The archiving and publishing of the proceedings of the introductory remarks and the first two plenary sessions 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.
William H. Burnett, Office of Statewide Planning and Development, State of California [Mr Burnett is a Senior Fellow of the Coastal Research Group.]: Others at this conference have presented, or will be presenting, evidence that problems of access continue to stalk us as a nation. My comments will speak to three main areas of concern – fragmentation of public policy relating to primary health care, the looming deficits of physicians in key segments of medical practice, and the precariousness of funding for primary care training programs.
The Evolution of “Primary Care” as a Concept
As we contemplate what policy options should be taken to promote health care access in the next ten years, much of the conceptual framework we will be using will date from the mid-1960’s through early 1970’s. The term “primary care” dates from that period – a vestige of an attempt to impose the language and principles of systems analysis in describing health care delivery in the United States. The term “tertiary care” also survives from this scheme, more often than not in pejorative contexts, to describe the circumstances that favor sub-specialization, bench research, and procedures in the academic medical centers.
“Primary health care” and “primary health care access” are related, although not identical concepts. But we rarely use the term “primary care” without an explicit or implicit reference to some problem of access. For 20 years it has been a principal mental construct to aid in the devising and promoting of policies to counter the inexorable process fragmenting medicine into sub-specialties. It becomes the matrix for corollary constructs – the ideas of comprehensiveness of care and of continuity of care.
Consider several important movements of the past two and a half decades – each advance to promote access to comprehensive, continuous primary health care (each represented by one or more members of this conference’s faculty).
- The idea of expanding urban health departments beyond such traditional roles as immunization, vector control, and food inspection to incorporate comprehensive health services to the medically underserved.
- The idea of establishing consumer-controlled neighborhood health centers, now usually referred to as community and migrant health centers and promoting them with federal support.
- The idea that the U.S. Public Health Service, whose patient clientele had once been limited to the Merchant Marine and to Native American tribal communities, should assume direct patient care responsibilities in certain defined geographical areas of need, most notably through the establishment of a National Health Service Corps
- The idea of creating a new medical specialty which came to be called family medicine whose elements – including the structure and content of training and requirements for board certification and periodic re-certification – were based on normative theories of what primary care training should be like.
The latter initiative, family medicine training, addresses the improvement of access for the underserved to quality primary care at two points in the career continuum of physicians. One is during the physician’s residency training when model primary care delivery would be provided in the residency programs themselves through the family health centers, family practice inpatient services, home care, and community-based satellite practices.
The second interaction is through the practices of the residency program graduates – those who have mastered family medicine in training and who are duly certified by the new primary care-oriented specialty board. Those graduates, it is envisioned, would collectively practice the enunciated principles of “ideal” primary care.
Delivering Primary Care
I have listed five kinds of primary care deliverers, each kind invented to promote access to care. Again, the five are: comprehensive health services by local health departments; community and migrant health centers; the National Health Service Corps; the family medicine residency programs; and family medicine residency program graduates.
Each of these kinds of primary care deliverers have had their detractors over the years. Many of the detractors, during the 1980’s, came to be convinced that a surplus of physicians would emerge in the United States, making these initiatives of the 1960’s superfluous since sub-specialists would be forced to enter primary care and a diffusion of physicians into ever smaller and less desirable communities would occur.
During the 1980’s, many who had been concerned with issues of primary care access found themselves on the defensive. Concepts of primary care, comprehensiveness, and continuity may have influenced each of these initiatives strongly, but the evolution of each occurred in relative isolation.
Systemic Linkages between Primary Care Entities
In two ares formal linkages do exist. One obvious kind of linkage is that between the family medicine residency programs and their graduates – an outcome, I think, of accreditation requirements, that encouraged community physicians to be participants in the residency programs as attending faculty, often an effective antidote to “town and gown” controversies.
A second kind of linkage is one promoted by federal policy, that the National Health Service Corps would become a principal means for assuring physician manpower for community and migrant health centers.
