introduction what is meant by primary, secondary and tertiary care? how are clinical health...

Introduction

• What is Meant by Primary, Secondary and Tertiary Care?

• How Are Clinical Health Professionals Rewarded and Compensated for Their Services?

• How Can We Ensure the System Has the Right Number of Health Professionals?

ScenariosHealth Professionals and the Health Workforce

In the hospital the nurse specialist examines you and consults with the radiologists, the gastroenterologist, and the general surgeon. Your medication is reviewed by the PharmD, and your meals by the clinical nutritionist. Throughout your hospitalization you are followed by a hospitalist. Once you get back home the home care team comes to see you regularly for the first two weeks and the physician assistant and registered nurse see you in the office. You realize that health care is no longer just about doctors and nurses. You ask yourself, what roles do all of these health professions play?

ScenariosHealth Professionals and the Health WorkforceJenna decides that after college she wants to become a doctor and practice medicine, thinking there was only one kind of doctor who could diagnose disease and prescribe medicine. Not so any more, says her advisor. There are allopathic and osteopathic physicians. In addition there are nurse practitioners who are often authorized to diagnose and prescribe medication as well as physician assistants who do the same under a physician’s supervision. Doctors now include doctors of nursing practice as well as others with doctoral degrees such as pharmacists and physical therapists. Understanding careers in health care can be as difficult for students as it is for patients, you think to yourself. Now she understands why her advisor asked: “What do you mean by practice? What do you mean by doctor?”

ScenariosHealth Professionals and the Health WorkforceSarah was about to begin medical school and was expecting two years of “preclinical” classroom lectures focusing on the basic sciences followed by the study of clinical diseases. Then she expected two years of clinical hospital” rotations” and electives checking out specialties like she’d heard about from her physician dad. She is surprised to find that medical school has changed. There are small group, problem-based learning sessions where she needs to be able to locate and read the research literature. There is contact with patients and their problems right from the beginning. There is increasingly a four year approach instead of a preclinical and clinical approach to medical education. She wonders: are these changes for the better? What else needs to be done to improve medical education?

ScenariosHealth Professionals and the Health Workforce

You are interested in clinical care as well as public health. “I need to make a choice you think to yourself.” “Not necessarily,” your advisor says, “there are many ways to combine clinical care with public health.” After a little investigation you find out that undergraduate public health education is increasingly seen as preparation for clinical education, and clinical prevention & population health is increasingly becoming part of clinical care. In addition many careers from health administration to health policy to clinical research combine the individual orientation of clinical care with the population perspective of public health. So what’s the best pathway to public health for you?

Selected Specialties and Sub-specialties of Medicine

General Certificate(s) Subspecialty Certificates

American Board of Allergy and Immunology

Allergy and Immunology

American Board of Anesthesiology

Anesthesiology Critical Care MedicineHospice and Palliative Medicine1

Pain Medicine

American Board of Colon and Rectal Surgery

Colon and Rectal Surgery



American Board of Dermatology

Dermatology Clinical and Laboratory Dermatological ImmunologyDermatopathologyPediatric Dermatology

American Board of Emergency Medicine

Emergency Medicine Hospice and Palliative Medicine1

Medical ToxicologyPediatric Emergency MedicineSports MedicineUndersea and Hyperbaric Medicine

American Board of Family Medicine

Family Medicine Adolescent MedicineGeriatric MedicineHospice and Palliative Medicine1

Sleep MedicineSports Medicine



American Board of Internal Medicine

Internal Medicine Adolescent MedicineCardiovascular DiseaseClinical Cardiac ElectrophysiologyCritical Care MedicineEndocrinology, Diabetes and MetabolismGastroenterologyGeriatric MedicineHematologyHospice and Palliative Medicine1

Infectious DiseaseInterventional CardiologyMedical OncologyNephrologyPulmonary DiseaseRheumatologySleep MedicineSports MedicineTransplant Hepatology



American Board of Medical Genetics

Clinical Biochemical GeneticsClinical CytogeneticsClinical Genetics (MD)Clinical Molecular GeneticsPhD Medical Genetics

Medical Biochemical Genetics4Molecular Genetic Pathology

American Board of Neurological Surgery

Neurological Surgery

American Board of Nuclear Medicine

Nuclear Medicine



American Board of Obstetrics and Gynecology

Obstetrics and Gynecology Critical Care MedicineGynecologic OncologyHospice and Palliative Medicine1

Maternal and Fetal MedicineReproductive Endocrinology/Infertility

American Board of Ophthalmology

Ophthalmology

American Board of Orthopaedic Surgery

Orthopaedic Surgery Orthopaedic Sports MedicineSurgery of the Hand



American Board of Otolaryngology

Otolaryngology Neurotology Pediatric OtolaryngologyPlastic Surgery Within the Head and NeckSleep Medicine

American Board of Pathology

Anatomic Pathology and Clinical PathologyPathology - AnatomicPathology - Clinical

Blood Banking/Transfusion MedicineChemical PathologyCytopathologyDermatopathologyForensic PathologyHematologyMedical MicrobiologyMolecular Genetic PathologyNeuropathologyPediatric Pathology



