The archiving and publishing of the introductory remarks and the proceedings of the first plenary session of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.
The First National Conference on Primary Health Care Access
ACCESS TO PRIMARY HEALTH CARE IN THE 1990’s
April 20-21, 1990: The American Club; Kohler, Wisconsin
Welcome – John E. Midtling, MD, MS, Medical College of Wisconsin [Dr Midtling is a Senior Fellow of the Coastal Research Group.]: Good morning! On behalf of the Department of Family Medicine at the Medical College of Wisconsin, I would like to welcome you to our special invitational conference on “Access to Primary Health Care in the 1990’s.” With more than 37 million Americans now without needed health insurance, this issue is sure to become one of the most prominent political issues of the next decade.
It is an issue that has now become a mainstream issue in the United States as the lack of health insurance has now impacted on the many middle class Americans and American business has become increasingly concerned about the cost of financing health care benefits.
We are now in a global economy competing with Japan and Western Europe which, to a large extent, factor the cost of health care into the tax structure. American business must factor those costs into product costs, placing American business at a significant competitive disadvantage. At the same time costs of health care have far outstripped the consumer price index.
We have a technology that is totally out of control and in many cases applied with minimal ethical or effectiveness considerations, creating a system about to collapse of it’s own weight.
As Charles Gessert will point out in this morning’s session, the access problem has been a problem that has always been with us. It is a problem that just will not go away. It is a problem that has come to the forefront of the national consciousness crying out for solutions.
Despite massive increases in total health care expenditures and massive increases in physician manpower, the access to health care problems has indeed not gone away. In fact, some would argue that physician specialty and maldistribution, access for the inner city and rural poor, and access for under served minorities have actually worsened over the past decade. That is why I believe it is so important for us to do careful policy analysis of why er are where we are, what have been the successes and limitations of past programs to address this problem, and what programs or interventions hold special promise for the future.
We will be developing conference proceedings which will capture the essence of this conference and its recommendations. These proceedings will be distributed to interested policy leaders around the country. In this regard, I would ask that each of the presenters provide us with a description of your prepared comments and we will be recording the discussion of sessions. These recordings and prepared comments will be synthesized into a document for distribution to the interested individuals unable to attend. I believe such a distribution will greatly magnify the impact of this conference, its work, and its recommendations.
It is my hope that each of our invited guests will participate as well with comments and questions and I would ask that as you address the panel, you identify yourselves so that the proceedings will properly reflect credit for your comments. I believe that the real target audience will be those who receive the proceedings. We purposely wanted a small, intimate working group that could discuss and analyze this access issue and come up with some recommendations.
We divided the conference into several sessions that I believe dissect this problem into its key elements. Today’s sessions include: “Access to Primary Health Care: The Challenge and Past Responses,” led by David Schmidt; “Emerging Problems in our Management of Primary Care Access,” led by David Werdegar; and “The Impact of Changing Reimbursement on our Ability to Manage Access to Primary Care,” led by David Sundwall.
Tomorrow’s sessions will include: “Improving our Management of Access to Primary Health Care for Minority Populations,” led by John Arradondo, and “Policy Options for the 1990’s, “led by Bruce Behringer.
Before we begin this morning’s session, I have asked Charles Gessert, Vice-Chair of the Department of Family Medicine at the Medical College of Wisconsin, to lead off the conference with some introductory comments. Charles was the Project Director of the California Area Health Education Center (AHEC) and a Senior Medical Officer with the Bureau of Health Professions in Washington before coming to Wisconsin. I believe that he has a unique longitudinal and historical perspective on the access problem. Charles.
Introductory Comments – Charles E. Gessert, M.D. It’s a real pleasure to see so many old friends and new friends who are able to join us at this conference and I think that we’re going to have an excellent group. I think that we ought to be willing to stretch our minds and look for a new perspective on the problems we’re going to be discussing.
Many of the problems we’re discussing are new new. I look around the room and see a lot of old hands, people who have been working with these issues for a long time. And that’s one of the two bookends that I want to provide for our discussions this morning. I’m hoping to provide for our discussions this morning. I’m hoping to provide some perceptions on the past and perhaps a few comments on what I perceive to be special issues for the future.
For the comments from the past, you have just received an article that’s from the June, 1927 issue of The American Mercury, which is a journal that I became aware of because of my enthusiasm for H.L. Mencken. If anybody wants me to, I could spend a little time apologizing for him. His obvious insensitivity to a lot of issues, including racial issues, is legend. But he nevertheless was a great commentator on his era.
