First National Conference on Primary Health Care Access (4th Plenary Panel, Part 1, Arradondo)

This archiving and publishing of the  proceedings of the fourth plenary session of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):

 

John Midtling, MD, MS; Chair, Department of Family Medicine, Medical College of Wisconsin

John Midtling, MD, MS, Chair, Department of Family Medicine, Medical College of Wisconsin [Dr Midtling is a Senior Fellow of the Coastal Research Group]: I would like to welcome you to the second day of our conference entitled “Access to Primary Health Care in the 1990’s.”  We have a few new guests here today.  I will mention again that the conference proceedings are being recorded.  IF you do make comments or ask questions, identify yourself.  It will help us in producing the final proceedings.

The session this morning is entitled “Improving our Management  of Access to Primary Health Care for Minority Populations.”  The principal presenter is John Arradondo, Director of the Department of Health and Human Services, City of Houston.  Panelists are:  Hector Flores, M.D., President Chicano/Latino Medical Association of California and faculty member of the White Memorial Medical Center in Los Angeles; Sandral Hullett, M.D., Medical Director, West Alabama Health Services; and Gerald Ignace, M.D., Past President of the American Association of Indian Physicians, and current Chair of the National Advisory Council of the National Health Service Corps, and a physician in private practice at the Harwood Medical Center, Wauwatosa, Wisconsin.  John.

John Arradondo, MD; Director, Department of Health and Human Services, Houston, Texas

John Arradondo. MD, Department of Health and Human Services, Houston, Texas: Upon being asked to address strategies to manage to access to primary care among ethnic minorities and underrepresented minorities, I immediately visualize the faces of Houston’s Black, yellow, and brown citizens.  In my brief stay there, these minority citizens have often appeared to be entangled in a medical care delivery system that almost always appears to be more responsive to the demands of its administrators and its full-paying clients than to the people who are on the margins of the system.

This isn’t to say that all minorities are on the margin of the system, although too many are.  It is to say that being Black or Hispanic in Houston puts one at a significant disadvantage for obtaining safe, reasonable, comprehensive care.

Lost in the web of special interests, these ethnic minorities confront great hardship in obtaining health and medical care.  Some of this hardship is due to their limited experience with the health care system, some to their lack of knowledge about their won health needs.  Additionally, the lack of culturally sensitive disease prevention programs in my town and insufficient income by many of its citizens to buy health services are clearly significant factors.

Increasingly, the publicly funded medical health care system, (and all those words – medical, health care, and system – have their own independent and collective meanings) is being starved by a decreasing revenue base, particularly in the metropolitan areas.

John E. Arradondo, MD; Houston Texas Director of Health
John E. Arradondo, MD; Houston Texas Director of Health

I see it pressured by managed medical care and other cost-containment programs.  And it seems to be perennially staffed by hurried, overworked professionals, whose lack of time and sometimes whose lack of sensitivity to the patient serves to triage clients out of the system rather than encouraging their entry into the system and encouraging their proper use of the system.

Ultimately, these urban system suffer from too few resources aimed at serving too many citizens.  So how can we facilitate access to the system by African, Hispanic, Asian, and Native-Americans?

As we examine ways to manage access, I would like each of us to remember that there is no one factor which predicts why minorities encounter more barriers to health care than their white counterparts.  There is no single obstacle which prohibits them from seeking care or entering the health system.  Rather, in my opinion, it is a confluence of several factors and complex circumstances that impede and restrict minority access to health care.

Accordingly, I have not seen one single, sufficient solution to manage access to care.  So let me begin, then, by identifying some of the factors which should be managed to assure access to primary care.  Then I will discuss some of the strategies to manage these factors.At least five factors act as barriers to access to health care among minorities in metropolitan areas.  I have simply listed them as:

  • a multipolar delivery system which has complex eligibility requirements;
  • deficient transportation (this was mentioned yesterday and I think it’s very important, maybe even more important in cities than in the rural areas, interestingly);
  • insufficient  knowledge  of the health care system by the users and very often insufficient knowledge of one’s own health needs;
  • availability of health providers, and, although this is not a topic that I’ll discuss very much, the attitudes of those health providers; and
  • lifestyle behavioral norms of the minority populations.

