We gratefully acknowledge the sponsorship of the Valley Consortium for Medical Education (Modesto. California) for funding the transcription and editing of this section of the Proceedings of the First National Conference on Community Health Center-Primary Care Residency Linkages (Lake Tahoe, Nevada, September 16, 1993):
Alan Strange, PhD, (Minnesota and Montana Primary Care Associations, Minneapolis, Minnesota and Helena, Montana): Thank you Marc. I run two state primary care associations, which are membership organizations that include federally funded health centers in most cases, but with non-federally funded health centers also, some rural health clinics, and some small rural hospitals.
The make-up varies between Montana and Minnesota, but there are a number of players in both states. I should tell you up front, two of my colleagues on this panel sit on my board of directors in each state – Mike Holmes in Minnesota and Lil Anderson in Montana. Marc Babitz deals with the kind of money that we get for the association in Montana, so I have to be very careful about what I say with all these people around.
I also will tell you that if you want to find out how Marc really feels about continuous quality improvement (CQI), and how Lil and Mike really feel about continuous quality improvement, you’ll have to separate them and talk to them in the bar when they are by themselves. (Laughter).
Marc has put a lot of material on the board, and community-oriented primary care (COPC) is something that not only the Bureau, but community health centers are very big on these days. It didn’t start out that way. One of the things I would like to do in summing up, is talk to you about three different models based upon population that we have gotten into in the community health care system that can utilize COPC more or less effectively, depending on where they are and what their populations are.
Defining COPC and Preventive Care
But I also will go over some things that may or may not have been readily apparent in the presentations that you just heard. For one thing, we have the emphasis on preventive care and treatment in a community coming out of the Bureau.
We supposedly have emphasis on community-oriented care and preventive treatment coming out of the Clinton health care plan. If you look at the sections of the health care plan and the way they define preventive care, you will realize that it is quite a bit different from the all-encompassing approach that Marc presented.
Reimbursements for Preventive Care
For the most part, their definition of preventive care as it’s been stated, has been a mammogram once every how many years. It’s under dispute. It also may include immunizations for all American children and possibly geriatric physicals being reimbursed under Medicare, on the one hand.
There are additional moneys for community health centers either through the Bureau or to community health centers through some other mechanism on a grant basis, with both these programs apparently increasing to about 900 million dollars a year by 1999.
Lack of Payment Mechanisms for Performing COPC
What Marc Babitz said about community-operated, community-oriented primary care being a combination, in some ways, or an interaction of public health and medical practice, is an important part of the discussion of how we fund preventive care [See Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, “Community-Oriented Primary Care and the Role of Community Health Centers” (Part 1, Babitz).]
Public health, traditionally, has been funded by lump sums of moneys provided to entities as grants. Clinical practices and medical treatment has traditionally been funded by small pieces of moneys sent in as reimbursements. I just want to remind you that nobody is going to reimburse you for treating the community. HCFA is not set up to do that. Insurance companies are not set up to do that.
Private patients, who pay you money, and their insurance companies, are not set up to do that. So, to the extent that the model works, it’s going to depend on continual injections of lump sums of money from somebody, for some state purpose on a national basis.
At this point community health centers, as they exist, are funded by the Bureau at about 600 million dollars a year for about 550 centers. To take that kind of program nationwide, even with the understanding that it would reduce expenditures for secondary and tertiary care in the long run, is obviously going to be an extremely expensive proposition.
The 900 million dollars presented in the current iteration of the Clinton plan is not going to come anywhere near to the coverage nationally that would be necessary to implement this program on more than what has been a trial basis.
Neighborhood Health Centers, Urban and Rural Health Initiatives and Similar Entities
To look at how it works, you would have to look at three different groups, that have come into or have been somewhat excluded from community health center programs over the last 20 years.
There are the large urban, medium urban and suburban clinics – some of whom came in as urban health initiatives, some of whom were the original neighborhood health centers. There are rural groups who came in as rural health initiatives. There are frontier areas that have been trying to come in as rural for several years and haven’t gotten the coverage of care that the other two groups have. I think it’s because they made a public relations mistake. They’ve been trying to present themselves as very small rural and they should be presenting themselves as very young urban. Maybe they could get more money. (Laughter).
But preventive care has come into those three population groups differently at different levels based to some extent on what they were designed to do in the first place and to some extent on what resources are available in the areas. Urban community health centers – the original neighborhood health centers – were set up to make sure that primary medical care was available to groups, who by reason of poverty or discrimination (including racial, cultural, and language discrimination) were not able to obtain care. Community oriented primary care within that group under health care reform is possibly the easiest to implement of any of the three groups.
