal: An Agenda for Transition. A Report The Final Report. Chicago, University of of the Commission on Public General Chicago Press, 1932. Reprinted by The Hospitals, Chicago, 1978. Department of Health, Education, and Welfare, Public Health Service, Health 4. Berman, A. and Moloney, T.: Are outpatient departments responsible for the fiscal Services and Mental Health Administracrisis facing teaching hospitals?J. Amb. tion, Community Health Service, 1970. Care Man. 1:37-53, 1978. 2. The National Health Care Services Reorganization and Financing Act. Con- 5. The Robert Wood Johnson Foundation: Annual Report 1977. Princeton, N.J. gressional Record 118: H2669, March 28, 1972.
Bull. N. Y. Acad. Med.
THE CURRENT ROLE OF THE HOSPITAL IN AMBULATORY CARE* ERNEST W. SAWARD, M. D. Professor of Social Medicine University of Rochester Rochester, New York
T HE title of this symposium, " The Hospital Reconsidered: A New Perspective," implies that it was earlier considered, and that since then significant change has occurred. But before outlining a new perspective of the hospital, particularly as it applies to ambulatory care, it is, perhaps, useful to recall some general background. A scholarly review of the many viewpoints in the vast literature on ambulatory care of even the last few years is impossible in this short presentation. In examining the hospital and its functions, my starting point is the famous 11th edition of the Encyclopedia Britannica. This pre-World War I edition tells how we were before the many revolutionary changes of this century. The article, by a British hospital administrator, describes not only the history of hospitals, but the problems current at that time. He particularly distinguishes between the problems of administering a private voluntary hospital and a publicly funded one. To those who live in this city his description is all too familiar. I cite this perspective of 70 years ago merely to humble us slightly as to the degree of our progress. Another fundamental examination of the organization of health services was that reported by the committee on the cost of medical care more than 40 years ago.1 The role of organized ambulatory care in relation to the hospital and its financing as described in this report is not only conceptually current, but we have yet to implement its fundamental recommendations. A third perspective of approximately a decade ago was a meeting sponsored by the American Hospital Association in Chicago and chaired by Dr. Peter Rogatz. The substance of this meeting was an advocacy of the hospital's role in providing high-quality, comprehensive ambulatory *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 at the Academy May 1 and 2, 1978.
Bull. N. Y. Acad. Med.
AMBULATORY CARE ~
~
MUATR
113 A
E
1
care in continuity. Challenging concepts expressed by the participants have yet to be carried out by this nation's hospitals. Some of these concepts were embodied in the American Hospital Association's design for national health insurance called Ameriplan.2 But there has been progress. It is evolutionary and not sudden and one can perhaps discern the trends that occur. I shall speak about these trends. The hospital's classic role has gone during this century from a largely caring function with occasional curative episodes to a largely secondary and tertiary curative role with unfortunately a perceived reduction of the caring function. Now I am aware that my nursing colleagues will instantly disagree, but unfortunately I find that not only individual patients but much of society agrees. I am also aware that there are many categories of acute-care general hospitals and that there is no constructive way simultaneously to generalize about major urban voluntary hospitals, major urban public hospitals, suburban community hospitals, and small rural public or private community hospitals.3 They have different roles, different problems, and are all necessary, so their roles must vary with local appropriateness. The question becomes, How does ambulatory care relate itself across this wide spectrum? If the hospital predominantly has secondary and tertiary care functions and most ambulatory care is not, there is an immediate dichotomy of purpose. The same hospital staff is unlikely to perform both functions equally well or with equal desire., Hospitals, particularly those serving the disadvantaged, throughout this century have characteristically maintained some type of ambulatory care services. At a Boston hospital where I trained many years ago it was quaintly called the Outdoor Department. As in many other hospitals, those who visited this department were economically disadvantaged, lived essentially in the immediately surrounding neighborhood, and when they needed inpatient care were admitted to ward service. This clientele differed from that of the private patients of the hospital attending staff, who were almost never seen in the Outdoor Department. It was largely the responsibility of the house staff to care for these ambulatory patients, comprehensively and in continuity to the extent that this could be done with an annually changing house staff, but with general and somewhat diffuse oversight by the attending staff because the latter periodically had to serve in the outpatient department to remain eligible for the attending staff. I cite this historic scene from my personal background because it reasonably respresents a status of ambulatory care attached to hospitals within the Vol. 55, No. 1, January 1979
11411
E. W. SAWARD SWR
E.W