The profile of the urban health care system is often characterized by multiple agencies, each serving a different constituency, usually based upon distinct eligibility criteria.  In Houston, for example, citizens’ health and/or medical needs are services by the City Department of Health and Human Services, a country health department, and county hospital district which has its own independent taxing authority.

Often the eligibility screening to determine patient participation is so cumbersome that it serves as a major barrier to services for the medically and financially indigent patient who, in my town, is usually a racial or ethnic minority. We have responded to some of these and I’ll mention those responses later.

In a study by our local March of Dimes chapter, a poor pregnant woman was transferred among city and county prenatal programs and the maternity care program of the county hospital district.  All three agencies have different methods of screening and registering patients.  IN all, some 57 different  questions could have been asked.

Patients seeking hospital district services are asked to supply documents, such as birth certificates and income statements.  An average, uninformed patient could make several trips just to qualify for services.

This example illustrates two other major access barriers;  transportation and knowledge.  Houston is spread out over 600 square miles.  Houston laps over into two other counties, but Harris County, the major county in which Houston is located, has 1800 square miles.  During the city’s boom years in the ’70’s and early ’80’s, many communities sprang up along the city limits.

These communities are generally characterized by crowded apartment dwellings, decaying streets, and, increasingly, refugee and resident alien populations.  Houston’s central city has the usual character of most large American cities, but there now is that additional South American look where the poor part of town often is in the fringes.  So Houston has two kinds of underserved urban areas.

This is not true for all of the areas in the suburbs or along the city limits, but for many of them.  Many such residents are potential clients of our health services and many depend upon public transportation.  When I first went there, I was told that 80% of our clients came in cars.  Everyone was comfortable.  No one worried about the public transportation.

Although I have long since forgotten my epidemiology, I remembered enough to determine that the statistic that showed that 80% of instances.  In fact, of course, it is almost the contrary.  As far as we can see, at best it might be that 50% of those who should be coming to us have access to cars and a smaller portion have cars.  That’s quite the opposite of the Texas norm.  I am not speaking of those who are eligible to come to us; I am speaking of the ones who are eligible and don’t have other means.  Those are the ones who should be coming to us.

By the way, I am not ruling out our going to them.  I am just speaking of what they – our clients and our potential clients – have.  When such an individual, who depends on public transportation, has to travel back and forth many times just to see a doctor or obtain medicine, it becomes quite a disincentive to participate in the system.  I pressure at some point we can talk about outreach, which is mandatory for my kind of department and for any organization that would provide services to the underserved.

Those underserved include ethnic minorities who have, in general, been underrepresented and who, in general, do not have available services, and who often are somewhat behind the curve in experience with the latest developments in health care, as it were.  I’m not so sure that keeping up with the latest is the best since I don’t buy the normal medical system dictum that the latest is the best.

That’s one of the things that got us to where we are now.  But very often the latest is very important.  People who have had less experience with the system often are not current with that which is available to them.  This lack of information about health services and how to access them, I think, inhibits potential users of the system, particularly of our system.

Several items of research suggest that some minority and low income consumers lack the organizational and educational sophistication to use the medical system.  They rely often on the health provider for their technical assistance as opposed to medical journals like Time and Newsweek or those more frequent daily exposition such as the Washington Post, Los Angeles Times, Wall Street Journal, and others who take it upon themselves to educate the public about medical matters.

Sometimes these publications do a reasonable job.  Yet, the users of which I am speaking often rely upon the health providers more than usual for their needed technical information and assistance.  At the same time, they often remain distrustful of these professional providers.  The providers, for their part, reinforce this distrust by frequently speaking technical jargon and ignoring the importance of patients’ extended families and other sometimes simple amenities, but sometimes very important interactions, that establish the appropriate rapport and begin the education of the client.

This lack of organization educational sophistication seems to be predicated on the fact that health care is often a peripheral interest of the consumer that I am describing.  Usually care is sought only at the time that symptoms if illness occur.  The knowledge which could prevent disease or foster wellness often is not present in the family and the mind of the consumer that I am discussing and describing.

Such knowledge might help eliminate this episodic use of the system or even slow its concomitant effect of increasing the cost of medical and health care.

