22nd National Conference – Breakout Group Questions for Monday, April 18, 2011

Breakout Group 1

Discuss and critique the following extract from the Consensus Statement of the Seventh National Conference on Primary Health Care Access:

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.

McCanne, Leader; Lee Burnett, Scribe; Freeman, Geyman, Weisbuch and Zweifler

Introductory comment: Since this consensus statement from 15 years ago, newer concepts of paying for health care have evolved, especially those included in the Patient Protection and Affordable Care Act, which reveals how prescient the authors of the Consensus Statement were. The very informal conversation following includes only abbreviated, selected statements which touch on some issues such as fee-for-service, (FFS) RBRVS, and the role of Accountable Care Organizations. Hopefully it would serve to provoke further thought and debate on these important issues.

From left clockwise: Doctors Joshua Freeman, John Zweifler (hidden), Jonathan Weisbuch, Don McCanne (hidden), John Geyman, Lee Burnett (at laptop).

Breakout Group 1 Scribe Notes:

Consensus statement from 15 years prior: 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.

Weisbuch: Relative Value System (RVRBS): Is that a prospective payment?

Freeman: It depends on how you interpret it

McCanne:  The last part sounds a little bit like the accountable care organization

Geyman:  This was too mealy-mouthed to be clear, the purpose was to get away from FFS.

Zweifler:  We’ve got to do something to get away from FFS because it increases billing.   There needs to be a balance of quality and cost incentives, “value based services” – It’s a tricky balance.  Any organization optimizes the system in which they work in to maximize revenue – whenever relying on a for-profit entity.

Wiesbuch:  Shouldn’t we remove the for-profit entity since they’re geared to profit rather than patient care?

Geyman:  Salaried physicians is another concept not present 15 years prior.  If that were used, it would change the value of primary care.

Freeman:  How is reimbursement different from salary?

Geyman:  If we need to revalue healthcare services and reduce the perverse incentives, how could one accomplish services being revalued?  If we had single payer it would happen, but are there other ways?

Freeman:  Why wouldn’t an ACO do that?  Doesn’t Kaiser already do that?

McCanne:  You integrate the systems then you become accountable for the care and savings component.  From a business perspective, it is very bizarre – it relies on altruism, since the ACO has considerable additional costs, yet under the Medicare Shared Savings Program, ACOs are paid less than they would be if they were not participating..

Questioner: Why would you encourage an organization to be an ACO?

McCanne:  There are commercial and Medicare ACOs.  We’re seeing the flood of consolidation for the commercial ACO – they’re looking at increasing their leverage.  And there is a battle between hospitals and physicians. Meanwhile the insurance companies are buying provider organizations to ensure they’re in control.

Freeman:  our hospital is concerned about Medicare – a system that brings more Medicare patients is not a good business model currently.  The margin is going down and the hospital is terrified that their margin has gone from 5% to 3% and the trend seems to be continuing.

Geyman:  Can we be sure that Medicare reimbusement is going down?

McCanne:  Payments will go down as productivity improves but that will eventually flatten-out.  In Obama’s speech he said GDP + 0.5% … You’re going to turn Medicare into Medicaid, because of the low reimbursement rates.

Freeman:  Medicaid mostly has its money go to nursing homes.  Mothers and children are relatively inexpensive.  Medicare is 65+ and covers everyone – it’s not feasible to operate an organization without including Medicare Patients.

Weisbuch:  If we went to a single payer system, doesn’t that create an incentive?

Freeman:  HMOs didn’t work because people moved every few years, so it was like Russian Roulette.  The only solution to controlling cost – we can save money on absurd reimbursements such as endoscopy – but the more we can prevent, the more we can save on end term care.

Weisbuch:  At 75-85 years old, the expenses go down. As you approach 95 years old, those individuals die quickly because of their age.  A living healthy individual is a contributor to society.  A living ‘decrepit’ is an expense.  We need to think what is the aggregate value of someone we try to keep healthy.  The study there needs to be repeated.

Freeman:  The social justice issue is clear:  give care when needed, keep patients healthy, and don’t unnecessarily extend life.

Geyman:  What are the dynamics with valuation of services of procedures versus primary care.  What changes the dynamics back to primary care?

Weisbuch:  What do we have to do to change the incentives?

McCanne:  The medical home and properly designed ACOs.  Medicare is already shifting those resources – especially away from imaging services, etc.

Freeman:  The RVRBS system didn’t work as intended.

McCanne:  The RUC is dominated by specialists, which is why it didn’t work.  There is an effort to create a body outside the AMA.

