The 23rd National Conference on Primary Health Care Access was scheduled for April 16-18, 2012 at the Park Hyatt Aviara in Carlsbad, California. The first conference events were breakout groups at the Vivace Restaurant on the Park Aviara’s lobby floor.
All seven groups had the following topic for discussion:
There are many examples of individuals and organizations who are committed to increasing access to quality primary health care, no matter what happens to health care insurance reform. Give examples of how you (or persons whom you admire) are addressing the problems of a population’s ill health or medical needs.
GROUP ONE: Clasen (Leader); Babitz (scribe), Flores, Leong, Renaud and Webster.
The following notes were submitted by Marc Babitz, Group One Scribe. They have been reviewed by Doctors Clasen and Renaud, who have revised and approved the quotes attributed to each of them.
Doctor Renaud is the 2012 Thomas Brown, Ph.D. Memorial National Conference Scholar
Flores: expresses admiration for Mark Clasen, great work analyzing demise of FP Residency. [See Measuring the Economic Impact of Closing a Family Medicine Residency: An e-publication of the National Conferences on Primary Health Care Access.]
Leong: seeing changes in HMO practice in his current work. CHCs always had tension regarding funding and balance of patients (payor source).
Flores: difference between publicly traded health insurance companies (for profit) vs. non-profit companies that reinvest into community.
Leong: CEO and Board determine direction of health plan. Do what costs the least or do what is best for the patient?
Flores: health care reform trying to justify profit margins and justify rates. California has tighter control. Workforce issues remain a challenge for everyone. Large employers who don’t care for the poor/Medicaid able to pay top dollar for providers.
Leong: why does Kaiser cost more if they are an “ideal” plan?
Flores: Kaiser financial person said that they needed to maintain their reserves. In the past insurance companies could pass on all increased costs and raise rates as desired. Kaiser is a model of efficiency.
Babitz: Intermountain health care is another model of efficiency.
Flores: biggest competitor for providers in California is Kaiser and the prison system (which is paying new FPs $250,000).
Leong: Any changes in training programs in primary care?
Clasen: big changes over 20 years in students and residents. Much greater use of computer tools. Current students can’t sit through a lecture. Need laptops and devices.
Flores: had residents lamenting that not all their classes were online!
Clasen: this changes their view of relationships. Learning a community and the people is slow work.
Webster: continually distracted by something else. Students don’t have to go to lecture, all online.
Flores: still hard working individuals, but at different hours and different things. Many now see medicine as a vocation that is a means to another end.
Babitz: has this changed relationships with patients?
Flores: No, the patients are like this too. Kaiser markets to this population. Patients like the asynchronous communication.
Clasen: his program was early adopter to electornic health record (EHR). Big paper charts hard to use, hard to read, hard to find informtion, EHR can flood provider with data. Can’t bill for reviewing that data. Primary care flow/productivity must change.
Leong: need to move to the patient management payment style, per member/month, pay for chronic disease management.
Flores: there is a retooling of delivery systems across the country to be more efficient. Community clinic model (paraprofessionals, patient navigators, etc.) to maximize provider productivity. PCMH rewards that system. Potential to get paid for doing this.
Babitz: what about cherry-picking of healthier patients by these systems?
Flores: yes, some may do that.
Leong: costs/visit at CHCs, for example, can be very different. Not rewarded for efficiency?
Clasen: elephant in the room is the mental health piece. A lot of residents just don’t want to go there. We are losing the unique story of each patient.
Babitz: doesn’t a third of the population have mental health issues? Are we going to ignore that?
Leong: Can we do preventive health for mental health problems? Need to have time to talk to patients.
Clasen: CEO of one health system bragged about seeing 12 patients/hour. I told him that the law suits will come later.
Leong: I was taught that 95% of diagnosis was based upon history alone.
Clasen: billing requirements, re. ROS, etc. driving care. Moving away from a true patient history.
Flores: learning to manage a patient panel without having to see them in the office, yet get paid for avoiding ER visits and other costs. How can small practices do this?
