"What Has Changed?": the 24th National Conference Welcoming Remarks (Haughton)

We gratefully acknowledge the sponsorship of the Presbyterian Intercommunity Hospital of Whittier, California for funding the transcription and editing of this section of the Proceedings of the Twenty-Fourth National Conference:

The following transcription is of the opening sessions of the 24th National Conference on Primary Health Care Access, held April 8, 2013 at the Grand Hyatt Kaua’i. 


Ana Bejinez-Eastman, MD, Presbyterian Intercommunity Hospital, Whittier, California: [Doctor Bejinez-Eastman is a Senior Fellow of the National Conferences on Primary Health Care Access].

Welcome everybody, I’m moderating today. I’m here to deliver the wedgie, pull the hook, – whatever needs to be done to try and stay on time.

A view of the Kalalua Trail on Kaua'i North Shore
A view of the Kalalua Trail on Kaua’i North Shore

I have one announcement to make. If anyone is interested in doing a hike this afternoon with Doctor Charles North on Kauai’s North Shore, there he is, the hiker extraordinaire.

The hike will go the beautiful Hanakapi’ai Falls, right, on the North Shore, partway through the Kalalua trail, so it should be beautiful. There will be free transportation. Who can pass that up? Anyone interested, please see him.

All right, without further ado I would like to introduce Dr. Kevin Haughton, who is going to review our last session.


Kevin Haughton, MD; Providence Health Systems; Olympia, Washington
Kevin Haughton, MD

Kevin Haughton, MD, Providence Health Systems, Olympia, Washington:    [Doctor Haughton is a Fellow of the National Conferences on Primary Health Care Access] 

Good morning! Welcome to the 24th National Conference. I recognize many faces from here from last year.

The tradition is that the person who does the closing comments at the end of the national conferences does the opening introduction of the succeeding conference.

The conference theme for this year is “What Has Changed?”

This is where we were last year, at the Park Aviara resort near Carlsbad, California.


And this is much more what it looks like this year.


So that’s, this is one thing that’s been a dramatic change.


Dr. James Herman gave us a talk last year where he talked about change, and I think it was mostly about a change machine that required dialogue in order to get change back out of it. So that’s been a theme even starting from last year.


Well, one thing that’s changed is that the general population has had enough. At our breakfast breakout meeting [see Discussion Question, Breakout Groups Announced for 24th National Conference First Day, April 8, 2013], we started talking what I’m hearing in my practice.

Patients come to me complaining about their specific items in their medical bills that sound completely outrageous; $1400 for some routine minor lab work. Tens of thousands of dollars for some hospitalization visit.

These medical bill items have hit the pop literature journalism pretty big time. A Time Magazine article about health care costs referred to a 10,000 percent markup for Tylenol, resulting in an image of a “bitter pill” on the cover of Time Magazine.


There are a number of things happening on these same lines. Here are three books published by the ABIM Foundation: Over-Diagnosed, Over-Treated and Epidemic of Care. There’s a theme I think that is emerging here. Some patients would have been better off if they had never sought care. There are a lot of things that we’re doing with our current system that’s motivating us to do a lot than we need to.


The Centers for Medicare and Medicaid Services (CMS) are involved with this. They are trying to fix primary care.


There are a lot of ideas up here that look familiar to you, like patient centered medical home and accountable care organizations.


There are some ideas about payment redesign that CMS has been supporting. Some of these are leaking out into the public.


But CMS also included a 2% cut in Medicare reimbursement as of April 1, 2013. I haven’t heard as much crying about that as I would have expected, but I’m anticipating this is expected to continue and I’m not sure anyone’s going to stop it. That will have a big impact on what we’re doing in our system.

I am in a hospital system that wants to become an integrated delivery system on the West Coast. In my particular office we have a deal where with a couple of different payers where we get paid our usual fee for service. In addition, we get a very small per member per month payment in order to build some extra infrastructure to monitor our patients more closely – our chronic disease patients primarily.

Then the actuaries figure out how much money that population of patients was expected to spend on hospitalization and emergency room visits. If we spend less than that amount, then we share that money with the insurance company. Some of what we are paid is dependent on meeting some specified quality targets.

This is very much a baby step. This is the “in-betweener”. There is the accountable care concept, which is as far as we’re hoping to go. Then there is this in the middle. Also there is our usual, old fashioned fee for service preferred provider organization , in which free range patients pay for random acts of healthcare – which is the way we’ve been doing it for the last 50 years.

To give a little history of where we’re going with the ACOs, we should go back to the HMOs of the 1970’s. They were really cranking; I was in Minnesota in the early 1990’s and it was kind of exciting times with managed care.

Then, you know we had a lot of backlash, and slid back to the sort of same old fee for service for a while. So we’re going to have to do it different now. I think th type of capitation we are going to face is much more complicated. Hopefully, it will make us develop a better system as opposed to just withholding care.

We are in a world where we have one foot on a boat and one foot on a dock, and the boat is leaving.

We’ve got to keep people out of the hospital, out of the cath lab and out of the operating room. That’s the boat that we want to get on.

In the meantime, we’re making all our money in those places and that’s what’s keeping the health system going.


Somehow, we have to transform the way we pay for this at the same time we’re transforming the way we do it. That’s tricky but we’re up for it!

 I will cite three geniuses here in a row.

First, Michael E. Porter gets a lot of credit for his 2006 book pushing value-based payment for healthcare. He’s really got us going. He really brought us a long way.

Porter just came out with an article in Health Affairs discussing an idea for redesigning primary care.

His idea is basically to break it up into subpopulations. People who are high-end users, high needs patients like those in the Program of All-inclusive Care for the Elderly (PACE). He’s going to put them on one pathway.

He would create another subpopulation of people who are in their middle age, but who have one chronic disease at the most to make sure they’re getting their mammograms and their colonoscopies.

Putting them in a category of their own with their own systems that manage them as they come through fragments the population. This has been hard for me to take, because I’m an “everybody comes to see me” kind of primary care doctor. That’s what I think of myself.

But Porter is a pretty smart guy. He’s figured out a lot of stuff, so I’m paying attention to what he says and to where he’s going.

That’s another genius we talked about last year, somebody has to do something, it’s just pathetic that it has to be us.


24PHCA 360H HAUGHTON 17Clay Christianson is another pretty brilliant guy. He is a “disruptive innovation guy” and pretty much gets credit for that term.

His model looks something like this: You have your established businesses, such as IBM in computers, who developed mainframes where there are very high margins. That is their main business.

IBM wouldn’t have come up with personal computers, which really disrupted their business, because personal computers couldn’t do all of the stuff that mainframes did when they first started, and the margins for personal computers would be very low.

The really disruptive innovations are people that open up new markets of people that have less money. Those new markets are cut out of the high end markets where the high margins are.

These new markets have low margins. Cars would be examples of this. So you have your Model T’s and then all of the Detroit stuff, and then they start making Cadillacs and fancy cars.


Then in the late 80’s and early 90’s Japan was making these little Datsuns and Hondas that were barely switched over from motorcycles. They disrupted the whole thing, then Japan kind of took off.

Now Japan sort of has been replaced by Korea that came in with inexpensive cars on the lower end of the market. And now there’s $2,000 cars being made in India and China that might do the same thing.

This model of disruptive innovation is pretty widely accepted now.


My question is what is the disruptive innovation for primary health care? What might there be that’s going to replace us? At the high end of the diagram (sustaining innovations) for health care, it is probably DiVinci robots, and MRI machines and hospitals and it’s everything high tech. We’re probably down on the lower end (disruptive innovations).

So you know there’s home urgent care visits by this company in Seattle, near where I’m from, offering webcam visits and phone visits,


Walgreens has two branches of Take Care clinics. One is like an instant care where you walk in and your seen by a nurse practitioner. Walgreen’s also offers employer-based primary care clinics.


This is, actually an effort by my old group health partners in Minnesota. They have virtual well, where they have 24/7 access to nurse practitioner for 40 diagnoses, similar to the walk-in clinics. There is lots of patient satisfaction for this really easy access, so innovation is out there.


There is lots of other nontraditional stuff that you can think about; lots of new ideas, direct primary care and concierge practices. We’re experimenting with telemedicine.

This is Second Life. It’s an avatar.  It’s where you can make an avatar of yourself, and then go visit some made up doctor and meet him on a fake world on the internet. It’s pretty clever, but apparently people can talk about things through their avatar online that they can’t talk about with a physician in person.


