This archiving and publishing of the proceedings of the fifth plenary session of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the Presbyterian Community Hospital Department of Family Medicine (Whittier, California):
Donald Weaver, MD; Director, National Health Service Corps: When one views the policy options for the 1990’s, a fair question to be asked is what are the expected outcomes? The options may fall into two categories: what we would ideal like to have; and what we absolutely need in order to meet some of the primary care needs of the nation.
In the absence of a national policy which entitles every member of our society access to primary care services, each program must do its part to improve access to care for the underserved. To achieve this, we must work together to remove geographic, financial, language, and cultural barriers to access.
To truly make a significant impact in improving access to primary care services, we need to have a blending of the precepts of primary care and public health. Whether you call it community-responsive practice (which was used by Madison and Shankin in the 70’s) or community-oriented primary care ( a term coined by the Karks), this philosophy of service delivery actively involves care for individuals and addressing the health care needs of the community.
The needs of both “patients” – the individual and the community – must be met to maximize the impact on underserved populations.
I believe that we need to return to the triangle of patient care, education, and research as we loo at the policy options for the 90’s. Every health care program that I am familiar with has one of these three parts of the triangle as its base, the area of major emphasis. Each program must decide, given its priories, how it can meet its’ mission and incorporate service to the underserved as a desired outcome.
If you agree with this concept, I would like to suggest that a continuum of experience can be developed, with the ultimate outcome being improved access to care. The challenge for the individual programs is to see where they fit along this continuum.
Since my experiences for the past 3 ½ years have been in the Health Resources and Services Administration (HRSA) with educational programs of the Division of Medicine and service delivery programs of the National Health Service Corps, I would like to develop a paradigm around programs on the educational and service delivery components of the HRSA which target primary care training and service to the underserved.
The term health professional will be used throughout the presentation, as I believe that the best solutions to improving access will be the result of a team approach to health care. There is not a single public health problem today that will be solved by one type of health care professional working in isolation from other health professionals.
As part of our long-term planning for improving access, we list what we are doing in each area along the continuum, evaluate the success or lack thereof in each area, and develop strategies to continue successful efforts and improve in areas where there are less than optimal activities.
We must begin at the entry level, working together to assure that individuals who are more likely to return “home” are choosing primary care health professional careers. A list of programs needs to be cataloged in each state so that everyone interested in recruiting individuals with the “right stuff” knows where complementary programs are.
A careful review also needs to be done of admissions committees in health professions schools to assure that their members include appropriate numbers of individuals with primary care backgrounds. These individuals are more likely to look for students who have characteristics to pursue careers in primary care.
There must be continued support of students during health professions training to emphasize career options in primary care and to provide experiences in serving the underserved. These activities should include mentoring programs which utilize practicing providers of primary care as advisors and career counselors. Student experiences in the community and individual patient aspects of care need to be available throughout training in underserved areas.
Educational experiences which feature service to the underserved in community settings need to continue in postgraduate training. Based on the foundation of support laid by mentoring and student experiences, these advanced health professions training experiences continue to support the concept of training health professionals in ways that most effectively serve the underserved.
In the midst of recruiting more health professional into primary care careers serving the underserved, we must be careful not to forget the individuals who are currently doing an outstanding job of providing care to those most in need. Support for people currently in service to the underserved involves assuring adequate back-up coverage, professional stimulation, and educational opportunities.
In addition, leadership training and networking are very important if the expected outcomes include a cadre of community-oriented providers.
Finally, there are individuals with experience in serving the underserved who are not currently in an underserved area. They would be willing, for the most part, to share their experiences with health professions students and are an untapped resource for helping to assure that there are future generations of providers who are willing to commit part or all of their professional careers to serving to those most in need.
To help assure that individuals are not lost along this continuum, they must be tracked. We cannot afford to lose any of these precious resources for lack of contact. As funding becomes increasingly difficult, we need to look for ways to better coordinate programs in service delivery to the underserved, primary care education, and primary care research.
In the ’90’s, we will increasingly have to look at outcomes. Clearly, there are institutions which have a track record for training individuals who are going into primary care. Sutton’s Law – “to go where the money is” – would seem a reasonable guideline for the future.
Those institutions with demonstrated track records of training primary care providers, increasing the numbers of underrepresented minorities, and graduating individuals who are committed to serve the underserved would receive preference for funding. We are looking for excellence in the areas that are described above.
It is not unrealistic to expect that there will either be funding preferences for meeting stated objectives in serving the underserved or set-aside to assure that these objectives are an integral part of any overall education program.
There are programs which bridge the activities which have been presented. AN excellent example of a bridge is the Area Health Education Center (AHEC) programs. AIDS Education and Training Centers and Geriatric Education Centers also serve as bridges between the academic community and populations in need by educating primary care providers and supporting their efforts in the community.
I have presented interventions along the educational continuum which assist in meeting service delivery goals. The “secret for success” for improving access to underserved populations may lie in applying a definition of primary care (first contact, continuous, and comprehensive) all along the education continuum.
The approach to the development of health care personnel who are willing to serve the underserved for part of all of their career must begin early if the desired outcomes are to be achieved. The strategy must be a coordinated one, with all interested parties seeing how the resources they have can be used in a more complementary fashion.
There are many incentives to encourage health professionals to pursue careers in the private sector. We need to work together to assure that the public sector receives its fair share of primary care providers.
Policy options for the 90’s should include placing requirements on those receiving public funds to demonstrate how their program is coordinated with other programs in their service area to meet the needs of the underserved. A fair question to be answered is, “How do you tie in with other state and local programs which are helping to meet the needs of the underserved?”
Experience has shown that where the leadership of educational programs and service delivery programs want to work collaboratively, a way is found to forge a partnership. To be sure, there will be situations where programs will be coordinated, but not totally linked, because the missions are not totally congruent. However, meeting the needs of the underserved with combined service delivery and educational program models has tremendous potential for a large return on investment.
Based on some common goals, strategies can continue to be developed which will improve access to primary care services to those most in need and provide unique primary care educational experiences in serving the underserved. In a time when everyone is clamoring for outcomes, the results will speak for themselves, with the primary beneficiaries being the people who rea in need of service.
The triangle of patient care, education, and research can be linked with a continuum of contact that will point us in the direction of our ultimate goal of improving access to primary care for all people o this land.
(Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Health and Human Services.)
Phyllis Kritek, RN, Ph.D.; University of Wisconsin: I do want to make a comment if for no other reason that I am the only nurse in the room. I came here and have tried to listen very hard, but I think my nurse colleagues would be amazed that I have restrained myself in such a dignified fashion.
But I do want to hear because I am convinced that the next question we have to answer is how we collaborate.We don’t have a good track record among us. I don’t mean just nurses and physicians. I mean all the disciplines.
I am going to make observations about what I’ve heard these days. I think David Kindig’s candor captured some of what I think we nurses experience, and we’re not the only group, and that is that whatever problems might exist it is primarily something that’s up to physicians to solve.
And so, David, your comments, for instance, on if you get PAs and nurse practitioners to substitute for specialty physicians, and whether women physicians, especially minority women, are more oriented to primary care, are all very familiar arguments.
There are assumptions from this whole discussion about whose got the power, whose got the clout and also whose being responsible and responsive to the people. I guess those are the things that I took form this discussion. I learned a lot today.
Kindig: I’ll just say I think it gets more important if, in fact, the model moves away from the acute care model where rightly or wrongly you may be able to get along without it for a while and if it does move in that direction, then those issues could come forth. I think you’re right. We don’t know how to work together around this.
I had a very difficult time as Vice Chancellor with our nursing school when we got a Robert Wood Johnson Foundation grant to look at some innovations in teaching nursing homes. I thought the invitation was, in fact to put a nursing power center model in place. We tried to. In that situation we went down a traditional nurses’ approach as well. So technically we lost an opportunity to show some leadership. So it’s real tough.
But I think that if the model changes, and the fat’s in the fire, you almost have to. You won’t be able to do it any other way.
Kritek: I think there are some habits in our minds and our hearts and I would say all of us. We in nursing are accustomed to not being heard and, therefore, because our opinions are not sought, escape responsibility for providing answers.
Gessert: Phyllis has suggested some things that I think would easily provide a focus for another very involved and detailed examination and probably deserves consideration .
I would like to summarize some of the things I heard said in this particular session. A lot fo what I heard, particularly in this panel but all through the two days, is a debate between different proponents of incremental and local demonstrations versus people who take a vocal view of the need for change.
I would like to stay with that for just a minute because I think in that is an issue or two that, again, need a lot more focus. While I recognize and am planning over the next couple years to participate in a lot more local demonstrations, I really have some pessimism on my part as to how far really good, well thought through local programs can go.
The reason I have pessimism is because of the conviction that we’re going to need new resources to make some big things happen.And if those resources already exist within the health care system, it would be unrealistic, unfair, and perhaps even adolescent of us to presume that we can go outside the pshare of the national budget that’s already spend on health to find the resources necessary to make the changes we all have been talking about the last two days.
That means that somebody’s ox is going to get gored. That’s the big problem. Incrementally, if there’s incremental changes to the system of your arena, then it’s like doing a slow amputation – ethically, politically.
So my sense is that local demonstrations may provide us with the food for thought, the framework in which to go, illustrations and paths we may wish to follow, but I would really like to endorse what Bruce Behringer was saying about the sense of this being an internal threat to national security which is of every bit as much magnitude now as the perceived external threat to national security ten years ago.
I would very much like to endorse what David Kindig was saying about the danger of inadequate sense of national will to come to grips with this internal danger. In fact, I think all of our panel right now has touched upon this. I guess I would like to leave the group with the thought from this panel that we need to look at how the resources are currently allocated within our own system, and how ethically and politically those resources might be reallocated.
Sundwall: I guess I can’t resist one comment. I would like to comment on some aspects of the presentation. One thing I’ve come away with in spite of Charles’ skepticism – I’m amazed at how much is going on. There’s a lot of energy being directed at solving these problems.
The assumption in the call for an expansion of national will is that we should do these things everywhere, but that’s unrealistic in a democracy. Even our value system, as laudable as that may be, may not wash at the national level.
There are other beliefs that may be more popular. Let me just close with one comment and that is a statement made by Debbie Steeleman when she presented at the National Health Council. I think she put her finger on what is fundamentally wrong with the American health care system when she said you have to take away the fear in our society.
She said there’s an underlying fear, not just among the uninsured, but among Medicare patients who have to spend that on their Medicaid nursing home. That’s wrong. That’s a societal wrong. If that commission can come up with something to do away with the fear that prevails out there, I think we’ll do a lot. I think we just might see the reform.
Kindig: The only thing I would add is that it’s so hard to – they always say, particularly in these times, that you have to get your new stuff out of savings from the existing things. But it’s so hard to find those savings in the existing things to make the investments. I’ll give you an example.
In Wisconsin, we developed a community options program which is a kind of community services alternative to nursing homes which is actually a little better way to receive the care. Yet the researchers didn’t know that. Everyone bet that that the community options program wouldn’t have the desired payoff.
But trying to get the money up front to make the investments in order to get those payoffs proved impossible. If there is no new money, where do you find the savings? I don’t know that it can be done in a “capped” funding situation.
Midtling: I’ll just make some closing remarks and musing. I believe that as we look back at the decade of the ’90’s, this conference will have played an important role in increasing the national focus on the problem. Bill Burnett told me earlier that having been at this conference will be like having the first collectors plate in a series.
I think that we potentially have touched upon some viable solutions here but whether or not these solutions are implemented, I think is going to be the task ahead and probably the most compelling reason why we need to continue these discussions. If there is one theme that I would like to emphasize, it’s that I believe that government as the major payor of health care has within its capacity the ability to make the changes that are necessary to manage the problem.
Bruce Behringer spoke earlier about the golden rule. There’s another golden rule and that’s that he who has the gold, writes the rules. I believe that we can address these problems for the past 10 or 20 years. And so I think we need to continue with this and I think we need to expand these programs. But I really think that if we’re going to solve this problem, it’s going to have to be a radical change.
Whether or not we have the resolve as a society, and I agree with what you said earlier, it’s not just a physician problem, it’s not just a nursing problem, it’s a societal problem. Do we have the guts as a society? DO we have the courage as a society to make the really tough decisions and reallocate the resources that are necessary to solve this problem?
I think in the past the dictates of the special interest groups, and we in medicine have bee part of that, and medical economics have been just too powerful to overcome. So I think we need to make some difficult decisions here. The real question, I think, is can we afford not to take these steps. I don’t think we can continue with the status quo.
I would like to thank all of the attendees, the participants, and faculty. I especially would like to thank Bill Burnett for bringing us all together despite busy schedules. Without him we wouldn’t have been here for the past couple days. And I would like to thank Charles Gessert for helping to put the conference in focus, providing guidance, and really, I think, giving a unique perspective to the layout of the conference that was very important to allow for meaningful discussion.
I want to thank everybody who contributed and I believe it’s been a very successful conference and I hope you have some time to enjoy the rest of the day here in Kohler. In future conferences, we can follow up on some of the issues that have been raised here these past couple days.
This archiving and publishing of the proceedings of the fifth plenary session of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the Presbyterian Community Hospital Department of Family Medicine (Whittier, California):
David Kindig, MD, University of Wisconsin: Well, that’s very provocative! Hopefully, it will stimulate some discussion after Don and I get done. I will make some comments on some more narrow aspects of issues that have come up during this conference, particularly specialty and geographic distribution.
I will go on then a little broader, actually picking up from some of the things Dave Sundwall mentioned vis a vis national health problems, and touching on some of the points made about national vs. local solutions.
I really would like to thank John Midtling and Charles Gessert for inviting me to participate in this conference. It really has been stimulating. I’ve been taking lots of these notes and having new thoughts and new questions. That’s really helpful. I think it’s important that we keep doing this, because I think these issues are newly alive again.
If at times it seems like deja vu, still it’s important. These things do cycle and maybe we’re back in the part of the cycle where we can give some thought to these things. Sometimes I get a little cynical about the deja vu part of it but I don’t think that’s appropriate because it’s a new time and we can come at it in some new ways.
These few comments I will make on the specialty geographic distribution issues. I’ll just make a few brief comments. I have a couple of policy papers that are unpublished if you are interested in these arguments being presented more fully. One is a paper I did for the Council on Graduate Medical Education [COGME] last summer on the geographic distribution of physicians.
It is not published and may not be, but is kicking around the HRSA bureaucracy. I just haven’t had a chance to turn it not something publishable. It’s a current summary of the state-of-the-art on those issues. Also there is a book chapter that, hopefully, will come out in a year on whether the supply and distribution of physicians will be appropriate for the national needs in the year 2000.
Probably the most depressing thing about this conference is the specialty maldistribution situation and some of the data that you presented that is not new. I think it’s depressing because I see rays of hope on some of these other issues. But that one is such a though nut and we’ve known it for 20 years. I have two illustrations.
The first one is the increase of the physician to population ratio caused by the cranking up in medical education in the ’60’s. What we sometimes forget is that we’re only halfway up that curve from the 1970’s to 2000. More or less its’ going to peak at 2010-2020. Obviously, it’s better to change a huge fixed think like this in a growth mode rather than to try to fix something that’s stable.
We seem to have lost. It’s not that we haven’t done somethings but really we’ve lost our best opportunity. I think we’re going to lose this other part as well for all the depressing things that you mentioned. I wish I had some optimistic things to say about that. I’m not sure that I do.
I don’t know if you’ve seen the Al Tarlov piece in Health Affairs where he talks about the third compartment. Essentially, he divides the care sectors into fee-for-service, the federal sector (like the defense sector or the public programs in the defense department) and then the capitated sector.
He makes some interesting projections about the degree to which the capitated sector will grow over the next 20 years. And then he applies the current HMO physician to population ratio to that sector and he comes up with “x” number of physicians that that sector will absorb. And then he takes all the rest and allocates them to basically the fee-for-service sector because the federal sector is negligible.
There’s three times more physicians per patient in the fee-for-service sector in those calculations as there is in the capitated sector. And it’s just hard to imagine how that can work. What he hasn’t published but he mentioned in private is that there are some specialties where the ratio is as much as 10:1, given kind of reasonable projections of current situations. So we are on that kind of course. That blows y our mind, both for cost and quality reasons, because these people are not going to be able to practice medicine. So bizarre things will happen. I’m really worried about that.
I think that RBRVS is an important step. I don’t know if anyone has done the projections over 10 or 20 years because that would be interesting. I think if we have these huge gaps in income, even with a little cut here and a little there, that’s not going to be very impressive.
But I think it should be relatively easy to project different scenarios, say at 10 or 20 years, as to what it would mean to physician incomes under the RBRVS revisions. Even if at 10 years you could show a significant lowering of the differential between primary care and procedural specialists through some kind of projection, it might increase the political opposition to implementing what is proposed.
But on the other side, it might be useful to show some young physicians now what may happen under an RBRVS system. There may be some reason for optimism at the levels of students who are not yet in medical school. Maybe something like RBRVS could help and obviously we have to support that; it’s in the right direction; should cause some movements the right way for both specialty and geographic distribution of physicians. It would be interesting to know how much.
Obviously, I am not going to say anything against the efforts of family practice and general internal medicine, because it’s really the specialists of medicine that are the other huge problem, if you will. I think family medicine has just been important and needs to continue to be supported. If there was any one thing you should do, you should try to continue to support family medicine.
The other issue on specialty distribution that I would like to make (it’s a little narrow technical one, but ti’s been a pet of mine since when I was running a hospital in New York City) is that sometimes we think that the number of specialists are just driven by physicians wanting to practice that specialty. But a lot of its is driven by the needs of the training programs for “x” number of house-staff on a given service.
If you’re ever a hospital director or a residency director, you have to fill these slots in order to have, say, Friday night and the weekends covered. I think the number of people in specialties at the PGY entry level is the critical thing. We experimented at Montefiore. We substituted a quarter of our surgical house-staff with surgical PAs for a variety of reasons, and it worked fine. I’ve often felt that this is an area where changes could be made, since so much of the work of residents is scut work loaded into the PGY-1 years.
Actually there’s some down time in the second year. There are fellowships and research time and electives and whatever. There has been some experience with decreasing the number of surgical house-staff that is worth looking at. In my experience, our internal medicine colleagues have been interested in looking at the movement to reduce house-staff and also the movement ot substitute physician assistants and nurse practitioners.
(I don’t mean to suggest there are no differences between PAs and nurse practitioners, but to a certain degree I think those are interchangeable kinds of roles, although I understand the differences.) But I think it might be possible. Our PA programs have grown up in a primary care mode, which I encouraged when I was in the Bureau of Health Professions. But I think training PAs and NPs for specialty slots as specialty substitution workload in these early years could do a lot.
As a matter of fact, you could even think of Medicare policies that would have some resident substitutability incentives along those lines.
We should also understand the sex composition of physicians being trained and whether there is any way that women medical students are more amenable to being encouraged in the primary care directions. There is some historic data for that, although the trends may be breaking down now. There is demographic change that is taking place in the physician populations which might lead to some solutions.
For geographic maldistribution, I really think there is a difference between inner city and rural issues. I started in inner city practice in the South Bronx and Chicago. I think that’s an easier problem. I don’t mean to put it down that way except to say that there are lots of physicians and other health providers who are living in urban areas who want to work there.
There are some different kinds of cultural problems but you don’t have that huge problem that you have in rural areas. There’s an interesting study that’s just being published that I reviewed while in press. Somebody interviewed a sample of all the residents in New York City who finished their residency (I think in 1987) and found out that 11% were commited to inner city practice, and that (I couldn’t believe these numbers) that 50% were willing to consider inner city practice.
The ones that were committed were primarily female, primarily from the inner city, and primarily Black. And what did they want? It was a guaranteed base income, access to medical consultants, and hospital admitting privileges. It’s not to say that all those things are easy to do, but they don’t boggle the mind. It takes some money: it takes some structure it takes good CHC’s or local health department clinics for some of those basic things. I think you can move those people in there.
I think federal CHCs in urban areas are critically important, state programs, or whatever, and/or other expansion of Medicaid financing so that those places can do these kind of things. But I think the people are there. This is the place where there is a lot of local opportunity.
I think the rural is more difficult because in a lot of ways we’re trying to get people to go to places that they might not have been from, obviously. Inner city recruitment strategies are important, and we’re still fighting to get these in place that but aat least the students have been to school in the city. I think rural areas are different for one another in terms of their characteristics and their physician needs.
I don’t think we’ve done a careful enough analysis of the variation of needs in rural areas nor of targeted strategies. There are great regional differences in physician to population ratios. I thought we would find some marginal effect, but instead the research showed a direct relationship between the number of commuters leaving the rural area each day and the areas physician-to-population ratio.
If 0% of the people commute (a non-metropolitan county) there’s a mean physician to population ratio of about 80. If 60% commute out to work, it drops down to about 20. That’s not counter-intuitive. Obviously, people are going to get some of their health care where they go to work. It certainly means that shortage criteria should be cognizant of this phenomenon, and would likely mean that placing people in the “high commuter” areas on the same criteria as the “non-commuter” rural areas, you would have less utilization and perhaps surplus provider time in the former.
Targeted strategies are important and I think local things can be done in regional areas. The tougher the problem, the more you add the strategies on. AHECs are terrific in a lot of places but they’ve got multiple components. Every tiem you add a component, it gets more expensive and it’s less clear that you can justify that marginal addition. But in places where you really have problems, we can look at recruitment, undergraduate education, graduate education, financing, and those kinds of strategies.
It’s just like the kinds of problem areas we addressed when we started the National Health Service Corps. It looks like these kinds of problem areas still exist in the Southeast. It’s pretty clear when you look at the regional problems. A major targeting should be done there and other places as well. The North Central region comes next.
Now, the immediate needs are terrible. I’ll just underline what we’ve heard here. It’s hard to believe what we’ve let happen in this decade and what we’ve let happen in these last couple of years. I just was down in Brownsville, Texas at a couple of the neighborhood health centers. They’re great, historically important CHCs.
Before this July they had 18 physicians (something like 12 were from the Corps) with some satellites. After July, their number of physicians is cut by six and they’re closing the satellites. These are areas on this side of the border, where 33% of the births are given by lay midwives.
Those are terrible statistics. Both at the federal and state levels we have to continue to support what we know works – the Corps, neighborhood health centers, and loan repayment. (I would crank loan repayment up to a magnitude beyond what we’re now doing both in terms of numbers and dollars to take care of those needs right now.)
I would look at some financing experiments. HCFA or some state compacts should look at innovations like the Rand health insurance proposal. One should, over ten years, pay one and one-half times, two times, even three times going salaries in certain regional areas that are matched.
You have to stay in there for ten years, so maybe some foundations would do it, but we don’t know now what the geographic dollar multiplier is that would attract physicians to these areas. There is no research on that. HCFA this year is adding 5% payments to Medicare.
If you’re in an 01 or 02 level priority health manpower shortage area, you can receive a 5% bonus on your fee-for-service rates. That’s great! A five or ten percent differential seems pretty low. We don’t know who is motivated to enter or stay in practice by a five percent differential. We don’t really know what those multipliers are that affect decisions. What little information there is from other countries, and there it is a lot more than that. It’s 50% or 100% to really move people.
Let me move to some broader issues beyond the issue of access to the whole set and talk some about the national plans – issues that David introduced us to a very nicely the other night. A dilemma I have about all of this, that I’ve had this whole day and a half, is how do you stay enthusiastic about and sustain the levels of energy, creativity, and commitment that exist in the projects that we have been hearing about which are making a difference here and there?
It is a historic fact that these kinds of projects come and go. And they come and go.. When the grant runs out or the local initiative ends since they’re not a part of the mainline system, they get grafted on or folded into the mainline. I think we have to preserve opportunities for pluralism and to channel this creativity so that not everything is the same.
