First National Conference on Primary Health Care Access (3rd Plenary Panel, Part 1, Sundwall)

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, Washington, DC

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.

Paul Starr’s “Social Transformation of Medicine”

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.

Daniel Callahan’s What Kind of Life?

“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.

Thank you.

This presentation was preceded by:  First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 4, Q & A)

This presentation was followed by: First National Conference on Primary Health Care Access (3rd Plenary Panel, Part 2, Midtling)


First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 4, Q & A)

The archiving and publishing of the  proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.


Dr Werdegar: On behalf of our panel I would say that we are open to questions, comments.

Charles E. Gesssert, MD; Vice-Chair, Department of Family Medicine, Medical College of Wisconsin

Dr Gessert: I would like to ask the panelists for their predictions for reform of the health industry.

Dr Werdegar: I think in some ways overall expenditures for health care will be capped and that will force certain reforms.  The best example of that perhaps is the Kaiser system.

The major economic battle is between Kaiser and the community hospital.  Sometimes the community hospitals run scared of the public sector system because it takes patients that have reimbursement.  But more importantly, they’re running scared of Kaiser as the enrollments of the Kaiser plans keep swelling.

Kaiser keeps opening new hospitals so the practitioners and the community hospitals are wondering where the end is in sight.  Kaiser itself isn’t happy about the competition.

David Werdegar, MD, MPH; Director, Department of Public Health; City and County of San Francisco

But they are eminently successful in most of the group plans because they operate, as you know, out of a capped base, and they are doing a number of things that are right.

They are emphasizing primary care, although not as much as they should.  I can think of many ways in which they could improve it, but nevertheless it is a primary care driven system with sparing use of the hospital, only using acute care services when needed.

And they are getting more sophisticated over time about prevention and health promotion programs, surveillance and other things.  So that’s what I think is going to force the reform:  putting a cap on overall expenditures.

Earlier Sandral Hullett was addressing the benefits package of the Alabama program.  Whatever the insurance programs are, they are going to set some limits on the benefits package, and that’s going to force some rearrangement in priorities with emphasis on primary care and prevention.  That’s at least my partial answer.

Dr Arradondo: I agree with the portion of Dave Werdegar’s answer dealing with capping.  Excessive health care expenditure is a disease.  You diagnose a disease and you treat it.  One of the ways you treat the disease of spending too much money is to stop making so much money available.  So capping, I think, will occur and the more efficient providers will begin to become more valuable.

John Arradondo, MD; Director, Department of Health and Human Services, Houston, Texas

Unfortunately, the people who are doing the capping, I think, will not recognize the value of the most efficient providers.  So they will hurt them in the process and it will have various side effects.  There is no doubt in my mind that a rational change that could be put into effect literally tomorrow and be flourishing by mid-decade just within the current system would be to pay family physicians twice the usual and customary charges.

Just do that!  And then flip some coins if you want to be rational about the rest and pick the appropriate number of sub-specialties and tertiary are specialties and pay them the appropriate amount less – 80%, 70%, whatever – the usual and customary charges.  Now this is clearly a child playground game.  But sometimes that’s the level of rationale that the financing system game plays.  So I’m using that deliberately.  But I think it would have the desired outcome.

Pick literally, randomly if you wish, alphabetically, by income level, by fee size, or by whatever means, the appropriate number of sub-specialties so as not to have the burden borne on just one specialty or two. There are almost a couple dozen more out there.  And just shave a bit to balance the change in the primary care reimbursement in the current system.  And patient services would change.

I would predict a more rapid decrease in hospital admissions which has already been occurring because of the capping.  I would predict a somewhat more rapid decrease in the length of stay and an increase in ambulatory procedures, whether in centers or in offices.  I think that kind of reform is less apt to happen, but the business of capping, I think, will occur.

I am optimistic that the Relative Value System at least has been looked at, and although proposed changes have not taken in their entirety, there is some motion being made in that way.  I think that the American Academy of Family Physicians is becoming a bit more confident in our medical care system.  And I am hopeful that that voice will grow, because more needs to be said.

The RVS debate somewhere along the line is going to lead to public differences among physicians and that’s not something that physicians have traditionally wanted to show.  But at some point I think that’s going to occur.  And when it occurs, I think some significant differences will be made.  In the meantime, the capping phenomenon of governments and cost restraints on health expenditures favored by the large corporations who deal with employee health care benefits, will have a lot to say about it.

William H. Burnett, MA; California Office of Statewide Health Planning and Development, Sacramento

Mr Burnett: I think one of the problems that faces us in the 90’s so far and has certainly during the 70’s and 80’s is that with the fragmentation of public policy formulation and development.  We now have subcommittees that deal with little pieces of public policy.

One of the outcomes that I would regard as progressive could be the re-emergence of the intellectual ideas of primary care that each of these different diverse deliverers of primary care descent from – to integrate back into the kind of “big picture”  thinking and support for public policy formulation that assumes that primary care is something that everybody would be better off with and all the deliverers would be better off with.

With the problems of access, the need is so great that nobody is going to be harmed by the public health departments getting a bigger piece of the action or the practicing family physicians doing more, or for that matter any physicians or nurses or nurse practitioners or community and migrant health centers or whatever, that can be a “point of light” in their community, doing what they need to do to get people’s behavior changed so that their life will be better off and their health status will be better off.

David N. Sundwall MD, MPH, Medical Director, American Health Care Systems Institute, Washington, DC

Dr Sundwall: Let me just follow-up for a second.  One in 20 adults in this country [The text of Dr Sundwall’s question is currently unavailable.]

Dr Arradondo: You were going well there until you said “and states.”

Dr Sundwall: [The text of Dr Sundwall’s response is currently unavailable.]

Dr Arradondo: That’s because the states rip off an excessive administrative overhead.  They do better than the universities and the research realm.  And you know some of those impose 80% to 110% indirect costs.   It doesn’t take that much to hand my little piece of the pie.  It really doesn’t.

I have been an advocate for sometime, long before I was in public service, that the problems need to be solved as close to where they are as possible.  I call that being a good citizen.  There are some other words for it, sometimes depending upon whether you do it by yourself or with some other people.  For a number of reasons the problems can be most readily recognized.

They are most readily felt at the place where the problems are occurring.  I think that the federal government, in some instances when its leadership has so deemed, has done well at helping to equalize things and have everybody on on a similar playing field.  That’s one of the unique roles of the federal government outside of defense and some other duties meant to protect the common wealth.