In a longer presentation I would suggest examples of other kinds of linkages, usually local, such as we have heard of in San Francisco. Between other deliverers in my list of five, but thinking in national terms with the exceptions noted, each has evolved independently. Characteristically, in an era when public policy formulation is so often a fragmented and episodic activity, each of the kinds of primary care deliverers noted has fought its own political battles.
I propose that we think of the five kinds of primary care deliverers as a partially connected pentagonal figure, showing the previously describe family medicine residency program-residency graduate linkage and the NHSC/community-migrant health center linkage.
Deficient Numbers of Primary Care Physicians
The concept of looming deficits in the supply of physicians in the United States may be an unfamiliar one in some policy circles. We were accustomed in the early 1980’s to consider our principal physician manpower dilemma to be an impending surplus of physicians over levels of adequacy enunciated by the Graduate Medical Education National Advisory Council.
I will not speak to whether or not the analytical approaches to forecasting physician need and supply advanced by the Graduate Medical Education National Advisory Council [GMENAC] were fundamentally sound. But too often predictable manpower deficits, which should have been of paramount concern to policymakers, were either unrecognized or assumed to be temporary problems which would abate as the “surplus” physicians searched for things to do.
I am not one who argues that we may be heading for an absolute shortage of physicians, although the 1960’s provided us with lessons that the predicted surpluses of teachers and engineers, which led to cutbacks in numbers being admitted to teaching and engineering schools, led in time to the recognition of national shortages of teachers and engineers. I suppose a devil’s advocate might note that our population is increasing, our health status by some important measures is declining, and our number of medical school places has ceased to grow and may be in long-term decline.
But two areas of physician supply seem to be grossly inadequate as we enter the 1990’s – physicians entering rural practice and physicians who deliver babies. Arguments for family medicine residency funding often have included the idea of the “bimodal curve” of family physician ages – that is, that most board-certified family physicians are either those trained since the early 1970’s who, therefore, are about 45 or younger, or are those trained just after World War II who typically are over 65 and nearing retirement.
We currently are living through the long-predicted period of retirement of the older hump in the bimodal curve. This is profoundly affecting health care patterns in rural America. Many rural towns are simultaneously seeking physicians to replace their long-time community doc and are finding the competition very rough. Typically, their small rural hospitals’ fates are themselves tied to their community’s ability to attract physicians.
Competition for Family Physicians
But the family physician, whose training is precisely designed to be the most useful physician for rural areas, apparently has become the physician of choice for a whole range of settings, vastly increasing the number of would-be recruiters of family physicians. Dr. Marc Babitz of NHSC’s regional office in Denver recently presented the information that every family practice medicine graduate has an average of 20 serious job offers to choose from.
Given the advantage that a region, rural or urban, that is host to a community-oriented family medicine residency program has in recruiting graduates of that training program, the difficulties that a rural area which has not had a long-term strategy for recruiting and retaining physicians can be formidable.
Even more ominous if the impending crisis in obstetrical manpower. Only two physician specialties – OB/GYN and family medicine – are trained to deliver babies, and physicians in both specialties have enough within their normal scope of practice that they can build busy practices without offering obstetrics. In fact, with the high cost of liability insurance for physicians who perform obstetrical services, and the practice time that delivering babies consumes, it is plausible that physicians in either specialty might actually increase practice income by dropping obstetrics.
It is apparently the preference of some medical communities that family physicians not deliver babies at all regardless of skill and training. This, and the specter of litigious patient clienteles, has caused larger numbers of family physicians and, for that matter, some graduates of OB/GYN residencies, to resolve from the first day of practice not to deliver babies.
But a poorly understood fact is that a large percentage of physicians who deliver babies give up their obstetrical practice in the period between ages 42 and 45 which suggest that, if we as a society wish to assure ourselves an adequate supply of physicians to deliver babies, that we be constantly producing a number of physicians who will give us a dozen or so years that we can count on them for this important purpose.
It is quite likely that we have not come close to producing that right amount of physicians trained and willing to deliver babies in the period since 1985 and that, if this is true, it will become increasingly obvious as the decade unfolds.