Mike talked about Minnesota [See Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, “Community-Oriented Primary Care and the Role of Community Health Centers” (Part 3, Holmes]. One of the tentative principals of the proposed Minnesota Care health plan is that everybody gets the same access card. One of the tentative principals of the national health care reform is that everybody gets the same access card.
To the extent that we haven’t already done away with discrimination on the basis of poverty (although there are still areas of the country where people with Medicaid are not being seen because they have Medicaid cards), the fact that everybody has the same card, does away with that bias.
Consider the other health care edifices that we think about when we think about what happens to somebody after primary care – nursing homes, hospitals, home health agencies, ambulance services, mental health, alcohol treatment, all of the things that go into making up the health care infrastructure. It’s probably going to be as easy in urban areas as it is anywhere to integrate COPC with the other providers up and down the line. In rural areas we have the same problems with general access to primary care, that is partially based on relatively low population density.
So we have the situation that exists in urban areas with a little less emphasis on poverty generally and a little more emphasis on distance, plus – as Mike Holmes indicated – hospital staffing problems as well. The rural physicians often work in the ER.
Physician assistants and nurse practitioners in some areas are handicapped by the fact they they cannot admit to hospitals in some states still, nor can they handle call. We have all of the community health department issues that Lil Anderson talked about [Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, “Community-Oriented Primary Care and the Role of Community Health Centers” (Part 2, Anderson)].
Such issues include being able to fund with alternative funding, whether it’s maternal and child block grant moneys or whether it’s preventive block grant moneys or other types of underfunding that have been given to health departments in the past.
Services in locations outside of the county seat
Without that health department financing, many services would not be provided outside the county seat. Very few rural areas in which there are community health centers operate out of the county seat. In Lil’s case, she does, and Billings is the largest urban area in Montana. But, there are areas of that county that are very difficult to reach.
In Mike Holmes’ case, he operates miles and miles away from the county seat and operates on resources that would ordinarily go for the health department staff that exist at the county seat who are not easily moved around to see his patients. Once you get to the frontier areas – if you know the definition of under six people per square mile, or more cows than people in a given area – you have all of the above problems that you have in an urban area, plus you have to build an infrastructure from scratch.
There’s very often no clinic building, no equipment, no hospital, no ambulance service, iffy Medi-Vac by air, no mental health services, no public health services. Try to do a community needs assessment in that type of area and come up with a meaningful program. Just a few frontier areas would make a hell of a dent in that 900 million dollars really fast.
Health care reform and the community health center
If you look at what community health centers are likely to do under health care reform, I think you’re looking at having to take a look at four basic tracks:
First, what do they mean when they say managed care? Everyone who says managed care in the Medicaid world is talking about gatekeeper services. Everyone who says managed care in our world, community health centers, is talking about increased access. The two do not coincide. Where do they coincide? Community health centers have to make a choice on what services to provide based on what’s reimbursable and what isn’t.
Second, what are they actually going to fund? Public health programs and community health programs at a level that will allow them to be implemented nationwide rather than in the areas they they are confined to now? We’ve talked about the fact that public health has been underfunded for years; and community health has been underfunded for years. These are very expensive programs in terms of actual dollars.
The difference for what you get in a reimbursable system for providing episodic primary care and what you would get in the system Marc Babitz has described can be guessed at in any case by looking at what the Bureau grants that come into a community health center versus what it would cost to reimburse a visit at cost.
The difference is considerable. To the extent that you are training people to come into community health centers in rural areas, you need to think about how much extra money that’s gong to add to the cost of delivering services for us. That, I understand, is a different problem from what quality of training you can get within community health centers.
Third, what’s going to happen to the traditional funding mechanisms that we now have? What’s going to happen to Bureau funding? How long is it going to be up on the hill with the Clinton health care plan before somebody says, 600 million dollars and all you’re going to do is outreach and translation for the people?
We have a card for everybody, why do we need you? If that happens then we’ll go back to thinking of preventive health care as reimbursable services, such as episodic pop smears and elderly physicals. To the extent that something is on that list, then community health centers will provide it just as everybody else does. To the extent that something is not on that list and is not reimbursable, COPC goes right out the window unless there are continuing programs like the Bureau’s.
