Introduction
The healthcare industry in the U.S. began as a charitable system where the patients pay little or no money for treatment and other services. However, the healthcare industry has undergone phenomenal changes. In fact, the healthcare system in the United States has currently evolved into a business entity that needs financial management, strategic planning, operational control as well as functional specialties in order to effectively maintain its viability. The Healthcare in the US is one of the largest industries employing over 13 million workers. As such, healthcare has become one of the most flexible and stable industries in terms of employment. Some of the sectors in the healthcare system include hospitals, long term care, mental and behavioral health, ambulatory care and public healthcare. The paper will focus on the historical development of ambulatory care as well as its current role in healthcare. Approximately 1.2 billion visits are made in ambulatory care setting in America every year. As such, ambulatory care accounts for approximately a third of the United States healthcare spending. Ambulatory care has developed over time and it has played a significant role in the US. Additionally, the US ambulatory care sector is always influence politically through the various legislations.
Historical Development and Current Role in Healthcare Delivery
Before the advent of hospitals and hospital based care, what we now define as ambulatory settings provided most of the healthcare services. During the 1900s, much of the healthcare in the United States of America was offered by individual medical practitioners who worked in privately owned offices and physicians who travelled to the homes of patients to deliver medical care. Additionally, some of the physicians preferred locating their offices in their own homes or I small office buildings unlike the current large medical office buildings as well as the medical clinics. The less developed technology used at the time allowed the individual physicians to pack their supplies and travel from one patient’s home to another delivering the much needed healthcare services.
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Homecare was common and very popular particularly among the wealthier patients who were capable of affording to request house calls to access their much sought after medical care. Horses and buggies were used by the physicians as a means of transport to patients’ homes and this limited the number of patients that could be visited in a typical day. Unfortunately, the poor and indigent patients underwent a lot of suffering because they could not afford the private physician care. This was followed by a steady development of ambulatory clinics that were developed by acute care hospitals to help cater for the medical needs of indigent populations in urban settings.
By the early twentieth century, several hospitals began offering ambulatory services as part of their charitable mission to meet the medical care needs of the indigent populations who needed better access to private medical care (Barsukiewicz et al., 2010). Concurrently, the number of hospitals significantly grew during this time. As the number of the hospitals grew, sanitation increased and hospital infections reduced as antiseptic surgery began to be practiced in the hospitals. 495 hospitals had launched ambulatory services and they provided popular settings for teaching and training young physicians. The young trainee physicians commonly staffed the ambulatory clinic in return for hospital admitting privileges. As such, the staffs at the ambulatory clinics were mostly young professionals in training hence making the services below the standard. Majority of the hospitals’ ambulatory clinics become busy helping with a wide variety of social problems and complex medical issues among the most indigent patients. This led to poor levels of compliance with the recommended treatment regimens resulting to high rates of discontinuities in care.
Advances in medical knowledge as well as the expansion in medical technology ushered in some significant changes in healthcare. The hospitals expanded their ambulatory services to accommodate the demand created by the increase in Medicaid and Medicare as well as the privately insured patients. This was based on the realization that it was less costly to test, diagnose and treat patients as outpatients as opposed to treating them as inpatients. This shifted the attention of hospitals from inpatient based care to out-patient based care. Majority of the hospitals responded by increasing their ambulatory services. Moreover, some of the medical centers started to organize businesses in satellite locations, local shopping centers and free standing medical clinics.
By the 1980s, the status of ambulatory centers changed significantly as they began to earn special recognition as vital components of the American health care system. The ambulatory centers generated a stream of inpatient admissions as well as a reliable source of revenue from the use of the hospital ancillary services. The earnings of ambulatory centers increased steadily throughout the decade. The ambulatory centers became well organized and well-staffed by private physician groups that transformed them into well-equipped centers.
The number of ambulatory centers continued to increase during the 1990s. Moreover, the types and quality of the services that were offered in the ambulatory centers increased considerably. Additionally, some of the ambulatory settings continued to be general practice clinics such as endocrinology clinics and cancer care centers. As such, the ambulatory centers have evolved to effectively meet the needs of the patients with specialized medical requirements. As such, several ambulatory centers have begun offering services such as diagnostic imaging, dialysis, outpatient chemotherapy, outpatient same day surgery, pain management, cardiac rehabilitation programs, wound care services and occupational therapy.