But in terms of managing ongoing programs with the uniqueness of the various regions and the states, the federal government sometimes gets to be like an elephant doing needlepoint.  I happen now to be in a state that constitutionally has the authority to divide into five states whenever it wants to.

I always knew Texas was big and I know that they have some big authority to go with it.  I have been in some smaller states too where state government has been unreasonably cumbersome, so apparently it’s not just the size of state government, but apparently it’s the processes within state government that can make it cumbersome.

There are a lot of federal dollars that should come directly to the cities which is, in fact, how they come from the cities.  I didn’t send my tax to Austin State Finances.  I sent it to Austin IRS – directly to the federal government.  And I am perfectly happy to get it back that way for all of my epidemics, HIV, STD, TB, infant mortality, air pollution, violence – all the epidemics I have in my town.

I would like to get  the federal piece back just the way we sent it because I think that I can manage it more rapidly, at least as efficiently, as my counterpart in Austin.  In fact, we have demonstrated that in several areas.  I think that philosophically there are a number of programs that need to be reexamined. A number of them are in health, a number of them in human services, as well as some education programs.

When I speak about one of the epidemics – infant mortality – most of the time I talk about education and jobs, because they are the two most important factors in determining infant mortality.  (Even  on Tuesday, when I have got out the annual Health of Houston report – all the data was there in those two large volumes.)

The most important factors that contribute to infant mortality are the education of the parents and income of the parents.  I spend an appropriate amount talking about that third factor, called prenatal care, that we in the medical health field work on.  But I certainly spend the most important part of that time talking about the two most important factors.

Dr Werdegar: Well, I think Dave Sundwall’s question was partly rhetorical.  I agree with much of what John Arradondo said, at least in this case certainly so far as the city health departments are concerned.  And, of course, there are just so many big cities and then you have the rest of the U.S. To be concerned about.

Even in private conversations with Dave Sundwall, I was saying that it was our local planning that enabled us to cope in San Francisco with the HIV epidemic and with some of the other urban health concerns.  It was the local planning that was creative, that was responsive to the community.  We needed outside dollars and we needed federal dollars.

The AIDS program within his agency, the Health Resources Service Administration (HRSA), would give us a block grant.  I feel as keenly as does John about this, that we were well-served by the block grant coming to San Francisco directly and not by way of Sacramento, which to this day doesn’t understand the HIV epidemic fully.

To have the State administer the funds for San Francisco would have just been a disaster.  And so having local planning, local initiative, local creativity, using federal dollars that come directly to cities is an effective approach.  There are, as I said, only so many big cities like Houston and San Francisco, and the states have their role.

There are large rural areas and smaller cities and the states should be helping them do their creative work.  So as for local planning, I would break a strong lance for that.  And I think that’s what you were saying – the federal government finding ways of matching or supporting that creative local planning effort.

Dr Werdegar: The most important ingredient in federal dollars is through the Medicare and Medicaid systems and how the Medicaid system is shaped in the state capital.  The local communities don’t have very much say in that.  You’re ultimately going to have to shape those major insurance schemes.

Nevertheless, as again illustrated by, in my case, the response to the HIV epidemic, local dollars for planning, surveillance, epidemiology, special programs, pulling people together, use of community-based organizations, setting new models is highly creative and needs federal dollars directly.  That doesn’t, in a way, preclude a state role.  It’s not a dilemma.  There is till the overall responsibility of seeing that there is a fair and equitable and universal health insurance problem in which federal dollars are going to play a big role.

Dr Arradondo: It was something Dave was saying.  In terms of reform, I have to go back to what I said earlier to Charles Gessert on capping and putting on economic pressure and then more efficient units being the result.  The ones that aren’t damaged by all of the interplay going on with cost containment efforts might be able to rise to the fore and be recognized and show how some new mechanisms would be more effective and perhaps more efficient.  That’s my prediction.

So what I am about to say now is more or less what could happen and, therefore, would be more my hope.  And there’s a difference.  I usually don’t bet my lunch on hope.  I’ll bet my lunch on my prediction.  What could be done – I advocate regularly that the federal government should pay for health promotion and disease prevention services for everybody up to age 25.

That takes care of all the kids.  Really I say from minus one to plus 25 for a good reason, because we know the condition of the mother before conception affects the child.  And we know all about prenatal care, and that the condition of the mother during pregnancy affects the child.

The upper limit of priority attention should be age 25 for a lot of reasons.  There are things that fall through the cracks all the way along the line – at school entry, during school, entry into college entry on the job.  That might be a better use of all the Medicaid dollars that the feds spend than the current use.  And I’m not knocking the poor.  I could comment further on that.

Or, of the five Medicare programs, say other than the program for 65 year olds, we could take a couple of those.  Once I am thinking about at the moment spends about $3 billion or $4 billion a year.  That would go a long way toward taking care of every person up to age 25 in preventive health services.  And that’s a lot of services.

Those are very clear possibilities where we have a lot of experience already.  It’s within the realm of the current medical care system, at least within the realm of things that primary care providers are trained to do.  It doesn’t require a lot of new training, but a little bit of attitude shift.  And certainly it can be done with the appropriate financial incentives.

That’s the kind of thing that I have been advocating on a regular basis.  If we’re talking about keeping what we have and adding, the thing I would add is care up to gave 25 because caring for the kids to the first six or eight years is very important, certainly during that minus one year.

And I’m talking about simple things like food, shelter, education, Head Start, HIPPY (Home Instruction Program for Pre-school Youth) where you get the mother to teach the kid and all of a sudden the mamma’s learning and your job wasn’t to teach the mom, it was to teach the kid.

And the mamma is teaching the kid, and learning how to teach the kid, and steadily teaching the kid, and before long the mo wants to go back to school and get a GED, wants to go back to school and face detractors and get a regular diploma and go on and get a job.  And I guess Bill Clinton, the Governor of Arkansas, is the best proponent of that.

There are a number of programs that have implications for health.  Health essentially is the final common denominator of all the social forces.  We are battling upstream when we try to take just the health matters which aren’t health at all but are a disease for the most part, needing treatment for the most part, and trying to change the end result of the social forces.  So I feel on safe ground when I just advocate spending a little to address the social forces.

I’m not going into building homes or anything like that, just a good tent and some reading and writing and a little arithmetic and some food.  And then all these good shots that we give and all the well baby care is within the realm of our existing entitlement programs.  Medicare will increase in the next ten years by the amount that I would ask for today if what I have just said were O.K.’d tomorrow.

