The archiving and publishing of the introductory remarks and the proceedings of the first plenary session of the Fourth National Conference on Primary Health Care Access (April 2-4, 1993) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.
John E. Midtling, MD, MS (Moderator): Thanks, David. Now, we’ll hear from Martha Evans, who is Chief of the Resources Development Section of the Division of Medicine within the United States Department of Health and Human Services’ Health Resources and Services Administration (HRSA).
Martha is in charge of administering our primary care grants programs. She describes herself as the “point” person in the Division of Medicine for the primary care loan program.
I could tell you that that is an accurate description because our dean serves on the Executive Committee of the AAMC. I can tell you that they are not at all pleased that all of that money is being diverted to primary care scholarships and loans, but I think it is necessary if we are to make the kind of changes that we have to make in this country to make health care reform a reality.
So, Martha, we are going to support you in any way that we can and try to make that change permanent and make it stick.
Martha Evans, United States Department of Health and Human Services Division of Medicine, Rockville, Maryland: Thank you!
The HRSA Division of Medicine seeks to address the needs of the local community needs. We will probably see a system that will reward the people who do a good job of producing primary care personnel that serves in needy areas.
Dr. Ramsey alluded to that in his discussion. It appears that so far the Clinton administration’s beliefs and goals are consistent with those previously stated by the the Bureau and, of course, the Division of Medicine.
Those goals relate to the need to emphasize primary care, the need to distribute the work force, the need to produce more minority health personnel, the need for adequate data bases, and the need to have a set of funding policies consistent with those goals.
In the Division of Medicine, long before we had talked of health care reform, we attempted to translate some of these needs into what we call our “strategic directions.”
Our mission is to be a federal leader in assuring that the nation has an optimal supply of specialty mix, demographic composition, and geographic distribution of appropriately trained physicians, physician assistants, and other providers to meet the public health care needs.
The HRSA Bureau of Health Professions Strategic Directions:
1) to promote generalism.
2) to promote work force diversity. (We are trying to attain a physician/physician assistant and health care work force profile that most closely represents the composition of minorities, women, and socio-economic disadvantaged individuals in the general population.)
3) to promote strategies to improve care for the underserved.
4) to improve primary care quality.
5) to increase primary care faculty and researchers. (We, of course, know that research is greatly needed in primary care.)
6) to emphasize public health and interdisciplinary training.
7) to strengthen surveillance, research, and evaluation.
8) to provide leadership through policy development and networking to better match the physician, physician assistant, and health care work force supply to health needs.
We realize that what we do in the Division of Medicine and in the Bureau of Health Professions in terms of dollars is not a lot of money, but we expect that those dollars have worked greatly to have enhance your programs.
It is my understanding that some of the things that we fund, although the money is not in large amounts, that it is significant enough to make a difference in the quality of your training programs.
With health care reform, once it is implemented, we expect to be there with dollars. We don’t know in what form, but we expect that the training of generalists personnel will be very, very high on the Clinton Administration’s list of priorities.
Midtling: What I would like to do at this time, then, is ask for some comments from the conference participants. I would like to ask for Kevin and Chris and A.I. to come up here and respond. David.
David Schmidt, University of Connecticut, Hartford: I would like to sound a warning! It is my fear that punitive managed health care has a potential of destroying the very foundation of family medicine, predominantly the doctor/patient relationship.
Our practice is literally 50 feet away from the corporate headquarters of Aetna in“Hartford.
Over the last 4-5 years, there have been 6 or 8 or 10 HMOs and PPOs that have been available. We have experienced on a small scale a patient who was forced to leave their doctor because the employer bought a cheaper program for his people and this particular physician is not in that. You can’t be in all of the programs – a very small scale.
This past year Aetna really went big in Connecticut. The State of Connecticut is divided into two camps – each with groups of hospitals and providers. Aetna sided with one group, not based on quality or price, but based on financial interactions.
Suddenly, the resulting exclusivity separated huge numbers of patients from their personal physicians. Certainly, Aetna will save money, but at the price of having the patients have to leave their established physicians.
I gathered dozens of personal examples and took them to the chairman of the public health committee. It is amazing how people in leadership, unless they have had to rely on this doctor/patient relationship themselves, really don’t know how important it is.
My warning is that there is all this great enthusiasm about competitive managed health care, but the doctor/patient relationship is being ignored. It is assumed that anyone can provide that.
I would have a system in which there is no competition for your primary care provider. Everyone has a primary care provider. But let the specialists compete to get the attention of the primary care doctor and the referral from the primary care doctor.