Take the case of kidney transplants.  What has now become a relatively routine medical procedure, paid for by most major medical insurances, is by and large outside the realm of possibility for many minority consumers.  Yet, they continue to demonstrate the greatest need for this one item.

This leads to a fourth and, perhaps, most significant and sometimes most difficult factor to manage, and that is the attitudes of both the health professional and of the patient or the consumer, especially attitudes that relate to cultural norms and beliefs – those particularly that affect health care.

I waver between being too general and too specific, but we have physicians who don’t believe in the germ theory.  If you don’t believe it, just observe how often they wash their hands after their hands have been in contact with infectious environments – air, water, solid.  Maybe sometimes it’s not a conscious disbelief, just a dichotomy between what they know and believe and what they do.

Sometimes we have the ability to separate those two.  In looking at the clients that I am describing, sometimes – most of the time – we have beliefs that affect their health care.

In a system of health care such as we have in Houston and certainly such as we represent, the decision making process is often dominated – in fact it is usually dominated – by the health professional. It is often dominated by public servants.  Only secondarily does the client have a piece of the decision making action.

The nature of this particular decision making adapts itself more readily to the needs of the health care providers than it does to the needs of the health care consumers.  Institutional strategies develop in accordance with provider needs in order to maintain control over a particular mix of service, (whether that is an economic or other drive needs), as well as some attempt to meet consumer demand, which in some instances is more important than others but almost never is the primary matter.

The end result if the creation and perpetuation of a system that’s driven mainly by providers’ demand and reimbursement for service and which leaves a growing void of humanism and cultural sensitivity in dealing with the consumers.

This system conforms to the medical model wherein you find a disease, you diagnose it, and you render treatment.  In this model, the physician’s role is paramount because of the physician’s expertise.  But the physician’s authority is often extended to decisions beyond simple medical care and medical diagnosis.

With little time or inclination to explain and inform patients about the course of illness, the provider leaves the consumer a marginal participant in his own care and in the system, thereby taking one further step to alienate the consumer and, thus, creating more barriers to access.

I said earlier that I wouldn’t talk much about he availability  of providers.  I think that the scarcity of African-American and Hispanic providers in my neighborhood, in my state, and nationally among all of the underrepresented minorities, is very well documented. If we explore further the ramifications of minority consumer attitudes that are based on cultural perceptions and beliefs, we have yet another significant obstacle to access of which the health beliefs model (which was mentioned yesterday) is particularly illustrative.

Motivation theory, as you know, deals with the subjective world of the behaving individual and not just the semi-objective  would of the scientist or the physician.  This concept of a psychological state of readiness to take action and the subsets of that whole perception of the benefits derived as a result of action and all the various cues which trigger action – all of those are parts of the model and I won’t say much about that.  I think that the model is useful, though , in thinking about the diverse ethnic responses for entering the medical health system.

The trained physician is often taught to believe that his medicine (in this instance I am not speaking just generically “his” because if the prototype was “her” I would say “her” – it’s not yet “her” – so I say “his” medicine) is the only one which works.  However, the environment which the physician enters has many medical traditions and beliefs and practices, some all to themselves and almost self-perpetuating.

As you know, medical care is a system of meanings and behavioral norms.  Some people talk bout the art of medicine rather than the science.  There is a lot of science but there is also a lot of hocus-pocus.  It’s good!  It works if you can reproduce it and many people can.  These meanings and norms are attached to particular social relationship and to particular institutional settings.

So the ethnic medial traditions may contact different concepts about body and different concepts about mind.  They may contain different kinds of healers and different process of healing.  All of these aspects of the system interrelate and they are governed by socially sanctioned rules (whether those are the socially sanctioned rules of the providers of the health industry or whether those are the socially acceptable rules of the recipient of those services, even those who haven’t received the traditional medical care services).

Any specific ethnic health tradition is deeply rooted in the identity of the particular group.  If you don’t know much about the group, you can’t do much about the problem.  I suppose I should refer you to a document that I received, and I presumed that Don Weaver and Sandral Hullett just received, entitled, “Education of Physicians to Improve Access to Care for the Underserved:  An Executive Summary.”  This was the second HRSA primary care conference, March 21-23, 1990, in Columbia, Maryland.