But, on the other hand, things that just get grafted on and are not part of the mainline system won’t survive. And so Charles Gessert asks why we are talking to ourselves? Why aren’t we making our influence felt? It’s because issues of access, primary care, and the underserved are not the main item of business. I think we have to get in conversations. Like Bruce Behringer was saying before, we have to be at the table with other players and make it a bigger problem, and these solutions have to be incorporated into the whole system.
So I am imterested in the new interest in national health plans. I want to share some of my thinking about those. Actually the first paper that I wrote in my residency was a paper with Vic Sidel which we wrote comparing seven national health plans in 1972 against criteria which we lined up.
It was a nice little chart, like the chart now that the American Public Health Association has put out on the different plans. The earlier plans all went the ways of regulation in the ’70’s and competition in the ’80’s. I think it’s really important that we’ve come back around to national policy on health plans, and I’m really glad that maybe in my lifetime we’ll get to work on this a little bit.
I have decided to spend the bulk of my academic work in the next ten years on this. We have organized the past year a faculty task force in our medical group with economists and ethicists and insurance people and business people looking at these issues. What I am going to say is essentially what I have learned from 20 seminars over this last year about this.
I think that it is terrific that the interest is cranked up, but I do not believe that we’re ready either politically or substantively to do anything. I’ll talk about that in a minute. I think that the past is prologue, David, but I’m not sure that we’re in totally new territory. I think one of the beauties of Paul Starr is the way he traces how health financing proposals have risen and fallen in favor.
The part that I read the most, and someone alluded to in a question yesterday, is the chapter called “The Triumph of Accommodation.” It’s a cheaper about passage of Medicare and Medicaid. What he says basically is that organized medicine and hospitals fought this for a variety of reasons until they were able essentially to pull the teeth on any system change and essentially crank into place the insurace mechanism which, in fact, did increase access and increase utilization.
But there were no (change in tape) programs that only provided more insurance. So that’s real important. If you haven’t read that chapter, I would encourage you to read it.
I think it’s possible that a national health program could reinforce our current model, might not decrease costs, and inhibit change for decades. In that case, we would be worse off than we are now, if you can believe that. But I think it’s possible, and that we have to be cautious about what we might get into.
We’ve talked a lot here about primary care and about prevention. I am equally interested in the epidemiologic shift that’s going on right now from acute to chronic care (with, perhaps, preventive components) as perhaps a fundamental kind of carrot. The role of the hospital declines while interfaces increase between medical and social and community services.
I am beginning to believe that’s what the next century is going to be about. I think if we lock in right now in an acute medical care model, we could miss an evolution in health care delivery that might be really important. We’ve had some conversation this meeting that the medical profession was having to become involved with all these social problems, and all these substance abuse problems.
I think we can either say, “It’s not really our business,” or, if we define out role more narrowly and not worry about it; believe that the epidemiology is changing, then we should prepare to assume new roles as physicians. Hospitals will become intensive care units; the whole business will be elsewhere; and we need to play in that game.
Right now people not only are falling through cracks in medical care, but they’re also falling in these cracks between medical care, public health, community services, and social services. My wife is a geriatric social worker at the VA. I know all these things, because I hear about it every night. And it’s true.
It’s difficult to cut across these boxes of programs, of financing, of professional turf, ideally if we do want to do something different, we ought to take a whack at that. I will never forget at Montefiore Hospital (I ran that hospital for five years in the late ’70’s) when we were under very strict cost control, and we laid off a couple hundred people every year.
I know that half of those people wound up on welfare in the South Bronx, taking more social resources than we were paying them for doing nothing. We don’t know how to make the social accounting work crossing those systems. But that’s a real challenge to make that happen in whatever new things that we’re doing.
It may be that physicians aren’t capable of or don’t want to take on this kind of broad view of medicine or of health. But I think if they don’t then they really have to step aside and do their thing and let some other people organize this broader concept, because I think it is the concept of health for the next century.
We may not be quite ready to think through what we want to happen, but I think that the politics of the deficit will preclude any kind of movement on these big things, except for some incremental things that could be done. I think the plans that are practical, except for their cost, don’t chagne the system and those that would change the system, line PNHP or Enthoven are not issues for a whole variety of political and social reasons. So, I think we are at that stalemate of not knowing where we want to go. But I also think that’s O.K.
I might sound too researched here and I worry about that coming from academia, but what underlines the work that our faculty task force on national health programs has been doing this year is that, whereas all these plans are interesting and have stimulated a lot of thought, that there really are a lot of fundamental policy questions and health services research questions, that really we should know the answers to in order to put something together like this.
I’m not going to bore you with all the things we’re doing, but we’re actually about to publish a research agenda on national health programs which lays those out. There are enormous problems to be solved about scope of benefits, about the nature of financing, about the nature of the delivery system, about the nature of the payment system, about capital financing, about administrative arrangements, about the extent of pluralism, about federal, state, public, and private roles.
You may say a lot of those problems are details and we’ll pick one plan and work the problems out. But you could also say, and I think it could be true, that there are a lot of those problems that you really can’t address by themselves until you have all of them worked out.
Some of these plans are really just models, like the Enthoven plan which obviously probably wouldn’t go anywhere in the real world. But it attracts a lot of interest. In the Enthoven plan, you get a voucher which organizations compete for. It’s an interesting kind of competition. But it assumes that there are groups of providers that have connections with hospitals and maybe nursing homes all over the country that can accept these vouchers and do this thing. So that plan will fail. I would say, for 20 years not having such systems in place. But can you get incentives that would bring that into place? I don’t’ know.
I don’t know if we can do this incrementally or if fundamental change, a broader kind of change has to happen at one time. I think we usually do things incrementally, so you have ot think that’s probably how it will happen. I think it also allows for local experiments and for pluralism and I think that’s important.
But I guess I also get stopped when I think of how much we are already into a national system with national private payers, with Medicare, and state demonstrations. We have to deal with all of that somehow. Perhaps through Medicare/Medicaid waivers. But what do you do with Prudential? I don’t know.
So I think maybe there are some more limited access demonstrations at a local level and those are important. But whether you can do State things or whether you can do incremental local things that allow you to get to this other kind of system, I’m not sure. I have a feeling you probably can at some lvel, and maybe you could build to it. Essentially that’s what Dave Obey’s would do – (I haven’t talked to him and I don’t know the details of it) encourages states to do some of these demonstrations. There is a foundation and federal role, however for getting some of this research and some of the micro-demonstrations going.
We had a little pot of money when I worked with Ken Endicott in the Bureau of Health Manpower – Health Manpower Education Initiative awards. We lost it sometime in the mid-’70’s because everybody thought it was Ken Endicott’s slush fund because it didn’t have any rules on it. Well it was his slush fund, but out of that slush fund came the WAMI program, came AHECs, came a lot of family medicine and nurse practitioner and physician assistant programs, and a number of other things.
So there is a role for having some of those loose resources around to do some of those things. But of course this is at ime when loose resources aren’t very often available. So that’s a dilemma.
Another dilemma I believe exists is that for some of these things you probably have to spend in order to save. But that’s hard to do in the short run for politicians. On the broader scale I agree with you. We have to solve this federal deficit because it keeps us form moving ahead. It saps the national will. It’s one thing for a year or two but if after ten years you start to say, “We can’t do this. We can’t do this. We can’t do this.”
Not that it’s only the federal government, but we can’t give money to Poland and we can’t work on health care and education. We can’t have an education issue if we can’t put any money on it. After a while you begin to believe that. I think we have to solve that because it’s not only for making any movement here which may need some federal money, but it’s also for these other crying domestic problems.
I wouldn’t argue that health is more important than education or the drug problem necessarily, but all of those are stalled for the same reason. They’re stalled financially. But I think they’re also stalled in terms of our national will to do something about it. Let me stop there.
This archiving and publishing of the proceedings of the fifth plenary session of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the Presbyterian Community Hospital Department of Family Medicine (Whittier, California):
John Midtling, MD, MS, Moderator: The session this afternoon is entitled “Policy Options for the 1990’s: Improving our Management of Primary Care Access Problems.” I am really excited about this session and have been anticipating it for quite some time because I think it allows uss the opportunity to have some dialogue about some innovation solutions to some of the problems that we spent the past two days talking about.
The principal presenter this afternoon is Bruce Behringer, Executive Director of the Virginia Primary Care Association and former Chair of the National Advisory Council of the National Health Service Corps. Panelists are David Kindig, M.D., Professor and Director, Programs in Health Management and former Vice Chancellor for Heatlh Sciences, University of Wisconsin, and Donald Weaver, M.D., Director, National Health Service Corps, U.S. Department of Health and Human Services.
Bruce Behringer, Virginia Primary Care Association (Mr Behringer is a Fellow of the Coastal Research Group): Access barriers to primary care services have been identified, defined, qualified, quantified and studied for decades.
Various strategies for change to reduce these barriers have been devised, tested, and evaluated since the 1960’s and, according to the old adage, the more things change the more they remain the same.
In a presentation I made recently to the American Medical Student Association, I attempted to echo the thoughts and sentiments of a variety of health care professionals and consumers with whom I have had the opportunity to meet and discuss the access issue. I jokingly entitled the presentation, “This is Not Your Father’s Oldsmobile Speech.”
Practicing medicine in the 1990’s, I told the attending medical students, should be recognized as somewhat different than during the times of our fathers. There are, if I can generalize, two major changes which have occurred.
The first is a change in the market place. Chart I indicates how far the national marketplace has grown from the indemnity insurance model which was prevalent not too many years ago. A little less than one-third of our nation’s population is now enrolled in these plans.
Health maintenance organizations and preferred provider organizations have grown dramatically. Public insurance, in the form of Medicare and Medicaid, is responsible for almost a quarter of the marketplace. Still remaining however, are approximately 37 million uninsured Americans for whom access remains problematic.
Linked with this change in the marketplace is the influence of actions of major purchasers of care, including insurance providers and the government. A whole litany of rules, regulations, contract stipulations, and review procedures have been put in place over time that intervene with the traditional integrity of the physician-patient relationship.
In the name of cost-containment or quality of care, physicians are finding their practices controlled by new pricing structures, selective reimbursement for procedures, control of specialty care, and ancillary service referral patterns, special malpractice pricing classifications, and new patient outcome and hospital mortality studies.
Each of these decisions has had both direct and spin-off effects which enhance or reduce access to primary care. If one considers just the two public insurance programs, Medicare and Medicaid, some of these effects become apparent.
Because of a complex reimbursement structure, including patient deductibles and co-insurance, balance billing regulations, participation and assignment issues, and inequities in specialty and geographic differentials, the Medicare program has been viewed both as the savior for access to care for the elderly and as a negative casual factor in medical education’s inability to sustain physician training programs which promote primary care selection.
The Medicaid program suffers from a similar dilemma. It has opened the door for many impoverished families to the mainstream of primary health care. The program, however, is not as widely accepted as a reimbursement mechanism as many states would desire. Physicians cite low reimbursement rates, paper work, and lack of timeless of reimbursement as reasons for not participating and accepting Medicaid patients.
A more common line of opinion I have heard frequently from older physicians is that introduction of the Medicaid program has reduced volunteerism and sense of shared responsibility among physicians for community health care access issues. Reliance on “the government” to solve the problem has, in fact, resulted in closing their doors to poor patients.
The Basic Investment Strategies
These two health care financing programs, Medicare and Medicaid, however represent only one portion of the overall federal strategy to improve access to primary care services. Two other areas, health manpower training and health care systems development, have also played critical roles in the federal investment strategy.
According to a report received by the National Advisory Council of the National Health Service Corps Program from a representative of the Council on Graduate Medical Education, federal dollars now pay approximately 80% of the costs of medical education in this country.
This includes monies from the National Institute of Health research grants, indirect medical education adjustments to teaching hospitals, direct cost reimbursement for graduate medical education, Medicare and Medicaid hospital disproportionate share systems, special Prospective Payment System reimbursements for teaching hospitals and reimbursement for services for publicly insured patients.
A parallel strategy was enacted in the 1970’s to support change in medical schools and residency curricula to enhance the probability of physician selection of primary care training and practice. These programs include those funded through he Public Health Service Bureau of Health Professions.
The limited allotment of funds designed to bring about changes in medical education is dwarfed by the massive amounts of research and reimbursement monies aimed at sustaining the current system which has resulted in greater specialization and continued access issues in primary care.
There has been substantial federal investment, also, in stabilizing health service delivery systems and practices. These have included funding to community and migrant health centers, the National Health Service Corps program and a multitude of categorical and block grand health service programs channeled through state and local health departments.
State governments, too, have invested sums of money using these three basic strategies. The focus of many state efforts has been on direct allocation of resources for medical education through state sponsored medical schools, through funding health services delivery directly through state and local health departments, and with matching federal programs and an ever-escalating investment in Medicaid.
Some states have become aggressive in addressing sub-sets of the access issues. A large number of legislatures have recently enacted and funded programs to address services for the uninsured, the indigent, and high risk segments such as pregnant women and infants.
To catalog all of the different management approaches being carried out at the federal, state, and local levels would be unending. From a public policy standpoint, the mixed experiences cited above with Medicare and Medicaid beg for some rational option in organizing both the process and product of our planning efforts.
Some method is needed to analyze the totality of the access problem while influencing the integration effort of the three basic strategies of health manpower training, financing, and service delivery development in such a way to make them produce reinforcing effects. This requires a diversity of input into the planning process.
Integrative Strategic Investment: the Virginia Five Point Plan
An example of this philosophy and approach has recently been attempted under the guidance of the Virginia Department of Health. Chart II, “Virginia’s Five Point Plan: How It Fits Into the National Picture,” displays the outcome of a long-term planning effort on access to care.
It included the Virginia Department of Health, the State Board of Health, the three medical schools in the state, the Virginia Primary Care Association (representing the community and migrant health center programs), the Statewide Health Coordinating Council, the Virginia Association of Health Systems Agencies, the Virginia Association of Counties and the Virginia Association of Area Agencies on Aging.
This broad-based coalition identified “The Big Picture” programmatic goals in response to a statewide assessment of waning primary care capacity. National trends and influences were reviewed, particularly declining interest in primary care training, the aging of the primary care physician population in the state, Medicare and Medicaid reimbursement trends particularly in rural areas, and the demise of the National Heath Service Corps scholarships, a program upon which underserved areas in the state greatly depended.
Once the goals were established, and assessment of national programs were identified and investigated which might assist the state in meeting these goals through the applications to create a state-federal partnership. Finally, proposals were drafted for the Virginia General Assembly’s consideration under the title of “The Five Point Plan.” All three strategies were included: health manpower training, financing for access, and service delivery system development.
A key factor in the willingness of the different parties to participate in such a planning process was an atmosphere of understanding and mutual respect for each other’s missions and a growing awareness of how fractionalized individual efforts had actually become. Initial efforts at promoting the reinforcing effects of major actors working collaboratively were demonstrated.
This was particularly true of cooperative efforts between local health departments and rural community health centers in sharing services and eliminating bureaucratic barriers which hindered good continuous patient care access.
The other key to the effort became a focus on how all parties could work together in assisting underserved communities throughout the state. This tended to focus attention on identifiable geographic areas and needs rather than amorphous, nameless, and faceless communities.
This approach, obviously, worked in demonstrating needs and projecting positive plans to our General Assembly. They funded the Five Point Plan activities at $7 million for the next biennium budget.
What is your next step in Virginia? We have identified three challenges which could be translatable to the development of policy options for improving the management of primary care access problems in the 1990’s for the entire country.
The Three Challenges
In confronting the issue of primary care access problems from a national policy option viewpoint, we must reconsider our basic premises which have guided actions in the area of health manpower, health care systems development, and health care financing. We must recognize that thorugh access is a national issue, its solution must be one which is locally based.
In order to accomplish this, we must face and confront three basic challenges.
1. Overcoming the Control of Language
A variety of people, mindsets, and languages are involved with health care. IN reviewing principles of social psychology, I believe the Whorfian hypothesis applies in this case. This concept asserts that people behave and think according to classification systems which they learn and subsequently use to lend meaning to features in their world.
Accordingly, the hypothesis proposes that language may not only be a vehicle by which people interact, it may also be an active determiner in what they perceive, how they think and, therefore, what they interact about.
Indeed, the language of “outpatient care” for hospitals, “primary care” for physician, “ambulatory care” for insuring organizations, and “preventive care” for public health are strangely similar in their meanings. Yet, the words become intricately separate in the minds of different providers. These separations are virtually meaningless, however, to consumers who may just need “to go to the doctor.”
A classic example of this terminology barrier is found in defining the health care mission of the 500+ federally assisted community and migrant health centers operating in medically underserved areas in this country. With the half billion dollar investment made by the U.S. Public Health Service, the federal government is investing in “primary care services” in needy communities.
I have attempted to describe the purpose, structure, and philosophy of health centers to innumerable communities and have found that the easiest explanation is to describe what health centers are not. Because of their emphasis on diagnosis and treatment as well as continuity of care through hospitalization and emergency services, health centers are not likely similar to most local health departments.
Because of their emphasis on disease prevention, health promotion, and community organizing, health centers are not too much like private physician offices. Because of their adherence to the principles of community-oriented primary care and serving as a “health home” for all patients regardless of their ability to pay, health centers are much unlike hospital emergency rooms or urgi-centers.
The unfortunate aspect of this approach is that highlighting differences sometimes leads to local fractionalization of support for the center among other health care providers. They may perceive an implied threat to their business. Others may feel the need for a health center with such a mission indicates in the community’s mind some shortcoming in their own practice.
The nomenclature within our business creates semi-rigid categories and classifications of services which doom potential collaborative relationships between health care organizations, sometimes before investigatory discussions are even held.
It is reasonable, therefore, to consider that non-health care providers may, in fact, have an advantage in seeing in, around, and through the jargon and minutely different classifications which we tend to create when talking at each other about health care access problems. They can draw some unusual but provocative analogies from their own professions in which they may have confronted similar issues.
They sometimes can, in fact, see and establish common issues rather than separate positions in negotiations between health care professionals and organizations. If we don’t “train the common sense out of them,’ community representatives might, in fact, help us to think through some of the knottier issues of access.
2. Building Consensus at a Local Level: Adopting and Integrationist Philosophy
After eliminating the language barriers and beginning to define the parameters of access to primary care, the next challenge becomes developing a mechanism for inter-organizational communication and planning.
In the past years, a great deal of health planning has been done on national macroeconomic policy using Medicare reimbursement as both the carrot and the stick. A more regionalized versions of health planning was elaborated in the health systems agency days pitting consumers versus providers in a cost-containment atmosphere.
Less has been done, however, and little has been organized to bring together all of the interests which affect the access issue at the local-level. One problem becomes defining the access issue to be studies or resolved. Community business coalitions, for example, attack the problem from a resource allocation and cost-containment standpoint.
Coalitions, including organizations like the March of Dimes, state perinatal associations and community groups that are interested in reducing infant mortality address access from a systems orientation, including patient and community education and collective action to confront malpractice liability rates which influence access.
Small communities facing the loss of their primary care physician capacity approach access from a standpoint of simple availability of care. Other broader based community interest groups have adopted a leadership development model. Programs are now being promoted throughout the Midwest by several foundations in which health care becomes one of several issues discussed in the context of community and economic development.
Access issues, of course, must take all of these diverse ideas into consideration. To assure this, local efforts must be inclusive rather than exclusive. They must integrate ideas, people, and resources rather than allow language and self-interest to separate them. A new basic set of principles to guide relationship building among organizations and viewing “big-picture” interests must be rooted in the milieu of local community values.
The ideals for this can be borrowed from basic business management philosophy. In a recent book by Max DePree entitled Leadership Is An Act, the author describes the art of corporate leadership as liberating people to do what is required of them in the most effective and humane way possible.” Tim Size of the Rural Wisconsin Hospital Cooperative has elaborated the DePree concepts into principles for effective inter-organizational rural health development. Among these principles are:
A. The organization’s right to be needed.
All community organizations must feel that they are needed as part of the solution to the access issue if they are to be productive locally and supportive participants in the planning effort. Each organization has unique assets that must be recognized, valued, and utilized in addressing the issue.
B. The organization’s right to be involved.
How many health planning efforts completed at a local level truly involve representatives of all those organizations already providing some type of health care service? In many cases, the “have nots” of health care, including local health departments and community voluntary organizations, are not even invited to the table even though their expertise and experience may be important in the access issue.
More often than not, regional medical centers, hospital systems, provider societies, and insurance companies are the “big guns” in these meetings. Other organizations must have genuine involvement in the planning and implementation of actions which will affect them. This means acknowledging “their right to the associated benefits of success as well as the risks of failure.”
C. The organization’s right to understand.
Another corollary principle to involvement is the willingness of all organizations to share in the knowledge and understanding of the environment affecting access issues. This includes an assessment of the reality and true value of local cooperation and coordination as well as the impact and understanding of broader environmental issues such as national strategies in health manpower, health care financing, and service delivery.
Local organizations and communities, therefore, must have the opportunity to recognize and understand those “Big Picture” budget and economic tradeoffs with which they fact in addressing access issues.
D. The organization’s right to make a commitment.
The Size paper also describes an interesting dilemma in inter-organizational relationships. He states “….as our (health care) systems have become more complex, decisions are seen as more impersonal and less rational.” Decisions, in many cases, are made on smaller portions of the larger picture, making the big question of access appear somewhat out of focus.
As he notes, people don’t commit directly to abstractions, they commit to people. Our Virginia Five Point Plan bears out this principle. Therefore, in the redesign of health care systems which will be more accessible, smaller modules such as neighborhood in cities and communities in rural areas must be the unit of solution within broader state and national plans which support a local problem-solving approach.
These four values must promote local coordination as well as a horizontal and vertical integration of resources at the community level. The principles of inclusion and respect for different organizational roles and missions are important. Flexible solutions which share integrated resources between health departments, hospitals, medical schools, and residency programs, health centers, and local voluntary organizations can become a 1990’s model addressing local access to care issues.
3. Promoting Pluralism
Each local solution which includes integrated organizational efforts will promote various weightings of the public and private parties involved. These weightings will be based upon negotiated roles and responsibilities for each organization. The politics of accommodation should account for emphasizing roles congruent with the strengths of each organization amended by the real depth and volume of the access issues in the community.
Pluralism not only means allowing different organizations ongoing roles in the solution, it also inherently implies acceptance of the notion that we may not necessarily find a single national comprehensive approach to the access issue.
The health care system as it appears and exists for those lacking basic access is now highly complex. It typically emphasizes key roles for different types of organizations in different communities. A recent survey completed by the Governor’s Task Force on Indigent Care in Virginia demonstrates this complexity.
The backbone of indigent care in three urgan areas (Richmond, Norfolk/Tidewater, and Charlottesville) in the state blessed with the presence of medical schools is a state appropriation for in-and-outpatient care funded for the purposes of “education and service.”
The roles of other providers of care in those cities, including private physicians, local health departments, and free clinics are clearly secondary to the health science centers.
In other urban areas, local health departments and hospital emergency rooms provide a bulk of the care. IN more rual counties, a greater reliance is placed upon local private physicians and community health centers. In most rural communities geographic and transportation barriers reduce access emergency rooms for anything but truly emergency acute care.
Local health departments in rural areas traditionally have provided limited categorical services in accord with a state statute which prohibits them from becoming anything but a “provider of last resort.”
In each community, therefore, the “system of care” for those who lack access is defined somewhat differently. We have found that an infusion of new financing programs might not adequately address access in many underserved rural areas since availability of any providers is generally lacking.
Systems development strategies might be of only secondary use in large urban areas where the volume of uncompensated care is regulated primarily by financial constraints of patients.
No one national strategy will solve this diversity problem. Making all of the country’s uninsured eligible for Medicaid or some other national insurance program will neither guarantee access in communities without care or insure that providers will accept the new insurance. Neither will the approach of establishing points of access in all communities solve the long-term problem.
Without heavy-handed centralized control of resources, including financial supports, health manpower, and new technologies distribution the access point strategy would falter and eventually crash on the rocks of American free market enterprise.
