This archiving and publishing of the proceedings of the fifth 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 Presbyterian Community Hospital Department of Family Medicine (Whittier, California):
Donald Weaver, MD; Director, National Health Service Corps: When one views the policy options for the 1990’s, a fair question to be asked is what are the expected outcomes? The options may fall into two categories: what we would ideal like to have; and what we absolutely need in order to meet some of the primary care needs of the nation.
In the absence of a national policy which entitles every member of our society access to primary care services, each program must do its part to improve access to care for the underserved. To achieve this, we must work together to remove geographic, financial, language, and cultural barriers to access.
To truly make a significant impact in improving access to primary care services, we need to have a blending of the precepts of primary care and public health. Whether you call it community-responsive practice (which was used by Madison and Shankin in the 70’s) or community-oriented primary care ( a term coined by the Karks), this philosophy of service delivery actively involves care for individuals and addressing the health care needs of the community.
The needs of both “patients” – the individual and the community – must be met to maximize the impact on underserved populations.
I believe that we need to return to the triangle of patient care, education, and research as we loo at the policy options for the 90’s. Every health care program that I am familiar with has one of these three parts of the triangle as its base, the area of major emphasis. Each program must decide, given its priories, how it can meet its’ mission and incorporate service to the underserved as a desired outcome.
If you agree with this concept, I would like to suggest that a continuum of experience can be developed, with the ultimate outcome being improved access to care. The challenge for the individual programs is to see where they fit along this continuum.
Since my experiences for the past 3 ½ years have been in the Health Resources and Services Administration (HRSA) with educational programs of the Division of Medicine and service delivery programs of the National Health Service Corps, I would like to develop a paradigm around programs on the educational and service delivery components of the HRSA which target primary care training and service to the underserved.
The term health professional will be used throughout the presentation, as I believe that the best solutions to improving access will be the result of a team approach to health care. There is not a single public health problem today that will be solved by one type of health care professional working in isolation from other health professionals.
As part of our long-term planning for improving access, we list what we are doing in each area along the continuum, evaluate the success or lack thereof in each area, and develop strategies to continue successful efforts and improve in areas where there are less than optimal activities.
We must begin at the entry level, working together to assure that individuals who are more likely to return “home” are choosing primary care health professional careers. A list of programs needs to be cataloged in each state so that everyone interested in recruiting individuals with the “right stuff” knows where complementary programs are.
A careful review also needs to be done of admissions committees in health professions schools to assure that their members include appropriate numbers of individuals with primary care backgrounds. These individuals are more likely to look for students who have characteristics to pursue careers in primary care.
There must be continued support of students during health professions training to emphasize career options in primary care and to provide experiences in serving the underserved. These activities should include mentoring programs which utilize practicing providers of primary care as advisors and career counselors. Student experiences in the community and individual patient aspects of care need to be available throughout training in underserved areas.
Educational experiences which feature service to the underserved in community settings need to continue in postgraduate training. Based on the foundation of support laid by mentoring and student experiences, these advanced health professions training experiences continue to support the concept of training health professionals in ways that most effectively serve the underserved.
In the midst of recruiting more health professional into primary care careers serving the underserved, we must be careful not to forget the individuals who are currently doing an outstanding job of providing care to those most in need. Support for people currently in service to the underserved involves assuring adequate back-up coverage, professional stimulation, and educational opportunities.
In addition, leadership training and networking are very important if the expected outcomes include a cadre of community-oriented providers.
Finally, there are individuals with experience in serving the underserved who are not currently in an underserved area. They would be willing, for the most part, to share their experiences with health professions students and are an untapped resource for helping to assure that there are future generations of providers who are willing to commit part or all of their professional careers to serving to those most in need.
To help assure that individuals are not lost along this continuum, they must be tracked. We cannot afford to lose any of these precious resources for lack of contact. As funding becomes increasingly difficult, we need to look for ways to better coordinate programs in service delivery to the underserved, primary care education, and primary care research.
In the ’90’s, we will increasingly have to look at outcomes. Clearly, there are institutions which have a track record for training individuals who are going into primary care. Sutton’s Law – “to go where the money is” – would seem a reasonable guideline for the future.
Those institutions with demonstrated track records of training primary care providers, increasing the numbers of underrepresented minorities, and graduating individuals who are committed to serve the underserved would receive preference for funding. We are looking for excellence in the areas that are described above.
It is not unrealistic to expect that there will either be funding preferences for meeting stated objectives in serving the underserved or set-aside to assure that these objectives are an integral part of any overall education program.