Clasen: uses a scribe with patients to keep computer from being between him and patient. Dayton has multiple computer health systems (Air Force, VA, hospitals) that don’t automatically communicate with each other. Hospitals want to keep them separate.
Webster: still have some small groups in private practice who are working to be PCMH. Those practices can have increased income with less work. New graduates not taking Medicaid, despite having 40% of population on Medicaid. Michigan Medicaid offers enhanced reimbursement for MSU practitioners.
Flores: challenge of these special programs/FQHC model, is if everyone did it, it would break the bank.
Leong: it would break the bank under current payment plans, but currently 80% of dollars go to the hospital.
Flores: Kaiser model is to squeeze dollars out of hospital costs. Medicaid has enough money, but hospitals have a powerful lobby. All elected officials have a hospital in their district.
Leong: hospitals depend on physicians (sub-specialists) to keep them open. If we could just shift percentage of physicians toward primary care.
Flores: DSH hospitals don’t want Medicare/Medicaid patients in managed care because it hurts hospitals’ bottom line.
Leong: don’t overly subsidize hospitals but don’t let them close.
Flores: need to organize hospital care such as Kaiser. Every hospital can’t be “center of excellence” for everything like private hospitals. Kaiser flatters their consumers so that they like/accept that system.
Renaud: do those patients have choice?
Flores: no, but employers are told pros and cons of Kaiser. If they don’t like it, employees can pay extra out-of-pocket for another program. Kaiser is a union program and they use that to go to other unionized businesses to attract more business. They also use their cost-effectiveness arguments. President Obama mentioned Kaiser as a model for a national health plan.
Leong: main access point to care remains primary care.
Babitz: what has happened to independent NP practices, drug store primary care?
Clasen: ran PA program. Many grads went into sub-specialthy care. ANPs had a very high referral rate which would not occur in FP practice. NPs no longer wanting to be in solo/private practice.
Clasen: Health care costs are now comprising a huge percent of the family budget. This is really a problem for working class families. Working poor need to rely on charity care systems! A problem when those patients need specialty care. Really worries about what will happen if Supreme Court overturns ACA.
Clasen: childhood poverty level is stunning (increasing).
Leong: hospitals are largest employer in rural areas.
Clasen: imagine Medicare being insurance company for all Americans. Let other insurance companies just do Medicare advantage. Then they would really have to compete.
Babitz: no one model is used throughout the country. Our nation is too different.
Leong: population likes Medicare.
Clasen: as geriatrician, loves Medicare.
Flores: many don’t know Medicare is a government program.
Leong: in Maryland, legislature told that changing Medicaid to a managed care program would save dollars. Every specialist has to make a living.
Flores: Gwande’s article about costs in McAllen, TX for Medicare patients. Costs were three times the cost of the same care in the Rochester system in MN.
Leong: can fee for service continue?
Flores: savings come from fees for global services; a problem for small, independent practices.
Clasen: need to teach team to do other duties.
Flores: train community health workers. Malpractice coverage depends on documentation of training and skills. Uses a Johns Hopkins model for training of assistants.
GROUP TWO: Flinders (Leader); Bachofer, Fredrick, LeRoy (scribe) and Rodos.
The following notes were submitted by Gary LeRoy, Group Two Scribe. They have been approved by Dr Fredrick and approved with revisions by Dr Rodos.
Dr Bachofer is the 2012 Charles Q. North, MD National Conference Scholar
Dr Fredrick is the 2012 Mark E. Clasen, MD, Ph.D. National Conference Scholar
Our discussion began with a debate about primary care and the recent match for residency training. What do successful medical schools do to have good match results in primary care?:
- Selective admissions process
- Clerkship experiences which are positive
- Changing social climate
This transitioned to a discussion about the community challenges of providing access to care. We work in a “lousy” system. Where are the individuals who will or can inspire the next generation of teachers of primary care, who will increase access to primary care.
There was a discussion about the history which led us to this point that we have such a broken system.