Geyman:  What specific recommendation can be made?

Weisbuch:  There is the hospital, procedure and primary care side to this.  40% goes to hospital costs, most paid under a payment for procedure.  What if the hospital went to a per-diem system – paid at the beginning of the year?  Would that make things more efficient?

McCanne:  DRGs were an attempt to do that. What does seem to work is globalization of budget.  With a fragmented payments system, how does that work?

Weisbuch:  In the Massachusetts prison system, that’s how it worked and it was efficient.  The per-diem was pretty fair.

Freeman:  Canada uses a global budget

Zweifler:  How do we get a public that supports it?

Freeman: I don’t know how to fix it.

Burnett:  You need to go to the multinational corporations to buy-in on change that saves expenses.  That drives legislation.

Freeman:  Like IBM has

Weisbuch:  Didn’t Clinton do that, and then the corporations backed off?

Freeman:  What happened?

Weisbuch:  I don’t know – I think the Chamber pushed against it.

Freeman:  We’re in a very polarized ideological environment with people in very hardened silos.  Companies are judged by how did they do this quarter, not future steps.

McCanne:  Showing how irrational this has been, our son’s company reported 1 cent over predicted and caused the stock to jump 12.4%

Zweifler:  The standard of care evolves.  How do you adjust for that?  What are the limits of what you can provide?  Nothing is really clear now.

Freeman:  Anything that has benefit for me is a priority. Anything that may benefit you is a lower priority.  The result of that is that if you’re disadvantaged you’re in trouble.

McCanne: An important issue  with integrated systems that we haven’t discussed is risk bearing.  With capitation, a lot of the risk is borne by the physician.

Freeman:  We used to have three nurses that ran phone service under an HMO model.  In a FFS model we don’t need the phone service and everyone needs to be seen.

Notes submitted by Lee Burnett, Breakout Group 1 scribe.

 

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Breakout Group 2

 

Discuss and critique the following extract from the Consensus Statement of the Seventh National Conference on Primary Health Care Access:

 

 

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.

Babitz, Leader; Kimball, Scribe; Bejinez-Eastman, Garcia-Shelton, Hara and Troy

From left, clockwise, Doctor Marc Babitz; Ms Elizabeth Kimball (hidden), Doctors Jimmy Hara (partially hidden), Warwick Troy, Linda Garcia-Shelton and Ana Bejinez-Eastman

Breakout Group 2 Scribe Notes:

Links to other fundamental problems. Strategies for solving healthcare issues via addressing other problems.

 

What changes, is it still the same?
Core human needs that go hand in hand with health care.  Society decides which to address.  Two factors that consistently based on education and income.  And we continue to look at race etc.
Population health. Well organized comprehensive primary care system and integrated health system.
Housing, shelter, nutrition, tied to income.
Kaiser integrated care, population health.  Covers wide range of income.
Prisoners only guaranteed health care, but if sick, and not that bad, let you out.
1996: Just seen the rejection of the Clinton plan.  Decided to not deal with it on the Federal level.
Roller coaster in interest in Family Medicine. Increased matches with United States medical school graduates.
Applicant quality up, board scores up.
Personal or institutional initiatives to address the above problems.
Family medicine research in tobacco use.  Advocacy for population health.
Amount of time spent on input, medication management, vs time spent on integrated medicine, psychologists, lack of pharmacy in programs.  Emphasis is care of patient in front of you, even preventative health can be an afterthought.
As residents progress they begin to incorporate more of social issues.
We are a small voice within a small speciality.
Influences on healthcare pharmaceutical corporations, medical equipment manufacturers, large healthcare/insurance corporations; malpractice vs. very small family medicine group.
Kaiser is poised to survive any changes to National Healthcare.
Kaiser proactive with fecal globin, mailed, mammograms etc.
Vouchers issues with poor decision making re buying insurance, betting on high deductible plans not getting sick.  Vouchers encourage not getting health care, preventative care.
What is the difference between acceptance of helmet laws, education etc., but not universal healthcare?  “Smack them over the head and they’ll get used to it.”
In the best interest of workplace to keep employees healthy.
Mortgage crisis, irresponsible marketing, similar to healthcare, there is irresponsible marketing, just won’t happen to them.
Change in societal norms of being willing to pay for others, socialism bent, now resistance to helping anyone but themselves.
Consequences of lack of access to basic healthcare. Very little consequences to not taking care of your health, as you can’t dump patients out.
Industry shutting down Emergency Departments to keep uninsured patients out.
Macro issues of population health, whole western world, inequality in distribution of wealth (see Dr Troy’s Note 1 below).  Getting worse and worse.  No action on it.  Requires a political arm, a social movement (see Dr Troy’s Note 2 below), for sweeping change.
Prisons, pharmaceuticals, how to reduce influence, countries where no pharmaceutical companies are allowed to publicize brand names.
Yes,  a lot of healthcare issues are wrapped up in larger global issues, 15 years later not huge change, and political desire to make the needed changes does not seems to be here.
Change requires it to hurt a lot, seeing your (or your politicians) children die, or cost a lot to get the public to act.