We have an hour and a half this afternoon to talk about financing and John Esselink has some time to talk about financing this morning. I just want to make the point that it’s extremely important to figure out how it’s going to occur before we figure out whether we’re going to need linkages between community health centers and residency programs.
Finally, I would just like to point out, there’s in obvious political result to treating the community. We talked about the difference between compliance and coping behavior – the difference between compliance that you know is possible and compliance that you now, up front, is not possible. But politically, there’s going to be a number of things sold on the basis of if we’re going to treat the community we have to make sure the community does not do a, b, c, whatever, eat red meat, ride motorcycles without helmets, smoke, drink, vote Republican, (Laughter).
There are two problems with that, one is, obviously, if you smoke, and I smoke, if you set the tax at $2.00 a pack, almost everybody will quite smoking and you won’t have that 105 billion dollars. Then what are you going to do to treat the people who are dying? If you put a tax on booze, you’re going to lose all the votes you gained by providing health insurance for everyone who drinks.
But I think the continuing search for money is going to lead us into the trap of blaming the patient as an individual. That doesn’t work. That doesn’t work in health education. That doesn’t work in provision of medical care. It doesn’t work in politics. I think we’re going to end up having to make sure we have a good solid broad-based funding for health care programs if we’re ever going to have a chance of covering everybody for whatever services we deem appropriate.
To the extent that we start cutting it off and claiming we can get money from here, from there, from this group, money from that group, and maybe these people are really utilizing too much and we’ll get most of the money from them. The upshot is that we don’t get anything passed except a hodgepodge of things that won’t provide us with the kind of comprehensive coverage that we’re looking for. And we won’t have saved any moneys. And we can hopefully just to back to running community health centers the way we always did except charging more money for the services.
I’m going to open this up for questions, I’m not going to answer them all, I’m going to point to somebody I think can answer the questions better, so first of all, I would like one question asked from somebody in the audience, the question I’d like is to be directed at Dr. Babitz, on whether the celebrations that we all planned for when our quality assurance shows that we have immunized everybody, are allowable costs on Bureau Grants?
Dr Babitz: Absolutely.
Dr Strange: Did you say absolutely?
Mark Clasen, MD, (Chair, Department of Family Medicine, Wright State University, Dayton, Ohio): My question is somewhat complex, so if you don’t mibd, I would like to read it and maybe we can ask Marc to comment and others. Funding of the COPC concept in a CHC may improve your primary care department in training students and residents in these sites. If the proposal for setting aside money for community consortia for training medical residents is accepted by the Cliniton administration. What do you think?
Dr Babitz: COPC clearly depends on primary care providers which we have a shortage of. But I think it’s more than that. It means primary care providers trained in a little different approach to providing care.
I have the fear that if we trained all family physicians in what I would call the pure room-to-room-to-room private practice model, we would have a small model, we wold have small impact. It would improve, no doubt.
It would improve but not to the degree that it would improve that we would begin to look a community needs and prioritization and cooperative ventures, collaboration and those sort of things.
We would begin to maximize our resources. Because the traditional practice model of primary care is not the solution in and of itself, in my opinion, especially given the depth of the problem we have today.
Dr Clasen: Dr. Babitz, assume that the CHC were to have medical students and residents in training and that it was a primary training site, so we could get some of the Medicare monies for Direct Medical Education (DME) and Indirect Medical Education (IME) that is sucked off into priority efforts. Consider instead a community consortium where we could now open that funnel of money up to that educational purpose with a clinical outcome that we might want to look at.
Dr Babitz: Dr. Clasen was just basically talking about the issue of the funding for graduate education going primarily to tertiary care institutions, instead of being allocated to the primary care training sites. From the Bureau’s point of view, we absolutely agree with you about financing. One of the struggles for health centers, is how do you pay for education when we’re a service entity? How do you pay for service when you’re an education institution? And clearly, one of the reforms that has to be made is how does the Federal government invest its money that is going into graduate health education training?
Dr Strange: Are there other questions?
Bernard Goodman, (Executive Director, Vicksburg-Warren Community Health Center, Vicksburg, Mississippi): This is a question as well as an advertisement to to tell you a little bit about the Vicksburg-Warren CHC. We are a community health center providing services in an area that is predominated by for-profit organizations, two for-profit hospitals and two for-profit medical groups. So, basically, we get all of the under-served residents of the Vicksburg area.
We are very interested in developing some type of residency program. We currently don’t have one. The organization of Vicksburg-Warren is about seven years old and we’re changing our mode of services to provide better services to the community.