The group discussed the pros and cons of faculty Balint sesions to identify how we, as professionals, feel about what we do. The participants feel more aware of what we do and the rewards.
- How are we going to pay off loans?
- The desire to always know the answer
- The cost of academic training in the community – it does not pay the bills.
PPACA is an “access to care” bill. It increases the number of Medicaid eligibles, but does not increase the numbers of primary care professionals.
In the pre-1970s (c. 1965) charity hospitals and medical schools cared for the underserved. There was a professional commitment of service to the underserved that seems to have eroded in the 2000s.
What do you do with the patient in “four days” after they have been hospitalized, stabilized, and discharged back into the environment from which they came?
There was discussion about FQHC and community health center missions of productivity and service. There is no mission to educate medical students to become the next generation of family doctors who will serve.
“Provider burn-out” can possibly be relieved by incentivizing physician to be clinical faculty and the ability to teach.
The next generation of physicians will be more interested in lifestyle management.The “Hot 100” patients who use all/most resources are now being identified by the community to prevent unnecessary hospitalizations and costs. Interventions are being given to these 100 individuals proactively. Students participate in these activities.
There is an increasing loss of appropriate physician to physician communication to sub-specialists for referrals. Now many referrals are triaged by PAs and APNs. There may be referral apps that we will use in the future.
When asked what other specialty of medicine we would do other than family medicine, all participants [in the breakout group said they] would do family medicine because of the perceived value in our work.
GROUP THREE: Hara (Leader); Broderick, Freeman, McCanne (scribe) and Ross.
The following notes were submitted by Don McCanne, Group Three Scribe. They have been reviewed and approved by Dr Hara.
The country needs to have at least 25,000 new family physicians. Yet, there has not been much change or improvement in the last two decades in the expansion of family medicine. There needs to be advocacy for GME reform, especially for family physicians; although there is a risk that changes in GME reform might result in even greater numbers of specialists, when primary care physicians are needed.
Medicare should not be the revenue source for GME funding. The current system produces an inequitable distribution of funds between primary care and sub-specialist physician training programs. Hospitals are at risk of being disallowed reimbursement by Medicare for GME.
Public hospitals care for the sick young and poor. They have less Medicare and therefore less funding. The Primary Care Access issues raised medically underserved areas and minority populations, including undocumented patients, regardless of whether the health insurance reform legislation is fully enacted, still needs to be addressed.
Medicare should change its reimbursement structure, slashing the reimbursement rates of sub-specialists. The marketplace will produce a shift to family medicine. Even sub-specialists will agree, since there will be less competition for the diminishing sub-specialty market.
Sub-specialists are worried about Accountable Care Organizations (ACOs). (BPs in orthopedists’ clinics being an example of difficulties in coordinating care).
Comparing CHCs and public hospitals: There is contrast between the Kaiser Permanente system that is fully integrated with registry coordinators and an integrated Information Technology system, compared to the loose coordination of CHCs and public hospitals.
The quality of data is essential for performance reports. FPs are likely to outperform in preventative medicine.
What do we do to get effective population health management systems? Population health requires Medicaid Managed Care, in which a joint effort between primary care, sub-specialty groups and hospitals can create a system. (Look at the example of Klamath Falls, Oregon.)
Hospitals cater to primary care in order to pick up revenue sources from sub-specialists to whom primary care physicians refer.
The health insurance system must be reformed. Eliminate parsasitic passive investors.
GROUP FOUR: Haughton (Leader); Burnett (WH), Geyman, North (scribe), Scherger and Wilke
The following notes were submitted by Charles North, Group Four Scribe. They have been reviewed by Doctors Haughton, Scherger and Wilke and Mr Burnett, who have revised and approved the notes.
Examples of increasing access to vulnerable populations:
The NHSC and IHS scholarship programs and FQHC federal programs were seen as the prototypical programs that effectively address the needs of diverse communities for access to medical care. The programs have been proven over time to meet access needs and now are addressing training needs and sustainability by becoming teaching community health centers.