memory of some of us. This activity was not intended to be financially self-sustaining and was regarded as charity. If we are to discuss trends, such a baseline must be delineated. The great change in technological medicine in America began around World War II. Antimicrobial drugs introduced shortly before the war not only changed the nature of the patient population in hospitals, but they also changed the attitude of the profession. But, perhaps much more important, they changed the attitudes of the public as to what technology could accomplish. The rapid technological developments of the last 30 years, although many are correctly characterized by Dr. Lewis Thomas as "halfway technologies," have profoundly influenced what can be accomplished in the hospital but even more profoundly changed public expectations of what might be accomplished. All of this has affected the hospital's ambulatory care role. The complaint immediately after World War II was basically that the quality of medical care suffered because too few of the physicians then in practice had been properly trained for the rapidly developing medical technology. A surge of specialization occurred so that, from most physicians being generalists, 20 years later most had become specialists. Fewer and fewer attending physicians attached to large general hospitals had a major interest in primary care appropriate to an ambulatory care setting. Many hospital ambulatory care settings had been divided into a multiplicity of specialized services. We all watched this process and felt frustrated by it. The responsive movement from the mid- 1950s to the latter part of the 1960s was to develop comprehensive care clinics. Primary care was not yet a vogue term, but conceptually the ideas differed little from those of today. Starting in the mid-1960s as a reaction against inappropriate subspecialization, both in medical school training and in residency training, emphasis was renewed upon training physicians specifically for ambulatory care and family-medicine programs began not only at medical school-affiliated hospitals but at community hospitals. Concomitant with the development of family-medicine programs, a number of the
leaders of academic internal medicine, having seen their departments fragment into a dozen or more subspecialty units, recognized a need for general internists and recreated programs to train this type of physician. Perhaps before either of these movements, the pediatricians had the foresight to develop strong programs in what was called community pediatrics. Nurse-practitioner programs and physician-assistant programs Bull. N. Y. Acad. Med.
AMBULATORY CARE
AMBULATORY
115
CARE
began and spread rapidly from the mid- 1960s. These last two professional categories find themselves much more at ease and more readily paid in the organized setting of hospital ambulatory care than in the isolation of an individual practitioner's detached offices, and it has been in such settings that many or most seek their careers. Obviously, training programs for family practice, general internal medicine, community pediatrics, and nurse-practitioners and physician assistants required new and expanded settings. These events were only partly a response to professional insight, but mainly responded to social demand. The public found it harder and harder to meet simple health-care needs, and the phenomenal increase in visits to hospital emergency departments was but one reflection of the need then current. Both those involved in medical care administration and the public at large recognized the inappropriateness of this. Therefore, the new manpower developments and the increased difficulty of access to appropriate ambulatory services combined to encourage a proliferation of ambulatory care programs in hospitals across the country. At first, fundamentally reflecting social issues of the late 1960s, these were aimed at the disadvantaged, but it became ever clearer that access to primary care services was a difficult problem for a significant number of the middle class as well. The popular press became full of criticism of the difficulty of obtaining appropriate services for simple illness. Although these needs are felt and expressed differently in central cities, in suburban areas, and in rural towns, they have had much in common. In 1969, in Rochester, N.Y., where I live, the hospitals and the local health-planning agency agreed that each major hospital in the community would provide a general ambulatory service on site, at one detached in a disadvantaged area of the community and, if possible, at one in the rural countryside surrounding the metropolitan area. Some of our local hospitals have accomplished this, and others have accomplished some part of the program. Meanwhile, changes in federal funding (originally through the Office of Economic Opportunity) have intervened and health maintenance organizations have developed, both as free-standing institutions and as part of hospital facilities. I cite these decisions in regard to ambulatory care a decade ago in Rochester as an example of their then current thinking and of the trend which had begun across the country stimulated by grants in some areas, but in many others by the local community itself without outside help. Vol. 55, No. 1, January 1979
11611
E. W. SAWARD E.W SWR