Last year, we talked about PPACA. At that meeting we were expecting a decision from the Supreme Court and Dr. Wilke predicted that the vote would be five to four.


We’re going to hear a lot about PPACA today. Here’s two guys we’re going to hear from.


So let’s get started on today’s adventure. Welcome! Let the Games Begin!

Dr Haughton’s Introductory Remarks are followed by: “What Has Changed?”: Health Reform in the U. S. A. – David N. Sundwall, MD


High School of Graduation and Family Doctor Practice Sites

The Coastal Research Group, through its National Projects on the Outcomes of Family Medicine Residency Training and the Community Impact of Family Medicine Residency Programs, is monitoring the practice sites over time of a sample of 2005 through 2010 family medicine residency graduates.

A preliminary presentation on early returns of the study was presented at the Nineteenth National Conference on Primary Health Care Access in April 2008 by William H Burnett of the Coastal Research Group and J. Scott Christman of ESRI, Inc., a leading developer of Geographic Information Systems.

Family medicine residents nearing graduation from participating family medicine residency programs were asked to fill out a survey form that included the following location information:

The name of their residency program

The graduate’s high school of graduation

The medical school of graduation

The practice location after graduation, if known

The mailing address after graduation.

An ESRI GIS program was utilized that plotted the locations of the high schools and the location of the practice sites. If no practice site was yet identified, the mailing address was used as a substitute.

For the sample under consideraiton, 275 practice locations were identified.  Additionally, 93 mailing addresses were added. (These were 2005, 2006 and 2007 graduates.)

There were a resulting 325 matches in which both the high school and the practice/or mailing address was identified. (This was a first cut of the data in the geocoding process.  As these data are further refined, the number of matches is expected to increase.)

The ESRI software has the capacity to measure the distance of each graduate from their reported high school to their current practice location or mailing address.

There were 302 records with solid matches of a graduate’s high school and practice/mailing address location.

For those 302 records, the minimum distance was less than one-half mile and the maximum was 17,000 miles. The mean is 1900 miles.

(Because foreign medical graduates were asked to identify their high school or high school equivalent institution, the mean is high because typically the foreign medical graduates do not return to the area in which they attended high school. Were only North American high school graduates considered, the mean distance would be considerably less and the resulting percentages in the categories described below would be higher.)

For those 302 records, 131 (43.3%)  graduates are located within 100 miles of their high school of graduation.

For those 302 records, 152 (50.3%) graduates are located within 200 miles of their high school of graduation.

Of those 302 records, 193 (63.9%) are located within 500 miles of their high school of graduation.

ESRI GIS Map of Pennsylvania High School Graduates and Their Location (April 2008)
ESRI GIS Map of Pennsylvania High School Graduates and Their Location (April 2008)

Because activities of the National Project on the Community Impact of Family Medicine Residency Programs for the years under study were concentrated in California and Pennsylvania, significant numbers of records in those two states permit a comparison of data for each state’s graduates.

For the graduates of the Pennsylvania family medicine residency programs, there were 108 unique graduates for which both high school of graduation and practice site/mailing address were known:

40 (37.0%) are within 100 miles of their high schools of graduation.

53 (49.0%) are within 200 miles of their high schools of graduation.

71 (65.7%) are within 500 miles of their high schools of graduation.

Analogous data to Pennsylvanias for the counties of Southern California. (This map is a subset of the data shown below for the State of California)
Analogous data to Pennsylvania’s for the counties of Southern California. (This map is a subset of the data shown below for the State of California)

The data for all three maps are from the same data base. For each map, the rectangles with squares represent high school of graduation of  family physician residency graduate and the circles represent practice location or current mailing address. In the middle map of Southern California counties, the lines between high school and current location matches data for an individual family physician.

For the graduation of the California programs there were 129 unique graduates for which both high school of graduation and practice site/mailing address were known:

Sample of Locations of California-trained Family Physicians and Their High School of Graduation
Sample of Locations of California-trained Family Physicians and Their High School of Graduation

78 (60.4%) are within 100 miles of their high schools of graduation.

80 (62.0%) are within 200 miles of their high schools of graduation.

95 (73.6%) are within 500 miles of their high schools of graduation.

The preliminary results are especially striking for the counties of Southern California. Future analysis will include an comparison of the self-reported ethnicity of the family physician residency graduates, data from state and federal government departments of education, which compile ethnicity information by high school, and census data on the  populations residing in sub-county areas.

As mentioned above, these data were preliminary results of early data.

Updated reports will include the 2008 graduates who have been added to the data, and the practice sites established for graduates from earlier classes who had in the earlier surveys not yet identified a practice site.

This process is expected to include further data analysis in collaboration with the Penn State University Department of Family and Community Medicine, James E. Herman, MD, Chair.)

National Project on the Outcomes on Family Medicine Residency Training

The National Project on the Outcomes of Family Medicine Residency Training is a joint initiative of the National Conferences on Primary Health Care Access and the Coastal Research Group’s Research and Data Base Management Committee and Policy Analysis Committee.

The National Project seeks to characterize the impact that family medicine residencies have had on the distribution of family physicians geographically, the range of settings in which family physicians work, the population groups they serve, and the effect the graduates of the training programs have had on the health status of general and specific population categories.

Coastal Research Group Executive Chair Perry A. Pugno, MD with then National Project Director William A Norcross MD at a National Project Workshop in San Diego, 1999
Coastal Research Group Executive Chair Perry A. Pugno, MD with then National Project Director William A Norcross MD at a National Project Workshop in San Diego, 1999

The data base contains both background information and current practice information on thousands of family physicians.  However, it is used solely for research purposes, and no commercial access to the data is permitted, nor is any information on individuals shared with any entity other than the residency program from which the individual physician graduated.

One of the unique features of the data base is that it contains the high school of graduation (or, in the case of persons whose adolescent years were spent in a foreign country of that country’s equivalent institution.)  This permits analyses of the relative impact of high school (the proxy for the area in which the physician spent formative years), medical school, and residency program on a physician’s practice locations.  This becomes especially dramatic when advanced Geographic Information Systems (GIS) are employed to display the associations between these various geographical influences. (For examples of National Project research using GIS see: High School of Graduation and Family Doctor Practice Sites.)

Photograph from a 1999 meeting of the National Project on Outcomes, with Doctor William Norcross, of the University of California, San Diego and Doctor Samuel C. Matheny of the University of Kentucky

As part of the National Project on the Community Benefits of Family Medicine Residency Programs, ongoing monitoring and analysis of the practice decisions of the 2005 through 2008 residency classes in the National Project’s  “profiled residency programs” is occurring.  An interim report was presented at the Sixth National Workshop on the Community Benefits of Family Medicine Residency Programs in September 2006 in Pittsburgh, Pennsylvania, with updates at the subsequent National Conferences on Primary Health Care Access.

The Family Medicine Residency Graduate Data Base

The ongoing activity of the National Project on the Outcomes of Family Medicine Residency Programs is a series of studies utilizing the Coastal Research Group’s Family Medicine Residency Graduate Data Base, which comprises the names, practice locations and background information on over 6500 graduates of family practice residency programs in California and Oregon.

On August 24, 1999 the first meeting of the National Project on Outcomes took place in Los Angeles. This provided the first opportunity for a group of interested researchers on family practice residency outcomes to assess the research potentials of the Family Practice Residency Graduate Data Base. Later meetings of the National Project in Los Angeles occurred on February 22, 1999 in Los Angeles July 19, 1999 in San Diego, and October 11, 1999 in San Francisco.  Subsequently, the National Project on Outcomes has been integrated into the National Project on the Community Benefits of Family Medicine Residency Programs.

The Origins of the Data Base

The first accredited family practice residency programs were approved in 1969, two (of 13 nationally) in California. In the mid-1970s an initiative began to keep track of all of the graduates from the California programs indefinitely. Under the sponsorship of Doctor Sanford Bloom, then of the Santa Monica Hospital family practice residency program, funds were secured to work with each of the existing California residency programs (as well as a program which had closed in 1974) to obtain complete lists of the names of each program’s graduates, and, to the extent possible, relevant background information on each graduate.