Native Alaskan health care systems are using dental extenders to provide access for frontier populations to basic dental services traditionally provided (or not) by dentists. The team-based approach to medical and dental care should not only be practiced but taught from the early years of medical, dental, public health and allied health professional education.
Faith-based organizations should play a role in service and education especially for marginalized individuals, communities and populations such as undocumented immigrants. Student organizations can be very effective in helping to staff and provide direct care to such populations through faith-based groups.
We don’t currently have a national health care system in the USA. We have a free enterprise system that is designed to reward the key stake holders -including insurance companies, hospital systems, big pharmaceutical and medical device companies. Doctors, especially proceduralists, have also benefited greatly.
Our current non-system is not designed to improve the health of the population nor is it designed to raise health status. Organizations that are designed to improve population health operate at the margins, not in the mainstream. The federal Indian Health Service and its partner Tribes, Native Corporations and urban Indian organizations are prime examples of entities designed to improve the health status of defined populations, but they have not been held up as examples for reforming a plan for the US population as a whole.
Other innovative examples include a school-based community clinic in partnership with the school of medicine and nursing and the school system in Albuquerque. Many medical schools sponsor student-based organizations that serve minority populations such as Latinos, African Americans, immigrants and other special populations. Located in medical clinics and community-based organizations or health fairs, students can participate in reaching traditional under-represented groups.
Who is the medical care system for? Whom do we serve? What is the role of faith-based religious organizations in meeting needs that are not adequately met by our systems?
What is the role of “direct care” primary care concierge type practices and the needs of populations to have better heath status?
GROUP FIVE: Henderson (Leader); Hansen (acribe), Olsen, Schwartz and Zuniga
The following notes were submitted by Thomas Hansen, Group Five Scribe.
Dr Schwartz is the 2012 J. Jerry Rodos, DO National Conference Scholar
Dr Zuniga is the 2012 John Geyman, MD National Conference Scholar
Schwartz: The ATSU Osteopathic Medical School in Arizona has opened regional campuses to help address needs of underserved within the community health center structure. Its possible that the role of the primary care doctor will be radically redefined given the increase in patients needing primary care docs.
Olsen: Board member of community health center under medical clinic in a mental health clinic. Its difficult to find primary clinicians willing to provide medical care in that setting.
Zuniga: There is a diversity of lifespan between Hispanic populations (73 years) and whites (86 years) in California. How to help addres this? There is a psychologist coming to his y medicine residency clinic to provide psychological services to Hispanic populations. Medicare is coming to evaluate their clinics to see if they can receive grants to help increase health information exchange between all primary care clinics to provide better services.
One example of how this will help is a common Electronic Medical Record (EMR) so that patients don’t receive duplicate services (e.g., vaccinations), with the health record available to all clinics.
Hansen: Creighton University MC provides 70% of the indigent care in the City of Omaha.
The Family medicine residency program:
- runs a refugee clinic.
- provides care for family doctors at local community clinics
There is a lack of transparency in tuition dollars and in the GME dollars for residency programs. How to establish more FM residency programs with limited resources.
Group Responses: The process for calculating indirect and direct GME funds is archaic.
Where do tuition and GME funds go? There is a lack of accountability. The administration has a huge gain from the residency generated GME dollars.
Residency programst don’t depend on CMS dollars. Is there a model out there that works?
FQHC – Future will depend on the next administration. Depending on who wins, we might see the dominance of healthcare administration vs. primary care residencies separated from hospital systems. FOr years, how to incentivize health care centers?
Innovations vs ris. To try and innovate how we teach students and residents in a way that makes sense but doesn’t cause financial difficulties.
GROUP SIX: Herman (Leader); Kasovac, Peck (scribe) and Squire
The following notes were submitted by Anna Peck, Group Six Scribe. They have been approved by Dr Kasovac and Ms Peck.
Mr. Squire is the 2012 F. Marian Bishop, Ph.D., MSPH Memorial National Conference Scholar.