A lot of collective interaction went on and some documents were produced right on the spot thanks to the modern use of word processing.  Four weeks later I received my copy.  I guess there were 14 commissioned papers.  I say that because there is a fair amount of description of the underrepresented minorities and also of underserved majorities.

One of the characteristics that has somewhat of a common theme is the identity of the particular group, a subset of the larger population.  That identity contains certain elements in which any health tradition that the group has followed is deeply rooted and it has to be understood.

If we look again to the case in Houston where a large segment of the population is Hispanic, we can see how this health beliefs scenario plays out, at least to some extent, from the Department of Health and Human Services perspective.  Much of the Houston Hispanic population is composed of second and third generation citizens.

Nonetheless, many still retain their indigenous language and cultural beliefs.  They have very strong family and community orientations.  These function as the cornerstone of their support system.  (In my report on the health of Houston the other day, I was surprised that the news media almost collectively – 95 to 100 of them – gasped when I just flipped up something that was already in the highlights that we had handed them earlier and said that the Hispanic population in Houston had the lowest infant mortality rate.

In fact, it was below the 1990 norm of nine.  I think that is the 1990 goal.  It’s about 8.8, 8.7, 9.6 in the inner city.  About 8.6 or 8.5 in the periphery o the city.  We divide our city up on the health status of those areas on a regular basis in a two volume report.  I was surprised that the news media almost collectively gasped.  There are some explanations of that, I think.

The use of the health beliefs model suggests that the importance of other behavioral and psychological factors which influence minority access to health care is something that we rally ought to pay attention to.  While I believe that these factors are of equal importance in determining access, I must caution against any use of constraining predictor over which the consumer has no control, such as ethnicity or race.  Sometimes we get a good identifier and somethings we misuse it.  So I caution against that.

The consequences, of course, of this misuse are odious and they prevent either the consumer or the professional from formulating any real meaningful strategy to manage access.  Sometimes they say a little knowledge is a dangerous thing.  In this instance, keeping that caveat up front while planning to use the consequences of health belief models among the underrepresented minorities is important.

If the delivery of health services is divided according to political subdivisions as it is in Houston – city health, county health, county hospital district, regional, state health (which is located in my town – then we have to take every measure to ensure that the delivery system encourages rather than discourages appropriate consumer use.

In the matter of prenatal care, for instance, people rail against the overlap.  And they did for sometime until the county health director and I pointed out that we’re both so underfunded that we aren’t anywhere close to meeting the need, much less overlapping.  Most importantly, our unit provides over 75% of the prenatal care to the people delivered in the county hospital system.

Among the various entities, identical eligibility criteria should be adopted for all the services that these entities provide.  A generic patient identification card seems simple.  It should include shared eligibility criteria, residency, and income, and it should be used by all delivery systems.  The hospital district in our neighborhood has a lot of requirements.

My own department has only two: 1)that you think you fit with the service we offer, and 2) that you say you live in Houston.  Those are about the requirements.  We want the criteria to be simple since many of our consumers speak some nine or ten languages in which we have trouble communicating.

We do very little “signing,” although we’re doing much more in 1990 than we did in 1988, and we are beginning to utilize other methods of communication.  So it helps if those needing our services are able to communicate their status to us.  Sometimes just being there communicates a person needs.

Sometimes one can identify a pregnant woman by her profile and a child who needs well baby care just by the child’s apparent age.  The county health department has eligibility criteria in between ours and the hospital district.  Once the client has satisfied these criteria of one health unit, that person should be able to use the services in all of the, and that idea begs for criteria common to all of the entities.

While I am discussing this, I would at least mention that some of this is possible.  We have virtually completed a pilot project utilizing five of our respective centers, one from the state’s Department of Human Services (which provides a fair amount of income maintenance and pays for some of the medial services), one from the county, one from the hospital district, two from our department.

The project is an integrated eligibility system where one comes to one spot and becomes qualified for all the services of all the agencies.  We announced the project’s success two weeks ago.  We are now planning in our department to expand the pilot to all of our facilities.  We’re making space for the eligibility process to include all of the agencies that should be using this.

