Proceedings of the Twenty-Second National Conference: First Day Opening Plenary Session (Part 1, Clasen, Flinders)

We gratefully acknowledge the sponsorship of the Sparrow Hospital/Michigan State University Family Medicine Residency Program of Lansing, Michigan for the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:


Mark E. Clasen, MD, Ph.D., Wright State University: As today’s moderator I’m charged with keeping the meeting going on time.  In past conferences, my colleague Dr. Gary LeRoy developed an interesting strategy for preventing speakers from going overtime. When there’s just a few minutes left allotted to the speaker, he’d saunter near the speaker. When he one minute left he’d kind of bump the speaker and then when the time was up he’d give them a wedgie.  Now I said last night to Mr. Burnett, that I am not giving Dr. John Geyman a wedgie.

First, I want to ask Doctor Rick Flinders to come up and welcome us into his part of the country.

 

RIck Flinders, MD; Santa Rosa (California) Family Medicine

Rick Flinders, MD, Santa Rosa Family Medicine: Where is this guy that’s gonna give me the wedgie? All right, you stay in your seat. I’ve got five minutes to welcome you, I don’t think I’ve ever said anything in five minutes but I promise to try.  I welcome you to the 22nd National Conference on Access to Primary Care Access whose them is “How will it work?” This is the question of the day, the question of the week and what we will be addressing ourselves to over the next 72 hours.

I’ll begin with some recent history, since, after all, the best predictor of the future is the past. In 2008 President Obama was elected. Hurrah!  We expected, finally, to get healthcare reform.

But in 2009, we had the debate on universal care, in which we argued that healthcare is a right after all and not a commodity. But, no, we were told – that’s too radical. We’ve got to be pragmatic politically.

Oh well, then, we argued for a single payer, right? That’s a no brainer. No, that idea is politically dead on arrival. (e.g., Dennis Kucinich’s plan)

Oh well, we’ll argue for a public option where people can at least have the choice for a national health insurance, right? Wrong, we were told. That won’t get 61 votes in the Seante. We’ve gotta be practical, we’ve gotta get what we can. So we got what we could. In 2010 we got the Patient Protection and Affordable Care Act (PPACA).

At the 21st National Conference in Kaua’I, we dedicated ourselves to these questions: What just happened? And what are the consequences?

We heard many warnings from our group,  and learned that many laws from history apply, that we are bound by the laws of the past.

Dr. John Geyman warned us that PPACA is not healthcare reform, but is instead a tweak of the insurance industry. And there are 1300 insurance industry.companies 27,000 insurance plans and one out of every three healthcare dollars is skimmed off the top, or the bottom, or the middle, for the healthcare insurance industry. John’s attitude toward the healthcare insurance industry is not subtle. He wrote a book, the title of which is Why Insurance Companies Are Dying and Why We Should Let Them. be John’s level of care for the insurance companies somewhere between DNR and euthanasia.

Dr Joshua Freeman warned us also, saying that the reason the health insurance industry and Big Pharma got off like bandits in the new legislation is because, well, they’re bandits.

Dr Mark Babitz warned us that the trend in primary health care training programs towards conducting training in community health centers could be a mixed blessing.. While they are enriching and supporting primary care, be careful, because the community healthcare centers, the FQHC ‘s, are driven by productivity, not teaching.

Dr. North warned us of the law of inverse care, which was first described by Dr Julian Tudor Hart in 1971. It states that the availability of good medical care tends to vary inversely with the need for it and in the population at large, throughout all populations. How ironic! This was his observation in the national healthcare system in Britain, as well as most other systems throughout the world.

Then there is The Law of Unintended Consequences. I won’t read to you again, but basically it means that unexpected things happen when one makes major changes in a system.

An example was the Medicare legislation. There’s nothing in the Medicare Act of1964 about civil rights, nor about graduate medical education. And yet,its unintended impact on both was unprecedented.  Because Medicare paid hospitals based on cost and that cost included the training of  interns and residents, it became one of the pillars of our medical graduate education funding.