Currently, ambulatory care is the predominant mode of healthcare delivery in the United States. The ambulatory centers located in urban areas continue to function as community’s safety net particularly for the marginalized populations (Laditka et al., 2009). Moreover, the specialty ambulatory facilities have become attractive to private physicians and researchers because they draw a narrow section of patients with common needs. As such, patients have access to highly trained and specialized professionals who have developed innovative ways to diagnose and care for patients’ conditions.
The ambulatory care services play a significant role in the health care system of the United States. Ambulatory care has helped to increase the quality and effectiveness of healthcare in the United States. Ambulatory services are no longer considered a separate from the core service and mission of hospitals. Therefore, ambulatory care has increased efficiency and improved access to health care.
The facilities providing ambulatory care play a significant role in facilitating virtual healthcare services. Virtual health care refers to education and care offered through the use of websites, email and telemedicine. Most of the doctors in ambulatory centers facilitate electronic consultations for patients. This provides a faster means of accessing healthcare information for patients. The email ensures that doctors schedule appointments, refill prescriptions and transmit standard laboratory results efficiently. Telemedicine has helped in providing healthcare to patients with chronic conditions, rural communities and patients who may not be able to travel to hospitals to meet face to face with doctors.
Ambulatory care centers facilitate fast and efficient access to primary care services as well as supporting diagnostics necessary for providing effective care for patients at a permanent location. As such, they provide patient directed care. Some of the patient directed care services include urgent care facilities and primary care offices that are opened for longer hours.
Political Influence
The ambulatory care in the United States is influenced politically particularly through the Affordable Care Act of 2010 (ACA). As such, the legislation expanded health insurance coverage to an estimated thirty million people. Unfortunately, such an expansion in coverall does not expand the actual care hence flooding an already strained and fragile health care delivery system (Hoffman & Paradise, 2008). The ambulatory centers are rendered ineffective and inefficient by the vast influx of patients covered by the health insurance according to the Affordable Care Act.
The Affordable Care Act increases stress on individual healthcare workers in the ambulatory centers and the organizations offering ambulatory services in the United States (Anderson, 2014). There has been a lot of trouble implementing the massive law because of its complexity. The law requires healthcare personnel in the ambulatory centers to meet several legal requirements as well as fulfilling professional obligations for high performance in the delivery of patient care. The overwhelming complexity of the law aggravates the problems of the health care workforce hence hindering the performance in delivering health care services to patients.
The increased number of insured US citizens and the decline in the growth of the healthcare workforce leads to heavier workloads for nurses, doctors and other medical professionals in the ambulatory facilities. Safety issues and work demands have increased making it difficult for the healthcare professionals to ensure quality care. Workforce stress and heavy workloads will increase the risk for medical errors from fatigue and poorer outcomes. Heavy workloads may lead to increase in healthcare disparities. Therefore, the additional strain occasioned by the ACA serves to overwhelm already burned out healthcare professional in the ambulatory facilities.
The conditions associated with the ACA have led to increase in more paper work due to the intense regulations hence reducing the time available for attending to patients. As such, the law increases the cost of healthcare due to the additional infrastructure and personnel required to ensure the highest level of payments in the ambulatory care facilities. The operating costs in the facilities increase because of the need to employ more administrative personnel in the ambulatory care facilities. The ACA adds 109 more distinct regulations for health care providers. As such, more time, effort and resources are required to meet the regulations hence reducing the time available to spend on direct patient care.
The penalty problem associated with the healthcare regulations in the United States affects the effectiveness of ambulatory care facilities significantly. The healthcare providers are required under the law to invest in appropriate technology. This makes healthcare institutions offering ambulatory care to have difficulties breaking even. With the tightening of healthcare rules, some of the healthcare providers may consider closing down.