In summary, I believe that these three challenges to policymakers call for a truly enlightened management approach. It relies upon federal, state, and local partnerships in integrating the basic access strategies of manpower, financing, and service delivery, It accepts that degree of pluralism of different weightings of involvement of public and private actors.
It requires building local leadership through coalitions of local interests to address local access problems. It acknowledges that the leadership capacity of each community and the importance of the access issue may vary. It calls for out national and state leaders to allow local integration of solutions and organizational structures over time without forcing adoption of a singular model.
In the future discussions and conceptual developments which will take place around the issue of assuring access, we should all measure our philosophical approaches with four simple guidelines:
First, apply the golden rule: do unto others (poor persons who lack access) as we would have done for ourselves (and our own families and friends). All persons should be treated with the same concern and dignity that we would expect for ourselves.
Second, there should be a sense of community responsibility around the access to care issue. As such, it should be treated with the same type of community concern and total involvement as other major community issues, not just be categorized as “medical” or a poor peoples’ issue.”
Third, there should be a sense of accountability created for the health care resources already in the community which can be used to address the issue.
There are, whether formally recognized or not, certain social contracts which bind those who have in the past of do now accept public dollars and society’s professional respect and advantages because of their personal or institution’s position and profession. Not creating this sense of accountability is a community’s fault and can only be promoted through seeing access as a community issue.
Fourth, we need not be apologetic about promoting more rather than less resources for health care in this country. Good health is a cherished value in America; we all want to live longer and healthier lives than past generations. Also, the concept of prevention is ingrained in our value system.
Evidence the billions of public dollars we spend to design weapons systems to deter enemy military attacks or building new dams to eliminate devastating floods or federal insurance to assume liabilities from mismanagemnet of savings and loans or farm support programs to ensure the survival of family farms!
All have been built on prevention concepts and have been “sold” to the public as necessary parts of the economy and, therefore, eligible for burgeoning tax support. Access to good health care can and should be a leading weapon in our country’s defense against our own “internal enemies of poverty, ill health, and lack of education and, therefore, subject to the same philosophical advantages in public debates about community and national support.
This archiving and publishing of the proceedings of the fourth plenary session of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):
Sandral Hullett MD, West Alabama Health Services, Selma, Alabama [Dr Hullett is a Fellow of the Coastal Research Group]: I would like to say hello again and that I’m very happy to be a part of this panel. I chose to be last because I knew that both speakers that we had before would cover many of the issues that I would be concerned about.
The issues of access to care for minorities overlap for all minorities, so the same issues are raised over and over again. The availability of providers is an issue. Having facilities where the care can be given is an issue. How people get to those facilities is an issue.
One of my special concerns is the sensitivity to minority needs of the training programs that the providers are trained in. I graduated from a family practice residency training program that I thought was very sensitive to the issues of the area. I’m from Alabama, but went to medical school in Philadelphia. I started interviewing out West because I really wanted to see the mountains and later come back home. I always wanted to come back home.
But then I thought, why should I train in an area that really would not be similar to the area where I planned to work? So I changed midstream and came back home to interview in the South and then ended up through the National Residency Matching Program in Alabama. I was one of the first women in the program and the first minority woman. I think that probably was a good thing to happen to me.
But as I look at the residents who come through the program now (and I work very closely with that program), I’m really surprised. There are now no minorities at all in this residency program, nor have there been in the last three years. The residency program faculty state they do not have a pool of minority applicants form which to choose. I am concerned about that. But then the majority of residents chosen who supposedly will be working with all people lack a great deal of sensitivity to what the issues are for minorities.
I even had, for the first time in working at my site in 11 years, a physician who was actually attacked by a patient. It was a situation where the patient was Black and the doctor was White. But the issue that caused this problem was truly a lack of sensitivity.
If the person had really been instructed a little bit more in the residency program, I think, even if that person did not have common sense (which the person didn’t have), it would have helped a great deal.
My issue with the residency program is faculty orientation. I’m concerned about faculty just as much as I ma concerned about residents. If the faculty members do not have direct contact with the people for whom they are training the residents to become involved with, I think we have a great deficiency.
How many faculty people are going outside of their offices or outside of the group of patients who come directly into their facilities? I think this is something we need to look at.
Another issue of concern are the actual training hospitals that we have. Are we all using public hospitals? Are we using a combination of public and community hospitals and private hospitals? I think we need to use all of them, so the students and residents can have a mixture of all.
They should not have just public hospitals. There should be a mixture. Again, this helps us to deal with that issue of culture sensitivity.
Another area of concern in access is that minorities usually use public hospitals. There is a mentality that exists in public hospitals. I call it the “clinic attitude.” IN our area we don’t’ call any of these public facilities “medical centers.” We call them “clinics.” People get “clinic attitudes” even though there are some marvelous clinics – Cleveland Clinic, Mayo Clinic.
But the majority of the country, not just the minority patients, are not accustomed to that word “clinic” used in the positive ways. Special people go to Mayo and Cleveland! The rest end up with this “clinic mentality” which affects the way the care is being delivered affects whether the patients follow through and continue to come.
Rural hospitals are very, very important. In this country, and especially in the Southeast, a very large number of the minorities live in rural areas. The aged especially live in rural areas. We see a large number of public hospitals, both rural and urban, that once primarily delivered care to the minority people in the area, which have closed.
Even more are closing. This will cause a major lack of access to care and is something that as health care providers, administrators, and policy makers, we all should pay attention to, because these places have historically served the underserved and will continue to serve the underserved if properly funded and staffed.
Those are just some brief comments that I wanted to make. The other three speakers have covered many of the issues and I would like for us to have some time for dialogue.
Dr Midtling: This is directed at Hector. One of the things that I discovered as a residency director in California is that we’re dealing with a relatively short period of time, the time a student is in high school until we get him in a medical school. IT could be four years; it could be five years.
Over a ten year period of time, I saw students go from high school, to college, to medical school, to residency, and come back and practice in Salinas, the community that I was in.
One of the really successful interventions was that of role models going into the schools, especially the schools that had very high drop-out rates.
We had a similar situation in Salinas where we had one school that had a drop-out rate in excess of 70%. I would like for you to comment on what you’re doing and what you see the place might be for that type of intervention.
We’re trying to do that in Milwaukee, but we’ve done it only on a very small scale and I must admit with, I think, very little success. At least I think the opportunity to expand it is much greater.
Dr Flores: Those are good points. I think what we’re trying to do is: first, in a microcosm we, as a program and as an organization, have adopted certain schools. For example, the residency adopted three elementary schools and then all the junior high schools they feed into and the five high schools that they feed into.
So we’re making a long-term commitment, not only be there as role models and promote higher education in addition to health profession careers, but also to do the health education classes and other services that are equally important to the student.
Secondly, we work with the teachers directly to give them any kind of support that they need in order to teach the students and help hem to be critical thinkers. One of the things we do as we analyze the school we participate in is to sit in on some of the classes.
A lot of what happens in the classroom is passive learning. You’re dealing with teachers who are either burning out or are working with very limited resources. So again, what we try to do is work with the school districts and identify some of the needs that we think are crucial for these students to have a better chance at succeeding. That is the microcosm.
In the larger picture, we realize California has dropped to 49fth in this country in state expenditures per capita on education. It’s a shame that the state with the most money in this country spends so little on education.
What we try to do, then, is work with the larger institutions and the Department of Education in the State to start bringing some of these issues to the forefront. If need be, we will try to shame officials into taking some sort of action but we recognize we must be part of the solution ourselves, rather than just raising issues without doing anything about them.
It has to be a long-term commitment, because by the time we get to college, we’ve lost a lot of those kids already. Even the ones that go to college sometimes are not adequately prepared to succeed in that environment. They become the 7 to 8 year seniors, and have irregular progress many times in medical school as well. It’s going to have to be a long-term solution. There is no quick fix to this.
One of the biggest concerns we have that Sandral and others have mentioned is the dropping applicant pool of minorities applying to medical school.
California is no exception. A study of trends over the past five years shows that the number of minority students in the applicant pool has dropped by greater than 20%. The success rate has not changed. Definitely, there needs to be a long-term commitment and we need to become part of it.
Dr Hullett: Something else we should consider is that while the number of students applying to medical school has decreased significantly, in the engineering department at the University of Alabama the number of very bright young minority students has increased significantly.
One of the major reasons is that they have an outright push with a full-time recruiter to do nothing but get minorities into engineering.
And what are we doing in medicine? Are we doing anything similar? I don’t know of us doing anything similar in Alabama. I believe having a paid recruiter to do nothing but get the best students into the engineering while the medical applications are dropping.
The medical schools don’t make that kid of a full, outright commitment to recruitment. We can send someone to the local schools and talk about the medical school program, but we don’t aggressively look for these young people. That’s something else we need to consider.
Dr Gessert: My question is for John Arradondo. (I was intrigued by your fairy tale of “Dodge City!”) In view of the urgent need give us your judgment of what the principles were that really made significant success possible. I am thinking particularly of the success around utilization and emergency rooms.
Dr Arradondo: This was a fairy tale that has an address. I am talking about Tennessee. I am talking about 1984-85 in Nashville. The Tennessee Association of Primary Care, which was principally an association of community health centers, decided to go after a grant to form an HMO.
That was at a time when we had six or eight years of priming the local government through the Tennessee Primary Care Advisory Board, which I had chaired, which advised the governor and the director of public health in the state.
We formed a program called Medicaid Plus. There were some subsidies in the initial organizational planning phase. I had an opportunity to sit on the medical advisory board of that organization, although I knew that my academic institution would probably be one of the providers.
The organization decided that it would use a kind of independent practice association model, since it had contracts with each individual provider or group of providers. What they negotiated with the State Department of Health and Environment, Medicaid Section, was a contract for 95% of the funds that the Medicaid division had thought they would spend during that current year.
They focused on the people who were recipients of Aid to Families with Dependent Children, which was a moderate user category compared to people who were on the Medicare side of the grandparents who were taking care of children who made them eligible for AFDC.
I guess there were, as I recall, 160,000 eligibles in the state. The average eligible had gone to the physician the previous year 3.9 times at a take of about $27-29 per visit to the physician, whereas the physicians bill was about $43 per visit. So they were getting form 60% to 2/3 of what they were billing for.
They chose to start in a small town in East Tennessee and after they had some experience there, the next town they would expand to would be Nashville and then they would go to Memphis and Chattanooga.
They had some modest enrollment goals that they wanted to achieve. In Nashville, for instance, they wanted to have 2,000 enrollees within the first six months or so, and they achieved that. Then when they went to Memphis, where they wanted to enroll about 10,000.
Although they were delayed going into Memphis, they did achieve that. Then they went beyond those numbers in Nashville and met their target in Chattanooga and then a small county in east Tennessee.
All of those added up to somewhere between 15,000-20,000 enrollees. In Nashville, the eligibles they had were around 20,000, so they were enrolling a small number of the eligibles. But then not all of the people eligible for the services had used Medicaid services in the previous year.
They were very clear about the voluntary aspect. The client had a list of providers. The client would choose and the client would sign on for a year. If the client moved and there was a provider nearby or if the client preferred a new provider, it was easy to change.
But the intention was that people who were providing the service would market this program to their patients. Rather than taking the 3.9 visits at $27 per reimbursement, the physician would opt to get this person to enroll and receive $5 per month for this person, which is $60 per year. This, participating providers were guaranteed $60 per year without having to bill (although there was a routine alternate billing to do a quality check.
Even though prepayment had replaced fee-for-payment reimbursement, those records from the alternate billings would be compared. A few people felt they would do that since who would determine if some providers’ patients were high users and others low users. A number of people did, in fact recruit some of their patients.
The Meharry Medical College did that, and a couple of smaller primary care clinics, one of which was in the housing project most nearly like “Dodge City” except it was several blocks south, and, rather than being 97% Black, it was about 18% Black.
The traditional patterns of Nashvillians, where they would live, was demonstrated in the different demographics of those tho housing projects, either of which actually could be called “Dodge City.” There was a private kind of health clinic ultimately funded by 330-331 funds. “Dodge City” which was right on the edge of it had a public health clinic that operated about four days a week.
That was the setting in that part of the city where this small practice existed (a building that had about 6,000 square feet on one floor, a number of exam rooms, a common room in the middle, and a multi-purpose room in the back).
Actually, it was set up to be a teaching practice, should the university want to use it for that purpose. But the five of us set it up with the permission of the medical practice plan. (Individual faculty members were permitted to set up a practice to set up a practice that was not controlled by the medical practice plan fully.
Certain payments would be made to the medical practice plan pursuant to income and other factors. These were the practices in which the medial practice plan didn’t invest very much for the start up and had a modest return. It was a “win/win” project.
Five full-time faculty members who used a part of their time to run a part-time practice were running this practice at about 2 FTEs, if you added up all of our time. We had psychologists and social workers. OF course, we had medical assistants and nurses.
We had a few other health providers who came. There was a dentist upstairs. There was a laboratory upstairs – a professional laboratory. This was on Main Street.
Two blocks to the north was a modest neighborhood of four by four blocks of single homes and duplexes or triplexes and then a few small apartment buildings of 6 to 20 apartment units – but all kinds of lower-middle class and upper-lower class people, in an ethnically mixed, but increasingly Black, neighborhood.
Four to five blocks to the northeast was “Dodge City,” which covered an area of about seven blocks long by about five blocks wide. It shared a basketball court with a new 5th through th grade middle school that had been established pursuant to a 29 year old NAACP court case that was settled by a consent decree. The middle school had as an admission policy, a ratio of two Whites to one Black.
There were other criteria. You had to be gifted and tested or recommended or your parents had to believe you were gifted. Those were the three ways you could get int. The waiting list, obviously, was white in Nashville which has only about 30% Blacks, 8% Hispanics and Native-Americans. That was kind of a new development in the neighborhood.
But the rest was kind of like “Dodge City” and then what is right next to “Dodge City” – Oprah Winfrey’s dad as a matter of fact. That was kind of the neighborhood. IT had its pluses and minuses. All of that was just a few blocks north of Main Street, eight blocks east of the river, then blocks east of the Capitol.
Those people went to the practice voluntarily, because it was there. They didn’t recognize me or any of the other four practitioners. A few of them recognized my name, not many. A few of them recognized the name of one of our practitioners because in another practice of his located against the number one community hospital in the city, had recognized him as the doc who had an ad on the back cover the the Yellow Pages.
If I were to call him right now all I would have to remember is 800-HELPDOC, and that’s his number. I can dial that number wherever I am in the country and I can get him by telling them that I am Doc Arradondo. They recognize my name on his switchboard.
But anyone of you could dial him and you would get some assistance and he would tell you where to get care wherever you happened to be. It was aimed at local people but it is a national 800 number. So they recognized him and a few people came to that practice because of him, but basically they came to the practice because of where it was located. A beautiful upscale practice!
After we had been there six months, 12 members of the Tennessee General Assembly out of 99 m embers were our clients. Nine members of the House and three members of the 33 member senate were our clients. Almost half of these people were Black but not all were.
We had other people who became clients, from the historic Edgefield neighborhood. We had clients where the current mayor lives. So it was a mixed practice of about 30% Medicaid, including these patients, and about 25% to 30% Medicare.
The rest were basically Blue Cross/Blue Shield, but with very few self-paying patients. The practice was about 50%-60% Black. We provided a fair amount of prenatal care.
We, in this particular practice, provided the services since we decided that since these people were coming to us because of where we were located, not because of who we were, that maybe we could get them to buy into what we were doing.
So we set out to do several things right away. Anytime a person would call, we would make sure that we would return the call right away. Our guideline was 15 minutes. The HIO’s guideline was soon.
Our first six months, it turns out, was seven minutes by their clock. All that was required was that it be less than 15 minutes. So the first thing the people discovered was that if you called one of us, you got an answer back right away.
At that time I didn’t have a phone in my car, but I had plenty of quarters and I knew here the pay telephones were as I was driving from East Nashville back to Meharry of from my home in the west part of the city to wherever I would come in the central part of the city. All of us did the same thing, including the two members of our practice who did have phones in their cars.
When people would go to the emergency room, we would always make sure we talked to the patient unless the patient was super sick – in trauma for instance. We should always talk to the patient, just as if the patient had called us. That, of course, set a precedent among the emergency rooms. They quickly learned that the approval for admission and for services lay with the designated physician.
We could have let them come under the emergency clause and the HIO would have paid for it. But the idea was to contact the patient. What a more wonderful teachable moment than the moment when the person says I want service and I want it now.
Here is some ignoramus professional provider saying, “I need to talk to you.” We did it in various ways. It was amazing how happy the patients were to talk to us. They weren’t getting talked to by the people in the emergency room.
Rather quickly the people in the emergency room learned who we were and learned that when the patient came in with a pink card, that meant Medicaid Plus, as opposed to the green card that was regular Medicaid. There was somebody who was going to be calling.
Typically, it was the person whose name was on the card. But they knew somebody was going to be calling and that’s how we began to educate people in the emergency room and in the admissions sectionof the public hospital, the three small community hospitals, and the very large No. 1 community hospital which also got a few of our clients.
Of course, we would almost invariably tell the patient to go ahead and get service or get the patient to make a joint decision.
Would you believe that in the first 32 times I did that, that 18 of the patients decided to leave the emergency room and to come to my office the next day, including one on a Sunday morning? We weren’t open on Sundays. We were open a half day on Saturday. But I dutifully met that person there before church. That impressed her.
She was about a 45 year old lady taking care of two of her grand kids. It just impressed her no end. Needless to say, I wouldn’t’ want to set that as a precedent. I had other things to do on Sunday. But that was the characteristic of the five person practice. We would really go over backwards to meet the patient. We were marketing to them.
Initially, 306 people signed up. Before long we were at 700. Before the end of the year I had 1000 that had my name on it and I think our total was about 1400-1500. It ended up being almost half of the numbers in Nashville, drawn mostly from “Dodge City” and secondarily from the neighborhood center and a few people who were living in private areas but who were on AFDC.
Those were some of the things we did. We tried to get people in to teach them things. There was more health education literature in our office than you could shake a stick at. In fact, I guess the fire marshall probably would have declared it a fire hazard if he came by to approve the premises, after we got going, rather than before.
In all the rooms, in the waiting room, on the TV, was all the health education literature that we preach in family medicine. The place was nice and plush and people loved it.
Dr Gessert: One detail on that. When the patient arrived at the emergency room, would you be talking to them on the phone before they were seen?
Dr Arradondo: Whatever the procedure of that emergency room was. If the admissions person in the emergency room figured out that this was Medicaid Plus patient and knew what that meant, she would call.
Of course, it surprised the emergency room staff that we would be calling back in such a short period of time. Not just the patients! It surprised them because we would call back just as rapidly for them as we would for the patient.
But sometimes they wouldn’t see that. They would just see the number and they didn’t realize what the pink card meant, didn’t read it, hadn’t been oriented although the HIO had visited all of the hospitals and had agreements with most of them in principle, not in writing.
They would send the person on back to wait or to get lab or whatever the procedure was. Sometimes people had seen the nurse of the doctor before they would call us. I talked to a number of physicians, some of whom took umbrage at the conversation.
But the payment mechanism was very clear. I had to O.K. it. IT was as simple as that. I didn’t mind them giving care if they thought it was necessary. If I agreed, I would sign off. And the HIO could overrule me at any time before or after I spoke. But I exercised that quite routinely and that was the most educational matter.
The orientation given was fine, but after a couple of calls from one of my colleges, the people in the emergency room knew about the “pink card” and they knew what it meant. They would call us then fairly early.
When a new employee would come in, they would go through the old procedure. If somebody had been on vacation, doctors and nurses would get on their case because the doctors knew quite readily what all that meant.
In many of the small hospitals, the ER was contracted out and the doctor billed. If the doctor didn’t get his bill, that hurt his take. It was a very serious educational matter for the staff of those hospitals. After maybe three months we would get calls right up front from the admitting people in the ER.
Also, we began to have fewer people going to the emergency room because the word began to spread, particularly in “Dodge City,” that these doctors were over here.
The practice had a little catchy name on it, and had a nice sing out front that had some family on it, plus the “digs” were nice – as good as any physician I’ve ever had and I’ve had doctors for 30 years. And the word began to spread. So we began to have people sign up. And people would come before they would sign up.
We weren’t taking anybody just as a Medicaid patient in general. IF you came to us, we would sell Medicaid Plus vigorously if you were eligible, because we thought that was much better. The $5.00/month was predictable.
We knew that you weren’t going to go to the hospital as often, because most of the hospitalizations were superfluous and unneccesary. So we sold it vigorously and I’m sure that the second half of our patient numbers were really referrals and a result of our marketing.
The first half were mostly people signing up because of where we were. But shoe were just some of the factors. Also, occasionally people would bump into one of the state senators or state representatives or somebody from historic Edgefield just up the way, or sometimes they would see the cars out front.
They realized that they were getting the same treatment as everybody else. Or they would see somebody coming in dressed how we’re dressed here today and they were never dressed quite like that. It was amazing how many patients began to get all scrubbed.
I used to have to tell some of them not to wipe away evidence. (You know how sometimes the patients get all fixed up for the doctor.) But we really tried to educate the patients. Many of them, when we changed the location of the practice, followed, which was at est of patient loyalty.
Mr Burnett: I had question of Jerry related to the efforts of persons who are trying in their region to increase the representation of underrepresented minorities.
It seems that if one has an ongoing strategic organization like the Chicano organizations and support groups in training institutions and schools, why it’s fairly easy to get more resources to Hispanic students. There are also similar Black organizations.
The question for the Native-American, is ti possible or appropriate to be pro-active there and does a group like the Association of American Indian Physicians have programs ongoing that some of us aren’t familiar with yet?
Is it logical to, for example, to be working with say, Morongo Valley Health Clinic which has a nearby residency program, and to be thinking in terms of trying to get Banning High School which has a large percentage of Morongo Indian students to try to build some program there? Do you have to wait for there to be an equivalent of Hector in the Morongo community or can one do something about it if you come from a larger society?
Gerald Ignace, MD, American Association of Indian Physicians, Wauwatosa, Wisconsin: As far as trying to recruit students, presently the Association of American Indian Physicians [AAIP] is one of, I think, two groups active in doing that. The other group is the INMET program for nursing.
The AAIP does have ongoing programs. Primarily, we hold three or four workshops for undergraduate pre-medical students every year, each workshop consisting of about 30 to 35 students who are interested in health career opportunities. These are rotated around the country to try to incorporate different regions so you don’t leave certain folks out.
In these workshops there is a two-day session about the steps you go through to get into medical school, including mock interviews. I think these have been successful. We have been doing this for over ten years. On occasion, the budgeting is limited and the budgeting tends to be decreased every time we get near our goal.
We have been able to, on a limited basis, go to those Indian reservations which have requested support for a health careers day or associated activities. Limited staff and budget restraints impede progress in this area. Part of the problem is that the Indian country is so diverse and so scattered with so many small communities that for them to be able to put together a program is often not really feasible. It is the larger tribes that do.
Sundwall: I just wanted to comment. Everything I heard from all of you underline the failures of the system of health care. Although they were culturally specific, there were problems with the system making it unfriendly to the minorities in particular.
I”ll just quote from a Bob Heisel lecture which impressed me. In Baltimore, after the passage of Medicaid, there was concern that the infant mortality rates were still high, even though Medicaid was available for all. The decision was made to survey the Medicaid cardholders.
These are the kinds of comments that those conducting the survey received. That the Medicaid cardholders regarded the Medicaid card as a very valuable piece of property because they used it for check cashing, food stamps, and incidentally for securing drugs.
These are some of the reasons they stated as to why they didn’t seek care: “They didn’t know they were supposed to.” “They were afraid to tell their mothers.” “They were afraid they would get kicked out of school.” “They were afraid of the large institution; they were afraid of doctors.” “They had a bad experience in clinic.”
Heisel’s point is that unless you have a culturally sensitive, user-friendly delivery system, that’s less threatening and more appropriate to the community environment, all the money in the world doesn’t help.
