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):
David Kindig, MD, University of Wisconsin: Well, that’s very provocative! Hopefully, it will stimulate some discussion after Don and I get done. I will make some comments on some more narrow aspects of issues that have come up during this conference, particularly specialty and geographic distribution.
I will go on then a little broader, actually picking up from some of the things Dave Sundwall mentioned vis a vis national health problems, and touching on some of the points made about national vs. local solutions.
I really would like to thank John Midtling and Charles Gessert for inviting me to participate in this conference. It really has been stimulating. I’ve been taking lots of these notes and having new thoughts and new questions. That’s really helpful. I think it’s important that we keep doing this, because I think these issues are newly alive again.
If at times it seems like deja vu, still it’s important. These things do cycle and maybe we’re back in the part of the cycle where we can give some thought to these things. Sometimes I get a little cynical about the deja vu part of it but I don’t think that’s appropriate because it’s a new time and we can come at it in some new ways.
These few comments I will make on the specialty geographic distribution issues. I’ll just make a few brief comments. I have a couple of policy papers that are unpublished if you are interested in these arguments being presented more fully. One is a paper I did for the Council on Graduate Medical Education [COGME] last summer on the geographic distribution of physicians.
It is not published and may not be, but is kicking around the HRSA bureaucracy. I just haven’t had a chance to turn it not something publishable. It’s a current summary of the state-of-the-art on those issues. Also there is a book chapter that, hopefully, will come out in a year on whether the supply and distribution of physicians will be appropriate for the national needs in the year 2000.
Probably the most depressing thing about this conference is the specialty maldistribution situation and some of the data that you presented that is not new. I think it’s depressing because I see rays of hope on some of these other issues. But that one is such a though nut and we’ve known it for 20 years. I have two illustrations.
The first one is the increase of the physician to population ratio caused by the cranking up in medical education in the ’60’s. What we sometimes forget is that we’re only halfway up that curve from the 1970’s to 2000. More or less its’ going to peak at 2010-2020. Obviously, it’s better to change a huge fixed think like this in a growth mode rather than to try to fix something that’s stable.
We seem to have lost. It’s not that we haven’t done somethings but really we’ve lost our best opportunity. I think we’re going to lose this other part as well for all the depressing things that you mentioned. I wish I had some optimistic things to say about that. I’m not sure that I do.
I don’t know if you’ve seen the Al Tarlov piece in Health Affairs where he talks about the third compartment. Essentially, he divides the care sectors into fee-for-service, the federal sector (like the defense sector or the public programs in the defense department) and then the capitated sector.
He makes some interesting projections about the degree to which the capitated sector will grow over the next 20 years. And then he applies the current HMO physician to population ratio to that sector and he comes up with “x” number of physicians that that sector will absorb. And then he takes all the rest and allocates them to basically the fee-for-service sector because the federal sector is negligible.
There’s three times more physicians per patient in the fee-for-service sector in those calculations as there is in the capitated sector. And it’s just hard to imagine how that can work. What he hasn’t published but he mentioned in private is that there are some specialties where the ratio is as much as 10:1, given kind of reasonable projections of current situations. So we are on that kind of course. That blows y our mind, both for cost and quality reasons, because these people are not going to be able to practice medicine. So bizarre things will happen. I’m really worried about that.
I think that RBRVS is an important step. I don’t know if anyone has done the projections over 10 or 20 years because that would be interesting. I think if we have these huge gaps in income, even with a little cut here and a little there, that’s not going to be very impressive.
But I think it should be relatively easy to project different scenarios, say at 10 or 20 years, as to what it would mean to physician incomes under the RBRVS revisions. Even if at 10 years you could show a significant lowering of the differential between primary care and procedural specialists through some kind of projection, it might increase the political opposition to implementing what is proposed.
But on the other side, it might be useful to show some young physicians now what may happen under an RBRVS system. There may be some reason for optimism at the levels of students who are not yet in medical school. Maybe something like RBRVS could help and obviously we have to support that; it’s in the right direction; should cause some movements the right way for both specialty and geographic distribution of physicians. It would be interesting to know how much.
Obviously, I am not going to say anything against the efforts of family practice and general internal medicine, because it’s really the specialists of medicine that are the other huge problem, if you will. I think family medicine has just been important and needs to continue to be supported. If there was any one thing you should do, you should try to continue to support family medicine.
The other issue on specialty distribution that I would like to make (it’s a little narrow technical one, but ti’s been a pet of mine since when I was running a hospital in New York City) is that sometimes we think that the number of specialists are just driven by physicians wanting to practice that specialty. But a lot of its is driven by the needs of the training programs for “x” number of house-staff on a given service.