Many healthcare professional in ambulatory care centers are concerned with various profound ethical and moral issues that regularly arise in the healthcare field. As such, they are always worried about their traditional ability to exercise their right of conscience under the new healthcare regulations. The ACA does not effectively protect the healthcare workers in terms of their moral and religious objections to certain medical procedures or treatments. Therefore, the current law does not contain any enforcement provisions as it disregards the right of conscience as it mandates insurance funding of sterilization, contraception and abortion inducing drugs. The marginalization of the current healthcare laws created by the ACA legislation infringes on the ethical and moral obligations of the medical professionals.
The ambulatory care providers have begun to implement direct care models that involve cash only practices that require upfront payments before treatment as a result of the complicated ACA legislation. The physicians do this in order to reduce overhead costs by eliminating patient billing and claims. This frees the physicians to set their own prices and patient care based on their discretion. As such, there will be no insurance company or third party influencing their decisions regarding treatment or care.
Quality Safety and Competition
The elements of quality, safety and competition play a significant role in influencing healthcare delivery in ambulatory settings. The quality of medical care services offered in the ambulatory setting has been improving significantly due to the new technologies being used in the delivery of care. The ambulatory care providers have been able to reorganize and streamline their care delivery processes in order to effectively meet the healthcare needs of patients as well as increase the quality of the services provided (Maj et al., 2004). Additionally, the mergers among ambulatory care institutions are no longer horizontal but rather vertical as they strive to control quality across the continuum of care. Moreover, efforts are under way to move care upstream to engage in preventive in order to keep the public out of the hospitals. Therefore, the emphasis on the quality of care in the ambulatory settings ensures that the public get the necessary healthcare services when they need hence improving patient care. As such, the ambulatory care providers are able to treat more people without admission to hospitals through the delivery of a broad range of services in a high pressure environment. Therefore, they strengthen the focus on quality improvement in order to enhance safer, efficient and effective patient care.
There has been an emphasis on safety in ambulatory care as an increasing amount of attention has been devoted in measuring as well as improving the culture of safety among the primary care physicians and patients themselves. Improvement of patient safety in ambulatory care settings involves initiating reforms in office practice functions as well as engagement of patients in their own safety. This has been done through the use of electronic health records (EHR). The electronic health records help in significantly reducing medical errors as well as tracking test results. Moreover, there have been efforts aimed at coordinating care between different physicians by ensuring that one medical records system is shared in the ambulatory care facilities. Patient engagement in the ambulatory care safety involves educating patients about their illnesses and their medical regimens by use of methods that require them to demonstrate understanding. As such, teach back method is commonly used to ensure that patients effectively understand the nature of their illness as well as their medications to promote drug adherence. Additionally, safety is enhanced by empowering patients and caregivers to act as safety double-check through provision of access to advice and test results as well as encouraging patients to ask care related questions (Mongione-Smith et al., 2007). Therefore, success has been achieved among patients taking high risk medications. Therefore, the patient safety practices in the ambulatory care settings have improved effectiveness in patient care in the United States.
The US government does not decide the prices and quality at which health care providers offer their goods and services in the overwhelming majority of markets. Therefore, the rival ambulatory care providers compete to satisfy consumer demand. On the other hand consumers make appropriate decisions on the basis of quality and prices of services provided by the respective ambulatory care providers. Therefore, it is important to realize that a well-functioning market strives to maximize consumer welfare especially when the consumers based their own consumption decisions on clear preference, good information and appropriate incentives. Stiff competition, whether price or non-price, can have significant benefits in healthcare as price competition results to lower prices hence increasing access to health products and services. Additionally, non-price competition serves to promote high quality services and encourages innovation. As such, competition can result in cheaper generic alternatives to the expensive branded drugs, new and improved drugs, treatment with less pain and side effects as well as offering of treatment in locations that are convenient and preferred by the consumers. Therefore, vigorous competition among the ambulatory care providers in the United States has promoted the delivery of high quality and cost effective patient care.
Future Challenges and Issues
Ambulatory care is on the rise due to the increasing consumer healthcare demands and expectations. However, the sector is not without its challenges. The capacity at the ambulatory care centers is at an all-time high given their popularity and convenience. The staggering patient loads in the facilities leading to long and frustrating wait times. This makes patient retention vary challenging. As such, there is a great need for the ambulatory care centers to be much more than just a clinical space. The facilities should therefore adapt to the changing medical practices as well as emerging technologies.