Just the increasein Medicare, having nothing to do with the containment programs – if that were shifted to a prospective approach to kids up to a certain age and for that matter to their maims as long as they have a kid up to that age, we could make a quantum leap in the health status of our people.

Dr Werdegar: I know that question that you asked is going to be returned to – Dave Schmidt touched on it this morning.  It’s going to be the issue of fee-for-service care and the modeling of systems, how much there should remain fee-for-service.  So I know the topic will return.

Dr Lawrence: I would like to re-ask what I thought I heard Charles as earlier about reform of the health care system

Dr Werdegar: Well, I probably should be blamed for introducing the notion of the cap.  What I meant was actually a sort of system cap – where you say you have so many dollars and then you have to use them most efficiently.  And that, for all its faults, is what the Kaiser system tries to do.

The first thing they accomplished is to try and make as sparing use of the acute care hospital as they could.  So they have driven their care way from The acute hospital setting into the ambulatory setting.  By degrees they’re learning more about how to give care in the ambulatory setting, because it used to be  multi-specialty clinic in format with patients going to too many specialty clinics.

They are learning increasingly how to center it in a primary care base and offer prevention services.  In some of the Kaiser hospitals – they differ, they’re not all uniformly the same – the care is truly family oriented and increasingly they are introducing health education in other models.

So that’s what I had meant by the cap that says they’re offering insurance at such and such a rate with a certain variety of benefits and they accomplish it by achieving economies.  They were forced to achieve them, and they did this in a successful way, and people re-enroll.  I’m not saying that that’s a total answer, but I was pointing to it as one of the ways you can bring about some changes in a competitive market place.  We all know that they have other advantages.

Their selection base is more favorable than would be in John’s and my public health care systems in terms of health and socio-economic status.  Nonetheless, I don’t want to wind up here being a Kaiser spokesperson.

In San Francisco they take care of a disproportionate share of HIV patients.  But in San Francisco they had the adverse selection of many with HIV.  They had a broad enough base that they could accept HIV patients into their insurance system and then be appropriately responsive in the services they gave, which is largely the full spectrum of care.

Dr Arradondo: I probably didn’t communicate well if I left you with the notion that a cap would be the cure.  I literally was answering as straightforward as I could Charles’ question, “What is the prediction for reform?”  And, of course, I said very little except that what reform is apt to occur, likely will occur as a result of cost containment.  You know when the going gets touch, the tough get going.  And there are some efficient providers here who have the right idea.

I think that some positive changes may occur as the cost containment measures become more stringent.  Now hospitals that never knew how to spell family practice have discovered family physicians.  They get their emergency room personnel to be friendly to them.  For the family docs who don’t like to go to the emergency room, they take care of their patients, they smile, and they get their patients back to them.  For the ones who don’t like to admit patients to the hospital, they’ll assign somebody to that patient in the hospital.  They’ll make all matter of money off the patient while the patient is in the hospital, get them out and do very well.

All of that is because the hospitals have been constrained.  So they have discovered family physicians.  Many of the large community hospitals have eaten the lunch of the teaching hospitals because the teaching hospitals hadn’t figured it out, particularly the university teaching hospitals.  Many of them still haven’t figured it out.

And the large community-based  hospitals that have become secondary in some areas, tertiary care hospitals, have just figured it all out and they ave gone out and they happen to know all the family docs.  Cost containment did that to them.. They couldn’t’ spell family practice prior to the cos containment efforts.  So I think that what reform will occur will occur as a result of that, Now I would rather it occur some other way.

My advice to the person who was dealing with  115 unionized Ford workers in 1979 spending $3,000 a head minimum on them, was to adopt a prospective approach to providing services to those workers rather than what they were doing at the time, which was a fee-for-service.  I outlined the whole mechanism for them.

Interestingly, over the last 10 to 12 years, they have moved a little bit closer to that because of negotiating pressures.  They could have gotten more service for themselves, saved money for the system, and however that accrues to the stockholders and to them, benefited by moving to that kind of system 10 years ago.

Large employers will probably make some difficult and unpopular decisions, and move the system a little bit closer to what, say, Kaiser is now doing.  A lot of others could make such decisions like that.  But some governments around the world have made pretty clear decisions along that line.  And when you start spending $30 or $40 billion or something like that, you’re entitled to sit back and stop  and maybe make a clear decision every once in a while.  And a decision to put the dollars in a manner that have been demonstrated to be more efficient, while you provide the same services, if not more, is a decision that’s over due.

I agree with you that the hospitals and some of the other institutions have eaten up the pie.  I have a fairy tale I could tell along that line and one that actually was true at midnight.  But I won’t do that today.  It has to deal with time.

Dr Hullett: One of the issues is the concern of reform …. [Dr Hullett’s remarks are presently unavailable.]

Dr Midtling: With that I think we should break.  As a moderator, thought, I have the last word.  I would say that five years ago, three years ago, maybe even two years ago, if we asked anybody in this room about the changes that are occurring now in Easter Europe, we would all have said “Impossible, it would never happen.”

And I think that only through great crises can there be change.  I think the change that is occurring in Eastern Europe is because the system is in crisis.  Oil prices went down.  The Soviet Union can no longer support the satellite system and that whole system began to crumble.  And I think our health care delivery system is on the verge of that.

I believe how much change we get will depend upon how much crisis occurs.  But I think it’s going to take  a major crisis to get tremendous change in the system and we may be headed for that.  I liken it to the movie, “The Right Stuff.”  Remember, as the guy kept approaching the sound barrier, they wondered what will happen when he exceeds the sound barrier.  Will the plane explode or will it be smooth on the other side?  I think we are approaching the sound barrier.  I really do.  I think the system is definitely in crisis.

The Second Plenary Panel Question and Answer Session was preceded by: First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 3, Arradondo)

 The Second Plenary Panel Question and Answer Session was followed by:  First National Conference on Primary Health Care Access (3rd Plenary Panel, Part 1, Sundwall)

First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 3, Arradondo)

The archiving and publishing of the  proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.


John Arradondo, MD; Director, Department of Health and Human Services, Houston, Texas

John Arradondo, MD; Director of the Department of Health and Human Services, Houston, Texas: My comments on the emerging problems and the management of primary care access will be relatively limited in that a number of them have been covered to some extent, and that’s the way a panel should operate.

