The following consensus statement was developed over the course of the Fifth, Sixth and Seventh National Conferences on Primary Health Care Access. Elements of the document will be considered at the Twenty-First National Conference, which will be held 15 years after this document’s development.
THE SEVENTH NATIONAL CONFERENCE ON
PRIMARY HEALTH CARE ACCESS
Williamsburg Lodge and Inn
Colonial Williamsburg, Virginia
March 28-31, 1996
1. Whether access to health care services is viewed as a right or an entitlement, a community should be concerned with the health of all its members.
2. Health care problems often are linked to other fundamental societal problems, including poverty, unemployment, racial discrimination, and poor education. Ultimately, strategies for solving health care problems may require addressing other problems.
3. Our nation should be comprised of communities where differences between persons are respected and self-esteem is built.
4. Continuous, comprehensive primary care should be available to everyone.
5. Linkages and exchanges between professionals in academic settings and other professionals (such as community health centers, managed care organizations and government entities) interested in these issues need to increase.
6. The following recommendations have been developed in hope of influencing federal and state policy makers, and the leadership of health professional associations.
[B] POVERTY AND HEALTH CARE NEEDS
1. Poverty cuts across all racial and ethnic lines. While issues of race and ethnicity are experienced by certain groups, poor people of all races share common problems.
2. Separate health care systems for those who are affluent and those who are impoverished should not exist.
3. Impoverished inner city populations have health behaviors which are inappropriate for maintaining health and they use the health care system in inefficient ways. Investments in behavior change strategies are essential to improve health status and system efficiency.
4. Even when we try to think globally, there is a general tendency to compartmentalize groups and problems, e.g., rural versus inner city. Although geographically disparate, in terms of access rural and inner-city people share many of the same problems.
[C] CULTURAL ISSUES
1. Behavioral and cultural traditions and attitudes that cause some people to seek care only in the most extreme emergencies, are also barriers to health care access.
2. Health care delivery systems need to incorporate cultural sensitivity and responsiveness to both the individual and community health beliefs of diverse populations, emphasizing that healing encompasses mind, body and spirit.
[D] FAMILY AND COMMUNITY MEDICINE
1. One of the national health priorities, formally recognized in the mid-1960s, is that every person should have access to a personal physician, who has comprehensive training and the skills to provide continuous care to the individual and family. The reasons for establishing such a national priority remain as valid now as they were at the time.
2. To provide comprehensive care, a primary health care provider should have the clinical training and expertise to provide health care to all members of the family, should incorporate the behavioral sciences into the practice of medicine, should understand and utilize the health and social resources of the community, and be knowledgable about and comfortable with the cultural heritage of the patients served.
3. Community-oriented primary care [COPC] should be promoted in medical schools and the COPC model integrated into health care delivery systems.
1. Increased resources should be allocated for primary care and comprehensive health education.
2. Public policy should promote health education programs. Advertising agencies should be enlisted in health education activities.
3. Prioritization of health services, when necessary, should be based on patient medical need, rather than patient income.
4. The profits of any organization, industry, or agency which provides health services, should be limited to appropriate levels.
5. A process for rigorously evaluating new technologies and the use of existing technologies should be instituted. A national consensus on the allocation of health care resouces should be sought.
A disproportionate share of health care resources goes to high technological health care, even though much less costly and more effective health care services often are available.
[G] HEALTH PROFESSIONS EDUCATION
1. The current education system for health care fails to produce persons who serve those most in need.
2. The central mission of primary care educators must be the creation of a primary care workforce to meet regional and national needs. Public policy should be concerned with how the kinds of financing mechanisms needed to support that mission can be established or enhanced, and how adequate funding to meet that mission can be secured.
3. Medical schools now rely on federal research funds and patient care reveneus derived from academic medical center hospitals. The value to academic medical centers of the primary care disciplines will increase in the future due to shifts in capitated revenues and increased funding of patient based research.
Medical School Curricula
4. The major forces of change in the medical school are external: rapid changes in health care delivery and payor need to improve access and control costs. Medical schools must develop a primary care base in order to maintain referrals practice to subspecialty faculty and trainees and to increase primary care physician graduates. Family medicine academic units are being asked to develop extensive primary care delivery programs for these purposes. While improving the power base of family practice in the medical school, this role is not without danger of adversely impacting the teaching and reserach roles of these units.
5. Though required family medicine clerkships are now the mode, most medical education is still based in the tertiary care medical center, where students, regardless of their initial orientation, are attracted to the glamour of tertiary care and the attendant role models. Students see limitation of graduate training opportunities as an infringement of their freedom of choice.