Eventually, our plan is to enable any one agency to do the qualifying for all agencies rather than having workers with the support of administrators.  It could be spearheaded by some other outreach personnel.  The dual purpose is not only to qualify the person but also to educate the person to the services available, how to use them, and, in some instances, how not to use them.  We can give examples of that in many ways.

This kind of integration of select information and delivery system and referral services is predicated on a one-step shopping model.  The goal that we have is for persons to be able to get all the services that they need in one place.  I say that from the perspective of the director of a Department of Health and Human Services.

We offer well over 50 different programs from day care for children and the elderly, to development in children and youth, to extension of that to juvenile delinquency prevention, to pregnancy prevention – a whole series of services that might not all be offered at one spot.  These services would be more than, say, a group practice of family physicians might offer on the preventive and the health promotion side.  Yet, many such family practices could and should and do access these county services in my town.

There are many more problems that we follow up for disease intervention that the private practitioner has referred to us than you would imagine.  That’s an appropriate public/private partnership.  After all, we really are the experts in sexually transmitted diseases, certain communicable diseases, and are the experts in dealing with epidemics. We have just decided to become the travel center, since most of the people who provide travel immunizations call us before they give the shot.

Initially some thought it strange that we should compete with the private sector.  The privatization that we talk about a lot is not good in and of itself.  It’s really only good because you change from one bureaucracy that has ceased to do a good job to another that can be more responsive.

After a while the private bureaucracy may become counter productive and it needs to be changed, either to another private bureaucracy or back to a public bureaucracy.  It makes little difference.  It’s the change that is probably the most important factor – a fresh outlook, a fresh set of hands, a fresh effort, and some increased efficiency.

We have done this in several areas.  We have now begun to do it in the travel area.  Our goal is to take care of 90% of the travel business in Houston.  Every day some 40-50 people arrive from around the world just to the Texas Medical Center for medical care.  We have decided we’re going to do that and we’ll update you on that maybe a year from now as to whether we’re still in business or whether we have needed a subsidy in which case we’ll just give it up.

This kind of public/private partnership, I think, is important needs to be inaugurated from several perspectives to deal not only with paying clients, but also with non-paying clients.

I think that a comprehensive system used by physicians, nurses, the traditional medical workers as well as health educators, public health people, social workers, and outreach workers can identify and train community-based workers to play a role in the system.  This is a natural for neighborhood health centers and community health centers.  It’s a natural for an occasional isolated primary care group practice.

But it’s basically an outlier for the larger part of our system.  Yet, it’s a perfectly good principle which is being used increasingly.  I have seen it in the practices of a number of graduates from my former life as an academician.  I know that they have found it cost-effective, despite the payment system.  I do know they got the idea from the community approach to family practice that we tried to teach them.  But they have also discovered how to make what we call a community diagnosis, to figure out the feasibility of setting up and operating a practice, the process of hiring people who could diagnose needs of that community before they market it.  So the outreach people served a dual purpose.

AT&T markets to me quite regularly and effectively, so effectively that while I’ve tried the other long distance lines over the decade, I have always used AT&T.  Sooner or later they have to come to match the price, exceed the convenience, and match the expertise of all the other newcomers.  Maybe that’s he reason why they still have the most long distance lines.

I see that kind of outreach marketing being used by the representatives of American corporate sector very readily.  There is no reason that small representatives of capitalism – small physician group practices – can’t use them.  The community health centers have used it well, I think, and I would offer it to all segments of the medical-health industry.  We certainly are using it increasingly in public health and we will need to use it more frequently.

I say all of that because I think it’s particularly important in minority communities.  It is important in any underserved community.  But I also say it because it’s important for you in establishing a market.  Whether you can afford to expend a large loss leader or not, it is still important.

Sometimes some of us think that we don’t have enough resources to do anything that is considered a loss leader.  We have to start making profit from the beginning.  In the short run that might be true, but in the long run even that attitude might be counterproductive.  So using the outreach techniques for both sensing and diagnosing as well as delivering services is a worthwhile endeavor.

Of course, when this kind of thing is done, I think everyone benefits from an enlightened view of the minority consumer and of his particular needs.  And whether the consumer moves on to self-empowerment is another matter.  But having a better view of the minority consumer enables the provider of services to deliver those services in a much more effective manner.