Some of the problems that we were asked to look at – problems that have been referred to earlier as “special problems,” “special populations,” a litany of the change in the National Service Corps’ mission as Don Weaver described it – captured some of those names, some of those titles.

Some of these special issues, in fact, do highlight the limitation on access to primary care – substance abuse, HIV, care for the elderly, and I might add care for the young.

Parenthetically, I suggest that had we in the ’60’s provided universal access – at least to the financing of medical care for those under 25 – our health status indices might look better today than they do now.

Instead, we provided universal access to the financing of medical care to those over 65 and then subsequently added to that venereal disease and other things.  It’s not just an economic or philosophical statement.  That’s a straightforward policy statement that I made before I went into medical education and I still feel that way.

The issue of ethics and the issue of resource allocation are the others that we were asked to touch upon.  All of these topics show weaknesses in our medical care system.  None of them have demonstrated any new weaknesses; they have merely demonstrated the insufficiency of our system.  HIV and its most commonly addressed complication, AIDS, have done that perhaps most clearly in the last 3 to 5 years.

Issues of allocation of resources, issues of immediate availability of service, issues of discrimination around confidential information – the kind of think that many of us take for granted and hear in the elevator about the clients of our colleagues and never think twice about it.  Many providers who treat HIV disease have been pointed out to be blatantly discriminatory and yet in the hospital, in the lounge, we talk routinely about specific cases.

In small neighborhoods whether in large cities or in rural areas, this  information is passed around and is used in various ways.  I somewhat looser neighborhoods, it gets out of the immediate circle and it gets to other people and it destroys lives and families.  That’s just one area in which people concerned about persons with HIV disease have had to take to the political front to try to force providers to do something that should have been done pursuant to one of the basis tenets of medical care.

The medial community attempted to address substance abuse 30 years ago and wasn’t successful at all, probably because people who abuse substances don’t have a lot of credibility, not in society in general, and certainly not very much in the medical care system that is supposed to have compassion, understanding and commitment to serve.

It’s interesting that those who have been working on the front in substance abuse have, in some instances, joined hands with those working to battle HIV epidemic and are sharing some of that old expertise and some of the old philosophies.  So I guess it’s no accident that someone referred to seeing some “old hands” around.

Primary care is not a new notion.  I’m really appreciative to Charles Gessert for quoting a 1927 article.  It looked fresh to me!  And I appreciate you putting 1927 at the end of the article since most of us scan before we read.  A lot of people will perceive that it’s fresh, up to date 1990 data, probably assume it is from the New England Journal of Medicine or their other favorite journal before they get to your attribution.

And there are other ways of bringing back the old, inf act intimately, intensively, new.  In the matter of substance abuse, for instance, there probably should be some better laws and regulations to govern some things.  Our No. 1 cause of mortality, I guess, from substance abuse is probably the complications of cigarette smoking.

We’ve known for almost a century now that that was deleterious to the health of human beings.  Since that time we’ve discovered that it’s deleterious to the health of our apes and our monkeys that we use to prove that it is, in fact, deleterious to us.  And laws can bring some things to people’s attention.  So there is a useful place there for laws.

Perhaps the second most frequent cause, I guess, of mortality certainly, and probably morbidity, is alcohol abuse, our only legal form of suicide.  Alcohol abuse certainly could be affected by laws, not some of the real limiting ones that we saw a half century or more ago but certainly laws that relate to peoples ability to impact the lives of others – people who use machinery that affect others; people who fly planes and drive cars and operate traffic signals occasionally when they aren’t on automatic; people who carry weapons to protect us or to deal with those who would invade our privacy or otherwise endanger us.

John Arradondo, MD, Houston, Texas Director of Health Services
John Arradondo, MD, Houston, Texas Director of Health Services

There are a lot of people whose mere presence affects the lives of others directly.  Laws, rules, and regulations along that line might help.  I suspect the biggest effect there could be just education in the matter of substance abuse.  It is amazing how far education goes!  And then the whole litany of techniques to try to change behavior.

These are areas that primary care practitioners learn a little bit about – some learn more, some learn less.  Institutions have tried to provide primary care and I don’t always equate those tow because one person being ill on a team may prohibit that team from providing primary care whereas a primary care practitioner who could do that can do it whenever that person is present.

Be that as it may, the institutions that attempt to provide primary care, and certainly the paragon of that is in small group family practice and the neighborhood health center, each in its own way could incorporate aspects of the other in an excellent fashion.

For the treatment of substance abuse, we could certainly use our human services activities, that some public departments of health and human services provide.  We should be working hand-in-hand with our mental health colleagues on the matter of substance abuse.  We’ve known for 30 years that medical providers and mental health providers do not communicate with each other, even when they share a patient population; yet we have very few funding mechanisms that support such communication, or rules or regulations that mandate it, or even encourage it.

For instance, we’ve begun to get the leaders in Houston to appreciate that many of the substance abuse treatment programs are, just simply put, a waste of money since the average treatment program is probably no better than a placebo when looked at two years sown the pike, providing a rate of success 8% to 15%, which is what a placebo does.

Yet, we’ve known for a long time that these very same substance abuse treatment programs, when coupled with powerful incentives, will have recidivism rate that’s less than 50%, perhaps less than 25%.  One that I am aware of that dealt with physicians who abused substances and were caught, did no better than placebo until incentives were applied – incentives that said you do this once and the next year we lift your license for two years;  you do this once in the next two years, we lift your license for five years, and other similarly clear incentives.

It was amazing!  These physicians no longer acted as if the treatment was no better than a placebo.  They began to act like the treatment program was was penicillin treatment of simple pneumococcal pneumonia, effective in over 90% of instances.  Truly amazing!

But this has been known for a while, yet the predominant treatment program, whether the advertised 14-day fix, 30 day fix, 6-week fix, plus or minus a modicum of follow-up, seldom adds an incentive, although it might be possible to get that incentive just by hooking up with the neighboring health entity where legal sanctions are involved.

So substance abuse and HIV have in some instances shown some of the weaknesses in our current system and I hope that we can address some of those and repair them.  Caring for the young and the dependent elderly have also exposed weaknesses.  Both should receive an extension of family care in its full definition – family care.

There are special obligations of the family when there is a dependent member among them.  There are special obligations of providers when there is a dependent child or dependent elderly member in family that that provider is serving.  That’s not to rail against family physicians who are trained in modern programs, but who shrink from dealing with the total family.

