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):
John Midtling, MD, MS, Moderator: The session this afternoon is entitled “Policy Options for the 1990’s: Improving our Management of Primary Care Access Problems.” I am really excited about this session and have been anticipating it for quite some time because I think it allows uss the opportunity to have some dialogue about some innovation solutions to some of the problems that we spent the past two days talking about.
The principal presenter this afternoon is Bruce Behringer, Executive Director of the Virginia Primary Care Association and former Chair of the National Advisory Council of the National Health Service Corps. Panelists are David Kindig, M.D., Professor and Director, Programs in Health Management and former Vice Chancellor for Heatlh Sciences, University of Wisconsin, and Donald Weaver, M.D., Director, National Health Service Corps, U.S. Department of Health and Human Services.
Bruce Behringer, Virginia Primary Care Association (Mr Behringer is a Fellow of the Coastal Research Group): Access barriers to primary care services have been identified, defined, qualified, quantified and studied for decades.
Various strategies for change to reduce these barriers have been devised, tested, and evaluated since the 1960’s and, according to the old adage, the more things change the more they remain the same.
In a presentation I made recently to the American Medical Student Association, I attempted to echo the thoughts and sentiments of a variety of health care professionals and consumers with whom I have had the opportunity to meet and discuss the access issue. I jokingly entitled the presentation, “This is Not Your Father’s Oldsmobile Speech.”
Practicing medicine in the 1990’s, I told the attending medical students, should be recognized as somewhat different than during the times of our fathers. There are, if I can generalize, two major changes which have occurred.
The first is a change in the market place. Chart I indicates how far the national marketplace has grown from the indemnity insurance model which was prevalent not too many years ago. A little less than one-third of our nation’s population is now enrolled in these plans.
Health maintenance organizations and preferred provider organizations have grown dramatically. Public insurance, in the form of Medicare and Medicaid, is responsible for almost a quarter of the marketplace. Still remaining however, are approximately 37 million uninsured Americans for whom access remains problematic.
Linked with this change in the marketplace is the influence of actions of major purchasers of care, including insurance providers and the government. A whole litany of rules, regulations, contract stipulations, and review procedures have been put in place over time that intervene with the traditional integrity of the physician-patient relationship.
In the name of cost-containment or quality of care, physicians are finding their practices controlled by new pricing structures, selective reimbursement for procedures, control of specialty care, and ancillary service referral patterns, special malpractice pricing classifications, and new patient outcome and hospital mortality studies.
Each of these decisions has had both direct and spin-off effects which enhance or reduce access to primary care. If one considers just the two public insurance programs, Medicare and Medicaid, some of these effects become apparent.
Because of a complex reimbursement structure, including patient deductibles and co-insurance, balance billing regulations, participation and assignment issues, and inequities in specialty and geographic differentials, the Medicare program has been viewed both as the savior for access to care for the elderly and as a negative casual factor in medical education’s inability to sustain physician training programs which promote primary care selection.
The Medicaid program suffers from a similar dilemma. It has opened the door for many impoverished families to the mainstream of primary health care. The program, however, is not as widely accepted as a reimbursement mechanism as many states would desire. Physicians cite low reimbursement rates, paper work, and lack of timeless of reimbursement as reasons for not participating and accepting Medicaid patients.
A more common line of opinion I have heard frequently from older physicians is that introduction of the Medicaid program has reduced volunteerism and sense of shared responsibility among physicians for community health care access issues. Reliance on “the government” to solve the problem has, in fact, resulted in closing their doors to poor patients.
The Basic Investment Strategies
These two health care financing programs, Medicare and Medicaid, however represent only one portion of the overall federal strategy to improve access to primary care services. Two other areas, health manpower training and health care systems development, have also played critical roles in the federal investment strategy.
According to a report received by the National Advisory Council of the National Health Service Corps Program from a representative of the Council on Graduate Medical Education, federal dollars now pay approximately 80% of the costs of medical education in this country.
This includes monies from the National Institute of Health research grants, indirect medical education adjustments to teaching hospitals, direct cost reimbursement for graduate medical education, Medicare and Medicaid hospital disproportionate share systems, special Prospective Payment System reimbursements for teaching hospitals and reimbursement for services for publicly insured patients.
A parallel strategy was enacted in the 1970’s to support change in medical schools and residency curricula to enhance the probability of physician selection of primary care training and practice. These programs include those funded through he Public Health Service Bureau of Health Professions.
The limited allotment of funds designed to bring about changes in medical education is dwarfed by the massive amounts of research and reimbursement monies aimed at sustaining the current system which has resulted in greater specialization and continued access issues in primary care.
There has been substantial federal investment, also, in stabilizing health service delivery systems and practices. These have included funding to community and migrant health centers, the National Health Service Corps program and a multitude of categorical and block grand health service programs channeled through state and local health departments.