Notes submitted by Elizabeth Kimball, Breakout Group 2 scribe

Responses from Dr Troy:

Dr Troy’s Note 1Inequality in distribution of wealth: The health of populations is determined by a set of macro issues including, in addition to those noted in the Consensus document, the following: nutrition, housing, safety, socio-economic and sociopolitical opportunities for self-development.  To these may be added the paragraph heading above.  Inequality is more significant than the absolute level of wealth.  Nations characterized by such inequalities are not capable of consistently providing for its citizens the macro issues identified above.  Health care is particularly vulnerable, and is illuminated in the U.S.  This contributes greatly to the gap between the gap in the U.S. between per capita spending (high) and health performance indices (not high) compared with other nations.

Dr Troy’s Note 2.  A social movement: The solution to a nation’s capacity to provide, say, health care access, in western nations derives from a mix of government and privately sourced activities.  In the provision of resources that optimize human capital, governments are usually the source of last resort when resources for critical capacities are scarce.  When this fails, and the private and NGO sectors cannot bridge the gap, the political motive forces may be the only option.  If circumstances are sufficiently dire, the motivation to produce a political solution may need to come from the force of a true social movement where a majority of the population manifestly supports filling the gap.  In such instances, “people power” can be capable of inducing the change necessary to produce the necessary political decisions.  Unlike most other western countries where the naked power of a mass social movement is not uncommon, it is extremely rare in its pure form in the U.S.  Here, such a movement can be discerned “below the surface, “ as it were, in successful legislation such as Medicare/Medicaid.

 

 

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Breakout Group 3

 

Discuss and critique the following extract from the Consensus Statement of the Seventh National Conference on Primary Health Care Access:

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.

Boltri, Leader; Peck, Scribe; Cobb, Haughton, Henderson and Smith

Ms Anna Peck (left, front row) and, clockwise, Doctors Kevin Haughton and John Boltri, Mr Tim Henderson and Doctors Stephen Cobb and George Smith

Breakout Group 3 Scribe Notes:

Re: Comprehensiveness – The definition of comprehensive training has no consensus. Training is variable due to training opportunity differences and physician areas of focus even within the discipline of family practice.

Many competencies are developed more fully after training, introducing another source of variability. Internal medicine primary care physicians (PCPs) not trained in pediatrics will not care for obstetrics patients – a definite rift in “comprehensive” skils. Care is also now delegated to hospitalist teams in the inpatient settings by some PCPs.

Re: Continuity of care (COC) – over a period of time, COC requires a physician to be in the same place for a period of time. It may be sustained even though the patient may see other providers when the patient is aware of the ongoing care relationship.

We discussed different definitions of continuity of care. There are different forms of continuity of care: these might include providing continuous care over a lifetime, continuity from hospital to outpatient, continuity in the traditional sense includes taking care of the whole patient, cradle-to-grave. (See below for other definitions.)

Does this cradle-to-grave continuity still happen? Possibly in some practices. – it seems to vary based on where one lives. Possibly more in the rural setting. The traditional doctor who stays in one place for his whole life and takes care of families is not the most common model currently in place even for primary care. In more urban settings, patients may see their PCP more rarely. Management by specialists may also be sought by patients and primary care providers, making PCP-based care potentially less comprehensive, depending on how aware the PCP is of the specialist’s plan.

Some patients my also come to a PCP only for referral in some insurance.managed care plan settings. In this scenario, the PCP may serve as a gatekeeper but if the patient does not maintain a relationship with the PCP, they are unable to build a continuous care relationship. Consultations at retail clinics for episodic issues may also prevent involvement in continuous care. It may not always be best for the patient if they wait for PCPs to be available to provide care.

Relationships established over time may be necessary to provide good comprehensive care. Without that relationship, patients may no be as likely to concur with the PCP’s care plan.