For years, we have sat back and we have provided services to the community as they have come into the facility. Listening to Dr. Babitz presentation, we are very excited about the possibility of developing a program that’s going to allow us to go out into the community, so I’ll certainly like to talk to you about your ideas. We have slots for four physicians.
We currently have one full-time physician and one physician that provides 40 hours of service. However, he is not full-time. We tried to recruit a medical director. We just moved into a new very beautiful facility, It’s about one and a half years old. We have ten adult clinical, or ten adult exam rooms and four pediatric exam rooms, so we are a very large, nice-sized facility and we can provide adequate services to the community.
I’d like to know what the ABCs are of developing a residency program There is a large university, the University of Mississippi, about 50 miles east of Vicksburg in Jackson, Mississippi. I think it’s important that we have begun to make connection and to develop a relationship with Mr. Boyd who is over at the University of Mississippi. So we’ve come here today to find out a little bit about the primary care residency linkage programs. If you can provide me with some information on how we can develop a program, it would be very appreciated.
Dr Strange: I assume you have brochures and a sample contract for the medical director.
Mr Goodman: As a matter of fact, that will be ready next month. We feel that we are in the mode where we are cutting down a lot of petrified trees – a lot of old ways of doing things – and we’re clearing out the land to move forward progressively. Within the past four months, we have done that, and we’re very excited about that. Within the next month, we will have a good physician recruitment and retention program developed.
Dr Strange: I’ll confess, I’m no expert on residency programs. Is there anybody in the room that knows about the Mississippi situation and could you…
Dr Clasen: I think I know who you’re talking about with Boyd, but you need also to go over and have a lengthy conversation with Lessa Phillips, the Chair of that Department of Family Medicine, because I think she will be very responsive to what you are talking about. So make the linkage with the Chair of that department.
Dr Strange: Thank you. Stop and see us too, I know that you’re going to talk to Marc Babitz, but make sure some of us get your card.
Alvin Jones, MD, (Chairman, Department of Family Medicine, Lubbock, Texas): I have a question for Mr. Holmes. On that program you have on all of the different outlying clinics and bases supporting the hospitals in those rural areas, is that an education-based program?
Mr Holmes: Our current setup is that we’re too far from the closest residency program in Duluth, at the University of Minnesota, Duluth. It’s 85 miles from one of our sites and it’s well over 150 miles from some of our other sites. We don’t have residency programs, as such, in our network right now. We do, however, participate in the University of Minnesota Rural Physician Associate Program [RPAC] which takes a third year medical student and places him or her on site for their third year with a preceptor.
Along with that on-site training, there are some rotations to balance out the activities within a small rural clinic versus the requirements they need for their third year. We have students come in periodically under that program. Minnesota has many more practice sites for the RPAC student than they have students interested in participating in that program. So we end up having a student in one of these sites probably every 2nd or 3rd year.
We also bring in students under the American Medical Student Association (AMSA) program to do summer projects and we will have up to 2 or 3 AMSA students per year and we’ve been doing that for about 10 years.
With our sites being so far from the residency programs, there are some logistical problems of having long-term residency commitments. We also do have some residents that come in and do one-month rotations with some of our staff.
Dr Jones: Well, I will just comment. The Texas Tech University family edicine department extends from Amarillo to El Paso, which is somewhat over 600 miles. Could I have a second question? Dr. Strange, I jut have a need to offer a different perspective from the standpoint of the smoking and lifestyle issue.
Basically about 50 percent of our health care costs and premature mobility and mortality rate relate to those and I would be more inclined to advocate a $5.00 a pack price for cigarettes. It’s an addictive disease so those folks are going to have the same problem whether it’s 50 cents or $5.00 a pack. The other question comes to, how are we going to be successful if we do not hold the community responsible for the part that they can deal with and help share the medical care costs.
Dr Strange: I don’t necessarily disagree with what you are saying. I don’t think you can hold a community responsible, because I don’t think they’ll vote to hold themselves responsible for it.
Mr Burnett: I just want to mention to those who are asking questions about the residency linkages. That’s up next. This first panel was introducing the background of community oriented primary care and some of the issues of the day.
This presentation is preceded by: Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, “Community-Oriented Primary Care and the Role of Community Health Centers” (Part 3, Holmes)
This presentation is followed by: Proceedings of the First National Conference on Community Health Center – Primary Care Residency Program Linkages, “Centering Primary Care Residency Training in a Teaching Community Health Center: Adventures in Academic Processes and Community Politics” (Part 1, Prislin)