I’ve said that it has been used by community health centers.  It’s been used by group practices.  It has also been used by the Medicaid HMO’s.  I had an opportunity to participate in a small voluntary Medicaid HMO – voluntary for AFDC recipients.  It’s still small.  I think their total number is less than 20,000 which, as you know, is very small for an HMO.

I realize that historically the “Blues” and some of the commercial insurers were experiencing 1,200-1,400 hospital days per 1,000 persons per year.  There were goals set at 1,000, then 800, and some of the HMO’s felt that they could get under 800-600 per year, and many of them did.  This particular HMO set as a goal of 400-600 patient hospital days per 1,000 people enrolled per year.  Not a bad goal – in fact, ambitious, particularly for a group of consumers who had been shown to have a high incidence of emergency room use and hospitalization.

In its first 18 months, that small HMO experienced a utilization rate of 450.  Excluding the first nine months, for the next 12 months which ended after the first 21 months (that second 12-month period), they experienced a utilization rate of something like 370+.  I remember it because my rate was 153 hospital days per year per 1,000 people enrolled.

All the people were enrolled in my little five-doc practice that we set up just east of the Capitol in this capital city, three blocks from the worst housing project in the city.  It was so bad in terms of crime that people who lived there called it “Dodge City” because they were dodging bullets in the night.

On the other hand, it was four blocks from the historic area and it was on the Main Street, eight blocks east of the Capitol.  This little practice was comprehensive by all criteria, Medicare-Medicaid mix, private insurer mix, male-female, ethnicity, age groups, and number of babies delivered.

The experience during that 12-month period, between the HMO’s 10th and 2st months was 153 hospital days per 1,000 people enrolled.  There were 700 people, all voluntarily enrolled, at that point in time.  It went on up.  Many in this particular program came from “Dodge City,” although a few came from other parts of the city.

I could tell you some other goo things about that story.  (It really is a fairy tale.)  But somewhere along the line teachers should be able to practice what they preach.  If not, they should stop preaching it.  You can imagine my not stopping.  Medicaid HMO’s can do it.  I think that Medicaid HMO’s, and I apologize to Wisconsin – it’s much better for me to tell this to the legislature or the governor but I haven’t met any of those yet – I think that they should give provider choice to the client who is enrolled.

I think that they should have a strong emphasis on health promotion and disease prevention services.  I think that they should clearly emphasize family physicians as the “primary” primary care provider and they certainly should emphasize the use of the primary care team.  That, of course, can be virtually any provider.  It can even be the patient, on the occasion, being the primary care team.

But most often the primary care provider or nurse or social worker or health educator, psychologist, or someone for that episode of illness is the leader of the primary referral and use and misuse of emergency rooms.  I think that they should build in strong incentives for provider remuneration, including residuals.

Those are very small residuals percentage-wise of the overall expenditure but awarded for savings on laboratory services, savings in emergency rooms, savings in hospitalizations. Yet, quality assurance and patient satisfaction were being measured steadily by this small HMO.

The other part of the fairy tale, the reason I got the award, wasn’t because of my savings.  We discovered that later.  I got an award during the middle of this 12-month period, which I think was at the end of the first 18 months as I recall, because I had the highest client satisfaction – our five-member practice had the highest client satisfaction of any of the provider groups.

That was kind of strange because our patients from the previous year’s tally,  by our analysis and their more extensive analysis and the secondary analysis of the state Medicaid office, had the greatest emergency room use, the greatest switching of providers, the greatest conglomeration of providers.

The average number of provider per client was the greatest.  They also had the highest number of complaints in the first six months of that program.  You had to hook into the program for one year and that was relatively well enforced, but certain circumstances could permit you to get out of it – allow you to change.

The greatest numbers of requests for change was among the “Dodge City” enrollees in our little practice.  In fact, we took many who had changed from other practices, with is another story.  How do you relate to somebody who comes to you in a hostile fashion for your services?

I think that large areas like Houston which have plenty medical and health science schools have some other opportunities.  These institutions should implement vigorous recruiting efforts to identify, matriculate, and graduate minority medical students. We’ve talked about this earlier.  But they also should do the same thing for culturally sensitive majority students.  We’ve talked about this earlier.