If you’re ever a hospital director or a residency director, you have to fill these slots in order to have, say, Friday night and the weekends covered. I think the number of people in specialties at the PGY entry level is the critical thing. We experimented at Montefiore. We substituted a quarter of our surgical house-staff with surgical PAs for a variety of reasons, and it worked fine. I’ve often felt that this is an area where changes could be made, since so much of the work of residents is scut work loaded into the PGY-1 years.
Actually there’s some down time in the second year. There are fellowships and research time and electives and whatever. There has been some experience with decreasing the number of surgical house-staff that is worth looking at. In my experience, our internal medicine colleagues have been interested in looking at the movement to reduce house-staff and also the movement ot substitute physician assistants and nurse practitioners.
(I don’t mean to suggest there are no differences between PAs and nurse practitioners, but to a certain degree I think those are interchangeable kinds of roles, although I understand the differences.) But I think it might be possible. Our PA programs have grown up in a primary care mode, which I encouraged when I was in the Bureau of Health Professions. But I think training PAs and NPs for specialty slots as specialty substitution workload in these early years could do a lot.
As a matter of fact, you could even think of Medicare policies that would have some resident substitutability incentives along those lines.
We should also understand the sex composition of physicians being trained and whether there is any way that women medical students are more amenable to being encouraged in the primary care directions. There is some historic data for that, although the trends may be breaking down now. There is demographic change that is taking place in the physician populations which might lead to some solutions.
For geographic maldistribution, I really think there is a difference between inner city and rural issues. I started in inner city practice in the South Bronx and Chicago. I think that’s an easier problem. I don’t mean to put it down that way except to say that there are lots of physicians and other health providers who are living in urban areas who want to work there.
There are some different kinds of cultural problems but you don’t have that huge problem that you have in rural areas. There’s an interesting study that’s just being published that I reviewed while in press. Somebody interviewed a sample of all the residents in New York City who finished their residency (I think in 1987) and found out that 11% were commited to inner city practice, and that (I couldn’t believe these numbers) that 50% were willing to consider inner city practice.
The ones that were committed were primarily female, primarily from the inner city, and primarily Black. And what did they want? It was a guaranteed base income, access to medical consultants, and hospital admitting privileges. It’s not to say that all those things are easy to do, but they don’t boggle the mind. It takes some money: it takes some structure it takes good CHC’s or local health department clinics for some of those basic things. I think you can move those people in there.
I think federal CHCs in urban areas are critically important, state programs, or whatever, and/or other expansion of Medicaid financing so that those places can do these kind of things. But I think the people are there. This is the place where there is a lot of local opportunity.
I think the rural is more difficult because in a lot of ways we’re trying to get people to go to places that they might not have been from, obviously. Inner city recruitment strategies are important, and we’re still fighting to get these in place that but aat least the students have been to school in the city. I think rural areas are different for one another in terms of their characteristics and their physician needs.
I don’t think we’ve done a careful enough analysis of the variation of needs in rural areas nor of targeted strategies. There are great regional differences in physician to population ratios. I thought we would find some marginal effect, but instead the research showed a direct relationship between the number of commuters leaving the rural area each day and the areas physician-to-population ratio.
If 0% of the people commute (a non-metropolitan county) there’s a mean physician to population ratio of about 80. If 60% commute out to work, it drops down to about 20. That’s not counter-intuitive. Obviously, people are going to get some of their health care where they go to work. It certainly means that shortage criteria should be cognizant of this phenomenon, and would likely mean that placing people in the “high commuter” areas on the same criteria as the “non-commuter” rural areas, you would have less utilization and perhaps surplus provider time in the former.
Targeted strategies are important and I think local things can be done in regional areas. The tougher the problem, the more you add the strategies on. AHECs are terrific in a lot of places but they’ve got multiple components. Every tiem you add a component, it gets more expensive and it’s less clear that you can justify that marginal addition. But in places where you really have problems, we can look at recruitment, undergraduate education, graduate education, financing, and those kinds of strategies.
It’s just like the kinds of problem areas we addressed when we started the National Health Service Corps. It looks like these kinds of problem areas still exist in the Southeast. It’s pretty clear when you look at the regional problems. A major targeting should be done there and other places as well. The North Central region comes next.
Now, the immediate needs are terrible. I’ll just underline what we’ve heard here. It’s hard to believe what we’ve let happen in this decade and what we’ve let happen in these last couple of years. I just was down in Brownsville, Texas at a couple of the neighborhood health centers. They’re great, historically important CHCs.
Before this July they had 18 physicians (something like 12 were from the Corps) with some satellites. After July, their number of physicians is cut by six and they’re closing the satellites. These are areas on this side of the border, where 33% of the births are given by lay midwives.
Those are terrible statistics. Both at the federal and state levels we have to continue to support what we know works – the Corps, neighborhood health centers, and loan repayment. (I would crank loan repayment up to a magnitude beyond what we’re now doing both in terms of numbers and dollars to take care of those needs right now.)