A. J. Henley, HealthPass, Philadelphia: Let me say that managed care comes in thousands of forms and shapes. The managed care program that I described is certainly not going to be the managed care program of U.S. health care or Lockheed or some of the other players that are going to be involved, nor are the players going to be concerned about doctor/patient relationships as were just described.
Most managed care plans have hospitals they contract with and they expect physicians to use those hospitals. It is the “nature of the beast.” Physicians are going to find themselves with the choice of either joining large numbers of competing managed care programs, or not being able to care for certain patients. We see that now. I think that it is only going to grow.
One of the things I want to say is that in an inner city population accustomed to a fee-for-service managed care program – a Medicaid program – what you are going to have is a lot of unhappy people when it comes to managed care.
Nobody in their right mind is going to want to give up a fee-for-service what we call “Blue Medicaid” card. It is just like having a gold American Express Card that you never have to pay and you can do anything you want to with it. In terms of patient satisfaction, people are going to be unhappy when they have to give that up.
I think that in rural America I have seen some things that are quite different, meaning that where physicians would not accept Medicaid and would not see people who had a card of any type, managed care comes, signs the physicians up, and then you have a group of people who now can see physicians they were never able to see before. So, it flips all over the place.
Kevin Grumbach, MD, University of California, San Francisco: There’s ways of managing care and there are ways of managing care!
Bad aspects of managed care – when your employer gets to choose among a selective group and then can change that at a whim and you are locked out. So you really don’t have a choice in that system.
A managed care that is not, I think, worthy of the name is when it is fee-for-service medicine “in drag” and it is somebody at the end of an 800 number who tells you when or when you cannot hospitalize your patient or you have to discharge them. That is worthless managed care in my view. All those kinds of things. I think it is trapped in this American health care system.
I think managed care should mean that everybody has a primary care gatekeeper that manages their care. The traditional notion that we would all agree with is a primary care physician who manages the care. I think it is John Frye England who says, “It’s the goal to protect the specialist from unnecessary referrals and to protect the patient from unnecessary referrals,” but without the kind of vicious incentives that are locked in now.
I think, again, the British model is a very interesting model of managed care. We don’t think of it that way. Every patient, through capitation, enrolls with a primary care gatekeeper. They have free choice. It is not their employer who decides. They can pick any general practitioner they want to – total free choice, publicly financed, but I think with a very different spin.
I think that is where we should move towards is where it is free choice. It should be a taxed financed system so that it is not that kind of change which is based on employment, and with a sense of providers have a budget and resources that are necessary and are allocated to them and they have to spend within the limits of those resources.
I think that would be the model that I would see of groups of providers, primary care gatekeeper system, define resources perspectively, and where the patient maintains the choice in that system.
Christian Ramsey, MD, University of Kentucky (Lexington): I won’t prolong this but I agree with a lot of what Kevin says. I like the idea of an individual account. I like for the patient to have the decision making of that money. How it gets there, whether it is put in by the government or an employer in a mandate, etc. doesn’t matter.
But I would like for the patient not only to make the purchasing decision and to have assistance where that is needed, but also to be able to exercise that freedom that you were talked about, Dave, which is very, very important.
I think as far as managed care goes that all of us probably would agree. We are really in a very early stage. The problem with most managed care today is that the care is really not coordinated. The insurance companies pay the primary care physicians and they separately contract and pay with the specialists and control both of us to an enormous extent that we really don’t need.
I think as we see more vertical integrations and incentives for more vertical integration you will see a lot more coordination between primary care physicians and specialists who are working with the patient to make decisions that are in much better interest of the patient for the long haul.
William C. Fowkes, MD, San Jose Hospital, San Jose, California: I certainly agree with David Schmidt. I just lost a scleroderma patient I have been dealing with for 25 years. Our residency practice has 15 HMOs with which we deal and it wasn’t enough because that patient’s husband’s employer had one that we weren’t on.
She says she is going to continue to come and see me any way.
I was happy to see that Dr. Satcher related to the issue which I think is critical in trying to get resources to improve access and that is one thing that we are “pussy footing” around which is limitation of care.
I do a lot of geriatrics now and I am not so concerned about waste in administration. I am concerned about waste in the delivery of care. We are spending over half of the health care dollar in the last few months of life now. I think we have to address that in our elderly population.
We have to change the attitude of not only physicians, specialists, but we have to really change the attitude of families. I see incredible waste of vegetative state people being maintained with feeding, on dialysis – I mean ridiculous kinds of things being done in and out of the hospital. Hundreds of thousands of dollars being spent on those things!