This archiving and publishing of the proceedings of the third and fourth plenary sessions of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):
Hector Flores, MD; White Memorial Medical Center, Los Angeles. [Dr Flores is a Senior Fellow of the Coastal Research Group.] : I want to thank John Midtling and Bill Burnett for inviting me to come and speak today. This certainly is an area of personal interest to me and also of interest to my organization, the Chicano/Latino Medical Association of California, which is a network of over 1,000 Latino physicians, primarily trained in California schools, but mainly trained in the United States.
I think that’s important because there’s a history that goes along with that. If I have some time, I’ll get into that later. Both John and Bill asked me to come and speak on the Hispanic experience, I guess, in the issue of access to health care. I want to talk bout the demographics in this country and particularly in California and also how that relates to the barriers to health care and the level of access that our people achieve. Then I will make some recommendations on what we should all be focusing on.
Demographically, in the United States Hispanics are the fastest growing ethnic minority group and, depending to whom you talk, approximately 8% of the U.S. population is now Hispanic. At the rate it is growing, by the year 2000 it will reach the 10% mark. That’s due in part to high fertility rates, but also the the large level of immigration that, depending on political and economic pressures in Central and Latin America, tends to fluctuate but usually is on the increase.
If we look at the 20 million or so Hispanics in this country, 63% are of Mexican-American descent; 11% are of Puerto Rican descent; 18% are Central Latin American and the remainder are Cuban, Caribbean, or Spanish ancestry. That’s important because part of my message today is that we’re not a homogenous group. Although culture and language unite us, there are some basic differences in terms of our history. 13 million Hispanics in this country live in the Southwestern United States and 53% of those live in California. Because I live in California. Of the 6.8 million Hispanics in California 80% are of Mexican-American descent. The total Hispanic population in California is 24% of the population.
I think we need to look at some of the issues that have already been addressed quite eloquently by John Arradondo and some of the other folks yesterday in terms of the health care access. But I want to give you some idea of the economic background of the Latina community in California. The median family income is $22,000 which is 25% lower than the Anglo counterpart in California.
It translates to a poverty rate that is two times greater than the rest of the community in California. IT also translates to unemployment rates that are almost twice the rest of the community. I think that’s important because when we talk about access that really leads to people who have very little expendable cash on hand to access health care.
The median family income figures tell us that even those who are employed are usually working poor – people who don’t have access to employer provided insurance. Approximately 30% of Hispanics in California are uninsured. Many of them work, but as I mentioned, they are working poor. There is evidence that a lot of Hispanics in California are also under-insured, so that even if they have some insurance through employment, the deductibles and co-payment involved are quite prohibitive and limit their access to health care.
Age is also another barrier. We don’t often think of it as such but among the Hispanics in California the median age is 22 years old as compared to 34 years old for the rest of the community. Typically, the medically indigent adults in our state come from the age groups between 18 and 45 and that certainly represents a lot of our community. Lack of formal education is another access problem. John Arradondo touched on it, but unfamiliarity with using health care systems and bureaucracies is a big limitation to access. That’s certainly part of the Hispanic experience.
But more than that, I just want to touch on the fact that Hispanics in California have about nine years of school as an average to 12 years for the rest of the community. That tends to decrease as the level of immigration increases, because most of the folks, coming in California have lower levels of education. In addition to that, inner city schools have a greater than 50% dropout rate.
In some cases such as John Locke High School in South Central Los Angeles, there is a greater than 85% dropout rate. What’s even more distressing are statistics from the junior high schools in the area. Bethune Junior High School which feeds into John Locke High School and two other high schools, has a 90% dropout rate when the students reach high school. Of the 10% that finish, you probably can count on your hand the number who go to college.
Legal problems are also another barrier for Hispanics, especially the fear of arrest and deportation. Penalties that threaten amnesty applicants certainly are a big deterrent to looking for health care, particularly in the Southwest. Then there are the cultural and linguistic barriers that we have touched on already. In Los Angeles County, a survey last year showed that 47% of Hispanic respondents declared that they had difficulty with the English Language. That’s fully half of the population.
In L.A. County about 40% of the population are new immigrants from Latin America, mainly Mexico. So we’re dealing with people who have a very clear problem with language and also with cultural issues. We talked about the cultural concept of disease, and communicating not only in language but experientially and culturally are equally important. And the poor coordination of services that John touched on already is itself a barrier.
I think when we look at the level of access not only are the barriers important but we should look at the access to primary care – basically what we’re touching on in this particular conference. According to the Office of Statewide Health Planning Development in California, 50% of Hispanics in California live in primary care physician shortage areas. As they define it, that’s one primary care physician for every 2,200 residents.
That translates to a shortage that obviously leads to poorer health outcomes, to a lack of intervention at the appropriate time leading to consequences of severe complications or even death in many situations. This is also evident in the Secretary’s report on Black and minority health in 1985 which showed that Hispanics have a higher disproportionate representation among chronic complications and deaths in cardiovascular disease, violence, and certain cancers.
Also important are the issues of infant mortality, perinatal complications and low birth weights. As John mentioned about Houston’s Hispanic population, an interesting phenomenon that is also occurring in Los Angeles County is that among Hispanics in general the low birth rates and infant mortality rates are quite surprisingly low.
One of the things we have noticed, though, in L.A. County is that among acculturated Hispanics – that is second or third generation Hispanics – there is a rapid rise in the number and percentage of low birth rates and infant mortality. Preliminary data show that a lot of them smoke and a lot of them drink. In a sense they’re adopting or responding to the heavy marketing that goes on in minority communities in terms of some of the lifestyle and habit decisions that are promoted through commercials and other endeavors by cigarette and alcohol industries.
I think the other parameter of shortage is the number of Hispanic physicians there is for our population. If you look in California, although Hispanics are 24% of the population, only 2.9% of practicing physicians are Hispanics. What that translates to is one Hispanic physician for every 4,000 Hispanic residents in California. We compare that to the Anglo population, where there is one physician for every 400 Anglo residents. That to me, when we deal with the cultural and linguistic issues of access to health care and quality of care, certainly has relevance.
In the United States the numbers are similar. Although Hispanics are 8% of the U.S. population, Hispanic physicians are only 3.7% of practicing physicians. Fewer of them are primary care physicians. It also translates to shortages in other health professions, particularly nursing. In California, only 5.5% of nurses are Hispanic and only 3.5% of dentists are Hispanic. It translates to similar impact on the access to care and on the quality of care that’s provided to them.
We talked about the uninsured. In California there are 5.5 million uninsured residents. One-third of them are Hispanic. The reasons this is mentioned is because a lot of them are undocumented, unfamiliar with utilizing the systems, and also because state cutbacks have limited eligibility to the entitlement programs such as Medicaid and because a lot of them are the working poor. They work in the service industry. They work in jobs that many people don’t want and, consequently, they work in the industries that can ill afford to provide them with health care benefits.
Well, what does that translate to in terms of what we must do? I think first we must recognize that despite the predicted physician glut, there is still a maldistribution of physicians and California is no exception; hat the physician diffusion model or the market forces model for providing access to primary care physicians is not working. We look at that in Southern California where I Have reviewed some of the data recently and we look at a community like Glendale, for example, which is an affluent community. It’s about 10 minutes away from White Memorial where I practice.
The ratio of physicians to patient population is 1:3000 and about ten minutes away in Santa Monica the ratio is 1:3000 also. So we can see that even though geographically physicians are located close to underserved areas, there still is a resistance to go and practice in those areas. So diffusion has really not worked in our communities.
I think we’ve talked about the issue of medical students selecting less and less the primary care specialties, perhaps the cost of education being a big factor. We need to recognize that we should not be complacent about that. In fact, we should do something about it.
I think it’s important to recognize that Hispanics are primarily an urban based population. In this country, about 90% are urban based and California is no exception. 90% in California are also urban based. I think that relates a little bit to what we talked about with the National Health Service Corps yesterday that when we look at providing primary care services, particularly family practice, to Hispanic populations, we’re really talking about providing family practice to urban underserved populations.
A corollary problem is the lack of Hispanic health providers in academia. Dr. Arradondo alluded to that. We look at how many faculty there are in our country. According to the AAMC, 1% of all medical school faculty in United States medical school are of Mexican-American or Puerto Rican descent. Those are two groups that I am going to be focusing on who enter into medical school have very few role models to help them academically, to be their advisors, and to be the people who guide them on into their health centers. That’s a very important issue when we talk about the admission to and retention in medial schools.
I am going to give you some data that demonstrate that Hispanics tend to choose the primary care fields more than their counterparts, but it’s important for us to recognize also we need to support those Hispanics when they look at academia and becoming professors and faculty in medical schools because it is medical school faculty who will become the deans of admissions and deans of medical schools and who will sit on boards that make very important decisions as far as future health manpower needs.
I think also we do need to pay attention to the level of indebtedness that minority students are encountering. Dr. Midtling mentioned that yesterday and that is particularly true for minority students. The average minority medical student graduates from medical school with a $45,000 debt. There is evidence that not only does the cost of medical education deter talented young minorities from pursuing careers in medicine, but that once they are in medical school it deters them from choosing primary care fields.
The other issue is the fact that we also are beginning to recognize that minorities tend to return to their communities which are often underserved and with a great preponderance tend to establish practice in underserved areas.
Two papers that come to mind are papers by Dr. Stephen Keith in the New England Journal of Medicinein 1985 and by Drs. Davidson and Montoya in 1987 in the Western Journal of Medicine addressing that very issue. I think the other important point to remember is that among Hispanics, in particular among Mexican-Americans, there is a great preponderance of choosing primary care fields.
If you look at the California experience, where we have quite a network that allows us to access most – if not all – of the Hispanic students in California medical schools. Over the past three years, 30% of graduating Hispanic students have gone into family practice. If we look at primary care involving family practice, internal medicine, pediatrics and OB, over 80% of those students are graduating into those fields. I think that has some important implications in terms of the strategies that we begin to develop for providing the health manpower needs of underserved communities, particularly the Hispanic community.
But above all, I want to make sure that we remember that the numbers coming out are quite small. We need to really work to develop ever larger pools of applicants as well as larger numbers of students entering and graduating from medical school. I think we need to look at the experience of the Black medical schools and see them as role models for what can be achieved for Hispanics.
Not that it would take away the responsibility of our state supported schools and other institutions from fulfilling their commitment to minority opportunities, particular Hispanic opportunities. Yet, if you look at the Black medical schools, each year they graduate about one-fifth of all new Black physicians. I think the time is coming where we need to look at developing a medical school for Hispanics that begins to address the same issues.
We have some exemplary models in Morehouse, Drew-UCLA, Meharry, and Howard that should be replicated for Hispanics as well. That relates to what I am doing now in working with the White Memorial Medical Center Family Practice Program. Our residency program is part of the Hispanic Medical Education Center. [HISMET] initiative that originally was seeded by the California Area Health Education Center.
HISMET was directed towards the manpower needs of Hispanic communities. It seeks to develop a comprehensive program of recruitment into the health professions among college students up to postgraduate training and residency. Part of the HISMET programs was to develop pre-baccalaureate support programs for MCAT preparation, for academic support during pre-med years, on to post-baccalaureate programs for those young Hispanics who failed to gain admission to medical the time that they applied. It also involved bringing in medical student support by means of HISMET clerkships. Those link up minority students with physicians already in practice in shortage areas so that they can model that fee-for-service or other types of practice are indeed possible and that viable practices are indeed possible in underserved areas.
One of the socializing problems that we run into in medical school is that we’re told constantly that practice in shortage areas is going to burn us out and economically we’re never going to make it. That’s part of what we’re trying to do at White Memorial.
Beyond medical school retention and support, the centerpiece of the entire HISMET initiative has been developing a residency oriented to training young physicians in shortage areas and particularly addressing the health care needs of the Hispanic community. This residency came about as a result of a two-year feasibility study, that told us there was a commitment to make sure that this was a quality program from the very beginning.
The right kind of consultants were brought in, not the least of whom was Dr. Sanford Bloom who had run the Santa Monica program in family practice for 14 years and brought it to national prominence. Basically, he brought the blueprint for that residency and adapted it to the multi-cultural population of East Los Angeles, a community of 300,000.
About 80% of the residents of East Los Angeles are Hispanic. About half of those are monolingual Spanish speaking. Dr. Bloom adapted it in such a way that it would take into account the type of payer mix that was not like Santa Monica as I mentioned earlier, but certainly would incorporate strategies to make sure that it became financially successful.
The next task was to recruit a faculty that was basically oriented to the HISMET mission. Having been part of the HISMET committee that planned this residency, it was not difficult for me to see that there was a place for me in that residency as well. I’ve always had an interest in teaching and always had an interest in serving in that community where I grew up.
There were several other individuals whom I knew who would also be interested in joining us in this project. The bottom line was that seven of us came together to become physicians and faculty in that area. It’s interesting that up until that point there was only one other family practice residency trained physician practicing in East Los Angeles. So when we came in, we basically increased the number by 700% of residency trained family physicians. Particularly, we were all bilingual.
I think what’s really important is we all grew up in the area and we all had an interest in returning to that community. This really relates to the issue of health manpower development. We can’t expect people who are not culturally and experientially affiliated with a community to leave everything and suddenly decide that they want to practice there. They must have an incredible commitment in order to do something like that. I give a lot of credit to the folks who have been practicing in those types of areas for many years.
I think what’s much more natural and much more cost effective is to start identifying students, young people in those communities who have an aptitude and an interest in health careers and nurture them as early as junior high and high school, because of the dropout rates, and nurture them throughout their entire education, supporting them in any way that we can so that they can succeed. We know that they will return to their communities as the data have begun to show and that our group as a microcosm has already shown.
What’s equally important for us is that we want to model successful inner city practices to young physicians who have similar goals. One of the things we have done is developed a practice management curriculum for our residents, basically modeled on what we have been able to achieve. Coming into that community, we know that a large percentage of the community was uninsured, cash-paying, and unable to pay the types of fees that we would have to charge to remain viable.
A large percentage was on Medicaid and other entitlement programs. But what we have done is: 1) looked at planning; 2) made sure that we had the type of training in utilization, management, and quality assurance to make the most of our resources. We were quite fortunate that the seven faculty members (which by the way are now nine total faculty members) all had training in one way or another in managed care and in understanding cost-effectiveness and quality assurance. That has helped us in developing successful practices. We’re trying to impart that knowledge to the young physicians who are a part of our residency.
The residency is slated to reach a level of 18 residents total, six per year. Right now we’re at five per year. We have been able to attract the type of resident who has a commitment to those communities. They are primarily Hispanic but not all of them are, because we’ve always recognized that the people who have been our role models by and large were not Hispanic. It doesn’t mean that simply because someone is not Hispanic they cannot provide sensitive care to these individuals. By the same token, somebody being Hispanic doesn’t automatically make them good candidates for providing services to those areas.
So the bottom line is, first, that we need to develop strategies in health manpower development that really focus on the types of things we’ve seen successfully done, such as bringing the types of students like minority students who return to their communities. We need to focus our health manpower development on those individuals and give them the type of support, economic as well as academic, in order to succeed.
Secondly, we need to look at programs such as the White Memorial program. I am sure there will be others that will rise in the wake of of this program because I am sure it will be successful in providing the health manpower needs for the particular region in which it exists. We need to support those types of programs. Whenever someone talks about creating one, we need to be there to give them the type of expertise they need to develop such a program.
Thirdly, we need to start thinking seriously about a medical school that is oriented to the Hispanic student, because that is tone way – as we have seen in the good models in the Black medical schools – of beginning to meet those needs.
I want to talk a little bit about what our philosophy is in the Chicano-Latino Medial Association. A lot of people ask me why we don’t use the term Hispanic when that seems to be the rubric everyone likes. The reason we chose Chicano-Latino is because it has a historical perspective to it. Our roots are in history. Our roots re in the civil rights movement and landmark issues such as the Brown vs. Board of Education, Plessy vs. Ferguson.
All of those decisions that occurred before us gave us the opportunities to become physicians in this country. What unites us all is that we all come from similar socio-economic backgrounds. That’s why we chose the term “Latino.” We are of Mexican-American descent; we’re Central American; we’re South American, but what binds us together is culture, language, and socio-economic backgrounds.
It’s very important to remember when we begin to work with health policy makers, that just because someone is Hispanic doesn’t necessarily mean they have the same priorities that our underserved communities have. They may be in this country because they were escaping very rigid economic sanctions from dictatorial governments and not necessarily because they came here looking for a better life. I think that’s a very important matter to remember.
What we do in CMAC is to look not only at health care issues such as access but also to look at increasing the educational opportunities for our communities. We really believe in community-oriented primary care. We need to get involved in the schools. We have an “adopt a school” program so that in a small measure we can address that, but on a policy level many of us are getting involved in the unfilled school districts and other areas of education. Secondly, we believe in the economic development of our communities.
I talked about poverty levels in our communities. But as physicians we can mobilize upwards of $1 million worth of resources simply by practicing medicine. We’ve begun to understand that and we’ve begun to understand the impact that we can have on a particular community by making sure those resources stay within that community.
Thirdly, we need to look at empowering ourselves politically as physicians while also empowering our communities. That’s an important role that physicians can have – making sure that people fill out their census cards and that they get out there and get their colleagues, friends, and family members to vote and to become politically aware. One of the hottest health issues in California is the reapportionment issue [at the level of county supervisorial districts]. That movement impacts directly on issues of self-determination and making sure that the expenditure of public funds benefits the right people.
We also need to look at developing our own leadership. That’s what CMAC is all about. Many of us are members of established medical organizations, yet we knew we had to develop an organization that addressed specifically the needs that were important to us and to able to have an organization that can mobilize people at a moment’s notice to support an issue that we feel is important.
It’s very important also to realize that we need to work within the established systems because the only way things are going to change is if we get into the mainstream. Lastly, we need to recognize the need to build coalitions. No one group can do it alone. We cannot afford to be cultural nationalists and say only Hispanics can answer Hispanic needs. We need to work together with our African-American colleagues, Native Americans, Asians, and the Anglo population because we are, indeed, a multicultural society that needs to work together.
I think one of the things that has always inspired me in my own medical education has been a mentor whom I had in medical school who happened to be an internist but who always supported my own goal of being a family practice physician. That was Dr. Ernest Gold who has since passed away. He always taught me that it was good to be important, but it was far more important to be good. And that’s exactly what we try to do in the CMAC.
This archiving and publishing of the proceedings of the fourth plenary session of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):
John Midtling, MD, MS, Chair, Department of Family Medicine, Medical College of Wisconsin [Dr Midtling is a Senior Fellow of the Coastal Research Group]: I would like to welcome you to the second day of our conference entitled “Access to Primary Health Care in the 1990’s.” We have a few new guests here today. I will mention again that the conference proceedings are being recorded. IF you do make comments or ask questions, identify yourself. It will help us in producing the final proceedings.
The session this morning is entitled “Improving our Management of Access to Primary Health Care for Minority Populations.” The principal presenter is John Arradondo, Director of the Department of Health and Human Services, City of Houston. Panelists are: Hector Flores, M.D., President Chicano/Latino Medical Association of California and faculty member of the White Memorial Medical Center in Los Angeles; Sandral Hullett, M.D., Medical Director, West Alabama Health Services; and Gerald Ignace, M.D., Past President of the American Association of Indian Physicians, and current Chair of the National Advisory Council of the National Health Service Corps, and a physician in private practice at the Harwood Medical Center, Wauwatosa, Wisconsin. John.
John Arradondo. MD, Department of Health and Human Services, Houston, Texas: Upon being asked to address strategies to manage to access to primary care among ethnic minorities and underrepresented minorities, I immediately visualize the faces of Houston’s Black, yellow, and brown citizens. In my brief stay there, these minority citizens have often appeared to be entangled in a medical care delivery system that almost always appears to be more responsive to the demands of its administrators and its full-paying clients than to the people who are on the margins of the system.
This isn’t to say that all minorities are on the margin of the system, although too many are. It is to say that being Black or Hispanic in Houston puts one at a significant disadvantage for obtaining safe, reasonable, comprehensive care.
Lost in the web of special interests, these ethnic minorities confront great hardship in obtaining health and medical care. Some of this hardship is due to their limited experience with the health care system, some to their lack of knowledge about their won health needs. Additionally, the lack of culturally sensitive disease prevention programs in my town and insufficient income by many of its citizens to buy health services are clearly significant factors.
Increasingly, the publicly funded medical health care system, (and all those words – medical, health care, and system – have their own independent and collective meanings) is being starved by a decreasing revenue base, particularly in the metropolitan areas.
I see it pressured by managed medical care and other cost-containment programs. And it seems to be perennially staffed by hurried, overworked professionals, whose lack of time and sometimes whose lack of sensitivity to the patient serves to triage clients out of the system rather than encouraging their entry into the system and encouraging their proper use of the system.
Ultimately, these urban system suffer from too few resources aimed at serving too many citizens. So how can we facilitate access to the system by African, Hispanic, Asian, and Native-Americans?
As we examine ways to manage access, I would like each of us to remember that there is no one factor which predicts why minorities encounter more barriers to health care than their white counterparts. There is no single obstacle which prohibits them from seeking care or entering the health system. Rather, in my opinion, it is a confluence of several factors and complex circumstances that impede and restrict minority access to health care.
Accordingly, I have not seen one single, sufficient solution to manage access to care. So let me begin, then, by identifying some of the factors which should be managed to assure access to primary care. Then I will discuss some of the strategies to manage these factors.At least five factors act as barriers to access to health care among minorities in metropolitan areas. I have simply listed them as:
a multipolar delivery system which has complex eligibility requirements;
deficient transportation (this was mentioned yesterday and I think it’s very important, maybe even more important in cities than in the rural areas, interestingly);
insufficient knowledge of the health care system by the users and very often insufficient knowledge of one’s own health needs;
availability of health providers, and, although this is not a topic that I’ll discuss very much, the attitudes of those health providers; and
lifestyle behavioral norms of the minority populations.
The profile of the urban health care system is often characterized by multiple agencies, each serving a different constituency, usually based upon distinct eligibility criteria. In Houston, for example, citizens’ health and/or medical needs are services by the City Department of Health and Human Services, a country health department, and county hospital district which has its own independent taxing authority.
Often the eligibility screening to determine patient participation is so cumbersome that it serves as a major barrier to services for the medically and financially indigent patient who, in my town, is usually a racial or ethnic minority. We have responded to some of these and I’ll mention those responses later.
In a study by our local March of Dimes chapter, a poor pregnant woman was transferred among city and county prenatal programs and the maternity care program of the county hospital district. All three agencies have different methods of screening and registering patients. IN all, some 57 different questions could have been asked.
Patients seeking hospital district services are asked to supply documents, such as birth certificates and income statements. An average, uninformed patient could make several trips just to qualify for services.
This example illustrates two other major access barriers; transportation and knowledge. Houston is spread out over 600 square miles. Houston laps over into two other counties, but Harris County, the major county in which Houston is located, has 1800 square miles. During the city’s boom years in the ’70’s and early ’80’s, many communities sprang up along the city limits.
These communities are generally characterized by crowded apartment dwellings, decaying streets, and, increasingly, refugee and resident alien populations. Houston’s central city has the usual character of most large American cities, but there now is that additional South American look where the poor part of town often is in the fringes. So Houston has two kinds of underserved urban areas.
This is not true for all of the areas in the suburbs or along the city limits, but for many of them. Many such residents are potential clients of our health services and many depend upon public transportation. When I first went there, I was told that 80% of our clients came in cars. Everyone was comfortable. No one worried about the public transportation.
Although I have long since forgotten my epidemiology, I remembered enough to determine that the statistic that showed that 80% of instances. In fact, of course, it is almost the contrary. As far as we can see, at best it might be that 50% of those who should be coming to us have access to cars and a smaller portion have cars. That’s quite the opposite of the Texas norm. I am not speaking of those who are eligible to come to us; I am speaking of the ones who are eligible and don’t have other means. Those are the ones who should be coming to us.