I would just advocate that those physicians join a larger practice so they can have time for their own families and, secondly, have time for the families of all their direct or indirect clients.  But it is to say that those who forget the principle of care to the whole family are doomed to repeat the mistakes of narrowly based specialties.  And we don’t have enough primary care specialists, much less family physicians.

Two short comments on ethics and how that’s an emerging problem.  We talk about health insurance programs and we have the best health insurance in 150 countries.  And that doesn’t do it!  It’s not the insurance, but the end result.  I merely use that analogy to say that when we talk about ethics and we talk about service to everybody, in a sense the real issue is equity in service.

If we are going to build a two-tier system, lets build one.  Let’s build the best two-tier system in 15 countries.  We could do that!  We could do that consciously. There are examples in various places of the world.  We could build even a three-tier system.  Surely there must be some people who are deserving of third-class care and certainly there are some that are deserving of first-class care in my town.

I’ve been there almost two years and still haven’t found a decent family doc.  And I refuse to commute 40 miles outside the city limits to find one.  I have a son and a wife who need ti even more than I do, according to their testimony.  And I’ve made that publicly known to the mayor of my town and to the presidents of both medical societies and some other people.

I refuse to go to a conglomeration of secondary care specialists.  And I insist on having medical care – not that it’s the most important think I need.  I need health care less urgently than some other things.  But I insist on having in my place a medical care in case I need it.  That’s just my town!  So the issue is equity in services.  The people that I serve should have access to the same services that I have access to.

And ultimately there should be equity in health status.  I don’t want to get into the analogy that we hear all the time when we listen to affirmative action and civil rights and all of that.  Equal opportunity is what everybody is willing to give nowadays.

Opportunity is great if there is equal ability to grasp that opportunity and move on it.  Then it’s a matter of the will.  It’s a matter of persistence, which is usually what success is related to.  But in the matter of health,  you could never achieve equity in status when the opportunity for the services is not there and when the service is there is inadequate.  So the matter of ethics is something that we ought to think about from time to time when we begin to look at national health services and national health programs.

The business of resource allocation is one that I’ve had a relatively fixed idea on.  That’s not to say that I have  a closed mind on it.  I just have a fixed idea.  I believe in primary care.  I think it has some wonderful attributes.  And that’s not an understatement form a family physician – that’s just a simple explanation of how I feel.  I think that the resource allocation in this country is upside down.

Research, from the government perspective, if you take out the entitlement programs, gets the biggest piece of the pie.  And that’s good, except that the research is seldom on primary care.  And if research is going to be that important, the biggest piece of research pie should be on primary care.

I was appreciative that some people form around the world took my constituent, the President [George H. W. Bush], to talk when he wanted us to do more research on the environment on Environment Day.  And I can talk about my constituent like that, Don.  He still comes to my town to vote.

We know enough that if we just applied a quarter or even 10% of the research dollars to primary care, we could do a lot of good.  We would move up on that list of 28 countries that Dave Schmidt showed in his presentation in a lot of ways if we just applied what we knew.  I have said that primary care should get greater than 50% of the pie.

So if the feds, or the state, or the city is giving out some money for health care, primary care should get at least 50% of it.  And I think that prevention services should get at least 20%.  I realize that the most expansive minds that publish nationally usually come in a single digit figures for prevention.  And I think that’s the disease care orientation.  IF you couple health promotion and take that additional step beyond prevention, and then I think you could see where 20% of the health care dollar might be needed because of the expense of promoting health.

When we look at special problems, we ought to put our resources where the problems are.  If you really want to deal with the top cripplers and killers, then we ought to do so in the fee-reimbursement system and put additional reimbursement into dealing with the things that treat it early.  And then we should do the same with violence, some of the communicable diseases and the other top killers and cripplers, even within the fee-for-service system.

I think that that system has a lot of looseness in it and I would prefer a prospective, pre-paid payment approach.  There the provider should agree for a certain amount per year to provide all the services that that provider can provide as long as they are appropriate to an individual, a family, or community with some modest contingencies to cover poor judgment and occasional lapses.  (But not just poor judgment every day or lapses every day.)  I think that might change the way we deal with health care.

In departments like mine we publish data sets, we publish plans, and we encourage people to take the data and to make their plans to allocate their resources.  I think that public departments like mine (mine is a department of health and human services) should link with academia, should link with hospitals, should link with medical societies, and should link with community-based organizations.

Such linkages should be designed to disseminate data, to provide services, and to try to improve the health of our respective community.  If for no other reason than providing primary care, our department sees perhaps the largest portion of the underserved of any of the entities that we talk about.

So if we want to learn about the underserved in Houston, come by my office and I can show you where they live, (except for the 10,000 to 30,000 homeless), and can share a lot of demographic data about them as well as all of our cities in our area.  So I think that health departments should be involved.

Some of us do provide primary care in the way David Werdegar was talking about.  Some of us don’t.  Some of us aspire to it.  Most of our departments address non-medical things that turn out to be important to health.  Environment is one that’s now becoming popular again.

It’s not just the air and the water but the environment in the home, safety issues, educating people about throwing out old medicine bottles that have poisons in them, dealing with vermin, and with stray animals – a lot of things that ultimately affect health on one end or the other.  Most of us do surveillance and project vital statistics and provide information, from which others in the system might make plans and allocate resources.

That’s often something that has not been used to best advantage.  And then some do provide other services, such as my department that provides a lot of human services and also acts as the area agency on aging.

So when looking at the emerging problems of primary care and access to primary care, I think that since primary care has been called upon to do some special things that the rest of the system hasn’t, to reach the undeserved, for instance, the rest of the system hasn’t; and reach each person and family in a more comprehensive manner and more consistent manner; and even in a less discriminatory, more interactive, and more humane manner.  (That is always one of the interesting requirements for primary care because I thought all the docs were supposed to be humane.)

Then, I think , primary care certainly should hook up with the different parts of the system that have been kind of left out there like the Maytag man and really don’t get any business.  Public health is one of those.  More and more primary care providers are seeing public health not just as giving shots and taking care of TB and VD, but as providing good data sets, as following up certain patients who have communicable diseases that the primary care provider may or may not have the resources to follow up.  That kind of linkage would be of great use.


Dr Arradondo’s presentation was preceded by:  First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 2, Burnett)

Dr Arradondo’s presentation was followed by: First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 4, Q & A)

First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 2, Burnett)

The archiving and publishing of the  proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.