I think we have to deal with that. I don’t think taxpayers, the rest of us, should have to support that kind of futility.
Dr Grumbach: This is at Stanford Medical Center, Bill, right? It is representative all over. There has to be some fundamental change of accepting limits under a new system. I agree.
Hector Flores MD, White Memorial Medical Center, Los Angeles: I have a comment and a couple of quick questions.
The comment – In California we have the managed care strategic plan which basically addresses the Medicaid population. In California, as in other states I am sure, the system is really a non-system. It is inherently over-utilized.
We look at the opposite of managed care as mismanaged care and that is probably what is happening elsewhere.
However, one of the concerns that has been raised in the state is that the Medicaid programs and MediCal programs in California are primarily designed because of the eligibility standards for women and children who are certainly deserving of comprehensive outpatient services – ambulatory care services – but they tend to be low utilizers of hospital care which is really the heaviest cost item in the Medicaid budget.
One of the concerns in California, I think is that we are allowing certain providers to selectively enroll the low risk utilizers. Yet, they are being measured against the heavy users who are the SSI eligibles, chronic CHF, etc. How do you deal with that problem? I will address the question to A.J.
In Philadelphia are you enrolling people across the board and how do you handle that?
Mr. Henley: We enroll. We don’t have a choice about enrollment. All the street people in Philadelphia are our members. All of the mental health patients that have been released from hospitals are our members.
You are right! It is not the AFDC population that are the heavy utilizers. It is mental health, substance abusing, and disabled populations that are the heavy consumers of services in our programs.
Still we find it possible without reducing services to those individuals to reap enormous cost saving in providing care.
Some of the things you have to look at is that once you walk out of the hospital in terms of cost, the next big cost item in a program is pharmacy. When you take a $200 million program and you spend $34 million on pharmacy.
When you look at what are the drugs you are spending the money on, it’s the H2 Antagonist drugs; it’s the Xanac; it’s those kind of drugs that are consuming the dollars. But you are absolutely right! It is not the AFDC population at all, but the other populations.
Providing care to them is certainly something that we find is also manageable. And we’re relatively new at this. We are working with the city and with the state now in trying to answer the question of whether or not a chronically or severely mentally ill person needs to be in a managed care program or should there really be another system designed to service those individuals by people who have been providing services to them for long periods of time.
It is crazy to take those people and put them in a new system of care where they don’t know anybody simply because somebody flipped a coin and all of a sudden they are in “X“ person’s plan. Those are questions that still have to be answered. Hopefully, we will answer them in the next 60 days or so.
Dr Flores: One other comment is that a lot of times people raise concerns about the consumer not having a choice. I am a firm believer, and you presented it – congratulations on a great program – because if the quality of the care is good, then the question of choice is a moot point. They are getting the kind of care that they deserve.
Mr Henley: Let me say something about that. We have 350 choices, meaning primary care physicians. The problem even with that amount is that without a number of other features, people still can’t make informed choices.
People want to go to doctors on Saturdays. They pick doctors who don’t open on Saturdays. They want to go to the doctor after 3:00 p.m. They pick docs who close their practices at 3:00 p.m.
It’s a highly mobile population that is constantly moving and they are constantly needing to change doctors because the doctors no longer – There are lots of problems even involved when you have open access.
Dr Flores: Just a final question, A.J. When you have the kind of success that you have, you spoil the payer because, at least in California, the payer has a tendency to ratchet down every year. If last year you could do it for “X” amount, next year we want you to do it for “x minus 10 percent.” Are you developing any kind of methodology that tells you what your basic cost is that you cannot below where you could no longer operate?
Mr Henley: There are things we don’t know. We don’t know and we are beginning to see now the HIV infected women and children. We didn’t see that four years ago. Four years ago most of the HIV we saw was the gay population. Now there is a shift and it is not the Afro male. It is the mother and child and we are beginning to see that impact in the hospitals, in the hospital days, etc. It is very, very difficult to tell you exactly where the lines can be drawn.
I think that what the Commonwealth of Pennsylvania is going to do in the next year or so is to say that “X” amount represents a reasonable profit for any company to make in providing managed care to a Medicaid population and that it may mean that the Commonwealth has to share in some of the risks. In sharing in some of the risks, they are going to share in the profits over and above a certain number, but I clearly expect to see that.
Dr Flores: Thank you.
Dr Midtling: I think what we are going to have to do is take a break. I know there are several people who want to make additional comments or raise questions, but I think we will have more time after the next session to be able to do that. I would like to take a 15 minute break and then reconvene at 10:15 a.m. Thank you.