I’ll give you a couple of quick quotes out of this article: “The new generation of American doctors are specialists.” “There is a smaller and smaller supply of the old style general practitioners who looked after most of the ills of the family and were often friends and counselors in other affairs as well.” “With the predominant tendency toward specialism, the expensive medical services become more and more burdensome.” “These findings are ominous. They indicate a rapid and dangerous disappearance of country doctors.
The doctors upon whom the rural districts are chiefly depend for medical service are a group of old men who are getting toward their end with nobody in sight to take their places. The high cost of medical education peculiarly influences the distribution of rural doctors. The rural districts today cannot pay the price of money that present medical service demands. Especially, they cannot pay the price in cultural advantages that our present graduates demand – city conveniences and accessories, things of that sort. We are turning out now what President Butler of Columbia has called ‘the country club type,’ but the actual country has nothing to offer them.”
In other points the article it makes observations about the specific problem of the diminishing access to obstetrics in rural areas, the role of medical education as a root cause and potential solution to the problems, the medical school faculties are being poor role models for future practitioners in view of their specialization and their lack of practice experience, and the growing disruptive role of research. This was in an era well before the NIH as we know it today.
To me the interesting aspects of this article are that it illustrates that many of the problems that we perceive to be so challenging to our generation have been with us for a long time and they promise to be with us for the foreseeable future. This observation should guide us in our understanding of the nature of these issues and what we might regard as a perfect solution to them.
Somehow I derive a calming and sort of comforting feeling from these observations in the sense that these problems have been with us for such a long period of time. My father used to periodically, if you got him mad enough, refer to the world as going to hell in a handbasket. It may be true but it may not be going to hell in a handbasket quite as quickly or quite as uniquely in our generation as we sometimes think.
Some of the more specific observations, though, on this line of thought would be rural areas have enduring generic characteristics which will “always” impact upon their ability to attract professionals. Medical education will always be urban based in view of the great interdependency of professionals within an academic community and will always create a culture of its own which will be difficult for young physicians to separate from. The tendency to develop highly technical specialized medical care has always, in a sense, competed with the need for generalists and has always had a particularly pernicious effect on the supply of physicians for under-served areas.
Lastly, in these general observations, you say that the high cost of medial education and other financial factors have always served as disincentives to getting physicians to work in less technologically advanced, undeserved communities.
Now, if you take this group of observations and pull them together, what does this mean? The principal thing it suggests to me is that some of our access to care issues are borne of the nature of our culture and are not peculiar to our generation, nor peculiar to our situation. And to the degree that this is true we will be frustrated in solving these problems. These are not particularly susceptible to solution. The underlying lay of the land which creates our access to care issues must be understood and policies which enable us to manage these problems must be identified.
I think that many of you may have observed the rather “contrived” titles of our panels. We have tried to insert the concept that we’re not asking people to sit down and tell us how they’re going to solve these problems. We’re asking people to sit down and help us think through how we can manage these problems better. Some of our problems have been with us throughout time and we need to learn to manage them.
The distinction between a public program as a solution and as a management tool is not trivial. With apologies to people like Don Weaver and David Sundwall who have worked much more intimately with the management of public policy than I have, I would like to submit a specific example – the National Health Service Corps. Again apologizing for oversimplification, the National Health Service Corps was created and to some degree sold to congress as a solution to access to care problems in underserved areas. We know this because of what the way that we measured its success or failure. We measured it down to the concept of the eventual elimination of the underservededness of a number of communities around the country. People were going to lose their designation as underserved areas. They weren’t going to be underserved any more, implying that we’re going to solve the problem.
Physicians under this model would serve their time in underserved communities and then remain there as a new graft which has taken in the host. As a solution to access to care problems in underserved areas, the National Health Service Corps has failed at least to the degree that physicians have generally served their time in underserved communities and moved on. It has failed because the expectation was flawed. A keener application of the appreciation of the enduring nature and root causes of underservededness might have led to the early advocates of the National Health Service Corps to promote it as a management tool and, as such, the expectations would have been that we’re going to need to implement this tool clinically.
Moreover, the people who managed the National Health Service Corps could and should have promised no more than what they controlled, that is to say the placement of individuals in communities for the duration of their obligation. From the outset the National Health Service Corps would have been recognized universally as a public policy success and as an important ongoing part of our Public Health Service.
I think we have come to that point of view, specifically in the last few years. I think it’s a very good thing, but we have had to go through a long period of adjusting expectations of the National Health Service corps. I think the National Health Service Corps, in my sense, is the kind of organization that could serve as an excellent management tool on an ongoing basis.