With funding from a grant from the American Academy of Family Physicians Foundation in Kansas City, Missouri, the data thus obtained were computerized. By 1983, the amount of data was sufficient to warrant the creation of a non-profit organization, the Coastal Research Group, to be custodian of the data base. Dr. Bloom was elected the organization’s president and Doctor John Blossom of the University Medical Center program in Fresno was elected the chairman of the Research and Data Base Management Committee. Subsequent chairs have been Doctor William A. Norcross of the University of California, San Diego and Doctor Perry A. Pugno of the American Academy of Family Physicians in Kansas City.  The current chair is Doctor Hector Flores of White Memorial Medical Center in Los Angeles.

The Structure and Philosophy of the Data Base

From the beginning, the data base was constructed to permit longitudinal studies of the long-term impact of family practice residency training. However, the data base was structured from the beginning to assure that it would be a confidential resource to the training programs, rather than public data. Thus, rules were established preventing the identification of individuals in the data base or to permit a comparison of the graduates of one training program’s graduates to another’s. The rules permitted qualified researchers to apply to the Research and Data Base Management Committee for access to the data base. But no data were available for use by accreditation or funding agencies.

The data base actually is several interlinked data bases. The principal data base is comprised of some 50 fields of data on each residency program graduate. The fields include the name, unique identifier code for that graduate, year of graduation and number of years in training program. The mailing address and practice address are recorded as two separate fields, with some geographic data on the practice address, including the county, census tract and state-recognized geographic unit (through which considerable socioeconomic data on the practice’s surrounding community are available). Two fields of data describe the type of practice and practice specialty. (Although most family physicians practice the specialty, a few have chosen to become specialists in other fields of medicine.)

The graduate’s high school, high school city and state (the principal proxy for where the graduate spent formative years) and medical school of graduation are included. Other data fields record birthyear, race/ethnicity and gender. If the graduate received a Certificate of Added Qualifications (CAQ) in geriatrics or sports medicine that is recorded, as is any other category of post-residency fellowships that become known to the data base managers. Also included is information on the data of initial certification by the American Board of Family Practice and latest re-certification.

Interlinked with the principal data base are other data bases that were established by means of Coastal Research Group Questionnaires in point of time. All such questionnaires, including a major one to all physicians in the data base in 1987-88, contained an identifying code that permits a researcher to add considerable supplementary material, including questions on scope of practice, both in clinical and hospital settings, and the graduate’s perception of the relevance of his or her training program curricula to the practice situation. One advantage of the linking each questionnaire to the main data base (as opposed to sponsoring anonymous questionnaires) is that the non-respondents to any question can be characterized by other data in the principal data base.

Maintenance of the Data Base

Maintenance of the accuracy of a data base with such large numbers requires considerable effort on the part of the Coastal Research Group, working with each participating residency program, to make certain that the practice addresses and other data are current and accurate. This includes cross-referencing the data base against various national data bases (while making certain that accurate data are not replaced by obsolete or wrong information which can be found in national and institutional records).

As one example of the problems, the data managers must work around, until 1997, board certification data had been obtained by comparing annual editions of the American Board of Family Practice’s directory of diplomates. The decision of the Board to cease publishing the diplomate book in 1997 has added new challenges to keeping these data fields current. A meeting with Board officials to find an adequate solution to this dilemma took place in Lexington in August 1999.

Use of Data Base by National Project on Outcomes

No other set of data on family physicians provides such rich opportunities for analysis of the impact of family practice training over time. It is a prospective, rather than retrospective data base, in that every person in the category of family practice residency graduate in California is contained in it, whether or not they remain in the specialty, retire or die. The high school data provides information on where the graduate was raised. (Although no study has begun yet that seeks to obtain it, information on the demographics of each high school by class year is available nationally). The data base is linked to socioeconomic information on the medical school and community of residency. Socioeconomic data exist on the communities in which the graduates practice. Both past and future questionnaires to the graduates can be used to supplement the general data.

Last Updated (21 February 2007 12:11)

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Colloquy: Joshua Freeman's "Red, Blue, and Purple: The Math of Health Care Spending"

[Editorial note: the leadoff panel at the Twenty-first National Conference on Primary Health Care Access will be moderated by and joined by Doctor Joshua Freeman on the Kansas University Medical Center in Kansas City. Recently, he posted this analysis of issues regarding the current health care reform legislation in Congress. Participants in the upcoming National Conference as well as other persons interested in the subject are invited to comment upon, endorse or disagree with Doctor Freeman’s essay. All comments are peer-reviewed, and should be sent to [email protected]]

The Business section of the New York Times on October 10, 2009, had a small article by Floyd Norris called “The Divided State of Health Care”. It looks at which states and, within those states, Congressional districts, have the highest number of uninsured. In a neat series of graphics, states are divided into “blue” (voted for Obama, have 2 Democratic senators), “red” (voted for McCain, have 2 Republican senators) and “purple” (some other combination). The red states had the highest percent of uninsured, led by my former state, Texas, with 26.5% of those under 65, including 17.8% of children under 18, uninsured. While not linear (the second highest percentage of uninsured is in Florida, a “purple” state, and third is New Mexico, a “blue” state), the association is strong. My home state of Kansas, which has only one (of 4) Democratic congressional districts, and only 2 of 105 counties that voted for the President, is the “best” of the red states. However, its 13.8% uninsured is worse than 14 of the 21 blue states and 7 of the 17 purple states.

From an ideological point of view, this is not surprising, given the vicious opposition of the Republican Party to any type of meaningful health reform. From a practical point of view, it might be surprising – why are the leaders of those states, where there is such great need, not interested in addressing that need? Or, at least, why do the people in the states that have such great need keep re-electing folks who oppose meeting their need? Part of the explanation may come from the second half of the analysis, which shows that it is theblue(Democratic) congressional districts within the red states that have the highest number of uninsured people. This is because these districts have a lot of poor and minority people and vote Democratic, but to the majority of people in the rest of those states, are the “other”: “Of the 10 Congressional districts with the least health insurance,” writes Norris, “seven are in Texas, two in California and one in Florida. Nine of those districts are largely black or Hispanic, and are represented by Democrats who faced little if any Republican opposition in the last election.” Whether this is explained mostly by classism, racism, or something else is an interesting question, but the result is that if you are a poor or minority person in a conservative state, you are in particularly bad straits.

Of course, it is not only the poor minority inner-city people who are left out. In Kansas, while Wyandotte County (Kansas City), one of the “blue” counties, is the poorest county, and also has a high percent of minorities, the next 6 poorest are in rural, white southeast Kansas. Why do these folks vote against their self-interest for Republicans? (Well, they don’t always.) Some of it is that there are other issues that attract their attention, and some of it is that they believe shamelessly propagated lies.

But some of it, as for so many Americans, is misunderstanding how health care costs work. Most of the money is not spent on most of the people. Journalists, living in their middle-class, young-to-middle aged worlds, are among the worst perpetrators of misunderstanding healthcare usage, writing about their rotator cuff surgery or their neighbor’s strep throat. 50% of people account for only 3% of health care costs; thus half of us are essentially “rounding error”. 5% of people account for 50% of costs. The other 45% are using about “their share”, or 47% of health dollars. If we look at this graphically, using (for fun) red, blue, and purple, we see:



The 45% of people who are using about “their share” are those who have chronic health problems and have to go to doctors more frequently, and get more tests, but don’t have frequent hospitalizations. It also includes the folks who have, in a given year, surgery or physical therapy – like for those rotator cuffs – but usually are in the low use group. This portion of the population includes a disproportionate % of seniors, who have more chronic disease and use more health care services.

Another way to look at it would be for $100 spent on 100 people (whose costs are distributed as per the whole population), 45 people would cost about “their share”, just over $1 each, 50 people would cost $0.06 (6 cents) each, and 5 people would cost $10 each.

Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.

This is an extremely important concept, because it is the reason that insurance exchanges have gone bankrupt in every state that has tried it, and will not work at the federal level. While it is acknowledged that insurance companies “game the system” and “cherry pick” healthier people, the efforts in the current legislation to try to prevent that will not be sufficient, because, given the above data, they don’t have to enroll only people in the “low cost” group (although I’m sure they’d like that!), they just have to find subtle ways to get rid of one or two of those 5 high-cost people. For each one of those people they can avoid, they save the same amount as their cost for 10 “mid-user” people or 167 “low users”. None of the current legislation will be rigorous enough to force each insurance company to enroll 5% of the high users (in part because we don’t always know who they’re going to be – see below – which is also why they can’t have none of them). The insurance “exchanges” for uninsurables will then, soon, just as they have in each state that has tried it, become unsustainably expensive while the insurance companies continue to make big profits. See the amazing report in the Washington TimesInsurer ends health program rather than pay out big” to get a sense of what we can expect from insurance companies. (And note that this is from a very conservative newspaper!)