Coninuity can be over episode, over time, over the chart recorde. There can be continuity of information or of the team, or geographical continuity, or continuity in the standards of care. Continuity of philosophy may attract patients to a care setting, such as a faith-based care system.

Continuity can also be provided by another PC provider, such as a nurse, when care providers cahnge a lot, such as in an academic-based care setting.

PHPs – personal health care records may be used by the patient to view one’s medical records. This may encourage the patient to see everything in one place. A physician e-mail system may increase continuity of care.

Why continuity of care?

1) It saves dollars; 2) patients want it; 3) it results in better health care; 4) its value increases with patient complexity; 5) it increases patient safety. Are there studies to show the benefits of COC? Yes, regarding patient safety in handoffs.

Are patients aware of the benefits of COC? It is possibly not a priority for them as access itself is not stable. Even with plans in place (Medicare, Medicaid), access to a provider may not be present locally. With Medicare/Medicaid, one may not be able to refer. Can care then be comprehensive?

Accountable care organizations (ACOs) may force continuity in some situations.

Re: access to a personal physician. Access is a key issue. Not all people can access a regular care provider. This may include people who move frequently, change insurance or are not insured and cannot afford access to care. Physicians may also move frequently. Insrance changes at employers may prevent choice of providers and prohibit establishment of long term relationships. Use of multiple physicians may also be a barrier to the “personal” physician (e.g. doctor shopping or just use of multiple PCPs.)

Notes submitted by Anna Peck, Breakout Group 3 scribe.

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Breakout Group 4

 

Discuss and critique the following extract from the Consensus Statement of the Seventh National Conference on Primary Health Care Access:

 

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.

 

Flores, Leader; Flinders, Scribe; Christman, Hansen, Hines and Maudlin

From front left, clockwise: Doctors Thomas Hansen, Hector Flores, Robert Maudlin (hidden), Rick Flinders and Thomas Hines; and Mr J Scott Christman

Breakout Group 4 Scribe Notes:

Consensus observation: Among educators (i.e. residency program directors):  Strategy is to move from crisis management to future planning.

But challenges, mostly fiscal, are formidable:

Spokane:

Regionalization of corporate leadership (Providence) has resulted in remote decision-

making

Funds scarce

Budgets harsh (cost-neutral)

Done by administrators

“Cuts”  means cuts in  Salaries/Wages/Benefits (= personel)

Santa Rosa:

Lessons learned:

beware single sponsorship;

danger in tying financial support to success of single hospital/corporation

strength in numbers, i.e. multiple partners

community partnerships, (consortia or otherwise)

FQHCs as sponsors gaining success

Boston:

At mercy of state budget woes

Spend reserves, then brace for layoffs…

Spend until it hurts, then we’ll see how bad is the bleeding

Omaha:

Pre-recession expansion has left huge overhead

Now clinical income is falling

Increasing tuition can’t make up the gap

White Memorial, Los Angeles:

Seismic costs substantial

Sponsors want to share costs but not control

Increased competition for retention of DSH dollars

Some General Suggested Strategies:

More alignment  with hospital and corporate mission and strategies

Example: full community benefit obligations

Medicare HMOs must pay GME $

Future benefits of ACO’s

Light candles in church

Notes submitted by Rick Flinders, Breakout Group 4 Scribe

 

 

 

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Breakout Group 5

 

Discuss and critique the following extract from the Consensus Statement of the Seventh National Conference on Primary Health Care Access:

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.

Frey, Leader; LeRoy, Scribe; Fernandez, Murray, Prislin and Sundwall

From left, clockwise, Doctors Michael Prislin, Gary LeRoy and Donald Frey. Not shown, Doctor David Sundwall

Breakout Group 5 Scribe Notes:

This topic provided the breakfast participants with great substrate for developing conversation surrounding the current national attention or inattention to matching health professional education output with the needs of the region.  The consensus of the group was that currently it is poorly matched.

We have an alphabet soup of accrediting agencies (AAMC, AMCAS, NRMP, LCME, etc.) who have separate often competing interests to control the pipeline of future physician professionals, but there does not seem to be a concerted effort to produce either a balanced number of graduates to serve either the national or regional social needs in respect to specialty or geographic distribution.

The question arises about who could make this determination of what graduates will ultimately specialize in and where they will practice.  Financial incentives have been used in the past in the form of loan repayment plans with some degree of success.  Dr. Sundwall spoke about the how the impact of working in the National Health Service Corps has been particularly instrumental in getting graduates to work in underserved and particularly rural areas.