By the way, I am not ruling out our going to them. I am just speaking of what they – our clients and our potential clients – have. When such an individual, who depends on public transportation, has to travel back and forth many times just to see a doctor or obtain medicine, it becomes quite a disincentive to participate in the system. I pressure at some point we can talk about outreach, which is mandatory for my kind of department and for any organization that would provide services to the underserved.
Those underserved include ethnic minorities who have, in general, been underrepresented and who, in general, do not have available services, and who often are somewhat behind the curve in experience with the latest developments in health care, as it were. I’m not so sure that keeping up with the latest is the best since I don’t buy the normal medical system dictum that the latest is the best.
That’s one of the things that got us to where we are now. But very often the latest is very important. People who have had less experience with the system often are not current with that which is available to them. This lack of information about health services and how to access them, I think, inhibits potential users of the system, particularly of our system.
Several items of research suggest that some minority and low income consumers lack the organizational and educational sophistication to use the medical system. They rely often on the health provider for their technical assistance as opposed to medical journals like Time and Newsweek or those more frequent daily exposition such as the Washington Post, Los Angeles Times, Wall Street Journal, and others who take it upon themselves to educate the public about medical matters.
Sometimes these publications do a reasonable job. Yet, the users of which I am speaking often rely upon the health providers more than usual for their needed technical information and assistance. At the same time, they often remain distrustful of these professional providers. The providers, for their part, reinforce this distrust by frequently speaking technical jargon and ignoring the importance of patients’ extended families and other sometimes simple amenities, but sometimes very important interactions, that establish the appropriate rapport and begin the education of the client.
This lack of organization educational sophistication seems to be predicated on the fact that health care is often a peripheral interest of the consumer that I am describing. Usually care is sought only at the time that symptoms if illness occur. The knowledge which could prevent disease or foster wellness often is not present in the family and the mind of the consumer that I am discussing and describing.
Such knowledge might help eliminate this episodic use of the system or even slow its concomitant effect of increasing the cost of medical and health care.
Take the case of kidney transplants. What has now become a relatively routine medical procedure, paid for by most major medical insurances, is by and large outside the realm of possibility for many minority consumers. Yet, they continue to demonstrate the greatest need for this one item.
This leads to a fourth and, perhaps, most significant and sometimes most difficult factor to manage, and that is the attitudes of both the health professional and of the patient or the consumer, especially attitudes that relate to cultural norms and beliefs – those particularly that affect health care.
I waver between being too general and too specific, but we have physicians who don’t believe in the germ theory. If you don’t believe it, just observe how often they wash their hands after their hands have been in contact with infectious environments – air, water, solid. Maybe sometimes it’s not a conscious disbelief, just a dichotomy between what they know and believe and what they do.
Sometimes we have the ability to separate those two. In looking at the clients that I am describing, sometimes – most of the time – we have beliefs that affect their health care.
In a system of health care such as we have in Houston and certainly such as we represent, the decision making process is often dominated – in fact it is usually dominated – by the health professional. It is often dominated by public servants. Only secondarily does the client have a piece of the decision making action.
The nature of this particular decision making adapts itself more readily to the needs of the health care providers than it does to the needs of the health care consumers. Institutional strategies develop in accordance with provider needs in order to maintain control over a particular mix of service, (whether that is an economic or other drive needs), as well as some attempt to meet consumer demand, which in some instances is more important than others but almost never is the primary matter.
The end result if the creation and perpetuation of a system that’s driven mainly by providers’ demand and reimbursement for service and which leaves a growing void of humanism and cultural sensitivity in dealing with the consumers.
This system conforms to the medical model wherein you find a disease, you diagnose it, and you render treatment. In this model, the physician’s role is paramount because of the physician’s expertise. But the physician’s authority is often extended to decisions beyond simple medical care and medical diagnosis.
With little time or inclination to explain and inform patients about the course of illness, the provider leaves the consumer a marginal participant in his own care and in the system, thereby taking one further step to alienate the consumer and, thus, creating more barriers to access.
I said earlier that I wouldn’t talk much about he availability of providers. I think that the scarcity of African-American and Hispanic providers in my neighborhood, in my state, and nationally among all of the underrepresented minorities, is very well documented. If we explore further the ramifications of minority consumer attitudes that are based on cultural perceptions and beliefs, we have yet another significant obstacle to access of which the health beliefs model (which was mentioned yesterday) is particularly illustrative.
Motivation theory, as you know, deals with the subjective world of the behaving individual and not just the semi-objective would of the scientist or the physician. This concept of a psychological state of readiness to take action and the subsets of that whole perception of the benefits derived as a result of action and all the various cues which trigger action – all of those are parts of the model and I won’t say much about that. I think that the model is useful, though , in thinking about the diverse ethnic responses for entering the medical health system.
The trained physician is often taught to believe that his medicine (in this instance I am not speaking just generically “his” because if the prototype was “her” I would say “her” – it’s not yet “her” – so I say “his” medicine) is the only one which works. However, the environment which the physician enters has many medical traditions and beliefs and practices, some all to themselves and almost self-perpetuating.
As you know, medical care is a system of meanings and behavioral norms. Some people talk bout the art of medicine rather than the science. There is a lot of science but there is also a lot of hocus-pocus. It’s good! It works if you can reproduce it and many people can. These meanings and norms are attached to particular social relationship and to particular institutional settings.
So the ethnic medial traditions may contact different concepts about body and different concepts about mind. They may contain different kinds of healers and different process of healing. All of these aspects of the system interrelate and they are governed by socially sanctioned rules (whether those are the socially sanctioned rules of the providers of the health industry or whether those are the socially acceptable rules of the recipient of those services, even those who haven’t received the traditional medical care services).
Any specific ethnic health tradition is deeply rooted in the identity of the particular group. If you don’t know much about the group, you can’t do much about the problem. I suppose I should refer you to a document that I received, and I presumed that Don Weaver and Sandral Hullett just received, entitled, “Education of Physicians to Improve Access to Care for the Underserved: An Executive Summary.” This was the second HRSA primary care conference, March 21-23, 1990, in Columbia, Maryland.
A lot of collective interaction went on and some documents were produced right on the spot thanks to the modern use of word processing. Four weeks later I received my copy. I guess there were 14 commissioned papers. I say that because there is a fair amount of description of the underrepresented minorities and also of underserved majorities.
One of the characteristics that has somewhat of a common theme is the identity of the particular group, a subset of the larger population. That identity contains certain elements in which any health tradition that the group has followed is deeply rooted and it has to be understood.
If we look again to the case in Houston where a large segment of the population is Hispanic, we can see how this health beliefs scenario plays out, at least to some extent, from the Department of Health and Human Services perspective. Much of the Houston Hispanic population is composed of second and third generation citizens.
Nonetheless, many still retain their indigenous language and cultural beliefs. They have very strong family and community orientations. These function as the cornerstone of their support system. (In my report on the health of Houston the other day, I was surprised that the news media almost collectively – 95 to 100 of them – gasped when I just flipped up something that was already in the highlights that we had handed them earlier and said that the Hispanic population in Houston had the lowest infant mortality rate.
In fact, it was below the 1990 norm of nine. I think that is the 1990 goal. It’s about 8.8, 8.7, 9.6 in the inner city. About 8.6 or 8.5 in the periphery o the city. We divide our city up on the health status of those areas on a regular basis in a two volume report. I was surprised that the news media almost collectively gasped. There are some explanations of that, I think.
The use of the health beliefs model suggests that the importance of other behavioral and psychological factors which influence minority access to health care is something that we rally ought to pay attention to. While I believe that these factors are of equal importance in determining access, I must caution against any use of constraining predictor over which the consumer has no control, such as ethnicity or race. Sometimes we get a good identifier and somethings we misuse it. So I caution against that.
The consequences, of course, of this misuse are odious and they prevent either the consumer or the professional from formulating any real meaningful strategy to manage access. Sometimes they say a little knowledge is a dangerous thing. In this instance, keeping that caveat up front while planning to use the consequences of health belief models among the underrepresented minorities is important.
If the delivery of health services is divided according to political subdivisions as it is in Houston – city health, county health, county hospital district, regional, state health (which is located in my town – then we have to take every measure to ensure that the delivery system encourages rather than discourages appropriate consumer use.
In the matter of prenatal care, for instance, people rail against the overlap. And they did for sometime until the county health director and I pointed out that we’re both so underfunded that we aren’t anywhere close to meeting the need, much less overlapping. Most importantly, our unit provides over 75% of the prenatal care to the people delivered in the county hospital system.
Among the various entities, identical eligibility criteria should be adopted for all the services that these entities provide. A generic patient identification card seems simple. It should include shared eligibility criteria, residency, and income, and it should be used by all delivery systems. The hospital district in our neighborhood has a lot of requirements.
My own department has only two: 1)that you think you fit with the service we offer, and 2) that you say you live in Houston. Those are about the requirements. We want the criteria to be simple since many of our consumers speak some nine or ten languages in which we have trouble communicating.
We do very little “signing,” although we’re doing much more in 1990 than we did in 1988, and we are beginning to utilize other methods of communication. So it helps if those needing our services are able to communicate their status to us. Sometimes just being there communicates a person needs.
Sometimes one can identify a pregnant woman by her profile and a child who needs well baby care just by the child’s apparent age. The county health department has eligibility criteria in between ours and the hospital district. Once the client has satisfied these criteria of one health unit, that person should be able to use the services in all of the, and that idea begs for criteria common to all of the entities.
While I am discussing this, I would at least mention that some of this is possible. We have virtually completed a pilot project utilizing five of our respective centers, one from the state’s Department of Human Services (which provides a fair amount of income maintenance and pays for some of the medial services), one from the county, one from the hospital district, two from our department.
The project is an integrated eligibility system where one comes to one spot and becomes qualified for all the services of all the agencies. We announced the project’s success two weeks ago. We are now planning in our department to expand the pilot to all of our facilities. We’re making space for the eligibility process to include all of the agencies that should be using this.
Eventually, our plan is to enable any one agency to do the qualifying for all agencies rather than having workers with the support of administrators. It could be spearheaded by some other outreach personnel. The dual purpose is not only to qualify the person but also to educate the person to the services available, how to use them, and, in some instances, how not to use them. We can give examples of that in many ways.
This kind of integration of select information and delivery system and referral services is predicated on a one-step shopping model. The goal that we have is for persons to be able to get all the services that they need in one place. I say that from the perspective of the director of a Department of Health and Human Services.
We offer well over 50 different programs from day care for children and the elderly, to development in children and youth, to extension of that to juvenile delinquency prevention, to pregnancy prevention – a whole series of services that might not all be offered at one spot. These services would be more than, say, a group practice of family physicians might offer on the preventive and the health promotion side. Yet, many such family practices could and should and do access these county services in my town.
There are many more problems that we follow up for disease intervention that the private practitioner has referred to us than you would imagine. That’s an appropriate public/private partnership. After all, we really are the experts in sexually transmitted diseases, certain communicable diseases, and are the experts in dealing with epidemics. We have just decided to become the travel center, since most of the people who provide travel immunizations call us before they give the shot.
Initially some thought it strange that we should compete with the private sector. The privatization that we talk about a lot is not good in and of itself. It’s really only good because you change from one bureaucracy that has ceased to do a good job to another that can be more responsive.
After a while the private bureaucracy may become counter productive and it needs to be changed, either to another private bureaucracy or back to a public bureaucracy. It makes little difference. It’s the change that is probably the most important factor – a fresh outlook, a fresh set of hands, a fresh effort, and some increased efficiency.
We have done this in several areas. We have now begun to do it in the travel area. Our goal is to take care of 90% of the travel business in Houston. Every day some 40-50 people arrive from around the world just to the Texas Medical Center for medical care. We have decided we’re going to do that and we’ll update you on that maybe a year from now as to whether we’re still in business or whether we have needed a subsidy in which case we’ll just give it up.
This kind of public/private partnership, I think, is important needs to be inaugurated from several perspectives to deal not only with paying clients, but also with non-paying clients.
I think that a comprehensive system used by physicians, nurses, the traditional medical workers as well as health educators, public health people, social workers, and outreach workers can identify and train community-based workers to play a role in the system. This is a natural for neighborhood health centers and community health centers. It’s a natural for an occasional isolated primary care group practice.
But it’s basically an outlier for the larger part of our system. Yet, it’s a perfectly good principle which is being used increasingly. I have seen it in the practices of a number of graduates from my former life as an academician. I know that they have found it cost-effective, despite the payment system. I do know they got the idea from the community approach to family practice that we tried to teach them. But they have also discovered how to make what we call a community diagnosis, to figure out the feasibility of setting up and operating a practice, the process of hiring people who could diagnose needs of that community before they market it. So the outreach people served a dual purpose.
AT&T markets to me quite regularly and effectively, so effectively that while I’ve tried the other long distance lines over the decade, I have always used AT&T. Sooner or later they have to come to match the price, exceed the convenience, and match the expertise of all the other newcomers. Maybe that’s he reason why they still have the most long distance lines.
I see that kind of outreach marketing being used by the representatives of American corporate sector very readily. There is no reason that small representatives of capitalism – small physician group practices – can’t use them. The community health centers have used it well, I think, and I would offer it to all segments of the medical-health industry. We certainly are using it increasingly in public health and we will need to use it more frequently.
I say all of that because I think it’s particularly important in minority communities. It is important in any underserved community. But I also say it because it’s important for you in establishing a market. Whether you can afford to expend a large loss leader or not, it is still important.
Sometimes some of us think that we don’t have enough resources to do anything that is considered a loss leader. We have to start making profit from the beginning. In the short run that might be true, but in the long run even that attitude might be counterproductive. So using the outreach techniques for both sensing and diagnosing as well as delivering services is a worthwhile endeavor.
Of course, when this kind of thing is done, I think everyone benefits from an enlightened view of the minority consumer and of his particular needs. And whether the consumer moves on to self-empowerment is another matter. But having a better view of the minority consumer enables the provider of services to deliver those services in a much more effective manner.
I’ve said that it has been used by community health centers. It’s been used by group practices. It has also been used by the Medicaid HMO’s. I had an opportunity to participate in a small voluntary Medicaid HMO – voluntary for AFDC recipients. It’s still small. I think their total number is less than 20,000 which, as you know, is very small for an HMO.
I realize that historically the “Blues” and some of the commercial insurers were experiencing 1,200-1,400 hospital days per 1,000 persons per year. There were goals set at 1,000, then 800, and some of the HMO’s felt that they could get under 800-600 per year, and many of them did. This particular HMO set as a goal of 400-600 patient hospital days per 1,000 people enrolled per year. Not a bad goal – in fact, ambitious, particularly for a group of consumers who had been shown to have a high incidence of emergency room use and hospitalization.
In its first 18 months, that small HMO experienced a utilization rate of 450. Excluding the first nine months, for the next 12 months which ended after the first 21 months (that second 12-month period), they experienced a utilization rate of something like 370+. I remember it because my rate was 153 hospital days per year per 1,000 people enrolled.
All the people were enrolled in my little five-doc practice that we set up just east of the Capitol in this capital city, three blocks from the worst housing project in the city. It was so bad in terms of crime that people who lived there called it “Dodge City” because they were dodging bullets in the night.
On the other hand, it was four blocks from the historic area and it was on the Main Street, eight blocks east of the Capitol. This little practice was comprehensive by all criteria, Medicare-Medicaid mix, private insurer mix, male-female, ethnicity, age groups, and number of babies delivered.
The experience during that 12-month period, between the HMO’s 10th and 2st months was 153 hospital days per 1,000 people enrolled. There were 700 people, all voluntarily enrolled, at that point in time. It went on up. Many in this particular program came from “Dodge City,” although a few came from other parts of the city.
I could tell you some other goo things about that story. (It really is a fairy tale.) But somewhere along the line teachers should be able to practice what they preach. If not, they should stop preaching it. You can imagine my not stopping. Medicaid HMO’s can do it. I think that Medicaid HMO’s, and I apologize to Wisconsin – it’s much better for me to tell this to the legislature or the governor but I haven’t met any of those yet – I think that they should give provider choice to the client who is enrolled.
I think that they should have a strong emphasis on health promotion and disease prevention services. I think that they should clearly emphasize family physicians as the “primary” primary care provider and they certainly should emphasize the use of the primary care team. That, of course, can be virtually any provider. It can even be the patient, on the occasion, being the primary care team.
But most often the primary care provider or nurse or social worker or health educator, psychologist, or someone for that episode of illness is the leader of the primary referral and use and misuse of emergency rooms. I think that they should build in strong incentives for provider remuneration, including residuals.
Those are very small residuals percentage-wise of the overall expenditure but awarded for savings on laboratory services, savings in emergency rooms, savings in hospitalizations. Yet, quality assurance and patient satisfaction were being measured steadily by this small HMO.
The other part of the fairy tale, the reason I got the award, wasn’t because of my savings. We discovered that later. I got an award during the middle of this 12-month period, which I think was at the end of the first 18 months as I recall, because I had the highest client satisfaction – our five-member practice had the highest client satisfaction of any of the provider groups.
That was kind of strange because our patients from the previous year’s tally, by our analysis and their more extensive analysis and the secondary analysis of the state Medicaid office, had the greatest emergency room use, the greatest switching of providers, the greatest conglomeration of providers.
The average number of provider per client was the greatest. They also had the highest number of complaints in the first six months of that program. You had to hook into the program for one year and that was relatively well enforced, but certain circumstances could permit you to get out of it – allow you to change.
The greatest numbers of requests for change was among the “Dodge City” enrollees in our little practice. In fact, we took many who had changed from other practices, with is another story. How do you relate to somebody who comes to you in a hostile fashion for your services?
I think that large areas like Houston which have plenty medical and health science schools have some other opportunities. These institutions should implement vigorous recruiting efforts to identify, matriculate, and graduate minority medical students. We’ve talked about this earlier. But they also should do the same thing for culturally sensitive majority students. We’ve talked about this earlier.
But they also should do the same thing for culturally sensitive majority students. Half the Blacks get their care, when they get it, from the whites. It is a very large group of people to work on. Plus, not all the minorities should be expected or required to go into practice in underserved areas or serve in primary care because some are still needed in some of the other areas of medicine. That’s another discussion for another day.
I think that culturally sensitive outreach effort need to occur for the reasons that I talked about earlier. But they also need to occur in an attempt to foster consumer competence. The whole business of training the client is very important. We do it passively anyway. Why not do it actively rather than passively? Why not set goals to get consumers in your practice to do certain things?
When I was an intern I remember preceptors in medical school saying, “Well, in my practice we don’t’ have….” (the disease of the day, whatever it was; it may have been hepatitis or ulcer disease associated with whatever). And I quickly learned that the reason they didn’t have it in their practice was because they educated all those patients to leave their practice. “You know in my practice, we don’t have many people who are overweight and have hypertension.”
Well, if you don’t like overweight people, they’ll sense your intolerance in a minute. “We don’t have many alcoholics or we don’t have people in my practice who use drugs.” They’ll leave if you aren’t sensitive to them. We understand that, of course, when it comes to ethnic minorities being in a practice, but it’s equally true for people who have various health problems.
Individual practitioners can become sensitive to their biases and make conscious goals to educate clients. So the business of fostering consumer competence can be a very dramatic and powerful tool to literally empower clients to take an ownership in what they do and take some responsibility for their own health. I am not necessarily advocating the approach of Milt Seufert, who has patients who sit on a board and run his practice.
His patient board makes decisions about a number of things, including his salary, whether they should expand a little here, get some equipment there, bring on a partner. I’m not necessarily advocating that, although it is a rather interesting experiment and it seems to be working. But getting particularly underrepresented minorities to take ownership or responsibility for their own health care for whatever you have to offer in your system of care is an important matter.
Only when this consumer feels able to make a contribution to the system and to effectively manage his or her own needs, can we really see change in the utilization of services – a cooperative attitude rather than a hostile attitude. Many of the clients I am speaking of now are never going to be able to buy into the health system the way many of us with our major medical insurance do. Then that person has to buy into the system in another way.
Understanding what the system can offer and getting the most out of it is one way they can buy into it. They can buy into it in that way through our educational efforts.
I think that institutions should train professionals to develop and expand the various curricula and courses and practica to encourage this kind of approach. Although the last ones that I have mentioned are the most difficult to make, I think that systemic and political changes should be encouraged.
For instance, in my city for the case of public transportation, I think city decision makers should take steps to ensure that transportation remains feasible through low-priced fares, through adequacy of vehicles, frequency of routes, and safe transportation stops. In a city like mine where homicide went up for each of the last two years, that safe transportation stop is an important matter.
I think that health care administrators should become actively involved in measures which would increase access to their services. I felt very good on Tuesday in giving our “Health of Houston” report when one of the top four news people in the city who reports on medical matters said, “If you do all of this (we were talking about outreach), aren’t’ you afraid that your waiting time is going to increase?” She had just written a beautiful article three weeks ago about the increased waiting time in some of our clinics.
All that did was garner us some resources because the people knew we were trying our level best. I then explained to her publicly for the first time how that was r risk. But then since I had been criticizing my own department, I didn’t feel too badly about taking the risk of increasing the waiting time if I knew that the waiting time increase professionals bringing in and getting good results in their outreach efforts. We have to relate in my city to the need not just to our capability.
If the only services we provide are to the 337,000 people that we can accommodate easily each year, then we have not dealt with the need when we know that we should be seeing 621,000 people. So the 500,000 that we saw last year often were seen later than they should have been seen. But the 600,000 that we will see this year will be seen much more quickly on the average than at 500,000 last year. So I will take the flak for that kind of progress. I think that health administrators, particularly in public systems, should be willing to do that.
Much of what I have said is not new. In fact, when I read through this on the way up here Thursday, I decided that there was nothing new in this. But a lot of it works. If we sustain our efforts along these lines, then we can better manage access to primary care.
The archiving and publishing of the proceedings of the third and fourth plenary sessions of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):
Jerry Rodos, D.O., Chicago College of Osteopathic Medicine (Dr Rodos is a Senior Fellow of the Coastal Research Group): I’m just going to make a few observations on some of the things we have been talking about this evening because it’s getting late. As I listened all day today as you have, You know it’s amazing without really having been terribly directed by the conveners that you have heard a coalescing of ideas about what to do about the problems, and a fair agreement about what the problems are.
We’ve heard some very simple solutions. I don’t mean “simple” solutions. But we heard solutions and we have some sense of what could be done. But the biggest problem always gets to be how do you get it all done. David Schmidt was very optimistic and he mentioned that little list of wonderful things going on that no one would have guessed a year ago would be happening.
But I do want to call your attention to the fact that none those things require the participation of the U.S. Congress. Therefore, they could happen relatively unexpectedly and uncomplicated and unmessed. One of the observations I would like to make about the effect of Medicare and Medicaid which all of us recognize, but it has a significant impact and then I would like to focus just a little bit on graduate medical education funding. I think we would have covered most of the issues that at least I would like to leave with you this evening.
The role of the hospital has changed and many of you who practiced in that period that David Sundwall described before 1965 will remember that the hospital was whether iw as community or teaching, a community institution. It had a social role. It was worthy of support. It treated the uninsured and it provided a lot of services to the community.
Hospitals, believe it or not, fund-raised. Some of you may even be old enough to remember that you worked in an institution that had endowed beds. Probably there aren’t many people here who even know what endowed beds are. (A few smiles!) But, in fact they did exist. We have so changed the role of the hospital that you could not fund-raise for hospitals very readily.
Although there are a few exceptions, the hospital is no longer a community charity for philanthropy. There is a rare teaching hospital that did go out and say to its board, “If you want us to conduct this educational program, we need $1 million a year.” And within two years, the board raised $10 million to fund their graduate medical education program. So that no matter what Medicare does, no matter what happens with funding, this particular childrens hospital has the funding for its program.