So if everyone looks at it from the point of view of their current self-interest, those in that “low use, low cost” group wouldn’t want to pay more for all those high-cost, high-use folks. This year, today, it wouldn’t be in our self-interest. Except…

…we don’t know when we, or our teenage children, will be in a car accident that rockets them from the low-cost to the high-cost group. And we don’t know when we’ll have a premature baby, or be diagnosed with cancer, or have us or our parents move from the mid-cost, have-chronic-conditions-and-see-the-doctor-but-rarely-be-hospitalized group to the high-cost be-hospitalized-a-lot-including-in-intensive-care group.

So we are all in it together. And the only system that prevents “gaming”, “cherry picking” and adverse selection is having one system. And that is what we need to adopt.

With profound thanks to Robert Ferrer, MD, MPH

Josh Freeman on the question of a national policy on the right to health care

At the Twentieth National Conference on Primary Health Care Access in Monterey, California in April, 2008, Doctor Joshua Freeman was asked to respond to the question as to whether there should be a national policy establishing a basic right to health care.

Josh spoke eloquently, and then posted his remarks on his weblog devoted to medicine and social justice. Another conferee Doctor Don McCanne, highlighted Dr Freeman’s thoughts on the website of the Physicians for a National Health Program. Dr Freeman’s weblog entry and Dr McCanne’s response follows:

Posted by Don McCanne MD on Friday, Apr 10, 2009

This entry is from Dr. McCanne’s Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP’s website.

By Josh Freeman
Medicine and Social Justice
April 10, 2009

Joshua Freeman, MD; Kansas University Medical Center
Joshua Freeman, MD; Kansas University Medical Center

At a recent conference, I was asked to be a “thought provocateur” (!!) on the topic “The nation needs a clear policy on the basic right to health care”.

This is an interesting question, since my first reaction is: “Of course, we need a clear policy on the basic right to health care! I mean, I have a pretty clear idea of what that policy should be, but certainly even those who would disagree with me would agree that we need a policy!”

But, on reflection, I don’t know that they do. I think that a great deal of the perseverance of our “non-system” of health care has been a result of a consensus among our leaders to NOT talk about this issue, to NOT grapple with it, to not have to take a position one way or another on whether health care is a basic right.

This is because, if one does take a position, there are implications, and things that we would then have to do.

If health care is a basic right, then we need to provide it to everyone. We can no longer diddle around with partial fixes, tinkering around the edges, covering (maybe) children but not their parents, covering people who are poor — as long as they are children and their mothers and are really poor and not working — but not those who are poor, or nearly-poor, depending on which state you are in. Or, for that matter, working-class, or, in increasing numbers, middle class.

But the problem is most people in power, including most politicians including the President, don’t want to have to take a position against health care being a basic right. It sounds, well, mean. There aren’t many people, except, well, mean people (and maybe some reactionary ideologues), who are willing to defend this position.

So we have shows such as “Sick Around America”, the Frontline “sequel” to T.R. Reid’s “Sick Around the World” (which Reid disassociated himself from). It interviewed insurance company executives who said “sure we can insure everyone”. If we make it mandatory and can make a profit, everyone. Hmm. The cost would be ridiculous. And the option of single payer was never mentioned. There is a lot more that has to be decided if we agree that health care is a basic right, like how to provide it, how to pay for it, and what will be and will not be covered. I mean, sure, other countries seem to have solved that problem, and we could model a system on one or more of theirs, but where’s the fun in that?

And if we agree that health care is not a basic right, we solve that problem, but we have other ones — like all these uninsured, and underinsured people.

  • And folks not getting preventive care but rather incredibly expensive curative care.
  • And companies like our automobile companies going bankrupt in some part because of the cost of health insurance.
  • And, oh yeah, people dying in the streets.

For the record, I do believe that we need a policy on health care as a basic right, and my belief is that it should be. Perhaps the most important reason is social justice; we all share in the public good. This is what virtually every other nation of the first world has long realized. When T.R. Reid asked the leaders of the countries he visited for “Sick Around the World” how many of their citizens went bankrupt as a result of health care debts, they all said none. The most dramatic response was from the President of the Swiss Confederation, a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”

The health of our society depends upon the health of all of us.

  • When people crowd our emergency rooms, not with minor illnesses, but with serious illnesses that could have been prevented with earlier treatment, that is a scandal.
  • When parents cannot afford their own health care and their illnesses threaten their ability to keep providing for their children, that is a scandal.
  • When people stay in jobs they hate, or forego the opportunity to start a new business, because they rightfully fear being uninsured, that is a scandal.
  • When our friends and neighbors, parents and children, only take partial doses of their medicine because it is a choice between that and not eating, that is a scandal.
  • When a hard-working man with chest pain can see the billboards advertising the superb heart care available at our local hospitals and know they are not meant for him because he is uninsured, that is a scandal.

When we are all in it together, we all have an interest in making the system be as good as it can be. The efforts of those of us who are more educated, more financially able, more vocal, more empowered will ensure that the needs of those who are less able to lobby for themselves are also met.

Just as our nation cannot survive half-slave and half-free, or with only half of adults having the vote, we cannot survive with only some of us having access to health care.

We need to do this for all of us, for, after all, ultimately, we are our brother’s and sister’s keepers.


The Coastal Research Group

Further remarks of Dr McCanne:

Don McCanne, MD; Physicians for a National Health Program, San Clemente, California
Don McCanne, MD; Physicians for a National Health Program, San Clemente, California

Joshua Freeman, MD is Professor and Chair of the Department of Family Medicine at the University of Kansas School of Medicine. I was fortunate to have been in the audience when Josh delivered his comments above at the Twentieth National Conference on Primary Health Care Access, sponsored by The Coastal Research Group.

Words on paper (or on a computer monitor screen) can express concepts, but they fall short in expressing the passion and inspiration communicated to the audience during the presentation of the speaker. This was one of those moments I’ll remember forever.

Josh had to leave before the discussion of a reactor panel assembled to respond to his comments. One physician from Nebraska expressed his views of health care as a matter of justice – comments which also moved me deeply. Another physician from Texas was not inclined to support health care as a right, and then he read us a passage from the Bible.

I’ll ask you, does the nation need a clear policy on a right to basic health care?

University of California Irvine's Family Medicine Residency Program: Outreach to Orange County's Latino Community

Discussion Leader: Charles P. Vega, MD, Residency Director

[The National Conferences on Primary Health Care Access highlight local initiatives throughout the United States that are designed to improve the health status of populations within our nation. One of the California’s largest Latino barrios, in Orange County, has been served for the past 35 years by the University of California Irvine’s family medicine residency program. Current initiatives will be discussed at the Twenty-first National Conference.]

Healthcare disparities faced by the Latino population in the United States have been shown to be related to access, language barriers, and poor communication. At the University of California, Irvine Family Medicine Residency Program, we have had success in addressing barriers to health care.

Charles Vega, MD; University of California, Irvine
Charles Vega, MD; University of California, Irvine

However, Spanish fluency and cultural knowledge among our trainees and graduates continues to fall short of the needs of our surrounding community.

While nearly two-thirds of their patients use Spanish as their preferred language, only 20% to 30% of our residents feel fluent in Spanish. At the same time, half of the residents do not feel competent in cultural issues important to Latinos.

In response, we have developed a longitudinal resident curriculum in Spanish language and Latino culture that incorporates didactic sessions, “language lab” experiences in the residents’ clinic, cultural immersion experiences in the local community, home visits, and community outreach.

Multiple outcome measurements have been or will be employed to judge the success of our efforts. We have performed baseline assessments with 2 validated surveys which assess general patient satisfaction with their physician as well as examine specific cross-cultural skills pertinent to Latino patients.

The baseline surveys provided some surprising results. In addition, the UCI Family Medicine Class of 2012 received a completely redesigned objective structured clinical examination, in which each standardized patient case emphasized Spanish language and issues of culture and disparities in patient care.

The most critical outcome to our project is the number of residency graduates who go on to provide high-quality, culturally-sensitive care for poor and disenfranchised Latino communities.

Overall, the Health Education and Language for the Latino Community (HEAL-LC) project has the potential to be replicated throughout the country to better prepare physicians-in-training for a multicultural environment and improve health care disparities for Latino and other populations in need.