American Board of Pediatrics

Pediatrics Adolescent MedicineChild Abuse Pediatrics2

Developmental-Behavioral PediatricsHospice and Palliative Medicine1

Medical ToxicologyNeonatal-Perinatal MedicineNeurodevelopmental DisabilitiesPediatric CardiologyPediatric Critical Care MedicinePediatric Emergency MedicinePediatric EndocrinologyPediatric GastroenterologyPediatric Hematology-OncologyPediatric Infectious DiseasesPediatric NephrologyPediatric PulmonologyPediatric RheumatologyPediatric Transplant HepatologySleep MedicineSports Medicine



American Board of Physical Medicine and Rehabilitation

Physical Medicine and Rehabilitation

Hospice and Palliative Medicine1

Neuromuscular Medicine3

Pain MedicinePediatric Rehabilitation MedicineSpinal Cord Injury MedicineSports Medicine

American Board of Plastic Surgery

Plastic Surgery Plastic Surgery Within the Head and NeckSurgery of the Hand



American Board of Preventive Medicine

Aerospace MedicineOccupational MedicinePublic Health and General Preventive Medicine

Medical ToxicologyUndersea and Hyperbaric Medicine



American Board of Psychiatry and Neurology

PsychiatryNeurologyNeurology with Special Qualifications in Child Neurology

Addiction PsychiatryChild and Adolescent PsychiatryClinical NeurophysiologyForensic PsychiatryGeriatric PsychiatryHospice and Palliative Medicine1

Neurodevelopmental DisabilitiesNeuromuscular Medicine3

Pain MedicinePsychosomatic MedicineSleep MedicineVascular Neurology



American Board of Radiology

Diagnostic RadiologyRadiation OncologyRadiologic Physics


NeuroradiologyNuclear RadiologyPediatric RadiologyVascular and Interventional Radiology

American Board of Surgery

SurgeryVascular Surgery


Pediatric SurgerySurgery of the HandSurgical Critical Care



American Board of Thoracic Surgery

Thoracic Surgery Congenital Cardiac Surgery4

American Board of Urology

Urology Pediatric Urology

Ideals and Realities of Primary Care

Primary care ideals

Realities

Contact The point of first contact with the health care system—the entry point

Patients enter the health care systems through many disconnected points including: ER, specialists, urgent care centers, nontraditional practitioners, etc.


Primary care ideals

Realities

Comprehensive Primary care intends to be able to diagnose and treat the great majority of problems

Rapid increase in possible treatments and high-volume practices increase proportion of patient problems that are referred to specialists


Primary care ideals

Realities

Coordinated Primary care intends to be the focal point for diagnosis and treatment with coordination through referral to specialists for consultation and feedback

Primary care physicians increasingly being replaced by "hospitalists," who are full time in the hospital and provide care for inpatients and direct patient access to specialists


Primary care ideals

Realities

Continuity Patient followed over many years—continuous care provision

Patients increasingly required or encouraged to change physicians/providers for insurance purposes


Primary care ideals

Realities

Caring Individualized care based on individual relationships

Primary care increasingly becoming an administrative entity without long-term individual relationship


Primary care ideals

Realities

Community Primary care designed to connect the individual patient with community resources and community requirements (required examinations, reportable diseases, vaccinations, driver’s licenses, etc.)

Health care professionals and public health have long history of distant and—at times—contentious relationships

Methods of Financial Compensation to Providers of Health Services

Compensation method

Meaning Examples Advantages Disadvantages

Fee-for-service Clinician paidfor eachcovered service

Physiciansoften paid formedical visitsand procedure,but may not bepaid forcounseling forprevention

Reward linkeddirectly to workPerformed

Encouragesefficiency ofdelivery ofservices

May encouragedelivery ofunnecessary, aswell asNecessaryservices


Compensationmethod


Capitation Clinician ispaid a setamount pertime period foreach patient forwhom they areresponsible,regardless oflevel of use ofservices

Primary carephysicians inhealth plansmay be paid aset amount perpatient permonth and areexpected toprovide allprimary careservices

DiscouragesUnnecessarycare, mayEncouragepreventive

care,allows forPredictablebudgeting

MayDiscouragenecessary care,may encouragereferral toSpecialistsunless specialtycare isfinanciallydiscouraged


Compensationmethod


Episode ofcare

Institution orclinician is paida set amountfor providingComprehensiveservices, suchas hospitaltreatment basedon the patient’sdiagnosis

Medicare paysfor hospitalcare based onDiagnosisRelated Groups(DRGs)Allowingdefined numberof days percondition

Encouragesrapid andEfficientdelivery of care

May encouragedischarge priorto ability toprovide self-care


Compensation method


Salary Set amount per time period

Governmental facilities generally pay clinicians on a seniority-based salary

May allow focus on quality

May discourage efficiency


Compensationmethod


Pay forPerformance

“P4P”

Compensationadjusted basedon measures ofthe quality ofcare delivered

AdditionalCompensationfor adherenceto evidenceBasedguidelines

Links incomewith qualityProvidingStrongincentive for quality

Difficult tomeasure qualityOutcomesmaybe relatedto factorsOutsideclinician’scontrol

Health Care System

Health Professionals

Health CareInstitutions

Health Financing

introduction what is meant by primary, secondary and tertiary care? how are clinical health...

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