I would look at some financing experiments. HCFA or some state compacts should look at innovations like the Rand health insurance proposal. One should, over ten years, pay one and one-half times, two times, even three times going salaries in certain regional areas that are matched.
You have to stay in there for ten years, so maybe some foundations would do it, but we don’t know now what the geographic dollar multiplier is that would attract physicians to these areas. There is no research on that. HCFA this year is adding 5% payments to Medicare.
If you’re in an 01 or 02 level priority health manpower shortage area, you can receive a 5% bonus on your fee-for-service rates. That’s great! A five or ten percent differential seems pretty low. We don’t know who is motivated to enter or stay in practice by a five percent differential. We don’t really know what those multipliers are that affect decisions. What little information there is from other countries, and there it is a lot more than that. It’s 50% or 100% to really move people.
Let me move to some broader issues beyond the issue of access to the whole set and talk some about the national plans – issues that David introduced us to a very nicely the other night. A dilemma I have about all of this, that I’ve had this whole day and a half, is how do you stay enthusiastic about and sustain the levels of energy, creativity, and commitment that exist in the projects that we have been hearing about which are making a difference here and there?
It is a historic fact that these kinds of projects come and go. And they come and go.. When the grant runs out or the local initiative ends since they’re not a part of the mainline system, they get grafted on or folded into the mainline. I think we have to preserve opportunities for pluralism and to channel this creativity so that not everything is the same.
But, on the other hand, things that just get grafted on and are not part of the mainline system won’t survive. And so Charles Gessert asks why we are talking to ourselves? Why aren’t we making our influence felt? It’s because issues of access, primary care, and the underserved are not the main item of business. I think we have to get in conversations. Like Bruce Behringer was saying before, we have to be at the table with other players and make it a bigger problem, and these solutions have to be incorporated into the whole system.
So I am imterested in the new interest in national health plans. I want to share some of my thinking about those. Actually the first paper that I wrote in my residency was a paper with Vic Sidel which we wrote comparing seven national health plans in 1972 against criteria which we lined up.
It was a nice little chart, like the chart now that the American Public Health Association has put out on the different plans. The earlier plans all went the ways of regulation in the ’70’s and competition in the ’80’s. I think it’s really important that we’ve come back around to national policy on health plans, and I’m really glad that maybe in my lifetime we’ll get to work on this a little bit.
I have decided to spend the bulk of my academic work in the next ten years on this. We have organized the past year a faculty task force in our medical group with economists and ethicists and insurance people and business people looking at these issues. What I am going to say is essentially what I have learned from 20 seminars over this last year about this.
I think that it is terrific that the interest is cranked up, but I do not believe that we’re ready either politically or substantively to do anything. I’ll talk about that in a minute. I think that the past is prologue, David, but I’m not sure that we’re in totally new territory. I think one of the beauties of Paul Starr is the way he traces how health financing proposals have risen and fallen in favor.
The part that I read the most, and someone alluded to in a question yesterday, is the chapter called “The Triumph of Accommodation.” It’s a cheaper about passage of Medicare and Medicaid. What he says basically is that organized medicine and hospitals fought this for a variety of reasons until they were able essentially to pull the teeth on any system change and essentially crank into place the insurace mechanism which, in fact, did increase access and increase utilization.
But there were no (change in tape) programs that only provided more insurance. So that’s real important. If you haven’t read that chapter, I would encourage you to read it.
I think it’s possible that a national health program could reinforce our current model, might not decrease costs, and inhibit change for decades. In that case, we would be worse off than we are now, if you can believe that. But I think it’s possible, and that we have to be cautious about what we might get into.
We’ve talked a lot here about primary care and about prevention. I am equally interested in the epidemiologic shift that’s going on right now from acute to chronic care (with, perhaps, preventive components) as perhaps a fundamental kind of carrot. The role of the hospital declines while interfaces increase between medical and social and community services.
I am beginning to believe that’s what the next century is going to be about. I think if we lock in right now in an acute medical care model, we could miss an evolution in health care delivery that might be really important. We’ve had some conversation this meeting that the medical profession was having to become involved with all these social problems, and all these substance abuse problems.
I think we can either say, “It’s not really our business,” or, if we define out role more narrowly and not worry about it; believe that the epidemiology is changing, then we should prepare to assume new roles as physicians. Hospitals will become intensive care units; the whole business will be elsewhere; and we need to play in that game.
Right now people not only are falling through cracks in medical care, but they’re also falling in these cracks between medical care, public health, community services, and social services. My wife is a geriatric social worker at the VA. I know all these things, because I hear about it every night. And it’s true.
It’s difficult to cut across these boxes of programs, of financing, of professional turf, ideally if we do want to do something different, we ought to take a whack at that. I will never forget at Montefiore Hospital (I ran that hospital for five years in the late ’70’s) when we were under very strict cost control, and we laid off a couple hundred people every year.