Forum on Educational Health Centers

Discussion Leader: Kevin Murray, MD, University of Washington/Tacoma General Hospital Family Medicine Residency Program

Kevin Murray, MD, Tacoma Family Medicine, Tacoma, WA
Kevin Murray, MD, Tacoma Family Medicine, Tacoma, WA

The concept of an “Educational Health Center” has evolved over several years as a result of collaborative process between the University of Washington School of medicine’s Department of Family Medicine (Department), Community clinics as represented by the Northwest Regional Primary Care Association (NWRPCA) with connection to the National Association of Community Health Centers (NACHC), and the University of Washington Affiliated Network of Family Medicine Residencies (Network).

In short, the concept is to combine the efforts and purposes of residency training and health center service in a more intentional model to serve the interests of both entities while expanding the network of service to the uninsured and the underinsured.

While these affiliations already exist in many forms between Health Centers (HC) and Family Medicine residencies across the country, the current regulatory and accreditation standards pose significant barriers to an efficient and economically sustainable co-location.

That it is accomplished in scores of programs and clinics is a testament to the effort and shared vision the leaders of those residencies and health centers maintain. In other words, it is hard to do and it is heavily dependent on the existing leadership on site.

The current idea is not entirely new. However it started as a “new” idea in a Network strategic planning session.  Many of our programs and many FM programs across the country were facing economic challenges to their survival.

Approximately 10% of FM residencies had closed in the preceding 7 years, most for economic reasons.  We knew that most of the physicians hired by HCs were FPs and we all considered graduates working in HC practices as a success.

We also knew they had many unfilled FP openings and yet were slated to be expanded by Federal plans as the government’s official way to provide care for the poor.  We also felt that there was a strong overlap in the type of patients seen in residencies by social, insurance, illness, and economic characteristics.

We knew the reimbursement for Medicare patients far exceeded our own in the federally Qualified Health centers and felt this adjustment could be a major help in stabilizing the economics of residencies.

We felt residencies had a lot to offer Health Centers in terms of training potential employed physicians, increasing the workforce in the “safety net” for our communities, and possibly stabilizing existing physician workforce in the HCs themselves.

This latter point of view came from our own experience of residencies either in HCs or with satellites in HCs.

We learned a lot! With support from the UW, faculty members performed qualitative research on the cultures of FMRs and HCs.

Structured focus groups run by Dr. Carl Morris explored administrative, economic, service, educational, personnel, regulatory, governance, and cultural issues in these groups.

This work has been published. In short, it revealed the same categories that had made us feel there was a good fit were the areas of barriers to collaboration.  It confirmed that there was a very similar view as to the potential benefits and alignment of values related to service and education.

However, the basic regulatory and accreditation rules posed conflicting measures of successful performance that were critical to each group’s fundamental purpose.  That is, direct clinical service to a defined volume of patients as versus successful provision of educational experiences that included service to patients but required significant elements other than patient service.

There were many apprehensions each group had about the other in terms of erosion of their core commitments and purpose if collaboration occurred.  These areas were explored and defined.

Dr. Morris, Dr. Frederick Chen, and others also reviewed our network’s history in future practice of our grads.  They found that residents trained in a HC environment were significantly more likely to work in a HC after training as well as much more likely to work in a health professions shortage area after graduation. These trends have since been confirmed by other residency networks with similar differences of training sites within them.

Finally, a varied group of residency directors, faculty, health center administrators, and others developed a concept each group could support.  It was felt that this type of entity could help supply an increased number of FPs for HC practice in the future, stabilize FMR finances, and simultaneously increase the role residencies play in “safety net” care in our communities.

It was appreciated that not all HCs and not all residencies could or would wish to transform into this new entity.  It was also appreciated that many legislative and regulatory changes were necessary to implement the Educational Health Center as we envisioned and defined.

A copy of this is appended in what we often call our “one pager”.

Recently, a close version of this was proposed in Senate health reform legislative language as the “Teaching Health Center”.

At the time of this writing, it has disappeared from the bill’s language but another bill creating funding for Medicare Pilots may allow it to be tried.  As you will note, key to this new model clinic working will be allowing GME funding to flow to it for the educational expenses.

Currently the GME funds flowing to residency training sites, or not, is totally dependent on voluntary agreements between the programs and their hospital sponsors.  To stabilize these new programs, a stable funds flow for the educational enterprise will be critical.

20th National Conference on Primary Health Care Access: Working Breakfast Topics

A scene at the Monterey Bay Aquarium
A scene at the Monterey Bay Aquarium

Among the distinctive features of the National Conferences on Primary Health Care Access are the early morning assigned breakfast breakout groups. Each conference registrant participates in a group of five or six persons. Every group has a specific topic for discussion that relates to the subject matter of the day’s plenary sessions.

The following is the topic for all assigned breakfast breakout groups for Monday, April 6, 2009:

Question: The 1960s was the decade in which the last major efforts at comprehensive health care reform in the United States were enacted, The major initiatives in that decade addressed federal health care financing (Medicare and Medicaid), but complementary efforts were made to reform primary medical education and health care delivery.

If, indeed, we are in a new period in which national health care policy is substantially redirected to “cover” most or all of the nation’s population, should new reforms be enacted that not only address health care reimbursement, but medical education and health care delivery as well? If yes, in what way?

Background reading for breakfast discussions (hit the hyperlinked pages referenced below):

Annals of the 4th National Workshop: Background of Natl Project

(particularly, the presentation of Dr J. Jerry Rodos on the impact of Medicare and Medicaid on the existing health care system of the 1960s.)

See also the followup comments, referenced  below:

4th Natl Workshop Internet Dialogues: Zervanos, Elison, et al.


The following are the APRIL 6, 2009 assigned breakfast breakout groups:

Group A (Geyman, Lead; L. Burnett, Clover, Colwill, Scherger, Sundwall)

Group B (Babitz, Lead; Berg, Fowkes, Rodos, Weisbuch)

Group C (LeRoy, Lead; Bradshaw, Erickson, Rush-Kolodzey, Webster)

Group D (Freeman, Lead; Clasen, McCanne, Murray,  Wilke)

Group E (Flores, Lead; W. Burnett, Flinders, Frey, Galazka, Herman)

Group F (Kasovac, Lead; Eastman, Fort, Kimball, McClellan )

Group G (North, Lead; Fifield, Leff, Leong, McCahill, Raye)

Group H (Olsen, Lead; Boltri, Harper, Haughton,  Zollinger)


The following is the topic for all assigned breakfast breakout groups for Tuesday, April 7, 2009 (except Group A, the Coastal Research Group Executive Board meeting):

Background reading for breakfast discussions (hit the hyperlinked pages referenced below):

Discussion Points: Physician Residency Programs and Los Angeles County’s Safety Net

Question: The health care reforms of the 1960s (including the establishment of Medicare and Medicaid) were implemented with very little regard for established efforts at the local level to provide “safety net” services to its indigent populations. Are there efforts in your community that you regard as promising improvements in your local health care system’s services to the “underserved”? Would you wish to see such initiatives enhanced, rather than replaced, by any future federal reforms in health care? If so, how might legislation be written to assure the preservation of such community-specific efforts?


The following are the APRIL 7, 2009 assigned breakfast breakout groups:

Group A (LeRoy, Lead; Babitz, Flores, Ross, Wilke; W. Burnett)

Group B (Sundwall, Lead; Berg, Clover, Flinders, Frey, North)

Group C (Boltri, Lead; Fort, Freeman, Haughton, Leff)

Group D (Clasen, Lead; L. Burnett, Colwill, Galazka, Herman)

Group E (Eastman, Lead; Fifield, Harper, Kimball, Leong)

Group F (Fowkes, Lead; McCahill, McClellan, Murray, Norman)

Group G (McCanne, Lead; Erickson, Olsen, Webster, Weisbuch)

Group H (Zollinger, Lead; Bradshaw, Kasovac, Raye, Rodos, Rush-Kolodzey)


The following is the topic for all assigned breakfast breakout groups for Wednesday, April 8, 2009:

Question:  Would society benefit if a greater proportion of the population were in a “medical home” in which they received more comprehensive health care with greater continuity than is the case for a large proportion of Americans? Would not this be an even more substantial reform than legislation simply mandating universal coverage of all citizens? How might the “medical home” idea be advanced by health care reform proposals?