Funding of Primary Care Physician Training Programs
My final concern relates to the funding of primary care physician training programs. I believe one of the intellectual achievements in the public policy debates of the 1960’s was the application of educational theory to the societal need of producing a particular kind of physician who could perform specific skills in just the right way. I think both the family physician and the family medicine residency program are living embodiments of a truly great pragmatic vision – the primary care physician trained in an ideal curriculum to perform an ideal role in the United States health care system.
There are now hundreds of family medicine residency programs, many of which are genuinely interesting and inspiring endeavors, and tens of thousands of their residency program graduates properly certified by their guardian specialty board. Great numbers are performing exactly as the inventors of the specialty dreamed they would and, as noted above, they have become a “hot item,” intensely recruited by private practices, community clinics, HMO’s and their residency programs themselves.
Lauding the programs cannot mask a fundamental weakness in the concept of “idealized” primary care training. Partly by necessity, partly by tradition, they were planned as something that teaching hospitals would sponsor. An accreditation body was organized to assure that the programs would contain all of the essentials of an “idealized” primary care program. However, the administration of the sponsoring hospital might well have a quite different view of what the hospital’s mission is and what it regards as proper priorities.
Consider for a moment what a hospital administrator might regard as the hospital’s mission – the emphasis on the very sick and concentration of resources on life-threatening illnesses, accidents, and acute care.
Consider the special features of a family medicine residency program that might be imposed upon that teaching hospital. These may very well contain requirements that are not considered to be part of the hospital’s mission – comprehensive care; three years of specified rotations that may be on services that that hospital doesn’t routinely choose to provide; continuity of care, getting the hospital into ambulatory care in a very specific, precisely defined way; behavioral sciences, requiring an interdisciplinary faculty that may not be the kind of staff that that hospital would normally have; community linkages which require resident time out of the hospital.
So you could imagine that with the figure in the center suggest that the hospital management might represent a narrower view of what a family medicine residency program should do within that hospital, and that the residency review community might well have a much more expansive view of what society needs that family practice residency program to do.
Well, no hospital can pay for all of the components that a properly operating family medicine residency program must have to maintain accreditation by means of revenues generated by the residency program. Thus, every family practice residency program operating in the United States is subsidized from one or more sources and ultimately it is the sponsoring institution, the hospital, that must absorb the shortfall between what the residency program generates in revenues and what external subsidies it can garner. This can lead to a tension between hospital administration and the accrediting society as to how much of the hospital’s resources the residency program should command.
The accessibility of residency program subsidies mitigates this potential tension. External subsidies usually exist as federal, state, and local grants for family medicine training. (The Medicare “pass-through” subsidy for teaching hospitals, though technically an external subsidy, operates more often than not as a resource whose use is discretionary with the hospital administrator and, therefore, is often perceived as an internal subsidy).
Beyond these governmental subsidies and residency program income, any shortfall in the costs of the family medicine training has to be paid for out of surpluses in other parts of the hospital. But the internal subsidies (the other services of the hospital) may very well be squeezed by price inflation in the health care sector, reimbursement by DRG’s, reductions (actual and proposed) in the Medicare pass-through, and the increases in uncompensated care that affect the hospital’s bottom line.
Meanwhile the government and non-profit sectors are affected as well – the concern of the federal deficit, the effect of the taxpayers’ revolt on state and local government revenues and expenditures, the philosophies of economic limits that affect resource allocations – all have affected particular hospitals, and particular states that squeeze their subsidies and, therefore, squeeze the hospitals. What you get is the simultaneous effect of the cost squeeze on hospital’s financial resources and the cost squeeze on the government, affecting both the internal and external subsidies of the hospitals.
The 1990’s will be a decade when strategic thinking as how to address problems of training the right kinds of providers will be required. As perplexing as it is likely to seem at times, we are indebted to the intellectual work of 25 years which has led to workable models of health care delivery that promote access. It is our task to preserve and improve upon this legacy.
Mr Burnett’s presentation was preceded by: First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 1, Werdegar)
Mr Burnett’s presentation was followed by: First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 3, Arradondo)