Missed or delayed diagnoses are also some of the challenges facing ambulatory care. Missed or delayed diagnoses lead to liability lawsuits involving significant medical conditions such as cancer. Common factors such as failure to adhere to a cancer screening protocol, failure to include cancer in the differential diagnosis, and lack of adequate follow up may be some of the factors contributing to missed or delayed diagnoses in the ambulatory care settings (Hing & Zhu, 2008). System defects and poorly distributed workloads may contribute to the increase in the number of such cases.
Delays in proper treatment present a significant challenge to ambulatory care providers. Substantial delays in diagnosis may lead to a corresponding delay in initiating proper treatment. This may be contributed partly by the patients’ failure to seek care in a timely manner. Such health care delivery failures may be due to time pressures, inadequately trained personnel, organization culture as well as inadequate communication with the patient and family.
Another challenge facing ambulatory care is the occurrence of adverse drug events. Some of the medications associated with adverse drug events include diuretics, cardiovascular drugs, hypoglycemic and anticoagulants. However, majority of the adverse drug events are preventable and they may be cause by misunderstandings between the patients and doctors. As such, human limitation to vigilance as well as presence of complacency with high alert medication increases the possibility of adverse drug events.
Another challenge facing the ambulatory care sector is the problem of communication and information flow. This is because the inpatient and ambulatory electronic health records are not integrated making the rendering ambulatory care providers unable to access the complete medical records of patients (Linder et al., 2007). Additionally, most of the patient medical information comes from different providers with disparate electronic health records.
Despite the challenges facing ambulatory care in the United States, it will remain a significant sector in future. Ambulatory care will remain critically important from different perspectives including delivery of comprehensive, coordinated patient care and financing. As such, ambulatory care will continue to expand because a significant number of procedures and treatments are transitioning to the ambulatory care setting. As such, improving ambulatory performance will become a top strategic priority for the health systems in the United States.
The significant advances in technology as well as the expanding number of prescription medicines will lead to complexity of treatment regimens in the ambulatory setting. As such, there will be increased cases of non-adherence to drugs hence affecting the quality of healthcare. Therefore, there will be a great need for interdisciplinary coordination in the ambulatory care settings.
Recommendations
Based on the current context of ambulatory care in the United States, it is clear that public policy is not enough to address all the problems facing healthcare delivery. More focus should be directed to encouraging more students from rural areas to enroll in medical and professional colleges. Additionally, congress should also reevaluate the current Graduate Medical Education program in order to more medical student enrollment and help to increase the number of medical care personnel in the United States. This will significantly help in improving the quality of patient care in ambulatory settings.
The ambulatory care centers should emphasize a culture of safety among the health care staff. Over the years, it has been increasingly clear that a culture of safety helps to enhance the reliability and effectiveness of processes and systems in the delivery of patient care. Therefore, a culture that embraces and rewards effective reporting helps to improve patient safety in the ambulatory facilities.
The ambulatory care providers should also support team based care models that seek to drive costs down and expand health care coverage. Additionally, specialty care solutions should be integrated in the process of patient care. For instance, specialty service lines such as cardiology should incorporate several care specialists such as nutritionists, psychologists and pharmacists in the process of delivering coordinated patient care. Moreover, the ambulatory centers should create a space for both collaboration and privacy. This will help in establishing new lines of collaboration, communication and cooperation in order to better serve the patient needs.
Conclusion
In conclusion, is clear that ambulatory care plays a significant role in the United States health care system. Ambulatory care has improved access to primary care among the less privileged communities in the United States. Over time, ambulatory care has evolved to become one of the critical sectors providing patient care to millions of American citizens. Ambulatory care has been influenced politically in the form of the Affordable Care Act. The law increased the number of insured people in the medical delivery system and instituted more regulations to the process of care delivery. Moreover, competition, quality and safety in the ambulatory sector of healthcare have interacted to improve the effectiveness and affordability of patient care. It is also worth noting that ambulatory care faces several challenges but it has remained vital in the processing of delivering the much needed patient care in the United States.
References
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