6. There is little emphasis in medical school curricula on the economics of health care, future changes in the health care delivery system, health care financing or health policy. Thus, the “pipeline” to primary care graduate training is slow to develop.
7. In the face of a physician surplus, defining minimal requirements may be less important than defining how many physicians can be gainfully employed.
8. Health professions schools should include training in understanding and communicating with persons from dissimilar backgrounds. Students should be taught about such values as compassion.
9. Increased flexibility to allow for rural training experiences should be permitted by physician residency review committees and family nurse practitioner and physician assistant training program accreditation bodies.
10. In any emerging reform of federal health care funding, increased resources (say, ten percent of federal health care expenditures) should be directed to support primary care education in ambulatory settings.
11. Predoctoral and graduate physicians should be exposed to managed care settings and systems, both in didactic and clinical experiences.
12. Traditionally hospital based, medical education must now reflect a model of ambulatory care, and embrace outpatient, continuity settings for training, beginning in the first or second year of predoctoral training.
Nurse Practitioner and Physician Assistant Education
13. Primary care physicians should play leadership roles in the education of physician assistants and nurse practitioners.
14. The inflow of graduates of foreign medical schools into graduate medical education should be capped at the 1993 level or below.
15. First year residency positions should be capped at 110% of the graduating medical students in a 50% generalist, 50% subspecialty mix.
16. An all-payer Graduate Medical Education payer pool should be developed to support national workforce goals with payments made directly to the applicant program.
17. With movement of student training into community ambulatory settings, community clinical faculty development should be a high priority.
18. Medical school admission and retention policies should favor students who are familiar with and sympathetic to persons from low income communities, especially those persons whose dominant culture and language differ from the mainstream society.
19. The financing of postgraduate medical education should be reformed to favor the production of more clinically and culturally competent primary care physicians. Culturally sensitive members of ethnic and racial minorities should be among the mentors and role models that interact with medical students.
20. Health professions education should be financed in part through mechanisms that pay the cost of the student’s education in exchange for public service obligations in underserved inner city, rural or other areas of need. In any emerging funding structure directed to health care reform, meaningful all payor contributions to the funding of primary care education in ambulatory settings is necessary in both predoctoral and graduate education.
21. All managed care systems and other health plans, whether public or private, should be expected to invest a portion of their resources in health professions education.
22. Subspecialist dominated medical schools are behind the market relative to managed care alliances. This is eroding the ability of the academic medical center to generate clinical dollars and to ensure an appropriate teaching base for students and residents.
23. Present levels of funding for primary care are insufficient to influence the adoption of primary care curricula in medical schools. Prestige, tradition, and the perceived requirement for maintenance of accreditation are strong barriers.
24. While state legislatures and other external sources of funding for medical schools long have favored family practice and primary care as principal medical school missions, they have become skeptical about the ability of medical schools to effect such missions on their own volition. Direct funding to family medicine departments, residency positions, third-year clerkships, rural training tracks and other “pro-primary care” strategies are now preferred in many state.
25. As research support wanes and clinical income declines, innovative mechanisms to fund ambulatory care education should be developed. The public and payor intermediaries must be convinced of the need to support medical education.
26. Physician residency programs should take a proactive role in the placement of physicians in underserved communities, including political support of service corps programs. A placement service for such communities should be instituted by medical schools, where appropriate.
27. Primary care physicians should be members of all influential medical school committees such as admissions, curriculum, faculty appointment and promotion, long term planning, and maintenance and expansion of the primary care patient base.
28. Health professions schools should be accountable to the communities in which they exist. Health professions schools should be responsible to produce a certain number of graduates who go into primary care and practice in underserved communities.
[H] HEALTH PROMOTION
1. Health education begins with the family. Resources devoted to health promotion should encourage families to educate family members on how to maintain good health.
2. Physicians and other health professionals should take positions of community leadership with the objective of promoting good health.
3. The monitoring of quality and outcomes should include the evaluation of access to and effectiveness of primary health care services. “Healthy People 2000” objectives should be incorporated into quality measures for such monitoring activities.
4. Hospitals and physicians who work in a community should invest in the community’s health and economic well-being.
[I] PRACTICE GUIDELINES
Guidelines should be established for appropriateness of care. the development of these guidelines should involve patients as well as health care providers. Primary care authorship of those dealing with health promotion and common medical problems is preferred.
Reimbursement should continue to move towards prospective payment at an overall fixed amount for providers and plans. Providers and plans should be held accountable for prospective budgets and allocation of resources that maximize access, efficiency and quality.
[K] MANAGED CARE
1. The managed care market should be regulated in a way that assures that providers increase services to the presently uninsured and underinsured. Providers should not be able to profit by limiting their enrollment to those who are in good health.