Examples of Institutions serving the underserved:
FMC in Cedar Rapids Iowa – Volunteers, staff paid from donations from the community, receives no federal funds
FQHCs are front line safety nets for underserved. These are self-directed and self-sustaining in the beginning. The downside is burnout and lack of continuity training.
Failure of a clinic can be devastating to a community. Once a critical mass of patient care is delivered, often relying on outside funding and volunteers.
Dr Kasovac noted that 2nd, 3rd and 4th year students from A. T. Still College of Osteopathic Medicine of Arizona are sent to work in community health centers across the country as a medical school rotation. Hospitalists associated with the health care centers often supervise the students.
Mr Squire volunteers at a homeless clinic in Salt Lake City. There will still be people who are either not willing or who can’t access the health care system. There are still access issues in health centers in rural and urban settings.
Dr Fredrick discussed global health initiatives: the Global Health Scholars program, helps people realize that thes services are also needed close to home and they need to be “specialize” in providing such care.
Concerns about health insurance reform legislation:
The reform process focused on funding for the uninsured instead of developing a care system that works for patients.
Physician Workforce Issues not solved (and likely exacerbated) by PPACA:
To get a 50/50 mix of generalists and sub-specialists (considered more optimal than the present system) one needs to change the rates of compensation for each. Often generalists cannot pay back loans at current compensation rates.
A need for developing new primary care residency programs.
Mr Squire: 20% of the workforce in any profession ends up being dissatisfied within the profession and looking for other career paths.
How do we help people choose the right careers? For primary care, provide early exposure to primary care practicea, and build awareness of the successful primary care models.
Question: are we successful at training primary care physicians because they choose to become iin primary care, because we are training them to do so? (push vs pull?)
Factors affecting the rate of producing primary care physicians: parents, socioeconomic status, race, and education level.
Rural programs may have students interested in medicine, but they may have family pressure not to leave the local community.
Interdisciplinary health care training is needed. Longitudinal projects could be used to increase interdisciplinary interactions.
Systems with a good history of setting up people to go into primary care, such as Canada, should be studied. Public health should be incorporated into primary care medical training programs.
GROUP SEVEN: Jafri (Leader); Christman, Coleman (scribe), Lee and Testerman
The following notes were submitted by Mary Thoesen Coleman, Group Seven Scribe. They have been revised and approved by Doctor Coleman and Mr Christman.
The Memorial Health System (Long Beach, California) will be operating as a 24/7 health care entity, with more primary care docs than other institutions in the area.
Adventist Heatlh (Roseville, California) established a medical foundation and has shifted focus from perfromance as a hopsital system to a more complete health care system, or integrated delivery network. They are aggressively rolling out Cerner electronic medical record applications to the ambulatory setting.
At Loma Linda University (Loma Linda, California), all services are being tied together through EPIC. There is concern that EPIC doesn’t have the ability to operate registries or primary care effectively. EPIC is using Dr Scott Fields (Oregon Health Sciences University) for data mining.
At San Joaquin General Hospital (Stockton and French Camp, California) they are using data in registries to do population management.
At Loma Linda University, to increase family medicine residents’ interest in serving the underserved, the interview process looks at the record of service. About 60% of the Loma Linda graduates go into underserved areas. Loma Linda is also moving the family medicine residency into an FQHC. The FQHC will provide a funding source for patient-centered medical home services (social work, mental health, dieticians, etc.)
At Louisiana State University (New Orleans), a pilot project is using Social Work students, Pharm. D. students, medical students, and community nursing students to provide care management for high risk diabetic patients.
A new strategy is to use non-physicians to increase access.
There are difficulties with having many insurance companies askng health care providers to do case management.
It would be helpful to bring together all payers and stakeholders to discuss how to do wellness care. Businesses are also into wellness, such as lowering the rate of smoking.
At Loma Linda University, a physician has been hired who who provides care for the homeless. She wears a backpack and visits the homeless wherever they live.