But that’s a rarity! How was graduate medical education funded before Medicare? Some of you do remember. The hospitals added small amounts of fees to the daily charges, and they were small amounts – $75 /month, $100/month, $150/month – and even though that was pre-1965, and that sounds like a pittance, it was.
But the hospitals were adding this either as part of their costs or the residencies were funded by the clinical departments out of the doctors’ pockets or partially by the hospitals and partially by the doctors, occasionally by some endowment that was externally funded.
If I had some prepared slides (and I thought about doing that because I do have some) that shows what happens to salaries and numbers of graduate medical education slots through this period until one gets to the last period that David Sundwall was talking about (the mid ’70’s), you see this gigantic rise in numbers and this gigantic rise in specialty, sub-specialty slots and with the increase in salaries that go with it. And now in the mid ’70’s you start to get a retrenchment.
The retrenchment has two effects. I think you’ve heard a little bit about the physician effect. Because we are, in fact, entrepreneurial while we are professionals, as the system responds to whatever it’s doing to try to control the costs of this program, the physicians and the hospitals move into various positions in order to try to make this system work with as much reimbursement as possible. So, in fact, David became a colonoscopist.
Hospitals discovered the role of the family physician even though, as John Arradondo said earlier, they couldn’t spell it because they understand that maybe this means referrals. And if they can control the primary care, they have learned a lesson that is very , very old. If you control the primary care, you’re going to control the tertiary care.
And so you see in various parts of the country, a whole variety of incentives by hospitals to bring primary care people in, in some ways even to reward primary care people for referring. And you see a whole variety of systems – some of them, I think, bordering on unethical.
Graduate medical education is one of the things we are very interested in. If we don’t deal with graduate medical education and prepare for these changes, family medicine and the primary care specialties are going to be significantly effected negatively, especially family medicine. In 1979, the direct medical education costs were a little over $1 billion.
In 1989, the direct medical education costs were $2.15 billion. That sounds like a lot of money! It is a lot of money. But I would ask you to just keep in mind what HUD’s going to cost us this year. What the savings and loan bailout is going to cost us this year! We’re also bailing out major mistakes of the Department of Defense.
So, in fact, we need to set priorities. If, in fact, this is a priority (as it obviously is not in Alabama), then we have to be able to effectively get the message across about how to do these kinds of programs which we already know about. Who has the responsibility? I think we all do.
I think that Dr Sandral Hullett talked about our individual potentials to do that. I talked about it earlier. We talked about community programs. And I have to come back to the academic medical center because though I do believe very firmly that academic health centers have a social contract and a social responsibility and that’s been stated by lots of folks.
I don’t believe that the contract is the same for all academic health centers. I think it’s a mistake to commit all academic health centers to the primary care mission because there are too many other institutions in our country who have that mission, have that commitment, have the faculty in place, and a nurturing environment.
So the feds have reached the point now at which they can say, “Fine! We tried to encourage people to do this. Now those who have a significant program, those that have done these things will be supported.” I believe there is a very definite need for more than one kind of institutional mission among our academic health centers.
So with those kinds of major comments, I think I’m going to allow for any discussion because it is way past longer than anyone should sit after the good meal we had. Thank you.
John E. Midtling, MD, MS, Chair, Department of Family Medicine, Medical College of Wisconsin (moderator) [Dr Midtling is a Senior Fellow of the Coastal Research Group]: We may have time for a few questions.
Charles Gessert, MD, Vice Chair, Department of Family Medicine, Medical College of Wisconsin: When you made the list, David (Sundwall), of the four things that the Commission was looking at, one of the things that you mentioned was effectiveness. There weren’t very many discussions of effectiveness that transcend technical effectiveness, such as effectiveness interventions which also include quality of life or cost considerations.
David N. Sundwall, MD, MPH, American Health Care Systems, Inc. [Dr Sundwall is a Senior Fellow of the Coastal Research Group]: No. In his overview, effectiveness was a subset of what he entitled “efficiency.” The impression of the Social Security Commission members is that there is a great deal of waste and duplication and inefficiency in the hospital system. They want to become more efficient and that’s what I suggested that part of their efforts to get that would be – medical effectiveness was part of that.
One of my current jobs is to represent AMHS in a task force that’s run by the health education and resource trust of AHA called the Quality Measurement and Management Project. Hospitals around the country are trying slowly, but some quite successfully, to implement what they call total quality improvement based on the Japanese model of quality, which was actually invented by some Americans.
Anyway, this has become fashionable in the hospital world. But where it has taken hold, they’re achieving 20%-30% more efficiency, in other words less costs based on doing things right the first time and parting with this notion that there is an acceptable mortality rate for a certain procedure. There is no such thing. Perfection is the goal.
They’re looking at efficiency and economies to be achieved from that. Part of that is the effectiveness research.
Dr Gessert: The basis of my question was really rather the concern that I have with the old National Center for Health Services Research activities in medical health care technology assessment areas. They, for instance, recently were reviewing liver transplants in an advisory capacity to HFCA.
Their assessment was just as you described, totally an assessment concerning the technical efficacy of the procedure. To me, the cost and the quality of life considerations were 98% of the issue and I think to many audiences would be 98% of the issue rather than the 2% that they were charged to examine. My question is very much relevant to the overall reimbursement question, in that if effectiveness is to have any role in eventual reimbursement decisions, that effectiveness has to be defined more broadly.
Dr Sundwall: Well, there was an interesting amendment to the law. I understand that in the statute creating the new agency for Health Care, Research and Policy, it is the charge of that agency to do effectiveness research or to do these practice guidelines, and it ties in cost effectiveness. So their recommendations henceforth have to include cost issues, not just whether it works or not.
Because clearly if things theoretically work, we’ll spend ourselves blind continuing to pay for those unless we factor in the cost effectiveness. We’ll see how courageous they are. They don’t like, at the federal level, to make those hard decisions.
Dr Rodos: I think that’s what the Oregon approach, for hose of you who are following it, is an effort to look at priority setting with Medicaid funding. The state has said, “Wait a minute! We have just so many Medicaid dollars. Should we be doing liver transplants? Forget effectiveness.” Shouldn’t the higher priority be prenatal care, perinatal care, immunizations, or whatever?
The Oregon law sets out to set those criteria and to set those priorities. Those of you who have not been watching it, I suggest that you do, because it will be very interesting just to see how it evolves and what they choose to do, when do you stop doing it, and whether they stop doing, say, renal dialysis when the federal program is not going to cover it. A very interesting program!
David Kindig MD, Ph.D., University of Wisconsin-Madison School of Medicine: I hear David Sundwall and John Midtling disagreeing about what the impact of RBRVS will be on primary care.
Sundwall: I just think that there’s an awful lot of hope being placed in this new payment reform that I am skeptical is going to translate into changes that are desired. I would welcome students choosing family medicine because they see a reassessment or maybe more economic benefits.
But when I look at those bar graphs that were put up on the specialty services, the specialists will come down a bit and the family docs will go up a bit, but they’re hardly going ot meet unless there is a lot more refinement and changes in the law. There’s still going to be a a real economic advantage to being a sub-specialist.
Dr Rodos: I think there’s going to be an unfortunate disadvantage! If you do the mathematics, an 18% reduction in surgeon’s fee and 27# increase, 22% increase, 8%, whatever number you like, of a family doctors fee, is not a wash. This is budget neutral because you’re watching what I think is one of the best shell games that you will see.
The dollars that are going to be taken off the specialists side I do not believe are going to appear on the primary care side. While primary care physicians, family physicians, are all enthused about this as if they won a victory, I think when the dust gets settled we’re going to see that they didn’t get very much out of this at all.
Dr Midtling: I think my comment relating to the RBRVS benefit spoke to the potential benefit to funding the graduate medical education programs. IF we could increase our practice plan earnings and increase those earnings above one-third of program costs, this will relieve at least some of the financial pressure on the programs. But I am very leery.
We’re already seeing the administration saying that they want to implement the savings early, so as to use it to offset the deficit. Now that they have this spigot, will it be cranked down? Will RBVRS ever be implemented? Will it be enough? It’s really hard to say.
Dr Sundwall: I left a slide home that I wish I had brought because it showed the history of payment to hospitals since prospective payment was enacted in 1984. The upper line of this graph showed what should be reimbursed according to the pro-payment assessment commission.
They really tried to be thoughtful and considerate of the market basket index and all the things that go into the cost of doing business. And then underneath the line, the slide shows what, in fact, has been awarded to hospitals each budget year. There’s a growing gap. As soon as you have a target that you can shoot for, Congress is going to underpay that by a certain arbitrary amount every year because of the budget deficit.
When we once have this upper line defined with the volume performance standards, I can guarantee you that Congress will allocate less than that in an attempt to get some savings. I think we would be remiss in this session devoted to physician reimbursement if we weren’t perfectly honest witho ourselves about the political realities in Washington. Can you imagine finding a congressman or a senator who’s willing to put in a bill or go down to the floor and fight for more money for doctors?
If you think for a minute that people in the halls of Congress spend a lot of time differentiating between primary care and referral specialists, you’re wrong. Doctors are doctors! We are overpaid professionals who are privileged having a heavily subsidized education and our stock is not high. I don’t care if one is compassionately serving in an underserved clinic.
If one is a medical doctor, one is not considered suffering, I can guarantee you. I think that the “oughts” and “shoulds” that you ticked off sound great. I think it’s going to be awfully hard to get Congress to focus on physician incomes or redistribution beyond what this new change in payment reform has enacted, because we’re all perceived as pretty well off and just fighting among ourselves for a bigger piece of an already very big pie.
Dr Schmidt: I think that no ther country in the world, no other period of history have physicians place in society and compensation ever been as high.
Dr Arradondo: I guess I spoke softly earlier today, but since I’ve written on some of these matters, I suppose I shouldn’t speak so softly. There are doctors and then there are doctors. Family medicine has shown that it can stand on its own. It’s the largest body of physicians in the world outside of the AMA – it is organized, and it is better organized today than it was in 1980 or 1970 or 1960.
In the ’60’s and ’70’s family physicians were mainly fighting for presence, name, and funding. Family medicine should be controlling Medical care in this country to the extent that physicians can control it. Other large institutions are doing much more than controlling of health care delivery than physicians are getting credit for controlling.
But in reality family practice could exert as much, if not more, control over the medical care than is currently being exerted for all physicians. IF family medicine can do that, why should family medicine take the flack that all the physicians are heaping up on all physicians in this whole endeavor? Maybe even salvage a part of medical care, especially if it expands into health care because all of these things are going on.
One of the hospitals’ favorite endeavors in the last decade, particularly 1975 through 1985, was on bonding and medical care. That little act in and of itself sustained all the hospital based people as well as many of those who were in and out of the hospital, procedural based people. And that was just a notion that hospitals pushed and many physicians bought and it became quite fashionable.
Many physicians are doing what family physicians can do as well with probably fewer complications to patients. We could go on with this. A slight disagreement that I would make with you Dave Sundwall. I share his pessimism that this RBRVS isn’t’ going to go that far – except that if you look at it in the long run, a smaller percentage of a much larger amount might be bigger than a large percentage of a much smaller amount.
But if you begin to take in the volume that the procedural people are pushing vigorously now, I think that if the number of family physicians grows as a result of this apparent benefit from business that some of the high income people have, might decrease and if then we add to that the percentage reduction, those lines might come much closer than they would in the short run.
I agree that the way the thing is set up, I wouldn’t’ put a lot of money on the lines coming closer together in the short run. I think the implementation of it should have been about 150% minimum of what the RBRVS recommended.
Dr Schmidt: The indebtedness of the medical student is a factor.
Dr Rodos: I have to go back to the fact that the junior and senior years are important. Let me point out to you that the admissions process is also very important. Faculties don’t like to hear this, but they don’t change the student. That’s why the admissions committee is so very important as to be the kind of student you take and what you do in the first two years.
By the time you worry about the third and forth years, folks, it’s too late. If you get negative role models in the first two years, it will offset everything you’re going to do in the third year.
Dr Sundwall: I’m going to take the lead speakers prerogative and suggest we have comments from Bill Burnett and then Charles Gessert and then retire or whatever you want to do this evening in Sheboygan or Kohler, Wisconsin. Is Sheboygan a hot place?
William Burnett, California Office of Statewide Health Planning and Development (Mr Burnett is a Senior Fellow of the Coastal Research Group): This follows John’s point. I believe that there are numerous concerns facing what I referred to in my remarks as the providers of “normative primary care” – the physicians who are intended to do particular things.
Even so, in the two decades since society invented the new kind of family physician (and I believe society rather than government or the professional societies should be credited with the invention of the family practice society) in the interim family physicians have become the largest group of physicians, unless you categorize all of the sub-specialties of internal medicine as the single entity of internists.
Were family medicine to begin again as its leaders did in the ’60’s to effectively present the agenda of meeting societal goals, they can help society solve some of its problems.
They’re doing this working with Bruce Behringer and his community and migrant health service; and with John Arradondo and Dave Werdegar in their public health departments. The post-1960s graduates are in rural areas; they’re in East LA; they’re even doing a lot of important things that they weren’t expected to do.
What they haven’t done collectively is begin to assert their presence in the numbers in a coordinated way. They may never do it. But then as John said earlier, we weren’t expecting Eastern Europe to turn into a bastion of transitional market economies that we’re seeing right now. That is one of the things we need to consider.
Dr Sundwall: We’re all talking here as though family physicians are saints who are going to save our system. Lord knows I’m an advocate of all the things we have been talking about. But I think we have to recognize that family physicians behave an awful lot like other fee-for-service doctors.
In fact, I’ve never forgotten that when I went to Los Angeles to speak to the National Medical Association [NME], I was amazed that NMA’s agenda, primarily was how to maximize fee-for-service, and how to maintain their incomes. NMA’s agenda was so parallel to the AMA’s primarily because they were practicing physicians and that’s what their primary interest was as an organization.
They had a subset of folks who were very concerned with the social responsibility. I think whatever group of physicians there are, they respond to the financial incentives which have been great in our society to-date but it can’t go on. It’s going to change.
Dr Gessert: I had the privilege of opening our discussions this morning with some thoughts. I think I can close it. I looked up a couple definitions. One definition is that someone tried to define promiscuity – it’s people who are having more sex than you are. To draw on our discussion, a definition of obscene income is a person who makes more money than you do. They make more than 10% of what you do. The reason I bring that into my closing remark is that a lot of our recent discussion has an intellectual air to it; it has a very emotional air to it as well.
I think the emotional aspect of it is that we are privileged in our American society to gross $80,000, $100,000, $120,000 or $500,000. But that privilege carries with it a great moral responsibility. The thing that makes us so irate about our industry and our colleagues is that so many accept the physicians high renumeration but ignore the physicians moral responsibilities to our society.
There is a language that tobacco executives use to justify their positions. I would like you to check out a couple of their phrases because they’re equally applicable to some of my medical colleagues, maybe even myself. “I didn’t make the rules.” “I do my job well within a larger system that I didn’t create and can’t change.” “What are we going to do with the people who demand ….” People have a language that they use when they are accepting a large reward from society and want to separate themselves from moral obligations.
Many physicians are as guilty of that mentality as the most cynical tobacco executive. So, with that stimulating thought, we can close this evenings session.
The archiving and publishing of the proceedings of the third and fourth plenary sessions of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):
Greg Nycz, Wisconsin Rural Health Research Center: It’s getting late and I’m going to try to be brief here. I am going to throw out a few things that I think are relevant to the discussions that we’ve had today that we’re working on at the Wisconsin Rural Health Research Center.
But before I get into that, I have been involved with trying to get care to medically underserved populations for the past 17 years and Fred Moskol and I have been on a legislative council in Wisconsin looking at how we might go about this at the state level.
I think I would be remiss if I didn’t kind of toss out my biases on this. Earlier we talked about access problems as being geographic, cultural, and financial. I think that sums it up pretty well but ever since that Robert Wood Johnson Foundation study came out a while back, people began to start shaping the problem of access in terms of lack of health insurance. I really think that’s a mist
ake. I think health insurance is one of many tools that we can use to improve access for populations, but I think it leads us down a road we really probably shouldn’t be going down. When you think about the political process, if we start defining the problem as the uninsured problem, you’ve got organized medicine as was indicated earlier looking out for its interests and if they could just provide these individuals with insurance, demand would rise and if there was adequate reimbursement, they would be doing fine.
You also have in this country a powerful insurance lobby which is looking out for its interests. If you think about insurance and look at the current uninsured in this country, we talk about a lot of those folks being working poor. But by and large it is a poor population. If you think of insurance as protecting one from catastrophic financial risk, this isn’t a real big issue with those people who don’t have any financial resources to protect.
I think we need to look at ways of financing care for those individuals, but not necessarily providing them with insurance.
Another problem we wrestled with on this legislative council was that insurance frequently does not cover preventive services. There has been a discussion at this conference about the need to do a better job in prevention, particularly with high risk and low income populations.
The other thing you find is their time of service of deductible barriers. I found it odd sitting on a panel where we were discussing the need to get the price of the insurance product down so that it was affordable to people who didn’t have much money. One of the approaches, sometime $500 or $1,000 of front-end deductibles. You find that poor people for whom this is theoretically targeted consider $500 to be a substantial barrier, and a reason why they don’t now have insurance.
So I think there are some real flaws and some real dangers with going down the route of relying on expanding coverage of health insurance to the presently under-insured.
The other issue, from a taxpayer’s standpoint, when you take a look at who are the uninsured and you talk about the working poor and the unemployed, for the working uninsured they’re primarily located in small groups. If you take a look at the insurance industry reports, commercial health insurance in terms of what their loss ratios are for the small group market or for the individual market, I believe a couple years ago was listed as 60%-65%.
What that means is that for $1.00 paid in, 60-65 cents is paid back to physicians and hospitals in the form of purchased benefits. It’s easier to think about getting that individual into a community health center or into a physician’s office or hospital and providing the care. It’s a lot tougher to swallow when you think that one-third of your money is being taken off the top for private insurance type solution.
Those are just some biases I guess I have which I wanted to get out on the table. I would also then like to go to some of the projects we have been working on with the Wisconsin Rural Health Research Center. Think about the Medicare beneficiaries in this country who buy into the Part B or supplementary medical insurance package which provides the physicians’ services, finance 25% of it.
If you think in terms of insurance terminology, it’s basically community rated across the country so everybody in the country, if they come into Medicare at age 65 or after a work situation, will pay the same premium. Across the country we’re all paying the same premium towards 25% of the benefits and the rest is coming from general tax revenues. When you look at how that gets redistributed back across the country to those same Medicare beneficiaries, you find that the reallocation back in the form of purchased medical services varies tremendously.
I’ll just try to explain what this is. As part of the Tax Equity and Fiscal Responsibility Act, Congress started a program of reimbursing HMO’s under a risk basis for Medicare. That meant that they had to develop estimates of what the fee for service equivalent cost in the communities were to provide Medicare benefits to beneficiaries.
What this transparency shows is a national ranking of of county estimates for 1990 what the federal government is going to pay under a fee for service system. This is adjusted for the age, sex, welfare and institutional status of the beneficiary. What you see, theoretically, is not a reflection of the fact that folks in California are older as Medicare people go, etc. This is basically supposed to be adjusted for that.
I think the question I would ask, and I would be real interested in thoughts that you might have on this, is there is a redistribution going on here and you can see the Midwest. We are essentially taking resources out of those areas in terms of reduced social security checks, etc. to pay for 25% of this insurance-type program and we’re shipping them off to other areas of the country.
The medical machines on the coast, for example, tend to do a pretty good job of utilizing those services. For those of you who have been involved with recruiting, I have been told by folks who recruit doctors, that Nebraska is a real tough place to go to. I’m sure that is not totally a reflection of what we see here. We’re trying to take a look at why some of this occurs.
In trying to model why we have this variation, we find that one of the biggest indicators we have been to identify is price variation and the fact that the federal government has 200 and some old fee localities and they reimburse for the same service differently across the country. We asked what would happen if you took this information and you additionally controlled for the differences in fees paid.
Would a lot of this variation disappear? We know that for instance California, New York, and Florida, have fee localities that are generally reimbursed on the higher end of the spectrum. Places like West Virginia have prevailing rates for those services that are generally lower. So you see that kind of a red blob there in West Virginia may very well be reflective of higher medical need in terms of the mining communities, etc.
What we did then was to utilize some information from the physician Payment Review Commission and this is based on information from 1984 to 1986. What you ee is a small lessening of the effect. If you look at the New York-Pennsylvania area, California, Florida, you see they don’t have quite so many in the top quintile anymore. But the Midwest, actually the effect in Minnesota, Wisconsin, Iowa was actually enhanced. We’re interested in learning more about why this is.
I would like to pose a scenario here. This type of information was developed for the HMO risk contracting program. If you think about an HMO that starts to contract for Medicare beneficiaries, the government’s perspective on that changes from the fee-for-service practice of medicine, because the incentives are reversed.
Under risk contracting, the HMO may not provide all needed services or may provide it at a poor quality so there is more of a watchdog function that the government takes on in an HMO setting. They have to make sure that the quality is there and that they’re not undeserving the covered patients.
I often wondered if we had an HMO that basically branched out into a rural community and set up a satellite clinic, maybe contracted with two local doctors in the community which may be 50 miles away from the nearest doctor, enrolled 30% of the Medicare beneficiaries in that area, and then those two doctors left. What would be the reaction of the Health Care Financing Administration if they were exercising some sort of oversight? Would they be concerned about that?
Typically, if you lose the resource, your per capita costs of providing the service are probably going to go down because people won’t get as many services and Blue Cross and other insurance companies typically don’t get involved in this. But under an HMO scenario, I would be curious what HCFA’s position on this would be.
If, in fact, they would be interested in seeing that that HMO has an obligation to provide the service to those people in that distant community because they are being paid to do that and that the community lost their medial staff. How far should the HMO go to replace those staff? If, in fact, we would agree that the HMO has a responsibility to do that, the question that I would raise is why isn’t that responsibility generalized to what goes on in this country. It just doesn’t seem that HCFA takes an interest.
I would like to be corrected if I am wrong here but in actual access issues. Many times I don’t think there is a coordination across the different branches of the government. Maybe we can get a comment from Dr. Weaver on this. To facilitate increased access for people where there are medically underserved areas, we’ve got the National Health Service Corps working to put the clinicians in some areas while the federal government under the major financing programs sponsors reimbursement in those same areas that is well below what they would pay the same physician if they located in a different area. Maybe some of this will be improved with the Resource Based Relative Value Scale.
To summarize this national map in terms of access and volume in metropolitan and non-metropolitan areas, I have a bar graph here. This just summarizes the results for the counties. You see that non-metropolitan counties comprise 76% of all counties yet they have 89% of the counties in the lowest quintile of volume. Metropolitan counties comprise 23.6% but only 10.6% are in the lowest quintile. So there is a different bias here when you’re looking at after adjusting for the rural-urban payment differentials.
One thing I mentioned in a previous graph we talked about the Resource Based Relative Value Scale as potentially making some further changes in the cost picture. But because of the GEPSEs that were mentioned – these geographic cost multipliers – the effect is not going to be as pronounced as we saw on the volume graph because there will still be differences in cost of practice that would be based on input costs from the local area.
Another issue that was discussed at some point was physician income in rural and urban areas. This was reported in the American Medical News and it’s basically drawn from the Medical Group Management Association physician compensation survey. So it’s focus is on physicians in group practice who are members of the American Medical Association. It is a fairly large sample.
One of the things we see is that the average compensation in groups for family practice, pediatrics, and internal medicine really doesn’t vary that much by community size. But when you get to some of the specialties, there are fairly dramatic differences.
One of the things we found at Marshfield, Wisconsin, which has developed a regional clinic system, is that if we establish a larger satellite and we put a general surgeon or radiologist there, they are not able to generate the type of gross charges that you see at the main clinic because of the funneling effect that you have in a large organization. This may be reflective of some of that.