2. National health policy should promote the positive elements of managed care, including cost containment and quality assurance.
3. Case mix adjusted premiums and provider reimbursement should be developed and implemented to distribute resources more appropriately.
[L] TEACHING COMMUNITY HEALTH CENTERS
1. Community health centers should be a part of community centers. A multidisciplinary team approach for the delivery of services should be established.
2. Teaching Community Health Centers [TCHCs] are a model for community-based service, education, and research. These TCHCs are expected to improve the quality and outcomes of health professions education by integrating medical education within model community-oriented primary care practices operating in a reformed health care delivery system.
3. TCHCs are entities that have a mission of improving the health of the community through: a) service, b) education, and c) research. They are public or non-profit agencies that provide comprehensive primary health care to medically underserved communities.
4. TCHCs in both urban and rural areas in all parts of the country should be developed and funded: a) to improve access to quality primary care services, and 2) to increase the number and distribution of primary care providers coming from and returning to underserved areas.
5. TCHCs should have administrative structures and systems that assure financial, clinical, and academic accountability and stability.
6. TCHCs should provide primary care across the life cycle in a continuous and coordinated fashion to a defined target population representing a diversity of diseases and conditions. Services should be provided as part of an integrated health care delivery system facilitating ready access to all levels of care with a coordinated multidiciplinary team approach.
7. TCHCs should focus on improving the health of the community through the application of the principles of community-oriented primary care.
8. TCHCs should be accredited as an ambulatory primary care provider by the appropriate accrediting body.
9. Physician training located within a TCHC should be sponsored by at least one accredited primary care residency program with a separate match number either as a free-standing organization or an affiliation with an established teaching institution. Such primary care residency programs must be in family practice, general internal medicine or general pediatrics. In addition, the TCHC provide post-graduate training for nurse practitioners, nurse clinicians, physician assistants, or certified nurse midwives.
10. The sponsoring institution must recognize and allocate suffiicient education time distinct from patient care responsibilities in accordance with accreditation requirements.
11 Research on improving the health of the community should be encouraged through participation in clinical trials and the development of databases for community health issues, clinical guidelines and health outcomes.
12. Evaluation of TCHCs should gauge the impact of the program on the community’s health; track its graduates working in underserved areas; and document the costs associated with these outcomes.
13. Changes should be made in federal and state statutes and regulations that accomplish the following:
a) TCHCs should be eligible to directly receive graduate medical education payments that reimburse these centers for their development and operational costs.
b) startup funds for planning and development of TCHCs should be identified and made available.
c) TCHCs will be recognized separately from non-teaching community health centers by taking into account the special needs of ambulatory-based teaching programa.
d) the National Institutes of Health, Agency for Health Care Policy Research, and other federal research agencies should increase their focus on primary care research by utilizing TCHCs.
e) faculty development, technical assisstance, and support programs for TCHCs should be developed and implemented.
f) loan repayment programs serving medically underserved communities should target residents and faculty of TCHCs.
[M] TORT REFORM
Tort reform should be achieved, so that fear of malpractice suits does not dictate inappropriate medical practice.
[N} PRIMARY CARE WORKFORCE
1. There is need to include definitions of primary care (American Academy of Family Physicians and Society of Teachers of Family Medicine) that distinguish the primary physician from the generic term of primary care provider that has been sought after by many of the subspecialty organizations to promote their self interest in the era of health care reform.
2. Predoctoral and graduate physicians should be exposed to health care teams and leadership functions necessary to coordinate teams developed.
3. The family medicine community should place high priority on retraining programs for subspecialists who desire to obtain credentials and certification in primary care.
4. There seems consensus that there are inadequate numbers of primary care physicians, although this is by no means an established fact. Other proposed configurations of health care providers including augmented utilization of nurse practitioners and physician assistants in provision of first contact medical care might even allow the reduction of medical school class size. However, there is consensus that there are too many physicians in the United States and that they are geographically maldistributed.
5. Though exactly how the reconfiguration of health care delivery will occur in an atmosphere of health care reform, there seem relentless forces forging rapid movement on the short term toward a managed, integrated system based on primary care. Though a different array of providers is possible, it is almost a certainty that primary care will continue to be delivered and controlled by physicians. If, as many believe, there is a serious geographic and specialty maldistribution, and that our educational programs have produced too many narrow specialists, then their redirection into primary care will likely occur in the future. With this redirection, the need for physician assistnats and nurse practitioners may be reduced. However, it is quite likely that there will be a continued significant role for nurse practitioners and physician assistants in managed care.