The subject of incentives to medical schools to produce socially appropriate numbers of graduates was discussed.  As more medical schools are increasing their class sizes to offset decreasing State funding of medical education and more medical schools are being established little attention is being given to the vanishing numbers of primary care residency slots and student interest to accommodate the needs of our society.

We reflected about the 1990’s Clinton Health Care Plan that proposed a balanced number of primary care and specialty care graduates.  This plan actually provided incentives to schools to produce certain numbers of specialty graduates. What are the pros and cons of revisiting such a plan for the 21st century?  The current PPACA does not specifically address this topic except through supporting teaching health centers, and the establishment of a committee to monitor the effectiveness of PPACA programming and initiatives.  We learned that although this 15-member committee has been established it has not been funded and thus has not yet met.

The topic of medical school social missions and how to finance the recruitment of a diverse class of students who will meet the needs of society was discussed.  As student indebtedness increases a focus on high reimbursement specialties becomes more of a reality for graduates.  The Deans of the U.S. medical schools continue to hide in plain sight the fact that the majority of their graduates that are included in the numbers going into primary care are selecting internal medicine for their initial primary care training and approximately 90% subsequently go into sub-specialty fellowship training.

If medical schools were to receive federal, State or local incentives to produce graduates that would serve the needs of society who would determine these needs and verify that schools are producing the correct numbers of corresponding graduates? How can we prevent medical schools from using smoke and mirrors to create the numbers needed to get the funding they want?

Changing the admissions criteria of medical students will also play a critical factor in where they will ultimately practice.  Respect for attracting a socially diverse group of medical students must be grounded in tangible fiscal incentives to do so.  If we continue to only focus on recruiting second, third, or fourth generation offspring of affluent physicians then we will continue to get graduates who only seek higher paying sub-specialties of medicine.

If we continue to place more concentrate on attracting the students who will garner us a better average MCAT, GPA, USMLE scores, or worse yet, a better U.S. News and World Report rating then we are doomed to fail to fulfill the health care social needs with the product that our U.S. medical schools will be producing.

Notes submitted by Gary LeRoy, Breakout Group 5 scribe.

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Breakout Group 6

 

Discuss and critique the following extract from the Consensus Statement of the Seventh National Conference on Primary Health Care Access:

 

 

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.

North, Leader; Jafri, Scribe; Clasen, Clover, Fowkes and Kahn

From left, clockwise: Doctors Norman Kahn, Charles North, Mark Clasen, Ms Virgina Fowkes and Doctor Asma Jafri

Breakout Group 6 Scribe Notes:

The group decided to use 2020 Healthy People objectives. The 2020 statement has more emphasis on youth and adolescents.

There was discussion about the NCQA certification criteria which include monitoring of primary health care services. There was discussion about the various criteria  and some discussion about whether it is better for practices to set their own monitoring criteria.

Electronic Health Record: EHR was discussed in terms of a tool for monitoring various quality criteria. It was noted that some of the current EHR systems are data managers that feed information to the physicians in an uncoordinated and poorly prioritized manner. Most physicians are overwhelmed by the amount of data provided to them.

Dr North took note of the EHR “signal noise” problem.  It is difficult with most EHR systems to sort through all the noise to find the signals, i.e. we get a lot of unprocessed data but need meaningful data summarized in a way that we can improve practices.  He thinks we all felt overwhelmed by data “noise” and long for knowledge and meaningful change driven by the knowledge.

Outcomes: There was discussion about the difficulty to collect outcome measures, especially over short periods of time. Since primary care access and services provide benefits to communities and populations over along period of time, it is hard to collect outcome data, therefore process measures need to be used in lieu of outcome measures.

Health Promotion: The CDC sponsored Tufts University.”Shape Up Somerville” (Massachusetts) program, which led to a measurable improvement in BMI for elementary school children, was discussed. It is a community wide effort supported by the Mayor and involved community partners in education, law enforcement, public safety, restaurants, grocery stores, parks and recreation, etc. The Mayor spoke at a meeting on childhood obesity last year.  It is an excellent model that could be spread and family physicians can partner with community services and programs.

There was discussion about smoking cessation programs.  The calorie content of fast foods and and restaurants is required to be posted in California.

Outcomes: There was discussion about Title VII grants and the kind of data tracking required is hard to collect and report.

Mental Health: Integration into primary care was discussed.

New Issues that are emerging with chronic medical disease management of psych patients (severely vulnerable). Physicians cannot handle the demands alone. Systems need to be developed around primary care practices to handle special population (i.e. elderly, mentally ill, multidiseases.