Also, because the Civil Rights Act of 1964 mandated that any hospital receiving Medicare payments had to be integrated, it transformed hospitals throughout the countr, especially in the South. In 1967 13% of the hospitals in Mississippi were integrated. By 1977, only ten years after Medicare was implemented, an unintended consequence was that 87% of those hospitals were now integrated. So the effects on graduate medical education and in civil rights were enormous unintended consequences of the Medicare legislation.

What are the intended consequences of the current one? This year we’re going to be looking at how it will work. There are legal challenges to the Act, so “authorized or approved” does not mean “appropriated or funded”.

Lst year we asked what might The Law of Unintended Consequences mean for the current legislation, The Patient Protection and Affordable Health Care Act? This year Bill Burnett has asked us to examine, “How Will it Work?” And what about the unexpected?

On the other hand, kids remain on parents’ coverage until the age of 26, preexisting conditions to exclude children from health insurance were eliminated in March of this year, and the lifetime cap on individuals health care reimbursement apparently will be lifted in 2014.

San Francisco Gas Prices (April 2011)

The questions for the next three days of the conference will be: What will work? What won’t work? And what about the unexpected?

We welcome you all to San Francisco, California… we have the highest gasoline rates in the entire country. Does anybody anywhere else outside this state pay $4.50 for a gallon of premium?

Hawaii, ok, yeah, right, well you see, we’re five miles from a port, from three refineries, 100 miles from 1,000 oil wells, but the reason we pay $4.50 for a gallon of gasoline is because we will. And the oil companies know this.

17th Hole with view of Golden Gate Bridge

Now just a few glimpses of San Francisco, places you might want to visit while you’re here:

The Golden Gate Bridge as viewed from Lincoln Park. This is from the 17th tee of Lincoln Park Golf Course, by the way, public golf course $25-30 to play 18 holes. I strongly recommend it.

Near the Palace of the Legion of Honor, where this wonderful piece of art sits and will greet you at the museum where fine collections of impressionist paintings are to be found.

Now, three questions on this. Who sculpted this wonderful piece? Rodin. What’s it called? The Thinker. Now, what is he thinking? I suggest “HOW WILL IT WORK?”

Rodin’s “Thinker”: How Will it Work?
Buddha Statue in Golden Gate Park

Alright, in Golden Gate Park, here is a wonderful statue of the Buddha given to us by Japan in 1948, it weighs a ton, it’s been sitting there peacefully since 1948.

It’s in a quiet corner of the Japanese gardens in a quiet corner of Golden Gate Park, near UCSF medical school, my alma mater. Used to come here when I was exhausted from studying.

Next is the Cliff House. Take the 38 Geary bus all the way out to the ocean and you will find one of the finest meals and the finest views that you can see in San Francisco. I recommend the apple crisp with Chantilly cream and raspberry, $8.50 and worth every penny.

The Cliff House, San Francisco

Here is The War Memorial Opera House. Bill Burnett can tell you more about this. There’s no opera scheduled here this week, but the San Francisco Ballet Company is putting on productions all week long.

San Francisco’s War Memorial Opera House

And this is AT&T Ballpark. Well, the Giants are out of town and this man at the plate you won’t find anyway, as he’s just been convicted of felony obstruction of justice and is a testament of chemically-induced acromegaly from Human Growth Hormone.

San Francisco Giants (AT&T Ballpark) Bonds at bat

But it’s a wonderful place. And the Giants, I think are going to be back in town Friday night against the Atlanta Braves and if you’re gonna be here this week it’s a place to see. It’s a wonderful shrine to baseball. So, welcome to San Francisco.

The Baseball World Champion San Francisco Giants

Oh by the way, did I say home of the 2010 world champion San Francisco Giants? We waited 52 years. And we welcome you all.