[O] RURAL HEALTH ISSUES (GENERAL)
Financing innovations aimed at equalizing access to health care likely would benefit both rural and non-rural communities. However, service delivery innovations that rely on the development of a competitive environment do not fit the situations of most rural communities, and may exacerbate the physician shortage problem.
[P] RURAL WORKFORCE ISSUES
1. Greater numbers of primary care providers are needed in rural communities than are presently practicing there. Some rural communities are unable to attract and retain physicians, given their remoteness, geography, and/or lack of amenities. Another important cause of the rural provider shortage is the United States health provider training system that produces too many subspecialists.
2. Public funding of health professional education should be based, in part, on how well this education meets the provider needs of the region. The ultimate success is the number of graduates who practice in specialties and geographic locations of need.
3. Optimal models for training rural providers should be developed and tested. Residency review requirements should be modified to accommodate the special training needs of rural providers. Financial support must be made available for more community-based training. Curriculum should be expanded to teach community medicine needed to practice in small town settings. Community and migrant health centers should have an increasing role in training future rural providers.
4. The number of training positions for health care professionals should be based on population needs.
5. Medical school selection preferences should be given to students from rural areas, and particularly to those from needy rural areas who plan to return to their home communities after training.
6. States, including their state offices of rural health, should play stronger roles in creating and supporting programs to recruit and retain health care providers. Hospital and clinic administrators and boards of directors need development of their management skills and ability to work with health care providers, preferably before new providers move into the community.
7. Program should be expanded to alleviate the debt burden of young rural providers.
8. Mechanisms should be developed to decrease the after-hours burden of many rural providers. Successful strategies include (1) facilitating cross-coverage arrangements, and (2) creating a pool of locum tenans providers to provide more extended respite.
9. Despite the effects of various programs, some particularly remote and impoverished rural communities will continue to experience primary care provider shortages. These communities will require ongoing support from the National Health Service Corps, financial incentive programs, and other programs specially designed for th emost challenged communities.
10. The National Health Service Corps should give preference in scholarship awards to individuals from areas likely to require future NHSC placements.
11. More funds should be allocated to Public Health Service regional offices to support NHSC and other rural and urban providers. Partnerships between regional and state offices of rural health should be fostered.
[Q] RURAL HEALTH SYSTEMS
1. Rural health systems should provide the infrastructure (support) for determining the mix of specific services that should be available in 1) all rural communities, 2) some rural communities, and 3) only in regional referral centers.
2. The process for developing rural health systems should involve consumer and community participation.
3. The optimal design of health services delivery and financing in rural areas is not now understood. Consequently, research on rural health service models should be developed and funded.
4. A telemedicine infrastructure to support rural practice should be developed, and reimbursement for telcommunicated consultation should be provided.
5. Mental health services and long-term care facilities in rural communities hsould be integrated effectively into the health care systems.
6. Rural health infrastructures do exist, but are much more decentralized than in urban areas. Much more flexibility should be allowed in rural communities in establishing rules and regulations governing health care.
[R] RURAL HEALTH FINANCING
1. Private and public financing of rural health care should assure continued viablity of essential health access points for rural patients.
2. Differntial provider reimbursement between urban and rural areas which result in the maldistribution of providers should be eliminated.
[S] INDIAN HEALTH SERVICES
Special notice needs to be drawn to the fact the Indian tribes are sovereign nations and there exists a special Federal trust relationship that must be honored in health policy consideraitons.
[T} RESEARCH ON PRIMARY HEALTH CARE
1, An NIH Instiute of Family Health and Rural Primary Health Care should be established and adequately funded.
2. Although it would facilitate the growth of primary care disciplines, creation of an NIH Insitute of Primary Care in the near future appears not politically feasible. One named a Family Health Institute might be more realizable.
3. There is need for a forum that will promote discussion of a) policy issues, b) program development and evaluation, c) impact of health systems changes (e.g., managed care) on the delivery of services to populations of special interest, de) how groups interested in the changing health care systems are coping in their local service areas and e) faculty development of the ability to perform scholarly studies related to these topics (e.g., funding and exploration of collaborative activity.)
[U] COALITION BUILDING
1. We must find out how to involve all groups in health care decisions, rather than just those with “speical interests”.
2. Coalitions of groups intrested in healt care reform, such as corporations, unions and consumer groups, should be encouraged.
3. A broader coalition of ersons interested in healt and primary care should develop mechanisms to influence government policymaking positively over a long period of time.