State governments, too, have invested sums of money using these three basic strategies. The focus of many state efforts has been on direct allocation of resources for medical education through state sponsored medical schools, through funding health services delivery directly through state and local health departments, and with matching federal programs and an ever-escalating investment in Medicaid.
Some states have become aggressive in addressing sub-sets of the access issues. A large number of legislatures have recently enacted and funded programs to address services for the uninsured, the indigent, and high risk segments such as pregnant women and infants.
To catalog all of the different management approaches being carried out at the federal, state, and local levels would be unending. From a public policy standpoint, the mixed experiences cited above with Medicare and Medicaid beg for some rational option in organizing both the process and product of our planning efforts.
Some method is needed to analyze the totality of the access problem while influencing the integration effort of the three basic strategies of health manpower training, financing, and service delivery development in such a way to make them produce reinforcing effects. This requires a diversity of input into the planning process.
Integrative Strategic Investment: the Virginia Five Point Plan
An example of this philosophy and approach has recently been attempted under the guidance of the Virginia Department of Health. Chart II, “Virginia’s Five Point Plan: How It Fits Into the National Picture,” displays the outcome of a long-term planning effort on access to care.
It included the Virginia Department of Health, the State Board of Health, the three medical schools in the state, the Virginia Primary Care Association (representing the community and migrant health center programs), the Statewide Health Coordinating Council, the Virginia Association of Health Systems Agencies, the Virginia Association of Counties and the Virginia Association of Area Agencies on Aging.
This broad-based coalition identified “The Big Picture” programmatic goals in response to a statewide assessment of waning primary care capacity. National trends and influences were reviewed, particularly declining interest in primary care training, the aging of the primary care physician population in the state, Medicare and Medicaid reimbursement trends particularly in rural areas, and the demise of the National Heath Service Corps scholarships, a program upon which underserved areas in the state greatly depended.
Once the goals were established, and assessment of national programs were identified and investigated which might assist the state in meeting these goals through the applications to create a state-federal partnership. Finally, proposals were drafted for the Virginia General Assembly’s consideration under the title of “The Five Point Plan.” All three strategies were included: health manpower training, financing for access, and service delivery system development.
A key factor in the willingness of the different parties to participate in such a planning process was an atmosphere of understanding and mutual respect for each other’s missions and a growing awareness of how fractionalized individual efforts had actually become. Initial efforts at promoting the reinforcing effects of major actors working collaboratively were demonstrated.
This was particularly true of cooperative efforts between local health departments and rural community health centers in sharing services and eliminating bureaucratic barriers which hindered good continuous patient care access.
The other key to the effort became a focus on how all parties could work together in assisting underserved communities throughout the state. This tended to focus attention on identifiable geographic areas and needs rather than amorphous, nameless, and faceless communities.
This approach, obviously, worked in demonstrating needs and projecting positive plans to our General Assembly. They funded the Five Point Plan activities at $7 million for the next biennium budget.
What is your next step in Virginia? We have identified three challenges which could be translatable to the development of policy options for improving the management of primary care access problems in the 1990’s for the entire country.
The Three Challenges
In confronting the issue of primary care access problems from a national policy option viewpoint, we must reconsider our basic premises which have guided actions in the area of health manpower, health care systems development, and health care financing. We must recognize that thorugh access is a national issue, its solution must be one which is locally based.
In order to accomplish this, we must face and confront three basic challenges.
1. Overcoming the Control of Language
A variety of people, mindsets, and languages are involved with health care. IN reviewing principles of social psychology, I believe the Whorfian hypothesis applies in this case. This concept asserts that people behave and think according to classification systems which they learn and subsequently use to lend meaning to features in their world.
Accordingly, the hypothesis proposes that language may not only be a vehicle by which people interact, it may also be an active determiner in what they perceive, how they think and, therefore, what they interact about.
Indeed, the language of “outpatient care” for hospitals, “primary care” for physician, “ambulatory care” for insuring organizations, and “preventive care” for public health are strangely similar in their meanings. Yet, the words become intricately separate in the minds of different providers. These separations are virtually meaningless, however, to consumers who may just need “to go to the doctor.”
A classic example of this terminology barrier is found in defining the health care mission of the 500+ federally assisted community and migrant health centers operating in medically underserved areas in this country. With the half billion dollar investment made by the U.S. Public Health Service, the federal government is investing in “primary care services” in needy communities.
I have attempted to describe the purpose, structure, and philosophy of health centers to innumerable communities and have found that the easiest explanation is to describe what health centers are not. Because of their emphasis on diagnosis and treatment as well as continuity of care through hospitalization and emergency services, health centers are not likely similar to most local health departments.