Hospitals' current problems in meeting community responsibilities simultaneously with elaborate constraints on reimbursement for their services have produced a particular turbulence readily visible in New York and elsewhere. A recent opinion states: "There is a growing, unfounded consensus among health professionals, government officials, and members of the public that ambulatory care is simply too much of a drain on our teaching hospitals' shrinking financial resources to be continued."4 But in this regard there is wide diversity in our large country. Ambulatory care services, whether attached to a hospital or at a detached site but related to the hospital, improve the occupancy of the hospital in a symbiotic relation. By usual hospital-accounting methods, the ambulatory services by themselves are seldom financially self-sustaining and they typically strain hospital finances. Whether the increase in hospital occupancy arising from ambulatory services yields an adequate offset has had much discussion. But there is no longer much discussion that appropriate primary care ambulatory services have become an accepted responsibility of the leading hospitals in most metropolitan areas and in many smaller communities as well. Although health-care planning for comprehensive services has been on the American agenda for half a century, rising and falling in interest at different times, Public Law 93-641 in 1974 and its gradual implementation in the last few years certainly has received renewed interest. High on the list of national priorities and in the priorities now expressed in the healthsystems plans of various health-systems agencies is access to appropriate ambulatory health-care services for the entire population. Unevenness of this access, geographically and by socioeconomic class, is an unfortunate but acknowledged fact of American health care. As a society we have attempted many devices to provide it. The main institutional sponsor, quite naturally considering its historic role, has been the hospital. Independently sponsored neighborhood health centers have been viable only by the use of federal funds. Prepaid group practice health maintenance organizations have successfully accomplished these goals for working populations by organizing a structured program for exactly this purpose. Not only have some of these programs been highly successful, but their cost effectiveness once again appeals strongly to the administration and forms a prominent part of current federal health policy. Such plans have widely diverse forms of sponsorship by consumer groups, professional groups, hospitals, medical schools, and universities, to mention but a few. Bull. N. Y. Acad. Med.
AMBULATORY CARE
AMBULATORY
CARE
117
In summary, the present status of hospital-related ambulatory care is that the concepts present for at least half a century have gradually been implemented in a widespread manner by a much greater variety of institutions, largely in response to fundamental developments in medical care itself. Technology has forced specialization of the health professions and, in turn, changed the hospital into an instrument of this technology and specialization. But, beginning over a decade ago, specialization of the profession, particularly as epitomized by the intensity of contemporary hospital care, created a gap for many in society, particularly the disadvantaged, in access for ordinary health needs. The result has been a demand both in many state legislatures and in the Congress to recreate the role of general physician as now embodied in training programs labeled family medicine, general internal medicine, and community pediatrics. These training programs relate to hospitals in their contemporary expanded role, and hence provide progressive amounts of ambulatory care. In many instances, previously specialized compartmented ambulatory clinics have been reorganized to take in broader comprehensive functions. The community perceives its hospital as by far the strongest institutional provider of health care, and therefore calls upon it not only to provide ambulatory services on site at the hospital, but often at detached areas of particular need in the community. A few communities of the United States have further developed peripheral outreach sites in the surrounding rural areas. Other institutional forms have developed from similar stimuli, as freestanding neighborhood health centers and health maintenance organizations as well as many less clearly defined forms. American health delivery is characteristically pluralistic in its devices and forms. It is the strength of the American hospital system, however regulated, however harassed by regulation, to be flexible enough to cope with community desires to fulfill locally perceived health needs. I hope I have made clear that there is no single way to do this, but multiple approaches are required. I have looked at the delivery of health services in many different parts of the United States. Problems are diverse and the outcomes of programs to cope with them are equally diverse. Surely, one cannot think of a single model solution for all of them. This diversity, through its many resultant innovations, gives us strength. Everywhere, the hospital, as a community institution, is looked to as having a responsible role, a role greatly expanded from the central role of inpatient care of a decade ago. Ten years ago fewer than one in 10 patient visits were to Vol. 55, No. 1, January 1979
118
E. W. SAWARD
outpatient departments or large group practices. Today, one of four visits is to such institutions.5 This trend is reason enough to consider what it may be 10 years from now. REFERENCES 1. Committee on the Costs of Medical Care: 3. Hospital Research and Educational Trust: The Future of the Public General HospiMedical Care for the American People: tal: An Agenda for Transition. A Report The Final Report. Chicago, University of of the Commission on Public General Chicago Press, 1932. Reprinted by The Hospitals, Chicago, 1978. Department of Health, Education, and Welfare, Public Health Service, Health 4. Berman, A. and Moloney, T.: Are outpatient departments responsible for the fiscal Services and Mental Health Administracrisis facing teaching hospitals?J. Amb. tion, Community Health Service, 1970. Care Man. 1:37-53, 1978. 2. The National Health Care Services Reorganization and Financing Act. Con- 5. The Robert Wood Johnson Foundation: Annual Report 1977. Princeton, N.J. gressional Record 118: H2669, March 28, 1972.
Bull. N. Y. Acad. Med.