Well, having provided one bookend for our discussions in this conference drawn from the past, I’d love to quote an article published in the year 2050 and tell you a little bit about the future and use that as a basis. However, the closest I can do is to recommend that everyone read, as a number of you have heard me say before, Daniel Callahan’s new book, “What Kind of Life.” In lieu of an article, I have selected what I see as a fundamental change in our culture, which I would like to have us focus on for a few moments.
This is a reiteration of some of what John said in his opening comments. I am referring to what I see as the beginning of a new examination of man’s relationship to natural forces, man’s relationship to natural laws. Not too long ago I finished reading Barbara Tuchman’s book, “A Distand Mirror.” It’s about the 1400’s. It’s a very helpful and educational book. Taking from that point of time to the present over the last 500 to 600 years, I think it’s very clear that our perception of our relationship to natural forces has been dominated by the fact that life has always been – up until the very recent past – short, unpredictable, brutal, unproductive, and dangerous; and that the conquest of natural fores has unquestionably made life safer, more predictable, longer, and more productive.
Generally there has been no need to question whether or not the conquest of natural forces is of benefit to mankind. As a matter of fact, what we call civilization or progress has largely been measured in our ability to control natural forces. This has been true, I would say, until recently. Our teeming population, our concerns for the environment, our new awareness of the downside of our growth and progress have all stimulated, in many, a reflection of the longer term subtler effects of the conquest of nature.
In many there is a new awareness of man’s dependence on a healthy environment and on a healthy nature in which to live. Some of this new awareness is unfocused. We have the sense that we are dependent upon a healthy functioning of natural checks and balances even though we don’t necessarily understand what all those checks and balances are.
This, I think, is leading us to a fundamental shift in our perception. We are beginning to move from the view that the conquest of nature is a good thing for mankind to one in which there is a new appreciation of our dependency on natural processes. There is a direct application of this rather broad thinking in medicine. Most directly, in what we call bio-ethical ethics, I see a growing willingness to question the wisdom of medical interventions in natural processes. Considerations of costs, quality of life, the non-medical aspects of health, and for that matter the non-health aspects of well-being, are all being raised and brought to the door of the medical citadel.
We are being reminded that health is not wholly or even predominantly comprised of medical care and that well-being is not wholly or predominantly comprised of health. I believe that the growing interest in these considerations should be encourage. If we are ever to move to a more modest or realistic allocation of our society’s resources to medical care or curative medical care, we’re going toh ave to make a lot of changes.
I believe that to the degree that these kinds of reconsideration or reexaminations of medical care can be brought into the public domain for the public debate, we may see some lessening of demand. Restraint on demand – through more judicious or selective or circumspect use of medical resources – carries far fewer political and societal consequences and problems than restrain on supply, which has been our principal approach up until the present time.
I hope that we will develop a new – what you would call default – position in that non-intervention may be assumed to be superior until proven otherwise. The burden of proof may shift to making sure that what we do not only makes sense in the short-term biological sense but that it also makes sense in a holistic sense in terms of its effect on the family, and also its effect on the community, including the distributed effect that is felt broadly in society through the bearing of the cost of care.
In this conference we are focusing on access to care issues. The considerations I just reviewed suggest that we should be asking, “Access to what kind of care?” Is not the overspecialized, overly technical medical empire sagging under the weight of the costs? Its ethical dilemmas? Of the disaffection which the public is beginning to feel from some of the imbalance in our allocation of resources for the society? Is this the empire to which we are trying to improve access as we debate access to care issues?
For many of us, and I think of my old colleagues sitting around the room, this interface between cost issues and access to care issues is all too familiar. It seems that access to basic care has been sacrificed before what I would call the insatiable god of curative medical care. If we would look at both sides dof the issue there isn’t really a conflict. We must assure basic nutrition, if you will, to all before anyone can gorge themselves at the banquet.
The analogy to feeding, I think, is apt. It is hard, or even silly or cruel, to try to convince a starving man that he ought to eat just nutritious stuff. And we have the same situation in our health care system. Our underserved communities cannot be expected to join in any general consensus on efforts to restrain health care costs until their basic needs are met. We must expand coverage or access for basic services so we can have a better basis for universal restraint. We are analogous to population workers in the Third World who find it difficult to get people to restrain their birth rate through birth control until infant mortality is brought under control.
With these thoughts and two doses of humility – one dose drawn from our knowledge that our problems are not unique to our generation and the other one drawn from the sense that there are distant rumblings of thunder on the horizon that may change some of the rules under which we operate – I’d like reiterate our welcome to all of you and I look forward to unique conference.
Thank you very much.
The opening remarks of the First National Conference on Primary Health Care Access were followed by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 1, Schmidt).