The last thing I wanted to point out in terms of the change that has been taking place. This is partial information; it’s not totally complete yet. This lists some of the regional clinic networks that have developed in the State of Wisconsin. This is going on in Minnesota , North Dakota, and pretty much in the Midwest.
We talked about managed care programs soaking up primary care providers – family physicians. I think when you see these large multi-specialty groups getting involved in satellite operations, they also have a greater need and they’re in a position where they can address some of the issues involved in recruiting much more readily than small communities.
The potential problem with this type of system is for those communities in the State of Wisconsin or throughout those areas that basically aren’t under these systems that have difficulty obtaining physicians, the competition is really tough. Fred Moskol may be able to comment on that.
I was at a patient compensation hearing in Madison a while back and one of the physicians said that unless you were tied in with the Dean Medical Center or Gunderson or Marshfield or one of these systems it was almost impossible to find physicians to come to your small community.
So while this may be very nice and helpful for those communities that tie into these larger systems, by and large the system may provide subsidy dollars for those primary care sites and feel that they can do that because they’re pulling in the referrals. And when they pull in the referral, they are generating extra revenue for the secondary and tertiary care which can then flow back to the community in the way of subsidy to get the primary care physicians out there.
The Resource Based Relative Value Scale, again, may help tilt that so the subsidy doesn’t have to be quite as great but also if it reduces the specialty revenues, the ability to subsidize will also decline.
Fred Moskol, Wisconsin Office of Rural Health: There’s another factor there, Greg, which is real subtle, but if you look at the Madison area you begin to see physicians who travel outside the Dane County area is shaded. When they return back their billings to the home office in Madison, those billings go out as if the service was provided in the metropolitan area. They’re reaping the benefit.
Nycz: Not necessarily. This is an area that we plan on talking to the Physician Payment Review Commission on, the folks who are working on boundary issues. I think it can be potentially real beneficial to small communities out there. For example, the St. Paul area (and Fred knows a couple of these circumstances) when they come across the river they get into a different state, a different carrier, a different fee locality, and the reimbursement under Medicare is grossly under what their circumstances were in the Twin Cities.
You will have to re-evaluate that position. It may be that since these are carrier rules, there may be variability in how individual carriers handle this circumstance. There may be differences between when you send a consultant out from an area to go to another area. You bill based on the consultant’s prime location. You set up a satellite. You bill based on where that satellite is located if it happens to be in a different fee locality.
We’re not sure ourselves exactly what the policy is across different fee localities and carriers. That’s something we want to research and it’s something that a lot of rural advocates are very concerned about.
The archiving and publishing of the proceedings of the third and fourth plenary sessions of the First National Conference on Primary Health Care Access (April 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):
John E. Midtling, M.D., M.S. Chair, Department of Family Medicine, Medical College of Wisconsin (Dr Midtling is a Senior Fellow of the Coastal Research Group): I am going to talk about the differentials that David Sundwall referred to, particularly as they relate to physician reimbursement, how that might impact upon our ability in primary care to attract more students into our specialty, and how that might affect our ability to finance our residency programs. Greg Nycz is going to talk about some of the rural differentials.
I think our ability to manage access to primary care depends upon our ability to attract students into the primary care specialties and ultimately to place them in geographic areas that are appropriate. I want to describe the magnitude of the problem that we’re facing in primary care.
Consider the national trends in numbers of office-based family physicians. In 1963, there were about 67,000 family physicians in the U.S. and today there are about 5,000 less. In terms of a percent of the total physicians pool, the decline has been from around 27% down to 10.8%. There has even been an absolute decline, despite a doubling of the physician population.
Even when you factor in the other two primary care specialties – and I use here the federal definition of primary care being family practice, internal medicine, and pediatrics – the decline is from 49% of all total physicians down to 34%. You can see that there has been virtually no growth in total numbers.
Although there has been some expansion in the numbers of internists and pediatricians, this has not offset the decline in the number sof family physicians. And in 1963, there were 53 primary care physicians in the U.S. For every 100,000 people. Today there are just 52 per 100,000. This goes along with what David Werdegar was saying, that we have not done a good job as academic health institutions in producing the numbers of primary care physicians that our society requires.
I think the problem is likely to get worse because it’s been widely recognized that there is a bimodal distribution of family physicians in the U.S. There is one group of residency trained family physicians with a median age of around 35 and a second group of general practice era family physicians with a median age of around 60.
Today, one out of three family physicians is over 55 years of age. There are 24,000 family physicians over 55, and we’re only producing 2400 new graduates each year. So simple arithmetic tells you that as these over-55 cohorts move out into retirement over the next decade, they will not be replaced at the rate of production of our new graduates. I believe that this is going to have a serious impact on rural areas in particular, because family physicians account for 65% of all office-based physicians in rural areas.
In the metropolitan areas of the U.S., we have 56 primary care physicians for every 100,000 people and in the non-metropolitan statistical areas just 42 for every 100,000. But the family physician cohort represents by far the majority of primary care physicians practicing in the non-metropolitan statistical areas of the U.S.
There have been studies which have shown that over the past ten or twelve years there has been about a 45% decline in office-based primary care physicians practicing in our underserved urban areas. So any decline in the numbers of family physicians, I believe, will severely impact the rural areas and the underserved urban areas.
Furthermore, the increases in managed care systems which have found primary care physicians – especially family physicians – to be effective utilizes of resources, has drained family physicians away from the traditional rural ares into more of the urban-suburban locations. This may further exacerbate the impending shortage.
It is clear that we must increase the numbers of family physicians in the U.S., if we are to impact the access problem. However, this has been difficult to do because we suffer from both a shortage of positions and applicants. In fact, we now have fewer residents in family practice than we did in the peak years of 1983 and 1984.
Between 1984 and 1987, the number of first year positions in family practice declined by 11%, the number declined in internal medicine by 6.8% and the number declined in pediatrics by 4.1%. Studies have shown that it is difficult to fund more more than one-third of program costs with patient care revenue. One-third must come from hospital support and the remaining one-third must come from external subsidies.
However, Medicare indirect cost payments have been squeezing the hospitals. There has been a ratcheting down already from 11.59% to 7.7% in the so-called Medicare indirect cost adjustment. This ratcheting down has occurred through a percent adjustment applied for each .1 increase in the resident-to-bed ratio in a hospital. HFCA is now proposing that this be further ratcheted down to 4.4%. If that occurs, that will have a marked impact on hospital graduate medical education payments.
Of the $3 billion paid last year for graduate medical education, roughly $2 billion was in the form of the indirect cost payments. Not only that, the administration is now proposing that the direct cost payment be capped. The direct cost payment is calculated by taking the resident’s salary, fringe benefits, and malpractice costs, teaching and administrative costs, and other costs associated with the residency programs and multiplying that by the percent Medicare says.
The proposal is that the direct payment be capped at the 1987 average resident salary of $25,574, updated to 1991 by the Consumer Price Index, to create a cap at $29,688. Although a 1.8 multiplier would be applied for primary care, this would still provide primary care programs with a direct graduate medical education payment of roughly $10,000 less in funding per resident than was provided as a national average in 1988. Furthermore, Medicare patients participating in managed care systems are excluded from the graduate medical education payment system.
I believe this differentially penalizes primary care programs located in community hospitals that participate in managed care systems. At the same time our federal training grants have been reduced in size.
Since 1978, there has been a decline of about $10 million in available monies for the federal training grants in family practice. Similar trends have been noted in general internal medicine and pediatrics. When you factor in the Consumer Price Index, there has been almost a two-thirds decline in monies available for family practice graduate medical education.
Thus, I believe, the funding of our training programs is becoming overly dependent upon patient care dollars. I feel this is an undesirable situation since it is clearly more cost-effective for hospitals to train residents in the procedurally oriented specialties where hour for hour they may earn up to 15 times or more the fees generated by residents in the primary care specialties. In addition, the cost of maintaining the model clinic in family practice has been an additional cost that the hospitals must bear.
I believe if we are to expand our programs, we need to expand these Title 7 payments for primary care education. We also need to factor into the Medicare graduate medical education cost payments the nation’s need for the specialty being trained. I believe that some sort of multiplier is needed for direct cost payment which would more than compensate for the ratcheting down of the indirect cost payment.
Finally, it’s possible that full implementation of the Resource Based Relative Value Scale [RBRVS] may help increase the percentage of residency training program costs generated through patient care dollars. If the projections are correct, family physicians could undergo a 37% increase in reimbursement and internists a 14%.
Data from Phil Lee’s commission modeled what would happen at full implementation of RBRVS (not what would happen to total family physician income, but what would happen to Medicare-derived income which accounts for about 29% of all physician income in the U.S). They have projected that internal medicine would get about a 14% increase; family practice a 37% increase; opthalmology and thoracic surgery – a 16% increase in reimbursement and in the largely rural areas about a 31% increase.
Since many of our programs are located in the small metropolitan or even rural areas, it’s possible that this could help increase practice plan revenue, increasing the financial stability of our residency programs.
Primary care training programs have also suffered from an increasing shortage of applicants, causing many programs to reconsider plans to expand or actually downsize. I believe any attempt to increase the numbers of primary care physicians in the U.S. must also address predoctoral education programs so as to influence specialty choice among U.S. medical students.
I am sure you’ve all seen the charts as to what has happened to the National Intern and Residency Match in primary care over the past decade. I’ll talk about what happened with the 1990 Match as well. Between the years 1978 and 1988 there was a decline in the ability of family practice programs to match with the U.S. seniors from around a fill rate of about 77% to about 61%. Pediatrics had a similar decline; and internal medicine virtually an identical decline to family practice, falling from 77% down to 63%.
However, general surgery and the surgical sub-specialties have increased their match from about 66% of positions to 80%. OB-GYN, despite student concern about the malpractice issue, has undergone a substantial increase, from 76% to 86%. Some of the surgical sub-specialties, like orthopedics, ENT, have been able to match in excess of 90% of their positions with U.S. seniors.
In 1990, family practice matched only 59.3% of its positions with U.S. seniors and internal medicine only 59% However, the figures would have been even worse, because in 1990 family practice offered 100 fewer positions than in 1988, and internal medicine offered 300 fewer positions than they did in 1988. So we’re offering fewer positions and doing less well in the Match. I think this trend is going to continue for several more years and I’ll show you why.
The Association of American Medical Colleges (AAMC) surveys U.S. seniors at the time they graduate from medical school. You can see over a five-year period of time there has been about a 5% reduction in student interest in family practice; 8% reduction in general pediatrics; and a 40% reduction interest in general internal medicine. However, look at this! A 39% increase in the medical sub-specialties. If these students who graduated in 1987 follow through on those career plans, there will be further sub-specialization in internal medicine.
Other data, based on AAMC surveys done at the time students take the medical college admissions test, are even more worrisome. The AAMC asked those students who subsequently matriculate at a U.S. medical school as to what specialty in which they intended to practice. Over a ten year period, there has been a 56% reduction in student interest in family practice as a career; a lesser decline in internal medicine; but a tremendous increase in student interest in surgery and the surgical sub-specialties.
These students that were surveyed and entered in 1987 will graduate in 1991. IF they follow through on these career plans, I would anticipate a further decline in student interest in primary care.
Well, many have tried to analyze these trends. Some have suggested it may be due to a movement way from the traditional values of social concern and service to an increasing emphasis on financial well being. Certainly studies of undergraduate students have shown this to be the case. Others have suggested students’ increasing concern about their ability to services large educational debt burdens with a career in primary care.
According to the AAMC, the average debt of graduating medical students in the U.S. increased from $5,000 in 1971 to $35,000 in 1987. This represents a 700% increase in student debt over a 15-year period, far outstripping the Consumer Price Index. What this doesn’t tell is that in 1987, 1 out of 14 medical students in the U. S. had educational debt burdens in excess of $100,000.
During the same period of time, there was a marked reduction in the federally subsidized loans for the health professions and the near elimination of the National Health Service Corps scholarship program. Most studies which have looked at the relationship between student debt and specialty choice, I believe, have been flawed because they have not differentiated between subsidized and unsubsidized student debt.
The guaranteed student loan (so called GSL), the national direct student loan (NDSL), and the health profession student loan (HPSL) are all federally subsidized loans. These must be differentiated from the health education assistance loan, the so called HEAL loan.
Unlike the other loans, HEAL debt interest begins accruing immediately at prevailing rates. Loan repayment then begins after the training period but interest accruals markedly increase the size of the principal to be repaid. In some cases initial loan amounts may double by the time the student begins repayment.
Subsidized loans became less available during the 1980’s. More students were froced to take out HEAL loans. Bazzoli, in a study done for the AMA in 1984, was able to show that for every $10,000 increase in HEAL debt burden, it decreased the likelihood of a student entering primary care by 7.5 percentage points. In fact, Bazzoli was able to model as early as 1984 that primary student reliance on HEAL debt at then prevailing debt ratios would decrease the number of students selecting primary care as a career by 1,597 students per year.
Unfortunately, Bazzoli’s mathematical models were never considered and policy extensions were made which implemented the policies of which Bazzoli’s mathematical experiment forewarned. The decline in student interest in primary care as a career could have been predicted and anticipated based upon the policies to fund medical education implemented in the 1980’s.
We now have a very unfortunate situation where HEAL debt burdens are so large in some cases that even the National Health Service Corps loan repayment program cannot service the student debt in many cases, to say nothing of reducing the principal.
While accruing ever larger unsubsidized debt burdens, students face the prospect of declining earning power for the primary care specialties. The normal laws of supply and demand have not influenced primary care physician earnings, since reimbursement rates are fixed by third party payers who reimburse for procedural services at a rate many times that paid for cognitive services.
Like other payers, Medicare has actually exacerbated the primary care access problem by paying sub-specialists more than primary care physicians for the same work, reimbursing urban physicians at a higher rate than rural, providing complete coverage for inpatient care, but requiring patient contributions for outpatient care, reimbursing physician time spent in undertaking a procedure at a rate several times that paid for time spent providing ambulatory care or cognitive services and in many cases not reimbursing for preventive care at all.
Not surprisingly, these differentials have encouraged physicians to choose specialties and practice locations already well supplied. In fact, the gap in income between the primary care and non-primary care specialties has been growing throughout the past decade. If you look at what a family physician earned in 1977, he earned 82% of average physician income. That same individual in 1986 earned just 68% of average physician income. Internal medicine declined from 98% to 91%; pediatrics a decline from 76% to 68%.
If you look at a rural physician in 1977, that individual earned 95% of average physician income. However, in 1986 that same individual earned only 86% of average physician income. If you break it down according to specialty, the gap is even more dramatic. Over a less than 10 year period of time, there has been a 15%-20% decline in family physician earning power as a percent of average physician income; similar declines in pediatrics and internal medicine; but in many of the procedurally oriented specialties, there has been almost a 20% increase in earning power as a percent of average physician income. So, over the decade of the 80’s, the gap in income between primary care and non-primary care has been growing dramatically.
Will RBRVS correct these differentials or will it be too little too late? I believe RBRVS holds great promise to attract and retain more students in the primary care specialties. However, will it augment earnings enough to make a difference? In some cases, as David indicated, we’re looking at two or threefold or more differentials in earning power. Will the preoccupation with the federal budget deficit prelude implementation as planned? HCFA now has a single spigot that can be cranked down.
Enactment of the administration’s current Medicare budget proposal would speed up payment cuts expected under the resource based payment system and use them for 1991 budget savings. Such a use of expected savings for budget reduction would preclude the redistribution of savings to primary care in rural areas as intended.
Phil Lee, Chair of the Physician Payment Review Commission, has recently gone on record as stating that such reductions could severely limit the funds available for crucial payment increases for primary care specialties and for rural areas. That may hasten the retreat from the primary care specialties and the rural areas, further exacerbating the access problem. It seems to me it is critical that we strongly advocate full implementation of RBRVS with savings directed to correct the primary care and rural differentials as originally intended.
I believe that medical education reforms are also necessary to increase the numbers of students selecting primary care as a career. Attention should be given to selecting applicants for medical school with a primary care preference. New efforts must be made to recruit more under-represented minorities into medicine.
There are fewer underrepresented minorities in medicine today that there were ten years ago. Another focus must be the medical school curriculum. Major new primary care curricular changes need to be made, especially at the third year level, during with most students make career decisions. Education in the ambulatory setting is costly and labor intensive.
Such a redirection of educational experiences would require substantial expansion of primary care faculty who are based in the ambulatory setting. Major new predoctoral training incentives, I believe, need to be established through Title 7 programs to provide the resources necessary for these curricular changes.
Perhaps we need to implement a primary care deficit reduction act modeled after Gramm-Rudman-Hollings where state and federal support for medical education would be base upon the production of at targeted number of primary care physicians. I believe that for family practice a reasonable target would be 25% of all U.S. graduates and for the three primary care specialties combined a reasonable target would be 50% of all medical graduates.
I believe that as the major payer of medical education, government can exert considerable influences on the specialty distribution of available training positions.
Finally, I believe that we as primary care educators have a unique role ot play in health services research. I believe that there are many places such as the State of Oregon which is trying to establish a Medicaid rationing program. This program is crying out for research data, too look at what works and what doens’t, what are cost-effective solutions, and what will benefit the greatest number of people. I believe that we in primary care need to provide a leadership role in developing this research agenda, which has great potential for developing strategies to control health care costs and improve access.
Ultimately, if we are to improve our American system of health care, we must be able to allocate resources in a way that is consistent with a well-thought out, national policy applied in a consistent and longitudinal fashion. We must advocate for the application of such a policy and we must learn from the mistakes of the past.
The archiving and publishing of the proceedings of the third and fourth plenary sessions of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):
John Midtling, MD, Chair, Department of Family Medicine, Medical College of Wisconsin (Dr Midtling is a Senior Fellow of the Coastal Research Group): This session is entitled, “The Impact of Changing Reimbursement on Our Ability to Manage Access to Primary Care.”
Our lead presenter is David Sundwall, who is Medical Director of American Health Care Systems Institute and former Administrator of Health Resources and Services Administration, Department of Health and Human Services. The panelists are Jerry Rodos, Consultant to the Director of the National Health Service Corps and Special Assistant to the President of the Chicago College of Osteopathic Medicine; myself; and Greg Nycz who is Director of the Wisconsin Rural Health Research Center in Marshfield, Wisconsin.
David N. Sundwall, MD, MPH, Medical Director, American Health Care Systems Institute (Dr Sundwall is a Senior Fellow of the Coastal Research Group): I have been asked to be funny. It’s pretty hard to be funny talking about federal health policy, but I’ll start with a true story. This was very painful but it was forever humbling and was one of the best experiences I have ever had in my life to let me understand the relative importance of federal health policy.
After I had been in the Senate about a year and thought I was really important – the Health Staff Director of the Labor and Human Resources Committee with all these important responsibilities – I was invited to speak to the Wyoming State Medical Society. They had a wonderful conference at Jackson Hole.
The speaker proceeding me was a pathologist from UCLA who spoke about the Shroud of Turin. He showed ultrasounds and X-rays of the actual cloth. He had us captivated and in the palm of his hand. Everyone, including myself, was enthralled with his presentation. I wasn’t quite convinced of the significance, but he essentially said yes this is the cloth that Christ was wrapped in.
Anyway, after he finished, and they introduced me, 75% of the audience got up and walked out. I’m not kidding, at least 75%. Talk about putting me in my place. I never again presumed that people were waiting with baited breath to hear what was new from Washington.
However, you’re a captive audience and if you get up and drift out, I won’t hold it against you – I’ll just leave when you talk.
I am very pleased to be here and honored to be with such a distinguished faculty. As all good speech teachers tell you, you’re supposed to tell the audience what you’re going to tell them, tell them, and then tell them what you told them.
So what I am going to try to do tonight, at the recommendation of John Midtling, is to give first of all an overview – a snapshot of federal health policy – before we talk about physician reimbursement reform. Then I am going to give you some personal predictions about what’s coming in the next decade. (I couldn’t agree more with David Schmidt that we’re not likely to have major national health reform very soon.)
To understand what we’re doing now, you really do have to step back and look at where we have been. When I walk to the “hill,” and I do often, along Pennsylvania Avenue there’s engraved in the Archives Building a statement that says something to the effect that “The Past is Prologue”. Well, I can guarantee you from what I see in Washington, that is not true in health care, because we’re going to be charting new territory.
We’re kind of learning as we go along. And one way to understand this a little bit better is to appreciate that the federal government’s role in health care is a relatively recent phenomenon.
The History of the Federal Role in Health Care
Concurrent with my going to Washington in 1981, I agreed to write a chapter for Dr Bob Rakel’s Family Practice textbook on the federal government’s role in health care. It forced me to do some homework – to go to the Library of Medicine and look up past articles.
I determined that there have been four eras of the federal government’s role in health. I decided the first era was from 1789 to 1900. That era began when Congress first convened in Philadelphia. While they did say there was a proper role for the federal government in health, it was limited to maintaining the health of merchant seamen. And to do that they built maritime hospitals in seaports. That’s about all they said about health.
For over a century, that’s pretty much all they did, with the exception of feeble quarantine efforts and trying their best to contain massive epidemics. To let you know how ineffective they were, it’s estimated that in the 1860’s in the Ohio River Valley alone, between 20,000 and 100,000 people died of yellow fever. That’s a pretty broad estimate. It shows you that they didn’t have a CDC or any effective epidemiological methods. But on the heels of that epidemic, they did create the Commissioned Corps.
The second era I said was from 1900 to World War II. At the close of the 1800’s there was finally enough “science” in medicine to actually help people. With an understanding of disease transmission through germs, the importance of antisepsis and the development of effective anesthesia, physicians for the first time had tools which were effective in preventing illness and saving lives.
But in this era, it was not improvement in clinical practice which were so important, but laws passed giving the federal government responsibilities as a regulator of air, water, food, drugs and biologics. As we all know, basic sanitation measures done at the local level with federal guidance and support have done more to improve our health than anything we have done since and remain the most effective means to improved longevity.
My description of this is a very broad brushstroke, as I am skipping over the creating of VA system after World War I, and very serious efforts to regulate a national health system. When the Social Security Administration was formed in the 1930’s, national health almost made it, with schoolteachers being the most vocal proponents. But it didn’t succeed.
The third era I wrote about in this chapter was from World War II to 1965. I categorized this period by an explosion of medical science and information and the government taking the lead in two areas – research and hospital construction. This was when our National Institutes of Health underwent multiple births and became the greatest biomedical research effort anywhere in the world.
The rationale was that basic science research would never be funded in the private sector, because there was no apparent immediate payback. Consequently, it was perceived as a proper role for the federal government. I think that was a very wise decision.
Congress also determined after World War II that the federal government should improve the nation’s hospitals (it was, I think, primarily a labor and employment issue). With Hill-Burton Act loans, they provided the catalyst to build a greatly expanded hospital intrastructure in this country. They also got involved with health manpower concerns in the early 1960’s and began providing funds for education.
The fourth era commenced in 1965, and when I wrote the chapter, I believed it extended to the “present” which was then 1980. I categorized this period as multi-specialty medicine, with the government for the first time becoming a major payor, or purchaser, of health care. Medicare and Medicaid were enacted in 1965 and were intended to pay for health care for certain sectors of our population. So it was the year I went to medical school that the federal government got into “health care” for the first time in a major way.
Before that, their total expenditure was a few billion dollars. So, it’s only been in my adult lifetime that our national government has been significantly involved in health care. But if I had done my homework more carefully, I would have realized we have already entered a fifth era which began sometime in the 1970’s.
I can’t determine just when it began because there was no landmark legislation. When Medicare and Medicaid were passed, for some reason it seemed as though it was now O.K. for the national government to start addressing lots of specific health problems. Social activists succeeded in obtaining federal funds for “neighborhood clinics”, which became a large network of community health centers.
The National Health Service Corps was established. There were more training grants in primary care, and there were dozens and dozens of good ideas that legislators translated into legislation – categorical grant programs to deal with rodent control, lead poisoning, emergency medical services, etc. These projects seemed to be good vote getters. It was the time when there was lots of good health legislation (if you think “good” means that there are federal efforts to address several social concerns).