William H. Burnett, MA; California Office of Statewide Health Planning and Development

William H. Burnett, Office of Statewide Planning and Development, State of California [Mr Burnett is a Senior Fellow of the Coastal Research Group.]: Others at this conference have presented, or will be presenting, evidence that problems of access continue to stalk us as a nation.  My comments will speak to three main areas of concern – fragmentation of public policy relating to primary health care, the looming deficits of physicians in key segments of medical practice, and the precariousness of funding for primary care training programs.

The Evolution of “Primary Care” as a Concept

As we contemplate what policy options should be taken to promote health care access in the next ten years, much of the conceptual framework we will be using will date from the mid-1960’s through early 1970’s.  The term “primary care” dates from that period – a vestige of an attempt to impose the language and principles of systems analysis in describing health care delivery in the United States.  The term “tertiary care” also survives from this scheme, more often than not in pejorative contexts, to describe the circumstances that favor sub-specialization, bench research, and procedures in the academic medical centers.

“Primary health care” and “primary health care access” are related, although not identical concepts.  But we rarely use the term “primary care” without an explicit or implicit reference to some problem of access.  For 20 years it has been a principal mental construct to aid in the devising and promoting of policies to counter the inexorable process fragmenting medicine into sub-specialties.  It becomes the matrix for corollary constructs – the ideas of comprehensiveness of care and of continuity of care.

Consider several important movements of the past two and a half decades – each advance to promote access to comprehensive, continuous primary health care (each represented by one or more members of this conference’s faculty).

  1. The idea of expanding urban health departments beyond such traditional roles as immunization, vector control, and food inspection to incorporate comprehensive health services to the medically underserved.
  1. The idea of establishing consumer-controlled neighborhood health centers, now usually referred to as community and migrant health centers and promoting them with federal support.
  1. The idea that the U.S. Public Health Service, whose patient clientele had once been limited to the Merchant Marine and to Native American tribal communities, should assume direct patient care responsibilities in certain defined geographical areas of need, most notably through the establishment of a National Health Service Corps
  1. The idea of creating a new medical specialty which came to be called family medicine whose elements – including the structure and content of training and requirements for board certification and periodic re-certification – were based on normative theories of what primary care training should be like.

The latter initiative, family medicine training, addresses the improvement of access for the underserved to quality primary care at two points in the career continuum of physicians.  One is during the physician’s residency training when model primary care delivery would be provided in the residency programs themselves through the  family health centers, family practice inpatient services, home care, and community-based satellite practices.

The second interaction is through the practices of the residency program graduates – those who have mastered family medicine in training and who are duly certified by the new primary care-oriented specialty board.  Those graduates, it is envisioned, would collectively practice the enunciated principles of “ideal” primary care.

Delivering Primary Care

I have listed five kinds of primary care deliverers, each kind invented to promote access to care.  Again, the five are:  comprehensive health services by local health departments; community and migrant health centers; the National Health Service Corps; the family medicine residency programs; and family medicine residency program graduates.

Each of these kinds of primary care deliverers have had their detractors over the years.  Many of the detractors, during the 1980’s, came to be convinced that a surplus of physicians would emerge in the United States, making these initiatives of the 1960’s superfluous since sub-specialists would be forced to enter primary care and a diffusion of physicians into ever smaller and less desirable communities would occur.

During the 1980’s, many who had been concerned with issues of primary care access found themselves on the defensive.  Concepts of primary care, comprehensiveness, and continuity may have influenced each of these initiatives strongly, but the evolution of each occurred in relative isolation.

Systemic Linkages between Primary Care Entities

In two ares formal linkages do exist.  One obvious kind of linkage is that between the family medicine residency programs and their graduates – an outcome, I think, of accreditation requirements, that encouraged community physicians to be participants in the residency programs as attending faculty, often an effective antidote to “town and gown” controversies.

A second kind of linkage is one promoted by federal policy, that the National Health Service Corps would become a principal means for assuring physician manpower for community and migrant health centers.

In a longer presentation I would suggest examples of other kinds of linkages, usually local, such as we have heard of in San Francisco.  Between other deliverers in my list of five, but thinking in national terms with the exceptions noted, each has evolved independently.  Characteristically, in an era when public policy formulation is so often a fragmented and episodic activity, each of the kinds of primary care deliverers noted has fought its own political battles.

I propose that we think of the five kinds of primary care deliverers as a partially connected pentagonal figure, showing the previously describe family medicine residency program-residency graduate linkage and the NHSC/community-migrant health center linkage.

Deficient Numbers of Primary Care Physicians

The concept of looming deficits in the supply of physicians in the United States may be an unfamiliar one in some policy circles.  We were accustomed in the early 1980’s to consider our principal physician manpower dilemma to be an impending surplus of physicians over levels of adequacy enunciated by the Graduate Medical Education National Advisory Council.

I will not speak to whether or not the analytical approaches to forecasting physician need and supply advanced by the Graduate Medical Education National Advisory Council [GMENAC] were fundamentally sound. But too often predictable manpower deficits, which should have been of paramount concern to policymakers, were either unrecognized or assumed to be temporary problems which would abate as the “surplus” physicians searched for things to do.

I am not one who argues that we may be heading for an absolute shortage of physicians, although the 1960’s provided us with lessons that the predicted surpluses of teachers and engineers, which led to cutbacks in numbers being admitted to teaching and engineering schools, led in time to the recognition of national shortages of teachers and engineers.  I suppose a devil’s advocate might note that our population is increasing, our health status by some important measures is declining, and our number of medical school places has ceased to grow and may be in long-term decline.

But two areas of physician supply seem to be grossly inadequate as we enter the 1990’s – physicians entering rural practice and physicians who deliver babies.  Arguments for family medicine residency funding often have included the idea of the “bimodal curve” of family physician ages – that is, that most board-certified family physicians are either those trained since the early 1970’s who, therefore, are about 45 or younger, or are those trained just after World War II who typically are over 65 and nearing retirement.

We currently are living through the long-predicted period of retirement of the older hump in the bimodal curve.  This is profoundly affecting health care patterns in rural America.  Many rural towns are simultaneously seeking physicians to replace their long-time community doc and are finding the competition very rough.  Typically, their small rural hospitals’ fates are themselves tied to their community’s ability to attract physicians.

Competition for Family Physicians

But the family physician, whose training is precisely designed to be the most useful physician for rural areas, apparently has become the physician of choice for a whole range of settings, vastly increasing the number of would-be recruiters of family physicians.  Dr. Marc Babitz of NHSC’s regional office in Denver recently presented the information that every family practice medicine graduate has an average of 20 serious job offers to choose from.