There are programs which bridge the activities which have been presented. AN excellent example of a bridge is the Area Health Education Center (AHEC) programs. AIDS Education and Training Centers and Geriatric Education Centers also serve as bridges between the academic community and populations in need by educating primary care providers and supporting their efforts in the community.
I have presented interventions along the educational continuum which assist in meeting service delivery goals. The “secret for success” for improving access to underserved populations may lie in applying a definition of primary care (first contact, continuous, and comprehensive) all along the education continuum.
The approach to the development of health care personnel who are willing to serve the underserved for part of all of their career must begin early if the desired outcomes are to be achieved. The strategy must be a coordinated one, with all interested parties seeing how the resources they have can be used in a more complementary fashion.
There are many incentives to encourage health professionals to pursue careers in the private sector. We need to work together to assure that the public sector receives its fair share of primary care providers.
Policy options for the 90’s should include placing requirements on those receiving public funds to demonstrate how their program is coordinated with other programs in their service area to meet the needs of the underserved. A fair question to be answered is, “How do you tie in with other state and local programs which are helping to meet the needs of the underserved?”
Experience has shown that where the leadership of educational programs and service delivery programs want to work collaboratively, a way is found to forge a partnership. To be sure, there will be situations where programs will be coordinated, but not totally linked, because the missions are not totally congruent. However, meeting the needs of the underserved with combined service delivery and educational program models has tremendous potential for a large return on investment.
Based on some common goals, strategies can continue to be developed which will improve access to primary care services to those most in need and provide unique primary care educational experiences in serving the underserved. In a time when everyone is clamoring for outcomes, the results will speak for themselves, with the primary beneficiaries being the people who rea in need of service.
The triangle of patient care, education, and research can be linked with a continuum of contact that will point us in the direction of our ultimate goal of improving access to primary care for all people o this land.
(Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Health and Human Services.)
Phyllis Kritek, RN, Ph.D.; University of Wisconsin: I do want to make a comment if for no other reason that I am the only nurse in the room. I came here and have tried to listen very hard, but I think my nurse colleagues would be amazed that I have restrained myself in such a dignified fashion.
But I do want to hear because I am convinced that the next question we have to answer is how we collaborate.We don’t have a good track record among us. I don’t mean just nurses and physicians. I mean all the disciplines.
I am going to make observations about what I’ve heard these days. I think David Kindig’s candor captured some of what I think we nurses experience, and we’re not the only group, and that is that whatever problems might exist it is primarily something that’s up to physicians to solve.
And so, David, your comments, for instance, on if you get PAs and nurse practitioners to substitute for specialty physicians, and whether women physicians, especially minority women, are more oriented to primary care, are all very familiar arguments.
There are assumptions from this whole discussion about whose got the power, whose got the clout and also whose being responsible and responsive to the people. I guess those are the things that I took form this discussion. I learned a lot today.
Kindig: I’ll just say I think it gets more important if, in fact, the model moves away from the acute care model where rightly or wrongly you may be able to get along without it for a while and if it does move in that direction, then those issues could come forth. I think you’re right. We don’t know how to work together around this.
I had a very difficult time as Vice Chancellor with our nursing school when we got a Robert Wood Johnson Foundation grant to look at some innovations in teaching nursing homes. I thought the invitation was, in fact to put a nursing power center model in place. We tried to. In that situation we went down a traditional nurses’ approach as well. So technically we lost an opportunity to show some leadership. So it’s real tough.
But I think that if the model changes, and the fat’s in the fire, you almost have to. You won’t be able to do it any other way.
Kritek: I think there are some habits in our minds and our hearts and I would say all of us. We in nursing are accustomed to not being heard and, therefore, because our opinions are not sought, escape responsibility for providing answers.
Gessert: Phyllis has suggested some things that I think would easily provide a focus for another very involved and detailed examination and probably deserves consideration .
I would like to summarize some of the things I heard said in this particular session. A lot fo what I heard, particularly in this panel but all through the two days, is a debate between different proponents of incremental and local demonstrations versus people who take a vocal view of the need for change.
I would like to stay with that for just a minute because I think in that is an issue or two that, again, need a lot more focus. While I recognize and am planning over the next couple years to participate in a lot more local demonstrations, I really have some pessimism on my part as to how far really good, well thought through local programs can go.
The reason I have pessimism is because of the conviction that we’re going to need new resources to make some big things happen.And if those resources already exist within the health care system, it would be unrealistic, unfair, and perhaps even adolescent of us to presume that we can go outside the pshare of the national budget that’s already spend on health to find the resources necessary to make the changes we all have been talking about the last two days.