“Cost Containment” as a Federal Policy Imperative
But it was not too long into the 1970’s that you didn’t see much of that any more. In fact, by the mid-’70’s the focus of Congress and the administration was not on addressing health programs, but on reining in costs. I categorize this new fifth era as high-tech medicine having outstripped our capacity to pay for what we’re theoretically capable of doing.
Much to my pleasure, after I prepared my chapter of Paul Starr’s book, “The Social Transformation of Medicine,” he suggests similar eras, and he also said we were in a protracted period of cost containment and retrenchment at the federal level.
So, where are we today? We have heard our speakers this morning talk about the unhappiness with our system. I am going to quote a few things to emphasize that. The AMA News had a cover earlier this year that I thought was accurately illustrative of the physicians perspective of the 1980’s. It shows the reflection of a doctor in a shattered mirror and it was titled “The Decade of the 80’s in Medicine.”
Discontent with the Present Health Care System
Without having to read what’s in between the pages, you know that organized medicine is very unhappy about the current state of affairs.
Dan Callahan’s new book – “What Kind of Life?” – was referred to earlier this morning.I particularly liked the introduction of the New York Times review of that book. It says this:
“These are the best of times for American health care. They are also the worst of times. Most of us will live to attain the biblical three score and ten. Many of us will avoid the pain and incapacity that would have bested the long-lived a century ago.
“Medicine’s technological capacity has never been more impressive and our society has shown itself willing to pay an ever-increasing amount for the promise of health and long life. No other industrialized society allocates so much of its gross national product to health.
“Yet, we Americans feel cheated, dissatisfied with many aspects of a system that has promised so much. Certainly, we are unwilling and perhaps unable to bear its ever more burdensome cost. There is a broad consensus that something should and must be changed.”
Well, there is no shortage of ideas. We have an increasing array of proposals on how to fix things. I would like to review some of them for you.
Before I review the specific proposals, let me make a few points. While all here are well aware of the unacceptable high cost of health care in the U.S., I just want to emphasize the current state of affairs with the budget.
Try to imagine you are an elected official and dealing with the current economic climate and a president who is very, very popular (I guess the last poll was one of the highest popularity polls ever – 82% approval in one poll) who says “no new taxes.” They’re really in a quandary. But, let’s just look at these slides.
The first slide (Figure 1) illustrates health care costs for the nation over the recent past, with projections for the future. It was prepared by Senator Kennedy’s staff in 1984. I was working as a professional staff member. Senator Kennedy is famous for having hard-working and capable staff, and they used this data for hearing on the cost of health care.
At the time, I frankly disbelieved the projections. Senator Kennedy, in his own inimitable way, with a deep sonorous voice, said that if we keep spending at the rate we had, we’re going to be spending by 1990 three-quarters of a trillion dollars. That seemed ludicrous to me because when I went to Washington in 1981, the entire federal budget was three-quarters of a trillion dollars. It just seemed impossible.
However, we saw this morning data which illustrates we’re just about on Senator Kennedy’s target. Even more scary is the projection that by the year 2000, if spending stays at the level of increase it is, we will be spending one-half trillion dollars for health care alone.
It reminds me of a joke. In the New Yorker, there were two doddering old Congressmen walking down the Capitol steps. One turned over tot he other and said, “You know I’m not going to run again next term because I don’t know what comes after a trillion.” I think most of us also are boggled by these extraordinary expenditures.
The second slide (Figure 2) is just another way of illustrating health expenditures, but as a percentage of Gross National Product (GNP). We’ve all heard arguments – “So what? Why don’t we keep spending whatever it takes? Health care is a good thing to invest in.” But when it’s in competition with so many other important federal agendas, it doesn’t wash well with the voters.
I also used to say why not? It employs lots of people. It’s a non-polluting industry. But now it seems that our hospitals – at least their refuse – are a legitimate target of environmental concerns.
Slide 3 illustrates the governments share of spending. The federal government’s concern is understandable when you understand these projections. If we are going to be spending half a trillion for “health” and the government’s share is 40%, then with a budget deficit they’ve got to restrain this growth. It would be irresponsible not to.
But what I really want you to note is the percentage of increases. From 1965 to 1988, it has increased about 3000 percent.
A health economist named Lynn Ethridge who worked for Presdient Carter in the Office of Mobilization and Budget (OMB) said at a recent meeting that if we had convened in 1965 the world’s greatest minds in business, and charged them to create something that would be a growth industry, they couldn’t possibly have come up with anything better than the catalyst that Medicare and Medicaid were to stimulate the “health care industry”.
When the government assumed a major role as a purchaser of health care services for the elderly and the poor, few expected it would be so costly.
The increases caught everyone by surprise in the 1970s. For example, when the End Stage Renal Disease Program (ESRD) was started, it was projected to cost $200 million. In fact, in less than ten years it was $2 billion, and continues to grow as we continue to dialyze more and more older people.
Slide 4 (Figure 3) compares us with other industrialized nations. Those horizontal bars are countries, the United States at the top and Turkey at the bottom. We spend more of our gross expenditures, and more per person, for health care than any other country by far, yet we all know that we don’t rank very well on commonly used health measures.
As an aside, I want to take issue with the infant mortality statistics that David Schmidt showed this morning. I had a chance to serve on the National Commission to Prevent Infant Mortality, representing Secretary Bowan, from 1986-1988. I learned that there is a lot more to be considered than nationally comparative data.
For example, Minnesota and Sweden are not very different in population, mix and size, and Minnesota has better infant mortality statistics than Sweden, the reason being that we do a better job at saving the very low birth rate babies with our high-tech neonatal units. It seems patently unfair that we measure the United States with countries that are much smaller and much more homogeneous.
Those kinds of gross comparisons that we often banter about aren’t altogether accurate nor fair. (I’m not saying that we can’t do a much better job, and the population-specific differences shouldn’t be improved. Black infant mortality in the U.S. Is clearly a disgrace.)
O.K. So, this is the climate we’re working with. We’re spending more than everybody else; we seem to be getting less value for our money, or at least that’s the perception; costs are out of control; access is limited for fully 30 million to 60 million (I hear such different figures; people say the census will double those who are estimated to be without insurance). And the quality of what we do provide is seriously under question.
Serious analysts from the Rand Corporation, led by Dr. Brooks, claim that much of what we do isn’t useful, isn’t helpful, and is unnecessary, if not harmful. That kind of scrutiny in what we do in the name of modern medicine is painful, but is understandable and appropriate, given economic concerns.
Now, one observation I have made of “Washington policy” is that part of the mess we’re in is because our policy makers for two decades have focused almost exclusively on financing of care and they’ve let so many other things essential in public health efforts slide. The reasons for this focus is understandable, given that those who benefit from the financing are clearly the most vocal lobbyists.
The providers, meaning doctors, hospitals, pharmaceuticals, medical devices, many more who are employed in our “medical-industrial complex,” are in a position to benefit from attention being paid to the financing.
Unfortunately, the poor and the disadvantaged don’t have a very effective lobby. The other observation I have made is that we have, in fact, “medicalized” or made part of the health care system things which really are not traditional health concerns.
And I don’t mean to say they aren’t eventually a health problem, but if you look at the big ticket items we’re dealing with, many are the result of social-behavioral problems.
Alcohol abuse and dependence is far and away the biggest problem statistically and cost-wise for the country. Perhaps second is tobacco use. Other costly social problems are drug abuse, sexually transmitted diseases, (the cost of care for uninsured AIDS patients being the most pressing of these), injuries, premature births, and infant mortality. All of those are theoretically preventable, saving the costs of medical treatment. But we’ve medicalized them and put them on the shoulders of the health care system.
The last issue I’ll mention before talking about specific health care reform proposals is malpractice. I also think it’s patently unfair to compare our country’s costs of health care to other countries when they don’t have anything similar to our system of seeking redress form malpractice, substandard care and, in many cases, “disappointments” in the outcome of medical intervention.
The total costs are unclear, but it is enormous. Former HEW Secretary Joseph Calafano used to state about $35 billion, or 25% of the total costs. My former boss, Senator Orrin Hatch of Utah, has been a champion of malpractice reform and thinks it exceeds 30%, when all factors are considered.
The AMA states $18 billion is spent for defensive medicine alone, and that doesn’t include the costs of payments for injuries or litigation. Anyhow, it’s “real money” no matter how you count it. And other countries don’t have anything resembling our tort system, and, thus, don’t spend extraordinary sums on related issues.
So where are we? We’re at the point in time where there is so much dissatisfaction that all kinds of good ideas have been put forth to reform U.S. health care. The American Public Health Association has prepared a comparative chart listing many of the proposals for health care reform, and then plotted them out to see how they address their against their association’s principles for reform.
The one they like the best is the most politically unfeasible legislation introduced by Congressman Roybal. His bill essentially federalized health care for all citizens. It must sound great on the speaking circuit, but cost estimates indicate it would add tens of billions to the federal outlays, so it’s not taken seriously.
There are other serious proposals – the Consumer Choice for Health Plan for the 1990’s by Enthoven; the Progressive Proposal for National Medical Policy; the U.S. Health Service Act (another free, comprehensive health program); and the Basic Health Benefits for all Americans (the Kennedy-Waxman proposal) which as received a lot of attention.
The latter may, in fact, have the most promise; however, again their costs estimates are around $60 billion when done by independent analysis. Their cost estimate is only about $30 billion.
Health Care for the Nation is the proposal of the National Leadership Commission on Health Care, a private sector coalition with former presidents Nixon, Carter and Ford serving as honorary chairmen, but actually chaired by former Congressman Paul Rodgers and Governor Raye of Iowa. This has limited federal involvement and this proposal would put more responsibility on states.
Other proposals include Health Access to America from the American Medical Association (which is endorsed by the American Academy of Family Physicians) and a call for comprehensive national reform from the American College of Physicians.
Then there’s the Pepper Commission. In fact, this year has been called “the year of the commissions” because we have three major high-level groups meeting, all charged to come up with the right answer. The Pepper Commission was the first out of the blocks with their report. It’s bipartisan, and includes people from the private sector. It is comprehensive, compassionate, and very well thought out.
However, in my opinion, it focused too much on coverage and financing, not on what’s immediately wrong with the health care system. Regardless, this proposal was put on the back burner because they didn’t come up with any mechanism to pay for it The costs are about $66 billion for the federal government, about $20 billion for the private sector (for employers) and those costs were so great that it has not yet received serious consideration. However, I expect elements of their recommendations to keep surfacing and eventually be adopted.
When President Bush spoke in the “State of the Union,” he mentioned health. You don’t understand how important that is until you realize that it was not mentioned during several recent “States of the Union.” But he did mention health and his chief health advisor on the campaign trail, was Debbie Steeleman now chairs the Quadrennial Social Security Commission.
This group is also charged to look at the future of health care in the nation and make recommendations. The President said he was concerned about cost, access, and quality and he was going “to do something” about the costs. That was interesting. He didn’t say he was going to do something about access or quality.
However, he subsequently directed Secretary Sullivan to come up with a plan to cover the uninsured. The chairman of that group is his HHS Undersecretary, Constance Horner, and she is now working with the help of Gail Wilenski, Administrator of the Health Care Financing Administration (HCFA). Their proposal is due next January.
The Steeleman Commission isn’t due until next year, but I have an “inside source” who sits on that Commission who told me what they’re considering. I think this is promising because if, in fact, that group can come to agreement on the five elements my friend tells me have been discussed, and the President makes it part of a legislative proposal, something constructive might happen.
The most exciting to me is the possibility of dealing with the access issue by federalizing Medicaid. I think that’s long overdue. I believe the state-by-state variation in Medicaid simply shouldn’t exist. Poverty is the same in Utah or Mississippi or Alabama or New York and I think there ought to be a national standard, and that services provided should be determined on the federal level.
Long-term care would be dealt with by creating incentives for a private insurance market. As I understand it, they believe that if the risks were shared broadly, long term care could be paid for through a private insurance program. Among this group there is great resistance to federalizing long-term care for fear it would be extraordinarily costly and replace so much of the care given by family providers and others. The third area of focus is on inefficiency, redundancy, and waste.
I don’t know what they’re going to propose to do about it, but it’s of major concern. I do know they are hopeful the attention recently focused on medical effectiveness studies will result in better financing. They are going to try and persuade the public that they’re going to have to carry more of the burden of their health care personally with co-payments and other forms of cost sharing. And the last area of focus is a recognition that the public health service delivery system works for targeted populations and that they should recommend strengthening this effort.
Believe it or not, Debbie Steeleman and the National Health Council talked about school-based clinics, about what she called “non-insurance models,” which I think means publicly funded clinics like HRSA’s community and migrant health centers. I personally believe that that’s the most appropriate and the best way to care for our medically indigent citizens.
There are probably other proposals in the process of development. My discussion has not been comprehensive. But, although the chorus is growing louder, they’re singing very different songs and there’s not agreement on many of the major issues.
The Institute of Medicine had a conference on access to health care about two weeks ago and Bob Blended from Harvard chaired a panel that included David Axelrod from the New York State Health Department, representatives from the United Auto Workers, Hewlett-Packard (representing big business), and the Small Business Coalition of Cleveland.
These representatives were all smart, sincere, and well spoken, but their views on health care reform were all over the map. If they are representative of our nation’s major voice in policy, we’re a real long way from agreement yet.
Before I give you my prognosis for the future, I would like to talk about one of the recent efforts in cost containment, which is physician payment reform. I have provided for this conference a monograph that I prepared on “The Impact of Physician Payment Reform on Hospitals.” I will make this available to be included in the Proceedings of the conference.
Although it sounds vain for me to say so, I recommend it to anybody interested in the history of how the federal government pays doctors. It has been a very complex process and the law recently enacted has been a long time coming. I”m not going to bore you with all the details but I”ll give you a brief run-through. When Part B Medicare was enacted, there was a half-and-half co-payment by patients.
Part B Medicare pays for physician and ancillary services, (about 80% going to doctors, 20% going to outpatient and ancillary services. This program is optional. When you get over 65 you can choose to buy that or not, but the vast majority of our citizens do. In 1972, the government started noticing, “Hey, wait a minute! This is getting out of hand here and the poor citizens can’t pay that much.”
And so they decided to help the beneficiaries by saying that the premium increase could not go up any more than the cost of living adjustment. So when they did that, guess what happened? The beneficiaries share went down, and down, and down, until now it’s about 25% and the rest of it is paid by the government.
When they did that, the government adopted pretty much what Blue Cross and Blue Shield had been doing. In other words, they decided to pay doctors the usual and customary fee in their community. But to let you know how complex that is, there are about 280 regions on which they base those usual and customary fees, and there is an extraordinary amount of variation.
In spite of efforts to restrain Part B spending, there have been sharp and almost unrelenting increases since the early 1970’s. Congress then tried to tie increases to a medical economics index (like a health inflation index). In the 1980’s, they also tried to freeze physician fees. They have crated a thing called PAR (Participating Physicians) giving doctors who agreed to accept Medicare as full payment some guaranteed increases.
All of those efforts sounded good on paper but the aggregate increases in Part B over the previous two decades have been about 15% per year! Some have been higher than that and this particular program sticks out as the fastest growing health expenditure in government.
As I said, the movement toward physician payment reform is not new. Anybody in family medicine has known for a long time that there has been inequity in how procedural specialists are paid as compared with primary care physicians, even though we all go the the same medical schools, we’re all smart, and we all care for people.
For years there have been consensus among health policy analysts that technology is overpaid. However, much to everyone’s surprise, Congress created, in 1987 a study group, which became the Physician Payment Reform Commission (PPRC). That’s when they also contracted Dr. William Hsiao of Harvard to develop the Relative Value Scale.
This study was then given to the Physician Payment Review Commission, chaired by Dr. Phil Lee of UCSF, who refined it, modified it, and sent it to Congress. To be honest with you, last year we thought it was dead, that it would sit on the shelf. We thought that there was “so much on their plate” and they didn’t have time to seriously consider this major reform proposal.
But do you know who saved it? I don’t think he gets sufficient credit, but it was Senator Jay Rockefeller of West Virginia. Senator Rockefeller surprisingly was unrelenting in getting this passed. In the monograph I referred to, I give some of the history of what happened. Another major surprise was that Secretary Sullivan testified in favor of physician payment reform if there was an expenditure target and only if there was a limit on the aggregate spending.
It seemed extraordinary that a Republican administration would not only set a national fee schedule but also support regulation of how much should be spent for doctors’ services. The AMA went bonkers. They were bitterly opposed to this. So when it was passed out of the House and went to the Senate, they lobbied hard for changes which modified the “expenditure target,” into “volume performance standards.”
I have heard Dr Allen Nelson, the President of the AMA, try to explain the difference, and ti sounded like a great success for the AMA to get this change. But I must have a learning disability, because it still seems like our national leaders have put physicians on notice that there is a limit to how much the public is willing to pay for our services.
Regardless, with Jay Rockefeller, the President, and Dr. Bill Roper (who was the administrator of HCFA) all saying this was a good thing, it was passed into law in the ‘Omnibus Budget’ Act of 1989.
n short, we now have a new national fee schedule (to be developed and phased in over the next five years); we have theoretical targets or Medicare Volume Performance Standards (MVPS) that will determine how much the federal government is willing to spend in each subsequent year for doctor services (for Medicare Part B); and, lastly, it limits doctors in their ability to “balance bill” or to recoup what they consider their losses by passing it on to the patient.
If you thought prospective payments for hospitals was a major accomplishment and hard to do, understand that there are only 472 diagnostic categories for hospital services and there are only 5,000 hospitals. This task that HFCA now has to implement is horrendous. There are over 7,000 doctor codes for billing and they have just begun to get what the relative value for each of those is, and there are 500,000 doctors!
Don’t hold your breath for this thing to be fully implemented. It’s going to take a long time for this thing to be completely phased in, and it will inevitably need to be refined. I’m certain that it will be challenged and tested every step of the way. But the bottom line is that it is going to happen, and it will make a difference.
The cost shifting probably will be more significant from region to region that it is from specialty to specialty due to consideration on inclusion of “geographic practice cost index” (GPCI). However, it has been estimated that primary care doctors, family physicians, internists, pediatricians, will have a raise of about 27% of their income from the care of Medicare patients.
Sub-specialists in certain fields would go down about 14%. How this will be “budget neutral” as promised, I don’t understand. But we’ll have to wait and see.
Now, let me get to he meat of what I was asked to address. I was asked to talk about what is going to be the implication for physicians and especially family physicians of these new payment reforms. In my monograph, I speculate about a number of things doctors might do to maintain their income, such as seek arrangements with hospitals, align themselves in groups, and do more things outside of hospitals if they can.
One intent of those who wrote this law is that if primary doctors were paid better, more people would choose to go into primary care. However, I am skeptical that the difference in income is going to be sufficient to make someone change their career. It would possibly make a difference if people were “on the line” but I don’t think that a thoracic surgeon’s income dropping from $500,000 a year down to $380,000 is going to dissuade someone from choosing that specialty.
A family doctor’s income may increase from $80,000 clear up to $110,000 or slightly more. Those are ballpark figures, but I believe that even under these reforms, our specialists are going to be paid significantly more than primary care physicians. The geographic redistribution may make a real difference. I think that, because specialists in rural areas will maintain much of their income with enhanced rates, it may help to address some of the rural and geographic maldistribution problems.
There’s one thing in here that troubles me, but I don’t know any of you are bothered by this. I have been a practicing clinician and I understand that if you do more you get paid more. But this doesn’t address the volume issues, aside from the aggregate volume performance standard. For example, ti says clearly in the law that a physician will be paid the same for a procedure regardless of their specialty.
Our family physicians colleges are going to catch on to this, and recognizing that the gastroenterologists can’t be paid any more than he or she could for doing a gastroscopy or colonoscopy, the family physician will seek to become “proceduralists” This law may greatly increase the number of procedures done overall.
By the way, by my introduction you may not know I really am a board certified, licensed family physician. I still see patients every week. Before I took my last re-certification exam I wen tout to UC Irvine for their 65 hour refresher course. I studied hard, took notes and passed my re-certification.
But what troubled me was the last day of the conference was an optional course on colonoscopy. I went and played with the various fiberoptoscopes (provided, of course, by the vendors). You could try your hand at the different models (ranging from $5,000-$10,000) practicing on rubber dummies. At the end of the day I received a certificate stating something like “you, too, are a colonoscopist.” Talk about collusion with the medical industrial establishment!
The proponents say “think of the screening for cancer.” I can’t deny that. Family physicians certainly may detect more colon cancer by doing this. However, I still think that serial stool tests for occult blood are pretty good screens, and probably preferable to routine colonoscopy.
There is a legitimate concern that our primary care docs, with encouragement from this law, will continue to escalate health expenditures by doing many more procedures. It will help close the gap in income between the specialist, but is it in the best interest of the patient?
Congress is not waiting for this law to be phased in before seeking more savings in Part B. The President’s budget this year requested a $2.2 billion cut in Part B Medicare, far and away more than the PPRC has recommended. So, due to pressures from the budget deficit, they’re not about to relax their efforts to seek more savings over time.
Let me just close on a more optimistic note. I think that there is a growing awareness and consensus about the flaws in our health care system. We see it in all the proposals for reform. They say the same things need to be fixed and that is heartening.
The best talk I have heard in a very long time was Robert Heisel, the President and CEO of the Johns Hopkins Hospitals, who gave the Rosenthal Lecture at the Institute of Medicine this past week. He said things that sounded as though he were a member of the Society of Teachers of Family Medicine from its inception.
I won’t read all of this but I”ll just tell you that he said without holding back that “academic health centers have simply breached their social contract with society, that [the academic health centers] one legitimate responsibility has always been better care for the American public. However, we fail to adjust our patient care orientation because the specialists are ever more narrowly focused and are not excited by prevention, primary care, and the problems of the aged.”
He goes on to say that “we need a new system. We need explicit responsibilities, new accountability, new incentives, both positive and negative.
In such a system, medical schools would be forced to reexamine how they teach, what they teach, where they teach, and primary care would assume its proper ascendant role. We would examine appropriateness of care and, by extension, outcomes of care. We should not need the almost overwhelmingly and increasing burdensome utilization review mechanisms.
We would begin to coalesce around a simplified payment system. We would break down the domination of specialist societies, and we would deal with our new realities by stepping up our old responsibilities. And we would create a series of nationwide demonstrations that would take into account geographic, demographic, epidemiological variation and local values across the nation.”
I won’t emphasize the importance of that last statement more because I honestly don’t think the federal government is going to come up with solutions which are likely to be as effective as those developed at the local level.
I now work for a large alliance of not-for-profit hospitals and I was very pleased to see the recent cover article in Hospitals magazine with my old pal Dr. David Smith, who used to work in HRSA, prominently pictured on the cover. David has left the Public Health Service and is now with Parkland Memorial Hospital. He’s in charge of setting up a network of primary care clinics to deal with the very serious medical indigency problems they have.
What I find fascinating is that the reason the hospital is doing this is not only out of altruism, but they have come to realize that it’s in their best interest. They can’t bear the unnecessary ER visits, the woman showing up with no prenatal care and no insurance, the AIDS patient with no primary care. For their economic survival, they’re investing in primary care. I would like to think that this and other examples are going to get the attention they finally deserve.
And the last note of optimism, I’ll just say that in spite of my and David Schmidt’s previously expressed pessimism about imminent national health reform, who knows? To use a chemical analogy, something that might catalyze as a major reaction in the next few years.
When Danny Ortega and Danny Quayle are “doing lunch” in Nicaragua (and this really happened) to talk about the transition of power, when there’s a McDonald’s in Moscow, and when Fitzhugh Mullen is in Russia right now on a meeting to talk about a western-style reform of their health care system, I’m telling you we’re living in strange and wonderful times, and all bets are off.
So hang on to your seats! Maybe we’ll have more in the way of progress towards a more rational and fair health care system sooner than we expected.