The following are the APRIL 8, 2009 assigned breakfast breakout groups:

Group A (W. Burnett, Lead; Broderick, Haughton, Murray, North)

Group B (Ross, Lead; Berg, Leff, McClellan, Raye)

Group C (Rodos, Lead; Boltri, L. Burnett, Eastman, Erickson, Frey)

Group D (Wilke, Lead; Fifield, Freeman, Leong, McCanne, Webster)

Group E (Clover, Lead; Clasen, Harper, Herman, Sundwall)

Group F (Olsen, Lead; Bradshaw, Kasovac, Kimball, McCahill)

Group G (Fowkes, Lead; LeRoy, Rush-Kolodzey, Weisbuch, Zollinger)

Group H (Babitz, Lead; Colwill, Flinders, Fort, Galazka)

Twentieth National Conference on Primary Health Care Access in Monterey

The Twentieth National Conference on Primary Health Care Access will be held at the Hyatt Regency Monterey from Monday, April 6 through Wednesday April 8, 2009. The Theme of the Twentieth National Conference will be “Primary Health Care Access, the American Medical System and Its Potential for Sudden Change”.

(To go directly to the Twentieth National Conference program, use the hyperlink: Twentieth National Conference on Primary Health Care Access: Program of Plenary Sessions.

The Twentieth National Conference theme

Although there is much to admire in the American health care system, there are obvious vulnerabilities as well. For several decades American policy-makers have assumed that health quality is enhanced if private employers “insure” that funds are available for the health care needs of their employees through contracts with insurance companies, that the federal government take responsibility for the health care of persons over 65, and that state and local governments provide the “safety net” for the health care of persons who are unemployed or indigent.

In the two decades since the First National Conference, increasing numbers of persons have begun to suspect that the status quo of the “American system” is based on the illusion that its elements were planned to be as they are, or that they are the products of an efficient marketplace.  In fact, Doctor Philip Lee, the chief health policymaker during President Johnson’s administration, when Medicare and Medicaid were established, proposed at the Tenth National Conference that every part of the current health care system should be regarded as the unintended consequence of a policy decision meant to accomplish some other objective.

During the past year, events have demonstrated that sudden change can overtake whole industries. The mortgage industry and investment banking are two of the economic activities that looked very different at the end of 2008 than they did at the beginning. In the 2008 presidential campaign, both major party candidates and their parties endorsed radical proposals to solve fundamental problems in the mortgage lending and banking industries.  One can begin to detect an emerging consensus that the United States should devise what one could characterize as a “commonwealth” approach to home ownership and housing.

Yet, at the beginning of 2008, neither the mortgage industry nor investment banking appeared to have been vulnerable to rapid change before their transformation. On the other hand, the health care industry has long appeared to have major vulnerabilities, and these vulnerabilities are likely exacerbated by the impact of financial sector problems on, say, the insurance industry and on government revenues.

For example, the number of persons “uninsured” or “underinsured” may be approaching half the population of a nation whose policies assume that insurance companies are the proper agents for handling the reimbursement of health care.

As a second example, the current revenue streams for health care are most advantageous for high cost, high technology, “end of life” care, and least so for the financing of primary health care, public health and preventive medicine. A significant factor used in the pricing of services for which these revenue streams are applied is what Medicare has agreed to pay. Yet Medicare appears to be approaching technical insolvency, and the national budget arguably has little room for the massive injection of new funds needed just to keep Medicare payments rates at the current levels for all services.

The transformation of banking occurred in the final days of an administration elected with no mandate nor any apparent interest in massive intervention in the financial sector, but circumstances forced it to become the agent of change.

On the other hand, the administration that succeeds it has expressed its determination to change health care policy in America. Whether or not raising the issue of health care reform was more of a campaign promise than a policy manifesto, circumstances could well require the administration’s attention to creating health care “commonwealth” policies also.

If, indeed, national policy moves towards treating the nation’s health care system as a “commonwealth” with a claim to public, as well as private resources, then the debate over whether health care is a “right” or a “privilege” is bypassed, because the major concern then becomes what governments and the private sector should do or be encouraged to do to promote the common good.

In our current environment is it safe to assume that just because a part of the system was financed at comfortable levels in the past, it will continue to be so in the future? Is the health care system really immune to sudden change?

The Lead-off Thought Provocateur

The first of the National Conference’s thought-provoking (thought provocateur) sessions will be a presentation by futurist physician Joseph E. Scherger, MD entitled “What is to be Done?: Designing American Health Care Policy to Promote the Common Good”.

The collapse of financial institutions, although certainly exacerbated by Securities and Exchange Commission (SEC) rule changes that permitted “bear raids” by short-sellers and general mischief by overleveraged hedge funds, made it clear that people remote from speculation on housing prices and sub-prime loans could be hurt badly – even if they did nothing wrong.

Some would argue that there should be have been more “laissez-faire” policies implemented, but the leadership of both political parties came to understand the need to consider housing in total as a “commonwealth” that impacts all of us. (This is stated more as a future historian might. Neither party used the term in its electioneering or its policy statements.)

Dr. Joseph E. Scherger will make the National Conferences lead-off presentation
Dr. Joseph E. Scherger will make the National Conference’s lead-off presentation

The same elements are there in health care, but it is even more precarious. If we could move back the clock to 2004, there are several things the nation could have done to prevent the collapse in housing and its devastating effect on financial institutions. However, the vulnerabilities in health care are omnipresent, and getting worse. There are fewer simple “fixes” in health care as there could have been in housing.

Doctor Scherger returns to Monterey, the site of his presentation of the Third G. Gayle Stephens Lecture at the Fourth National Conference on Primary Health Care Access, which might be perused on this website at The Third G. Gayle Stephens Lecture by Joseph E. Scherger, MD, MPH.

Sub-theme: Primary Health Care Access – Forty Years in the Wilderness: Unintended Consequences of the Health Care Reforms of the 1960s.

The year 1969 seemed like a year of promise for the health care system in the United States. Medicare and Medicaid had become law, and was in the process of implementation. The new Nixon administration (even though railing against the underlying concepts of the previous administration’s “Great Society”), within a year would bless such innovations as an expanded role for the United States Public Health Service, including establishing the National Health Service Corps and the “federally qualified” community health center and defining “primary health care shortage areas”. Both the public and private sectors had endorsed the idea of rejuvenating the “general practitioner” in the newly established specialty of family medicine.

Yet things happened that neither the supporters for nor detractors from an expanded government role in primary health care had expected nor intended to happen. For example, the structure for “charity care” that existed in most communities in the United States, was obliterated in many of them, without Medicaid replacing them.

The federal government intervened massively in the health care system through the Medicare program, yet – without consideration of what the consequences might be – delegated to private entities such important tasks as defining “relative value scales” on how much to reimburse physicians and health care providers.

As part of this sub-theme, a panel of plenary faculty will conduct a roundtable discussion identifying specific decisions and non-decisions that have created the current crisis of “the uninsured and underinsured”.

Doctor J. Jerry Rodos, Dean Emeritus of Midwestern University’s Chicago College of Osteopathic Medicine, who has been an esteemed member of the nineteen previous National Conference faculties, returns again in his role of historian of medical education policy development in the United States.

Dr Rodos’ major plenary presentation for the Twentieth National Conference is entitled: “The Majesty of History and its lessons for health care reform: an overview of the Glass-Seagall Act, The Social Security Act (FICA) and the role of Congress.”

Dr Rodos, who was the 1995 Charles E. Odegaard Lecturer also will take part in a roundtable discussion in which he joins a previous G. Gayle Stephens Lecturer, Doctor Alfred O. Berg (1994) and a Previous Charles E. Odegaard Lecturer, Doctor Mark E. Clasen (1996), on the continued relevance of the topics they discussed in the mid-1990s to today’s problems.

Additionally, Doctor Jack Colwill, an emeritus member of the Council on Graduate Medical Education, will analyze and comment upon national physician workforce projections.

Doctor Richard Clover, Dean of the University of Louisville School of Public Health and Information Sciences, will provide his perspective on the public health challenges facing the United States.

Sub-theme: Primary Health Care Access: The Promised Land – What Can Go Wrong: There is the Will, Now is there the Way to Make Things Better Without Making Things Worse?

Much of the National Conference will be spent seeking to understand the mistakes of the past, in an attempt to identify what must be done to obtain real health care reform.

In a later session, Doctor Mark E. Clasen of Wright State University Boonshoft School of Medicine will lead a panel entitled “Right or Risk Pool?: Issues Raised When the Insurance Industry is Expected to Manage Health Care Reimbursement”.