A population approach: A doctor with care coordination and case management are key to developing programs for the vulnerable populations.

Notes Submitted by Asma Jafri, Breakout Group 6 scribe.

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Breakout Group 7

 

Discuss and critique the following extract from the Consensus Statement of the Seventh National Conference on Primary Health Care Access:

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.

Ross, Leader; Erickson, Scribe; W.H. Burnett, Coleman, Kasovac and Lee

From left, clockwise: Doctors Mary Coleman, Mitchell Kasovac and Jay Lee; Mr William H. Burnett (hidden); Doctor Robert Ross; and Ms Delight Erickson

Breakout Group 7 Scribe Notes:

Dr Lee: Is the health reform legislation (PPACA) weak tea? At its best, there is no thinking about the details needed to build the capacity to meet the need.

Dr Ross:  There is no policy to address health care disparities. Funding is expected to “just happen”. No funding is developed, nor returned to the program to be seed money. The teaching health systems are in community health center (CHCs) whose practice site is governed by boards made up of patients, who may have no idea of costs nor the medical needs of populations beyond those served by their patients.

Dr Kasovac: The hospitals will get the Medicare moneys for physician graduate medical education on a breakeven basis, and there is seed money for community health center rotations for physician training.

This should help the model of undergraduate education established by the A. T. Still University School of Osteopathic Medicine (ATSU) in Mesa, Arizona. The ATSU Arizona medical school is based on the Calgary model from Alberta. The participating community health centers (CHCs) are medical school rotation sites, beginning in the second year in which networking connections and the shadowing of physicians occur.

Dr Ross: the hospitals provide a poor model of primary care, with much of the hospital’s staffing comprised of mid-levels and physician hospitalists. Therefore, why should hospitals get the Medicare dollars for primary care physician education? The principal center of primary care education is the family health center, the medical home, and similar sites in which ambulatory primary care teaching can take place. Why incentivize the hospitals to seek to administer primary care physician residency programs?

The Administration’s leadership does not exhibit knowledge of primary care. Vice President Biden’s pronouncements appear to be based on the Kaiser model of delivery, as if there is no other model. Unfortunately, there is no working definition or model of primary care appearing in the legislation. We need a system that attracts students to primary care.

Dr Lee: The National Health Service Corps (NHSC) and other United States Public Health Service (USPHS) programs appear to support purer models of primary care. Their scholarships promote diversity. Could not the ties between medical school and admission, scholarships and service through the Corps be increased?

Mr Burnett: A major change in the NHSC occurred in the mid-1980s, when the emphasis changed from medical school scholarships to postgraduate physician loan repayment for service programs. Although that change helped resolve the concerns about medical school students accepting NHSC scholarships, then choosing a subspecialty that could not be used by the Corps. However, the NHSC is expected to expand substantially over the next few years, and perhaps new programs, such as funding for student scholarships to community-based, primary care oriented medical school tracks could be implemented.

Dr Coleman: One should look at how funds for expansion of health care coverage are expended. Policies should promote increased salaries and reimbursements to primary care physicians, and to patient-centered medical care.

Dr Lee: We should explore ways to captivate interest in primary care beyond reimbursement increases. One way might be to incentivize community-financed disbursement of funds, rewarding those programs that produce physicians that meet community needs.

Accountable care organizations: we’ve heard of them, but has anyone actually observed one working?

Who bears the risk? Primary care physicians must not just be at the table, they should assume leadership. You need to be able to know what to ask of those who hold the purse strings.

Theoretically, rotations of only two weeks are superficial and those of nine months are good, but funding committees usually don’t follow through with funding for the longer periods.

Is it politically feasible to impose service obligations on medical students?

State demonstration projects, where locals decide what they need, are a good way to draw down federal funds.

The “all payers” idea is interesting: how to expand that pool of cash and how do you get into that pool? If all providers/payers contribute a dollar, there would be no problem in funding.

Dr Coleman: The financing model should be changed, and replaced with one that is a better use of taxpayer’s money.

Dr Ross: There should be “exposure driven funding”.  Primary care must be valued, if we are to really attempt the expansion of the health care market to everyone. The OHSU people are now looking at primary care.

Kasovac: Do we choose the students, or do the students choose primary care?

Dr Lee: th business-driven model implied in the legislation is not a social model. How do we do this better to get the dollars to provide the services, and expand acccess to care?

Notes submitted by Delight Erickson, Breakout Group7 scribe.