Given the advantage that a region, rural or urban, that is host to a community-oriented family medicine residency program has in recruiting graduates of that training program, the difficulties that a rural area which has not had a long-term strategy for recruiting and retaining physicians can be formidable.

Even more ominous if the impending crisis in obstetrical manpower.  Only two physician specialties – OB/GYN and family medicine – are trained to deliver babies, and physicians in both specialties have enough within their normal scope of practice that they can build busy practices without offering obstetrics.  In fact, with the high cost of liability insurance for physicians who perform obstetrical services, and the practice time that delivering babies consumes, it is plausible that physicians in either specialty might actually increase practice income by dropping obstetrics.

It is apparently the preference of some medical communities that family physicians not deliver babies at all regardless of skill and training.  This, and the specter of litigious patient clienteles, has caused larger numbers of family physicians and, for that matter, some graduates of OB/GYN residencies, to resolve from the first day of practice not to deliver babies.

But a poorly understood fact is that a large percentage of physicians who deliver babies give up their obstetrical practice in the period between ages 42 and 45 which suggest that, if we as a society wish to assure ourselves an adequate supply of physicians to deliver babies, that we be constantly producing a number of physicians who will give us a dozen or so years that we can count on them for this important purpose.

It is quite likely that we have not come close to producing that right amount of physicians trained and willing to deliver babies in the period since 1985 and that, if this is true, it will become increasingly obvious as the decade unfolds.

Funding of Primary Care Physician Training Programs

My final concern relates to the funding of primary care physician training programs.  I believe one of the intellectual achievements in the public policy debates of the 1960’s was the application of educational theory to the societal need of producing a particular kind of physician who could perform specific skills in just the right way.  I think both the family physician and the family medicine residency program are living embodiments of a truly great pragmatic vision – the primary care physician trained in an ideal curriculum to perform an ideal role in the United States health care system.

There are now hundreds of family medicine residency programs, many of which are genuinely interesting and inspiring endeavors, and tens of thousands of their residency program graduates properly certified by their guardian specialty board.  Great numbers are performing exactly as the inventors of the specialty dreamed they would and, as noted above, they have become a “hot item,” intensely recruited by private practices, community clinics, HMO’s and their residency programs themselves.

Lauding the programs cannot mask a fundamental weakness in the concept of “idealized” primary care training.  Partly by necessity, partly by tradition, they were planned as something that teaching hospitals would sponsor.  An accreditation body was organized to assure that the programs would contain all of the essentials of an “idealized” primary care program.  However, the administration of the sponsoring hospital might well have a quite different view of what the hospital’s mission is and what it regards as proper priorities.

Consider for a moment what a hospital administrator might regard as the hospital’s mission – the emphasis on the very sick and concentration of resources on life-threatening illnesses, accidents, and acute care.

Consider the special features of a family medicine residency program that might be imposed upon that teaching hospital.  These may very well contain requirements that are not considered to be part of the hospital’s mission – comprehensive care; three years of specified rotations that may be on services that that hospital doesn’t routinely choose to provide; continuity of care, getting the hospital into ambulatory care in a very specific, precisely defined way; behavioral sciences, requiring an interdisciplinary faculty that may not be the kind of staff that that hospital would normally have; community linkages which require resident time out of the hospital.

So you could imagine that with the figure in the center suggest that the hospital management might represent a narrower view of what a family medicine residency program should do within that hospital, and that the residency review community might  well have a much more expansive view of what society needs that family practice residency program to do.

Well, no hospital can pay for all of the components that a properly operating family medicine residency program must have to maintain accreditation by means of revenues generated by the residency program.  Thus, every family practice residency program operating in the United States is subsidized from one or more sources and ultimately it is the sponsoring institution, the hospital, that must absorb the shortfall between what the residency program generates in revenues and what external subsidies it can garner.  This can lead to a tension between hospital administration and the accrediting society as to how much of the hospital’s resources the residency program should command.

The accessibility of residency program subsidies mitigates this potential tension.  External subsidies usually exist as federal, state, and local grants for family medicine training.  (The Medicare “pass-through” subsidy for teaching hospitals, though technically an external subsidy, operates more often than not as a resource whose use is discretionary with the hospital administrator and, therefore, is often perceived as an internal subsidy).

Beyond these governmental subsidies and residency program income, any shortfall in the costs of the family medicine training has to be paid for out of surpluses in other parts of the hospital.  But the internal subsidies (the other services of the hospital) may very well be squeezed by price inflation in the health care sector, reimbursement by DRG’s, reductions (actual and proposed) in the Medicare pass-through, and the increases in uncompensated care that affect the hospital’s bottom line.

Meanwhile the government and non-profit sectors are affected as well – the concern of the federal deficit, the effect of the taxpayers’ revolt on state and local government revenues and expenditures, the philosophies of economic limits that affect resource allocations – all have affected particular hospitals, and particular states that squeeze their subsidies and, therefore, squeeze the hospitals.  What you get is the simultaneous effect of the cost squeeze on hospital’s financial resources and the cost squeeze on the government, affecting both the internal and external subsidies of the hospitals.

The 1990’s will be a decade when strategic thinking as how to address problems of training the right kinds of providers will be required.  As perplexing as it is likely to seem at times, we are indebted to the intellectual work of 25 years which has led to workable models of health care delivery that promote access.  It is our task to preserve and improve upon this legacy.

Mr Burnett’s presentation was preceded by: First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 1, Werdegar)

Mr Burnett’s presentation was followed by: First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 3, Arradondo)

First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 1, Werdegar)

The archiving and publishing of the  proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.


David Werdegar, MD, MPH; Director, Department of Public Health; City and County of San Francisco

David Werdeger, Director of Public Health, City and County of San Francisco (California): Thank you, John [Midtling], for the nice introduction.  For all in this little group, I want to say once again how lucky Wisconsin is to have recruited two such able individuals, originally Wisconsinites who spent a lot of their careers in California – John Midtling and Charles Gessert – who together have a sense of the relationship of family physician training to statewide and national health care needs.  It’s a powerful one-two combination, I think, you’ve got in the department here at the Medical College of Wisconsin.

I’ve been fortunate enough to be able to see health care from at least two vantage points now – one, the university which, as you know, gives you a very distorted, unreal view, but you at least know what goes into the training of physicians; and being very directly on the firing line in a health department in the midst of several epidemics.

