This is the Healthcare Marketplace Specialization, Healthcare Marketplace Overview. My name is Steve Parente, and this is module 2.1.4, Physician Sites of Care. So where are physicians practicing? Lots of different places. After all, the hospital is the physician's workshop, and so inpatient hospital is one major place that they're operating. On the outpatient hospital side, there's a whole range of different things they could be doing. On the ambulatory side, they could be in clinics actually providing services, the same thing they would do at a group practice. Emergency room, their offices, house calls, surgical centers, all coordinated at this level. Long term care facilities are also in play here, so skilled nursing facilities really like a hospital, but really designed more for taking care of folks that are really infirmed. Home health care, which are really visits. And then, hospice care, which sort of a mix of folks coming to your home or going into a specific hospice facility for, in general, end of life care. So there have been big changes in the ambulatory care market over the last few decades. There's been enormous shift from inpatient to outpatient care. A lot of this has been driven by the prospective payment system, the DRG system, we'll talk a little bit more later. We also have seen some changes where physician visits per year are going up, though not by much, 75% to 79% in 1996, from 1980. A lot of this is just really the population aging that's attributed to that. But we also see, interestingly, hospital stays are decreasing. And a lot of this is really the result of DRGs or prospective payment where we're now paying hospitals on a per admission basis rather than a per day basis. Now when we look at sites of visit there are some major differences that we see. Here's three different services we're going to focus on. Services, outpatient care and then physician visits. The lion's share of where visits occur are really in the physician's office, not as much in the. What we do see, though is that there are some race differences, where folks who are non-white basically are getting more services in the More in hospital outpatient settings and less in MD office. Now, part of that could also be location of where those facilities are located. But there definitely is a distinguishing difference that goes on here. When we look at white versus other, there's really not many attributes at all. It's a black versus non-black or really white distinction, that's what's going on. If we look at income as another way of looking at visits, there's some major changes here as well. If we look at all visits, 84% of them are in physician offices. But when we look at folks that are basically with 30% or more poverty, we see that there are less visits occurring in physician offices and more occurring in outpatient departments, mainly Facilities. If we're talking about under 20% poverty, we're now closer to 86%. This is essentially a wealthier population, and somewhere in the middle, sort of the balance between the two. And then getting into Care, what's really there? Is it all super urgent? Actually, not. Only about a third of it is really urgent. Emergent is where it could actually become urgent, a major problem. Semiurgent is, well, we're not quite sure, we're going to watch you for a bit. And then there's 10% where it's not really that serious, but probably better you went there maybe than not, but it's expensive to go to the. And then we have other folks, we really just don't know what's going on there so we have to take that as sort of noise. One change that happened really dramatically, matter of fact this was part of my PhD thesis, looking at this, was the change between 1994 and 1998 if we look at where surgeries were being done by physicians. And in particular, looking at ambulatory surgery and inpatient surgery. And it wasn't just that more centers were built, it was just the nature of the technology had changed dramatically. We saw ambulatory surgery really ramp up substantially from a rate of 50.5 to 57.7. And then it basically decreased, it almost mirrors that exactly on the inpatient side. And what really enabled this was laparoscopic surgeries. This is where you're doing a minimally invasive surgery, where you're not opening up the person's gut or their heart or something else. You're actually, essentially doing what's known as Band-Aid surgery. You make, if this is a person's body, you make a tiny incision, say around their belly button and sort of put in three probes. One that's it's cutting or lasering, another one is a camera, another one is suctioning out. And by doing that, you can have much faster recovery times, but it also increased the utilization of these surgeries being done as well. And one thing you might say is, well, what type of surgeries are we really talking about? Well the dominant, and this is mostly cash practice, there's not much insurance for this, except if it's severe burns, cosmetic or plastic surgery is the number one. We then find, from there, ophthalmology, and that's really LASIK procedures that are being done there. We do find that pain management and gastroenterology procedures are also a pretty substantial focus as well. Now, there could be some of the gastric stuff that might be lap banding for folks that have obesity. A major growing area, actually, is orthopedic centers, that's probably going to be more so as time goes on. Urological procedures is a little bit less than that. General surgery, for most common surgeries, is somewhere in the middle. But this gives you a sense of, for these free-standing ambulatory surgical centers, what really is constituting their major practice. And this concludes our module looking on physicians and their sites of care today as they practice medicine.