4. The groups and individuals participating in the National Conference Series on Primary Healt Care Access share a commitment to improving access to high quality primary health care services, and support the development of coalitions to advance this goal. The inclusion of individuals and groups who are currently delivering high quality primary care services in such coalitions is recommended, as well as representatives of health services systems that share a commitment to and responsibility for primary care. Coalitions should be guided by the needs of the patients and the communities that should be served.
5. Coalitions, like treaties, arise when parties decide that the benefits of joining forces to advance their common agendas outweigh the potential costs and compromises required to maintain them separately. The current crisis in access to primary care is of such a serious magnitude that such coalitions are now necessary.
6. Those attempting to build such coalitions must remain vigilant for deterrents arising from different histories and cultures of participating groups.
7.The goals of coalitions to further access to primary care are: a) developing rational, effective primary care delivery systems responsive to clients, their families and communities; b) enhancing the biopsychosocial education and training of primary care health professionals, including team training; c) developing the primary care research base in health services delivery, clinical outcomes, and training and evaluation methods; and d) reforming health policy and financing systems to reestablish the central role of primary care and to provide adequate service delivery to all our citizens.
8. The specific coalitions for each of the above goals will be differnt and should be established on both local and larger (state and national) levels.
9. Local coalitions should include representatives of each cultural group being served, to ensure that services desired by such groups and cultural sensitivity of systems will increase. Such interaction will also foster population-based primary care goals and facilitate beter measurement of progress.
10. Foundations interested in health care should be included as they often foster and finance creative new approaches. Finally, local governments, managed care organizations and insurers may be involved to create multi-partner solutions to local delivery problems.
11. National coalitions should be formed with large consumer groups such as the AARP, NRHA, NACHC, the Children’s Lobby, major labor unions and others. Such coalitions should facilitate local cooperation and influence national policy.
12. Locally, coalitions should start among MDs and DOs in general internal medicine, general pediatrics and family practice and expand quickly to include nurse practitioners, physician assistants, registered nurses and other health professionals engaged in delivering primary care services.
13. Such coalitions should focus on evaluation and revision of curricula and training, assessing the competency of generalists, joint faculty development, disseminating the primary care curriculum proposed by PCOC, implementing such curricula, and advancing the primary care knowledge base through collaborative research.
14. A suggested method is to survey the local environment to find those with ideas, vision, power and common interests who might be “brokers”. Nationally, the primary care organizations should establish structures that will facilitate collaboration. As they become more familiar with each other’s cultures they will find new, mutually beneficial ways to collaborate productively.
15. Local coalitions can help facilitate local changes in primary care priorities.
16. Nationally, primary care organizations must develop an effective and singular voice on health policy and financing reform. At all levels they should become more effective at presenting the message that primary care is essential to the future health of the nation and can only be provided in a quality fashion by those who are trained and specialize in it. This message must be successfully conveyed to our citizens and our political decision-makers
17. Dialogue should be increased between leaders of organizations that represent physicians in family practice, general pediatrics, and general internal medicine, and between practitioners in those three primary care specialties.
18. The contributions of each of the major primary care specialties to primary care research should be better understood through increased communication and collaboration among leaders and researchers in those specialties. For example, the contributions of general internists to studies of the doctor-patient relationship, of family physicians to family health systems and of pediatricians to child development should be diffused throughout all three specialties.
19, More extensive dialogue should be encouraged between researchers in the primary care medical specialties and the mental health specialties.
20. The Primary Healt Care Access conference series should include among its invitees increased numbers of representatives from general internal medicine, general pediatrics, nurse practitioners, physician assistants and certified nurse midwives.
21. The conference should define primary health care by content and function rather than by the specific kinds of health professionals who perform primary care services. Consensus should be reached as to the content of primary care, including definition of comprehensiveness and continuity of care, and skills needed for delivering primary health care. Primary care’s relationship to the larger health care system should be defined.
22. The knowledge base of the primary care specialties should be augmented to include greater understanding of the behavioral sciences and preventive medicine. Funding of studies of the behavioral and biopsychosocial aspects of health care should increase.
[V] PERSONAL VALUES
1. Certain core personal values (“guiding principles”) are linked closely to effective primary care. Medical trainees choosing primary care specialties tend to rate benevolent personal values (helpfulness, honesty, loyalty and service) significantly higher than trainees choosing non-primary care specialties. Conversely, many subspecialists rate power values (wealth, social standing) significantly higher.
2. Family physicians whose personal values for benevolence are high and for power low have been found to be more satisfied with their work.
3. Many physicians enter medical school with benevolent personal values, which often become distorted by the educational process.
4. Selection of medical students with benevolent personal values is recommended, as well as educational strategies that reinforce and preserve attitudes of helpfulness, service, honesty, compassion, loyalty, kindness and respect.