Recently, concerns have been raised about the adequacy of life insurance companies investments to meet their contractual life insurance obligations to their insured. Even so, their risk pools have been carefully selected, and actuarial information employed to assure an extremely high likelihood that all such obligations will be met.

Almost no one has articulated a “right” to life insurance that would impose external obligations to such risk pools. It is quite a different matter regarding health care.

If public policy were to be aimed at requiring insurance companies to add large numbers of presently “uninsured” to their risk pools, it could play havoc with any actuarial calculations they have made. But if insurance companies are to be the major managers of health care payments, how can all of the uninsured become insured without a major transformation of that industry, with unfathomable unintended consequences? But is our nation ready to agree that there is no right to health care, thus alleviating any “pressure” on health insurance companies to cover substantially greater numbers of persons, and these for substantially greater levels of service?

And, can we even be sure that the insurance industry, with its presently “pre-selected” risk pools, has a handle on the costs of managing the high costs of the present health care system as the nation’s population ages, any more than investment bankers had a handle on entering mortgage contracts at high interest rates with persons unable to afford them?

Also, as part of this sub-theme, Doctor Terry Zollinger of Indiana University will lead a panel entitled: “The Concept of a Medical Home: A Key Part of the Solution?” Other topics will announced soon.

Special Topics: Family Medicine and Community Need

Doctor Rick Flinders of the Sutter Santa Rosa Family Medicine Residency Program in Santa Rosa, California leads a panel entitled: “The Family Medicine Residency Program as a Community Change Agent”.

Doctors John Boltri and Judith Fifield will update the National Conferences on Mercer University’ Department of Family Medicine’s program to develop church-based community diabetes programs.

Doctor Margaret McCahill will update the National Conferences on the University of California San Diego/Saint Vincent de Paul Village joint family medicine-psychiatry residency program, located in Southern California’s largest facility for serving homeless populations.

Doctor Hector Flores of White Memorial Medical Center, Los Angeles joins Doctors Flinders, Boltri and McCahill in a panel discussion.

Stanford University’s Virginia Fowkes will make a presentation on community need issues in San Jose, relating to the transfer of a community-oriented residency program from one hospital to another. She will be joined by O’Connor Hospital’s family medicine residency director, Doctor Robert Norman.

The Importance of Geographic and Population-based Goals in Health Care Reform: Development of Policy Papers

In the 1960s a major goal of health care reform was addressing the needs of underserved or inadequately served geographic areas or populations. The institutional bases for addressing these needs included the evolution of community health centers, rural health initiatives, and activities of the United States Public Health Service and Indian Health Service. The principal medical education reform was the creation of family medicine education and residency programs with geographic goals.

The National Conferences, through the National Project on the Community Impact of Family Medicine Residency Programs, has conducted an ongoing study of the populations and communities served by family medicine residency programs. A task force has developed the framework for three policy papers, each of which will be addressed in activities of the morning breakout groups.

The current drafts of the policy papers can be accessed on this website. (See February, 2009 archives for the texts of the three papers or follow the hyperlinks for Care of Underserved Populations, for FMRP Impact on Medical Community, and for Public Health Impact of FMRPs.)

The Named Lectures and other Major Presentations

The distinguished permanent faculty of the National Conferences includes noted author Doctor John Geyman, Emeritus Professor of the University of Washington. For the seventh consecutive national conference, he will make a major presentation in the field of health care policy. For a feature on Doctor Geyman’s series of presentations, see: Noted Author John Geyman in Eighth Appearance at the National Conferences on Primary Health Care Access

Doctor David Sundwall, Director of Public Health for the State of Utah, has been designated the Nineteenth G. Gayle Stephens Lecturer.

[Left: Doctor David Sundwall, Director, Utah Department of Health will present the Nineteenth G. Gayle Stephens Lecture.]

Doctor Sim Galazka of the University of University of Virginia has been designated the Sixteenth Charles E. Odegaard Lecturer. The topic for his lecture is “The Role of Academic Medicine in Rural Health and Medical Care”.

[Below: Doctor Sim Galazka will present the Odegaard Lecture.]

Doctor Jonathan Weisbuch, MD, MPH, former medical director for the public health departments of the City of Phoenix and the County of Los Angeles will present the Fifteenth J. Jerry Rodos Lecture.

[Below: Doctor Jonathan Weisbuch, the Rodos Lecturer.]

Provoking Thoughts

One of the innovations of the 20th National Conference will be designation of key faculty members as thought provocateurs. Each presentation in the thought provocateur series of topics will have a responder panel.

Proposition: American health care should be considered a public utility, for whom the cost and provision of basic services should be regulated by federal and state governments.

(Provocateur: Doctor Marc E. Babitz)

Proposition: The federal government, in coordination with states and private health care entities should assure that networks of primary health care training programs exist, with strategic mechanisms including decentralized medical school admission and education models to ameliorate the geographic maldistribution of primary care physicians. Such networks would include specific obligations for care to underserved and safety net populations.

(Provocateur: Doctor Kevin Murray)

Proposition: The federal government should establish a clear policy on what should constitute basic health care rights for Americans and mechanisms for assuring that basic health care services are accessible to them.

(Provocateur: Doctor Joshua Freeman)

The following are confirmed faculty as of 3-18-09. 

Marc E Babitz, MD, Utah Department of Health, Salt Lake City

Alfred O. Berg, MD, University of Washington, Seattle

John Boltri, MD, Mercer University, Macon, Georgia

Mark E. Clasen, MD, Ph.D. Wright State University Boonshoft School of Medicine, Dayton, Ohio

Richard Clover, MD, University of Louisville (Kentucky)

Jack Colwill, MD, University of Missouri, Columbia

Ana Eastman, MD, Presbyterian Intercommunity Hospital, Whittier, California

Judith Fifield, PhD, University of Connecticut

Rick Flinders, MD, Santa Rosa Family Medicine Residency, Santa Rosa, California

Hector Flores, MD, White Memorial Medical Center, Los Angeles

Virginia Fowkes, Stanford University, Palo Alto California

Joshua Freeman, MD, Kansas University Medical Center, Kansas  City

Donald Frey, MD, Creighton University, Omaha, Nebraska

Sim Galazka, MD, University of Virginia, Charlottesville

John Geyman, MD, Friday Harbor, Washington

Kevin M. Haughton, MD, University of Washington Family Medicine, Olympia

James Herman, MD, Penn State University, Hershey, Pennsylvania

Margaret McCahill, MD, UCSD St Vincent’s Psychiatry/Family Medicine Residency, San Diego

David McClellan, MD, Texas A & M Family Medicine, Bryan

Kevin Murray, MD, University of Washington Family Medicine, Tacoma

Robert Norman, MD, O’Connor Hospital, San Jose, California

Charles Q. North, MD, MS, U. S. Indian Health Service, Retired, Albuquerque, New Mexico

J. Jerry Rodos, DO, Midwestern University, Western Springs, Illinois

Robert Ross, MD, Sky West Medical Center, Klamath Falls, Oregon

Joseph Scherger, MD, San Diego, California

David Sundwall, MD, Utah Department of Health, Salt Lake City

Jonathan Weisbuch, MD, Phoenix, Arizona

Allan Wilke, MD, University of Alabama, Huntsville

Terrell Zollinger, DrPH, Indiana University, Indianapolis



Among the concepts integral to all of the National Conference activities are the propositions that (1) all Americans should have access to primary health care, (2) that health care resources should be geographically distributed to promote such access, with special attention to rural and inner city areas, (3) that the concepts of family medicine, and of accessible comprehensive and continuous health care services are critical elements for improving health care in the United States, (4) that family medicine residency programs and community health centers enhance primary health care access.

Registration fee INCLUDES hotel room

The Twentieth National Conference registration fee INCLUDES three nights of hotel accommodations (Sunday, April 5; Monday, April 6 and Tuesday April 7, checking out at noon on April 8, 2009.)

About the National Conference:

The Twentieth National Conference, like its predecessors, is an intense two and a half-day experience that begins in assigned breakfast breakout groups each date at 6:30 a.m. and continues through mid-day.

No events are scheduled on Monday or Tuesday afternoon or evening. As with all of the National Conferences, spouses/partners and families are welcome and encouraged to come. The dedicated free time permits conference registrants to assure their families that they will have time for them. Alternatively, it permits registrants to enjoy the surroundings in one of the world’s premiere destinations.