Because of their emphasis on disease prevention, health promotion, and community organizing, health centers are not too much like private physician offices. Because of their adherence to the principles of community-oriented primary care and serving as a “health home” for all patients regardless of their ability to pay, health centers are much unlike hospital emergency rooms or urgi-centers.
The unfortunate aspect of this approach is that highlighting differences sometimes leads to local fractionalization of support for the center among other health care providers. They may perceive an implied threat to their business. Others may feel the need for a health center with such a mission indicates in the community’s mind some shortcoming in their own practice.
The nomenclature within our business creates semi-rigid categories and classifications of services which doom potential collaborative relationships between health care organizations, sometimes before investigatory discussions are even held.
It is reasonable, therefore, to consider that non-health care providers may, in fact, have an advantage in seeing in, around, and through the jargon and minutely different classifications which we tend to create when talking at each other about health care access problems. They can draw some unusual but provocative analogies from their own professions in which they may have confronted similar issues.
They sometimes can, in fact, see and establish common issues rather than separate positions in negotiations between health care professionals and organizations. If we don’t “train the common sense out of them,’ community representatives might, in fact, help us to think through some of the knottier issues of access.
2. Building Consensus at a Local Level: Adopting and Integrationist Philosophy
After eliminating the language barriers and beginning to define the parameters of access to primary care, the next challenge becomes developing a mechanism for inter-organizational communication and planning.
In the past years, a great deal of health planning has been done on national macroeconomic policy using Medicare reimbursement as both the carrot and the stick. A more regionalized versions of health planning was elaborated in the health systems agency days pitting consumers versus providers in a cost-containment atmosphere.
Less has been done, however, and little has been organized to bring together all of the interests which affect the access issue at the local-level. One problem becomes defining the access issue to be studies or resolved. Community business coalitions, for example, attack the problem from a resource allocation and cost-containment standpoint.
Coalitions, including organizations like the March of Dimes, state perinatal associations and community groups that are interested in reducing infant mortality address access from a systems orientation, including patient and community education and collective action to confront malpractice liability rates which influence access.
Small communities facing the loss of their primary care physician capacity approach access from a standpoint of simple availability of care. Other broader based community interest groups have adopted a leadership development model. Programs are now being promoted throughout the Midwest by several foundations in which health care becomes one of several issues discussed in the context of community and economic development.
Access issues, of course, must take all of these diverse ideas into consideration. To assure this, local efforts must be inclusive rather than exclusive. They must integrate ideas, people, and resources rather than allow language and self-interest to separate them. A new basic set of principles to guide relationship building among organizations and viewing “big-picture” interests must be rooted in the milieu of local community values.
The ideals for this can be borrowed from basic business management philosophy. In a recent book by Max DePree entitled Leadership Is An Act, the author describes the art of corporate leadership as liberating people to do what is required of them in the most effective and humane way possible.” Tim Size of the Rural Wisconsin Hospital Cooperative has elaborated the DePree concepts into principles for effective inter-organizational rural health development. Among these principles are:
A. The organization’s right to be needed.
All community organizations must feel that they are needed as part of the solution to the access issue if they are to be productive locally and supportive participants in the planning effort. Each organization has unique assets that must be recognized, valued, and utilized in addressing the issue.
B. The organization’s right to be involved.
How many health planning efforts completed at a local level truly involve representatives of all those organizations already providing some type of health care service? In many cases, the “have nots” of health care, including local health departments and community voluntary organizations, are not even invited to the table even though their expertise and experience may be important in the access issue.
More often than not, regional medical centers, hospital systems, provider societies, and insurance companies are the “big guns” in these meetings. Other organizations must have genuine involvement in the planning and implementation of actions which will affect them. This means acknowledging “their right to the associated benefits of success as well as the risks of failure.”
C. The organization’s right to understand.
Another corollary principle to involvement is the willingness of all organizations to share in the knowledge and understanding of the environment affecting access issues. This includes an assessment of the reality and true value of local cooperation and coordination as well as the impact and understanding of broader environmental issues such as national strategies in health manpower, health care financing, and service delivery.
Local organizations and communities, therefore, must have the opportunity to recognize and understand those “Big Picture” budget and economic tradeoffs with which they fact in addressing access issues.
D. The organization’s right to make a commitment.
The Size paper also describes an interesting dilemma in inter-organizational relationships. He states “….as our (health care) systems have become more complex, decisions are seen as more impersonal and less rational.” Decisions, in many cases, are made on smaller portions of the larger picture, making the big question of access appear somewhat out of focus.
As he notes, people don’t commit directly to abstractions, they commit to people. Our Virginia Five Point Plan bears out this principle. Therefore, in the redesign of health care systems which will be more accessible, smaller modules such as neighborhood in cities and communities in rural areas must be the unit of solution within broader state and national plans which support a local problem-solving approach.
