For HLTH 4200

1. Jessica Liang
HLTH 4200
Public Health Determinants and Trends
Social Determinants in Public Health
Access to medical care had the largest influence on medical services
delivered at Upstate Cardiology, my internship site. Upstate Cardiology is a part of
the Bon Secours Medical Group, whose vision statement emphasizes accessible care
that is high in quality and low in cost. My internship site embraced this outlook
wholeheartedly. Since the overarching health delivery system valued equity of
access, these principles were translated into the indiscriminating care provided at
my internship site. My preceptor repeatedly stressed to me the importance of the
practice’s ability to provide necessary medical care, even if the patient could not
afford it. As one of the most reputable cardiology practices in the region, Upstate
Cardiology receives patients from all socioeconomic backgrounds and provides care
regardless of the patient’s ability to pay. Once, I asked my preceptor about what
happens when a patient is unable to pay for cardiac services—which can get very
expensive. He told me that owing to the practice’s values, Upstate Cardiology always
delivers care to the patients and any cost that the patient can’t afford is absorbed
into the Bon Secours Health System. Given the gravity and urgency of heart related
problems, services provided by Upstate Cardiology are often life saving.
Promotion of disease prevention and overall health promotion also had an
influence on services provided at Upstate Cardiology. Since heart related issues are
usually chronic, one of the best ways to remedy them is through living a healthier
lifestyle. When applicable, the doctors and nurses at my internship gave patients
tips and access to resources for incorporating a better diet and exercise plan into
their lives. During a “lunch and learn” activity, my preceptor and the staff had a
thought-provoking discussion about whether disease prevention in society would
result in decreased business for a cardiology practice. At first glance, this was a
conflicting ethical issue for any practice—having a healthier population would
seemingly reduce the amount of patients a practice receives, resulting in less
generated revenue. However, everyone agreed that medical practices have an
obligation to improve long-term health. We all concluded that health promotion is

2. Jessica Liang
HLTH 4200
the most beneficial for society, as it has the potential to reduce the burden from
preventable medical costs. Also, a healthier population isn’t necessarily detrimental
for the functioning of a cardiology practice because people with genetic
predispositions to heart disease in need of care will always exist.
Organizational Behavior and Governance
The referral system is crucial to the services that are provided at my
internship site. Physicians both in and outside of the Bon Secours Medical Group
refer many patients to our practice. Likewise, Upstate Cardiology refers patients to
other specialists for additional health issues they might have. It is crucial to have an
efficient referral system because numerous health issues are time sensitive. Patients
need to be able to receive the care they need from an appropriate provider in a
timely fashion. In order to provide holistic quality health care and maximize patient
access, referral systems should be standardized and accurate.
The referral system is relatively simple when providers refer their patients
to other providers within the same health system, like the Bon Secours Medical
Group. The electronic records program that all practices within the Bon Secours
Medical Group use is the same, making it easy to access all of the patient’s exiting
information within the system just by searching their name. Practices within the
Bon Secours Medical Group also have regular interactions with each other so
physicians readily know which practices are accepting new patients and which ones
are reducing the number of appointments they accept.
However, the process becomes more convoluted when referrals are made or
received from providers who are not in the same health system. I had the
opportunity to shadow Upstate Cardiology’s referral coordinators for a day and
there was a disparity in the quality of referral forms. Practices had differing forms,
which took more time for the coordinators to sort through. Some were missing
information like the patient’s date of birth or insurance provider. This was very time
consuming because the referral coordinators had to take the time to contact the
patient to get the appropriate information. Sometimes, the patient couldn’t be

3. Jessica Liang
HLTH 4200
reached right away; further delaying the time for them to book an appointment and
receive needed care. While most practices are or have already transitioned to an
electronic system of conducting referrals, some still rely on handwritten paper
forms. These forms can be a headache for referral coordinators because it can be
hard to decipher the patient’s contact information, a key part of making an
appointment.
If I could make the referral system more efficient, I would make it a policy
that all medical providers across the country use the same electronic referral
system, drawing from the same database containing patients’ basic contact and
insurance information. To protect patient privacy, the database would not include
their medical history. By having the same electronic referral system for providers
around the country, the process becomes much more efficient. Referral coordinators
wouldn’t have to waste precious time trying to obtain missing patient information,
decreasing the amount of time a patient has to wait between referral and
appointment. Furthermore, a national standardized referral system could allow
providers to make and receive a referral—along with all of the necessary
information—in just one click. I would also make it a law that all medical providers
have to switch to an electronic referral system within a certain period of time. This
would also improve efficiency because referral coordinators would no longer have
to discern illegible handwriting or poor printing from a fax machine.
Health Administration Concentration Question
A cost-effective policy intervention that I would suggest is to make it a
requirement that physicians cannot overbook their appointments. This is a very
simple intervention that can save time for both physicians and patients. I was
present when an issue was brought to my preceptor’s attention about how a few of
the physicians at the practice were over booking appointments. This is problematic
because multiple appointments were booked in the same time slot or too close
together, causing the physician to increasingly delay the time that he could meet
with the following patients. This results in frustration for physicians and patients,

4. Jessica Liang
HLTH 4200
while also lowering patient satisfaction. The problem of overbooking is caused by a
combination of physician and checkout error. The physician may forget that a
previously open time slot has already been filled, and tell the schedulers to book a
patient for that time-slot, resulting in two patients with the same appointment time.
The schedulers trust the physician’s word and do not double check the time slot to
prevent overbooking.
The intervention to this is simple and cost-effective. Every practice should
make it a policy to disallow more than one patient for a time slot. A warning should
be integrated into the electronic appointment system to alert a scheduler when a
double booking is attempted. There should be open communication between
schedulers and physicians to inform of changes in appointments. This would
produce better health at a reasonable cost because physicians will be able to see all
of their patients without having to work overtime—reducing the cost of overtime
pay. Patients will be able to receive the care they need without waiting for a long
time in the waiting room, especially important for time sensitive issues like cardiac
related problems.