I know that half of those people wound up on welfare in the South Bronx, taking more social resources than we were paying them for doing nothing. We don’t know how to make the social accounting work crossing those systems. But that’s a real challenge to make that happen in whatever new things that we’re doing.
It may be that physicians aren’t capable of or don’t want to take on this kind of broad view of medicine or of health. But I think if they don’t then they really have to step aside and do their thing and let some other people organize this broader concept, because I think it is the concept of health for the next century.
We may not be quite ready to think through what we want to happen, but I think that the politics of the deficit will preclude any kind of movement on these big things, except for some incremental things that could be done. I think the plans that are practical, except for their cost, don’t chagne the system and those that would change the system, line PNHP or Enthoven are not issues for a whole variety of political and social reasons. So, I think we are at that stalemate of not knowing where we want to go. But I also think that’s O.K.
I might sound too researched here and I worry about that coming from academia, but what underlines the work that our faculty task force on national health programs has been doing this year is that, whereas all these plans are interesting and have stimulated a lot of thought, that there really are a lot of fundamental policy questions and health services research questions, that really we should know the answers to in order to put something together like this.
I’m not going to bore you with all the things we’re doing, but we’re actually about to publish a research agenda on national health programs which lays those out. There are enormous problems to be solved about scope of benefits, about the nature of financing, about the nature of the delivery system, about the nature of the payment system, about capital financing, about administrative arrangements, about the extent of pluralism, about federal, state, public, and private roles.
You may say a lot of those problems are details and we’ll pick one plan and work the problems out. But you could also say, and I think it could be true, that there are a lot of those problems that you really can’t address by themselves until you have all of them worked out.
Some of these plans are really just models, like the Enthoven plan which obviously probably wouldn’t go anywhere in the real world. But it attracts a lot of interest. In the Enthoven plan, you get a voucher which organizations compete for. It’s an interesting kind of competition. But it assumes that there are groups of providers that have connections with hospitals and maybe nursing homes all over the country that can accept these vouchers and do this thing. So that plan will fail. I would say, for 20 years not having such systems in place. But can you get incentives that would bring that into place? I don’t’ know.
I don’t know if we can do this incrementally or if fundamental change, a broader kind of change has to happen at one time. I think we usually do things incrementally, so you have ot think that’s probably how it will happen. I think it also allows for local experiments and for pluralism and I think that’s important.
But I guess I also get stopped when I think of how much we are already into a national system with national private payers, with Medicare, and state demonstrations. We have to deal with all of that somehow. Perhaps through Medicare/Medicaid waivers. But what do you do with Prudential? I don’t know.
So I think maybe there are some more limited access demonstrations at a local level and those are important. But whether you can do State things or whether you can do incremental local things that allow you to get to this other kind of system, I’m not sure. I have a feeling you probably can at some lvel, and maybe you could build to it. Essentially that’s what Dave Obey’s would do – (I haven’t talked to him and I don’t know the details of it) encourages states to do some of these demonstrations. There is a foundation and federal role, however for getting some of this research and some of the micro-demonstrations going.
We had a little pot of money when I worked with Ken Endicott in the Bureau of Health Manpower – Health Manpower Education Initiative awards. We lost it sometime in the mid-’70’s because everybody thought it was Ken Endicott’s slush fund because it didn’t have any rules on it. Well it was his slush fund, but out of that slush fund came the WAMI program, came AHECs, came a lot of family medicine and nurse practitioner and physician assistant programs, and a number of other things.
So there is a role for having some of those loose resources around to do some of those things. But of course this is at ime when loose resources aren’t very often available. So that’s a dilemma.
Another dilemma I believe exists is that for some of these things you probably have to spend in order to save. But that’s hard to do in the short run for politicians. On the broader scale I agree with you. We have to solve this federal deficit because it keeps us form moving ahead. It saps the national will. It’s one thing for a year or two but if after ten years you start to say, “We can’t do this. We can’t do this. We can’t do this.”
Not that it’s only the federal government, but we can’t give money to Poland and we can’t work on health care and education. We can’t have an education issue if we can’t put any money on it. After a while you begin to believe that. I think we have to solve that because it’s not only for making any movement here which may need some federal money, but it’s also for these other crying domestic problems.
I wouldn’t argue that health is more important than education or the drug problem necessarily, but all of those are stalled for the same reason. They’re stalled financially. But I think they’re also stalled in terms of our national will to do something about it. Let me stop there.
This presentation was preceded by: First National Conference on Primary Health Care Access (5th Plenary Session, Part 1, Behringer)
This presentation was followed by: First National Conference on Primary Health Care Access (5th Plenary Panel, Part 3, Weaver, Final Discussion)