These four values must promote local coordination as well as a horizontal and vertical integration of resources at the community level. The principles of inclusion and respect for different organizational roles and missions are important. Flexible solutions which share integrated resources between health departments, hospitals, medical schools, and residency programs, health centers, and local voluntary organizations can become a 1990’s model addressing local access to care issues.
3. Promoting Pluralism
Each local solution which includes integrated organizational efforts will promote various weightings of the public and private parties involved. These weightings will be based upon negotiated roles and responsibilities for each organization. The politics of accommodation should account for emphasizing roles congruent with the strengths of each organization amended by the real depth and volume of the access issues in the community.
Pluralism not only means allowing different organizations ongoing roles in the solution, it also inherently implies acceptance of the notion that we may not necessarily find a single national comprehensive approach to the access issue.
The health care system as it appears and exists for those lacking basic access is now highly complex. It typically emphasizes key roles for different types of organizations in different communities. A recent survey completed by the Governor’s Task Force on Indigent Care in Virginia demonstrates this complexity.
The backbone of indigent care in three urgan areas (Richmond, Norfolk/Tidewater, and Charlottesville) in the state blessed with the presence of medical schools is a state appropriation for in-and-outpatient care funded for the purposes of “education and service.”
The roles of other providers of care in those cities, including private physicians, local health departments, and free clinics are clearly secondary to the health science centers.
In other urban areas, local health departments and hospital emergency rooms provide a bulk of the care. IN more rual counties, a greater reliance is placed upon local private physicians and community health centers. In most rural communities geographic and transportation barriers reduce access emergency rooms for anything but truly emergency acute care.
Local health departments in rural areas traditionally have provided limited categorical services in accord with a state statute which prohibits them from becoming anything but a “provider of last resort.”
In each community, therefore, the “system of care” for those who lack access is defined somewhat differently. We have found that an infusion of new financing programs might not adequately address access in many underserved rural areas since availability of any providers is generally lacking.
Systems development strategies might be of only secondary use in large urban areas where the volume of uncompensated care is regulated primarily by financial constraints of patients.
No one national strategy will solve this diversity problem. Making all of the country’s uninsured eligible for Medicaid or some other national insurance program will neither guarantee access in communities without care or insure that providers will accept the new insurance. Neither will the approach of establishing points of access in all communities solve the long-term problem.
Without heavy-handed centralized control of resources, including financial supports, health manpower, and new technologies distribution the access point strategy would falter and eventually crash on the rocks of American free market enterprise.
In summary, I believe that these three challenges to policymakers call for a truly enlightened management approach. It relies upon federal, state, and local partnerships in integrating the basic access strategies of manpower, financing, and service delivery, It accepts that degree of pluralism of different weightings of involvement of public and private actors.
It requires building local leadership through coalitions of local interests to address local access problems. It acknowledges that the leadership capacity of each community and the importance of the access issue may vary. It calls for out national and state leaders to allow local integration of solutions and organizational structures over time without forcing adoption of a singular model.
In the future discussions and conceptual developments which will take place around the issue of assuring access, we should all measure our philosophical approaches with four simple guidelines:
First, apply the golden rule: do unto others (poor persons who lack access) as we would have done for ourselves (and our own families and friends). All persons should be treated with the same concern and dignity that we would expect for ourselves.
Second, there should be a sense of community responsibility around the access to care issue. As such, it should be treated with the same type of community concern and total involvement as other major community issues, not just be categorized as “medical” or a poor peoples’ issue.”
Third, there should be a sense of accountability created for the health care resources already in the community which can be used to address the issue.
There are, whether formally recognized or not, certain social contracts which bind those who have in the past of do now accept public dollars and society’s professional respect and advantages because of their personal or institution’s position and profession. Not creating this sense of accountability is a community’s fault and can only be promoted through seeing access as a community issue.
Fourth, we need not be apologetic about promoting more rather than less resources for health care in this country. Good health is a cherished value in America; we all want to live longer and healthier lives than past generations. Also, the concept of prevention is ingrained in our value system.
Evidence the billions of public dollars we spend to design weapons systems to deter enemy military attacks or building new dams to eliminate devastating floods or federal insurance to assume liabilities from mismanagemnet of savings and loans or farm support programs to ensure the survival of family farms!
All have been built on prevention concepts and have been “sold” to the public as necessary parts of the economy and, therefore, eligible for burgeoning tax support. Access to good health care can and should be a leading weapon in our country’s defense against our own “internal enemies of poverty, ill health, and lack of education and, therefore, subject to the same philosophical advantages in public debates about community and national support.
This presentation was preceded by: First National Conference on Primary Health Care Access (4th Plenary Panel, Part 3, Hullett, Ignace Q&A)
This presentation was followed by: First National Conference on Primary Health Care Access (5th Plenary Session, Part 2, Kindig)