But they also should do the same thing for culturally sensitive majority students.  Half the Blacks get their care, when they get it, from the whites.  It is a very large group of people to work on.  Plus, not all the minorities should be expected or required to go into practice in underserved areas or serve in primary care because some are still needed in some of the other areas of medicine.  That’s another discussion for another day.

I think that culturally sensitive outreach effort need to occur for the reasons that I talked about earlier.  But they also need to occur in an attempt to foster consumer competence.  The whole business of training the client is very important.  We do it passively anyway.  Why not do it actively rather than passively?  Why not set goals to get consumers in your practice to do certain things?

When I was an intern I remember preceptors in medical school saying, “Well, in my practice we don’t’ have….” (the disease of the day, whatever it was;  it may have been hepatitis or ulcer disease associated with whatever).  And I quickly learned that the reason they didn’t have it in their practice was because they educated all those patients to leave their practice.  “You know in my practice, we don’t have many people who are overweight and have hypertension.”

Well, if you don’t like overweight people, they’ll sense your intolerance in a minute.  “We don’t have many alcoholics or we don’t have people in my practice who use drugs.”  They’ll leave if you aren’t sensitive to them.  We understand that, of course, when it comes to ethnic minorities being in a practice, but it’s equally true for people who have various health problems.

Individual practitioners can become sensitive to their biases and make conscious goals to educate clients.  So the business of fostering consumer competence can be a very dramatic and powerful tool to literally empower clients to take an ownership in what they do and take some responsibility for their own health.  I am not necessarily advocating the approach of Milt Seufert, who has patients who sit on a board and run his practice.

His patient board makes decisions about a number of things, including his salary, whether they should expand a little here, get some equipment there, bring on a partner.  I’m not  necessarily advocating that, although it is a rather interesting experiment and it seems to be working.  But getting particularly underrepresented minorities to take ownership or responsibility for their own health care for whatever you have to offer in your system of care is an important matter.

Only when this consumer feels able to make a contribution to the system and to effectively manage his or her own needs, can we really see change in the utilization of services – a cooperative attitude rather than a hostile attitude.  Many of the clients I am speaking of now are never going to be able to buy into the health system the way many of us with our major medical insurance do.  Then that person has to buy into the system in another way.

Understanding what the system can offer and getting the most out of it is one way they can buy into it.  They can buy into it in that way through our educational efforts.

I think that institutions should train professionals to develop and expand the various curricula and courses and practica to encourage this kind of approach.  Although the last ones that I have mentioned are the most difficult to make, I think that systemic and political changes should be encouraged.

For instance, in my city for the case of public transportation, I think city decision makers should take steps to ensure that transportation remains feasible through low-priced fares, through adequacy of vehicles, frequency of routes, and safe transportation stops.  In a city like mine where homicide went up for each of the last two years, that safe transportation stop is an important matter.

I think that health care administrators should become actively involved in measures which would increase access to their services.  I felt very good on Tuesday in giving our “Health of Houston” report when one of the top four news people in the city who reports on medical matters said, “If you do all of this (we were talking about outreach), aren’t’  you afraid that your waiting time is going to increase?”  She had just written a beautiful article three weeks ago about the increased waiting time in some of our clinics.

All that did was garner us some resources because the people knew we were trying our level best.  I then explained to her publicly for the first time how that was r risk.  But then since I had been criticizing my own department, I didn’t feel too badly about taking the risk of increasing the waiting time if I knew that the waiting time increase professionals bringing in and getting good results in their outreach efforts.  We have to relate in my city to the need not just to our capability.

If the only services we provide are to the 337,000 people that we can accommodate easily each year, then we have not dealt with the need when we know that we should be seeing 621,000 people.  So the 500,000 that we saw last year often were seen later than they should have been seen.  But the 600,000 that we will see this year will be seen much more quickly on the average than at 500,000 last year.  So I will take the flak for that kind of progress.  I think that health administrators, particularly in public systems, should be willing to do that.

Much of what I have said is not new.  In fact, when I read through this on the way up here Thursday, I decided that there was nothing new in this.  But a lot of it works.  If we sustain our efforts along these lines, then we can better manage access to primary care.

Thank you.

This presentation was preceded by: The First National Conference on Primary Health Care Access (3rd Plenary Panel, Part 4, Rodos, Q & A)