The Coastal Research Group requires that all registration fees be received in advance, including for extra room nights, and does not permit refunds. However, a full credit for all payments may be applied to registration for future National Conferences (provided that a cancellation of a registration is received in time to prevent the impostion of charges on the Coastal Research Group, which would be deducted from any credit). All persons holding credits are automatically invited to future National Conferences.

For further information, contact the Coastal Research Group at [email protected]

Twentieth National Conference on Primary Health Care Access: Program of Plenary Sessions

Conference theme: “American Health Care System: An Imminent Metamorphosis?”

The Monterey Peninsula coastline
The Monterey Peninsula coastline

Monday, April 6, 2009

6:30 AM – 8:00 AM Working breakfasts in preassigned groups (conference registrants only) Cypress Room – First Floor of Conference Building


8:10 A.M. – 12:00 PM Plenary session, Windjammer 1 and 2 (first floor)

(Mark E. Clasen, MD, PhD, Wright State University, Dayton, Ohio, Moderator)

Welcome and Opening Statements:

     Ana Bejinez-Eastman, MD, Presbyterian Intercommunity Hospital, Whittier, California


8: 20 AM Thought Provocateur #1 “What is to be Done: Designing American Health Care System to Promote the Common Good”

     Joseph E. Scherger, MD, MPH, University of California, San Diego

8:45 AM Questions and Comments from the Plenary Audience

    Lead Question from J. Jerry Rodos, DO, DSc, Midwestern University, Matteson, Illinois


9:00 AM The Fifteenth J. Jerry Rodos Lecture: “The Obama Health Plan Debate: Its Historical and Mythological Context”

      Introduction: J. Jerry Rodos, DO, DSc

      Lecturer:  Jonathan B. Weisbuch, MD, MPH, Phoenix, Arizona  

9:25 AM Questions and Comments from the Plenary Audience

     Lead Question from Hector Flores, MD, White Memorial Medical Center, Los Angeles


9:35 AM  “State of Public Health in the United States: Some Observations” 

Richard Clover, MD, University of Louisvlle (Kentucky)

9:55 AM Questions and Comments from the Plenary Audience

Lead Question from Charles Q. North, MD, Indian Health Service (Albuquerque), retired

10:05 A.M. Break 


10:15 AM Access and Affordability in Cancer Care: Canary in the Coal Mine?

     John P. Geyman, MD, University of Washington Seattle, Professor Emeritus

10:40 AM Questions and Responses from the Plenary Audience

     Lead Question from Marc E. Babitz, MD, Utah Department of Health, Salt Lake City


Adventures in the History of Ideas, Part I

10:50 AM “Health Care: Right or Risk Pool?: Issues Raised When the Insurance Industry is Expected to Manage Health Care Reimbursement”

Mark E. Clasen, MD, PhD

11:15 AM Questions and Comments from Plenary Audience

  Lead Question from John P. Geyman, MD


11:25 AM Revisiting Named Lecture Themes from the Early and Mid-1990s: Evidence-Based Medicine, Managed Care, Cultural Competence, Integration of Behavioral Sciences into Clinical Medicine

Alfred O. Berg, MD, MPH, University of Washington, Seattle; Mark E. Clasen, MD, PhD,  J. Jerry Rodos, DO, DSc,   and Joseph E. Scherger, MD, MPH

12:00 PM Adjournment of First Conference Day


Tuesday, April 7, 2009

6:30 A.M. – 8:00 AM Working breakfasts in preassigned groups (conference registrants only) Cypress Room – First Floor of Conference Building

8:10 AM – 12:00 PM Plenary session (Joshua Freeman, MD, University of Kansas Medical Center, Kansas City, Moderator)


Adventures in the History of Ideas, Part II

8:15 AM  “The Majesty of History and Its Lessons for Health Care Reform: an overview of the Glass-Steagall Act, The Social Security Act (FICA) and the Role of Congress” 

J. Jerry Rodos, DO, Sc

8:45 AM Questions and Comments from the Plenary Audience

     Lead Question from William H. Burnett, MA, Coastal Research Group, Granite Bay, California


8:55 AM The Eighteenth G. Gayle Stephens Lecture: “Old Wine in New Bottles – Family Medicine rediscovered in the 21st Century ”

    Introduction: Jack Colwill, MD, University of Missouri, Columbia

     Lecturer: David N. Sundwall, MD, Utah Department o f Health, Salt Lake City

9:20 AM Questions and Comments from the Plenary Audience

Lead Question from Richard Clover, MD


9:30 AM  Thought Provocateur #2: “Should American Health Care Become a Regulated Utility”

Marc E. Babitz, MD

9:50 AM Questions and Comments from the Plenary Audience

     Lead Question from Virginia Fowkes, FNP, MHS, Stanford University, Palo Alto, California

10:00 AM Break


10:10 Innovative Community Initiatives: Translating Clinical Diabetes Trials into Church-Based Interventions

   John Boltri, MD, Mercer University Macon, Georgia; Judith Fifield, PhD, RN, University of Connecticut, Farmington


10:35 AM  Thought Provocateur #3 “The Family Medicine Residency Program as a Community Change Agent”

Rick Flinders, MD, Santa Rosa Family Medicine Residency, Santa Rosa, California

10:55 AM Mission Oriented Residency Programs: A Discussion

      Hector Flores, MD; Margaret McCahill, MD, UCSD St Vincent Psychiatry/FM Residency, San Diego


11:15 AM Family Medicine Education in the Stanford-South Bay Region: The Fight for Survival

     Virginia Fowkes, FNP, MHS; Robert M. Norman, MD, O’Connor Hospital Family Medicine Residency, San Jose

11:35 AM Questions and Comments from the Plenary Audience

     Lead Question from Cynthia Olsen, MD


11:45 AM Thought Provocateur #4 “The Family Medicine Residency as a Medical Home”

     Terrell W. Zollinger, DrPH, MSPH, Bowen Research Center, Indian University, Indianapolis

12:00 PM Adjournment of Second Day


Wednesday, April 8, 2009

6:30 AM – 8:00 AM Working breakfasts in preassigned groups (conference registrants only) Cypress Room – First Floor of Conference Building

8:15  AM  “Primary Care Shortages for Care of Adults: Are They Solvable?”

     Jack Colwill, MD

8:35 AM Questions and Comments from the Plenary Audience

     Lead Question from David Sundwall, MD, MPH


8:45  AM The Sixteenth Charles E. Odegaard Lecture: “The Role of the Academic Medical Center in the Health of Rural Americans: A Conversation and Dialogue”

    Introduction: Mark E. Clasen, MD, PhD

  Lecturer: Sim S. Galazka, MD, University of Virginia, Charlottesville

9:10 AM Questions and Comments from the Plenary Audience

     Lead Question from Allan Wilke, MD, MA, University of Alabama, Huntsville

9:20 AM Context and Commitment: Internet Strategies for Diffusing Information

     Lee A. Burnett, DO, Student Doctor Network, Sunset Beach, California; Robert G. Ross, MD, MScEd, Cascades East Family Medicine, Klamath Falls, Oregon; and William H. Burnett , MA

9:45 AM Questions and Comments from the Plenary Audience

     Lead Question from Gary LeRoy, MD


9:55 A.M Thought Provocateur #5: “Should Educational Health Centers Legislatively Meld Health Center Service and Family Medicine Training for Mutual Survival?”

     Kevin F. Murray, MD, University of Washington Family Medicine Residency, Olympia

10:15 A.M Residency Program Survival: A Discussion 

     Peter Broderick, MD, MEd, Stanislaus Medical Center, Modesto, California; Kevin M. Haughton, MD, University of   Washington Family Medicine Residency, Olympia, and Kevin F. Murray, MD

10:40 AM Questions and Comments from the Plenary Audience

   Lead Question from Mark E. Clasen, MD, Ph.D.


10:50 AM Thought Provocateur #6:  “Nation Needs Clear Policy on Basic Right to Health Care”

     Joshua Freeman, MD

11:10 AM Right to Health Care: Reactor Panel

     Donald R. Frey, MD, Creighton University, Omaha, David McClellan, MD, Texas A&M Family Medicine, Bryan; Allan J.   Wilke, MD, MA

11:35 AM Summary of Conference Themes and Final Audience Remarks

 James E. Herman, MD, MSPH, Pennsylvania State University, Hershey


12:00 PM Conference Adjournment