That means that somebody’s ox is going to get gored. That’s the big problem. Incrementally, if there’s incremental changes to the system of your arena, then it’s like doing a slow amputation – ethically, politically.
So my sense is that local demonstrations may provide us with the food for thought, the framework in which to go, illustrations and paths we may wish to follow, but I would really like to endorse what Bruce Behringer was saying about the sense of this being an internal threat to national security which is of every bit as much magnitude now as the perceived external threat to national security ten years ago.
I would very much like to endorse what David Kindig was saying about the danger of inadequate sense of national will to come to grips with this internal danger. In fact, I think all of our panel right now has touched upon this. I guess I would like to leave the group with the thought from this panel that we need to look at how the resources are currently allocated within our own system, and how ethically and politically those resources might be reallocated.
Sundwall: I guess I can’t resist one comment. I would like to comment on some aspects of the presentation. One thing I’ve come away with in spite of Charles’ skepticism – I’m amazed at how much is going on. There’s a lot of energy being directed at solving these problems.
The assumption in the call for an expansion of national will is that we should do these things everywhere, but that’s unrealistic in a democracy. Even our value system, as laudable as that may be, may not wash at the national level.
There are other beliefs that may be more popular. Let me just close with one comment and that is a statement made by Debbie Steeleman when she presented at the National Health Council. I think she put her finger on what is fundamentally wrong with the American health care system when she said you have to take away the fear in our society.
She said there’s an underlying fear, not just among the uninsured, but among Medicare patients who have to spend that on their Medicaid nursing home. That’s wrong. That’s a societal wrong. If that commission can come up with something to do away with the fear that prevails out there, I think we’ll do a lot. I think we just might see the reform.
Kindig: The only thing I would add is that it’s so hard to – they always say, particularly in these times, that you have to get your new stuff out of savings from the existing things. But it’s so hard to find those savings in the existing things to make the investments. I’ll give you an example.
In Wisconsin, we developed a community options program which is a kind of community services alternative to nursing homes which is actually a little better way to receive the care. Yet the researchers didn’t know that. Everyone bet that that the community options program wouldn’t have the desired payoff.
But trying to get the money up front to make the investments in order to get those payoffs proved impossible. If there is no new money, where do you find the savings? I don’t know that it can be done in a “capped” funding situation.
Midtling: I’ll just make some closing remarks and musing. I believe that as we look back at the decade of the ’90’s, this conference will have played an important role in increasing the national focus on the problem. Bill Burnett told me earlier that having been at this conference will be like having the first collectors plate in a series.
I think that we potentially have touched upon some viable solutions here but whether or not these solutions are implemented, I think is going to be the task ahead and probably the most compelling reason why we need to continue these discussions. If there is one theme that I would like to emphasize, it’s that I believe that government as the major payor of health care has within its capacity the ability to make the changes that are necessary to manage the problem.
Bruce Behringer spoke earlier about the golden rule. There’s another golden rule and that’s that he who has the gold, writes the rules. I believe that we can address these problems for the past 10 or 20 years. And so I think we need to continue with this and I think we need to expand these programs. But I really think that if we’re going to solve this problem, it’s going to have to be a radical change.
Whether or not we have the resolve as a society, and I agree with what you said earlier, it’s not just a physician problem, it’s not just a nursing problem, it’s a societal problem. Do we have the guts as a society? DO we have the courage as a society to make the really tough decisions and reallocate the resources that are necessary to solve this problem?
I think in the past the dictates of the special interest groups, and we in medicine have bee part of that, and medical economics have been just too powerful to overcome. So I think we need to make some difficult decisions here. The real question, I think, is can we afford not to take these steps. I don’t think we can continue with the status quo.
I would like to thank all of the attendees, the participants, and faculty. I especially would like to thank Bill Burnett for bringing us all together despite busy schedules. Without him we wouldn’t have been here for the past couple days. And I would like to thank Charles Gessert for helping to put the conference in focus, providing guidance, and really, I think, giving a unique perspective to the layout of the conference that was very important to allow for meaningful discussion.
I want to thank everybody who contributed and I believe it’s been a very successful conference and I hope you have some time to enjoy the rest of the day here in Kohler. In future conferences, we can follow up on some of the issues that have been raised here these past couple days.
This presentation was preceded by: First National Conference on Primary Health Care Access (5th Plenary Session, Part 2, Kindig)