There are parts of the system I don’t know as well – in particular, of all things, the private practice community and community hospitals although I’ve certainly had many interactions over these last five years as health director – and I’ll be interested as the discussion goes on over several days to learn more about them.  In the equation there is also the Kaiser system, which in California is a very big health care system, and in San Francisco, I would say, probably provides 20% to 25% of the care.

I would say the public health department probably provides a third of all the care in San Francisco.  Between Kaiser and the public health care systems that I’ll be describing, you might account for half of all health care in San Francisco.

The university hospital has its small share and most of that is as a reference hospital. It has some primary care programs, but it’s mainly a major reference center.  The Veterans Administration is a flawed health care system, but the VA is there.  Then the remainder consists of the community hospitals and practitioners.  As we talk about access, I have in mind several of those large systems.

All the talk these days is of access to care, cost of care, quality of care.  They’re all interrelated.  I do believe, Dave Schmidt gave a sort of pessimistic view as to how quickly structural changes will occur, but I do think structural changes in the health care system are actually occurring right now before our noses and will occur at an accelerating rate.

I think we’re always going to have to evaluate the structural changes that are occurring basically in terms of whether they have as a building block a strong primary care, family oriented care foundation or whether they are designed to enhance that.  In fact, in my view, the acid test of various health care systems is the strength of its primary care base, which I believe has to be a family-oriented primary care base.

Dave Schmidt was careful throughout his talk, which to me was a very thought provoking, to give examples which give room for optimism, case studies of approaches that were successful, from which we can hopefully distill a constructive process.

My principal interest really is in the architecture of health care services.  I want to talk about organizing, financing, assessing quality, assessing technology, assessing outcomes.  I’ve grown interested in how it’s put together.  I think that’s probably an interest shared by many here.

One should look at its foundation stones to see if the base is strong.  If the base is strong, I think everything else falls into place thereafter, including issues of cost and quality.   But the base has to be something that is a family-oriented primary care program.  We would probably not find easy to define, yet we would be in general agreement about the descriptives for that family-oriented primary care.

Now, I have been asked to examine some of the pressure that was, you might say, beyond the system.  The title was how we could manage some of the emerging new problems in primary care.  And while I’ll cite some of them and use some of them perhaps as examples, in nominating such problems as AIDS and HIV, substance abuse, the growing numbers of elderly, growing numbers of immigrants, growing numbers of distressed families, and growing numbers of homeless – one may readily discern that these are really all individuals with patient care problems who should fit into a primary care system.

And we have to see that the design of the primary care system is one which does allow their entry and is also geared to serve them.  I’ll probably be drawn to substance abuse and AIDS for some contrasting looks – at least from the San Francisco perspective – at what it might teach about access to primary care and to primary care itself.

When I started in the health department I was quite naive.  I had never managed a health care system of that size.  I didn’t realize going into it that the public health department of San Francisco is a vertically integrated health care system with a $500 million budget.  But It has all of the elements that one would wish in a health care system, more than are in the Kaiser system per se.

We have an acute care hospital, which is well known, the San Francisco General Hospital, the county hospital with a university affiliation.  We have an 1100 Bed long-term care facility, mostly for care of the elderly, but it is a designated facility for long-term care and we are opening an AIDS unit there.

There is a network of district health centers, places where people could get immunizations and prenatal care of sorts, and “well-baby care.”  They were traditional, I would say early 20th century health centers.

They were not true primary care centers but grew out of a model that existed when private practitioners wouldn’t let health departments participate in tradition health care except on a limited basis – venereal disease, well-baby care, etc.  It’s only now in the 1980’s and now 1990 that I’ve been converting, without any outcry from the private sector, all of the district health centers into a network of primary care health centers.

The department is also responsible for mental health services, substance abuse services, care in the jail, care in what is euphemistically called the youth guidance center, and then traditional environmental health and toxic responsibilities, which I’ll put to one side.  The health department reflects the longstanding dichotomy between general health care services and mental health and substance abuse services.

Mental health services are somehow off to one side.  They are not integrated with primary care services in any way.  And even more separate are substance abuse services, whether we provide them directly or we provide them on a contract with a community-based organization.

They exist unto themselves with all the stigmas that are attached to substance abuse.  They’re in isolation of primary care and I’ll comment on that in a moment.  But this system is vertically integrated are all the elements one would need for comprehensive service.

In addition to the health care system the heath department has the responsibilities for health education in the community, for surveillance of health status in the community, and an ability to feed back quickly information about the community health status, into health planning for the community.

I came from the university under some special circumstances in late ’84 or early ’85 as the AIDS epidemic was gaining momentum.  Actually the first day I was on the job I was asked to come to a meeting, where there was a great hubbub over a longstanding problem about children’s services.

Children, particularly children from heavily distressed families, would be bounced around all of the different agencies in the community – the Department of Social Services, the foster care system, juvenile probation, the youth guidance system.

There would be doctors involved; there would be a separate child abuse clinic, San Francisco had a wealth of services for the children, but it was all totally fragmented and I was asked to come to this conference because they were looking for some way of integrating it all.

There was much talk about case managers, that’s a buzz word that has come to annoy me over the last several years because case managers come in all varieties.  Anyway I sat down at this conference and they said, what do you think we can do about this, Dr. Werdegar?

I said the problems have been solved.  They all looked at me, really astonished.  I said “Yes.  You know they train an individual who can really coordinate all of these things – to talk to the family, to talk to the social worker, to work with the nurse practitioner.”  Oh, they said, really in astonishment.  Yes it’s called a family physician.

This was news down at the health department and amongst all of the agencies.  I can’t say that it’s happened fully, but in our network of primary care services, which are mainly staffed by family physicians and mainly staffed by family physicians who we ourselves have trained at San Francisco General Hospital right there where the needs are seen.

Those primary care centers now offer the best opportunity for providing the coordination that had been long sought for years and lots of task forces and lots of meetings.  Other services will be co-located in the primary care centers.  For example, representatives from the Department of Social Services will actually do casework services there in the primary health centers and bring their caseload.

The primary centers, which are strategically located throughout the city, will interact with a cluster of schools so that there can be care provided back and forth between on site services and the school and services available at the neighborhood health center.  The centers are very neighborhood oriented.

San Francisco is a city of neighborhoods and often, each with a different racial-ethnic composition and outlook.  The health centers are designed to serve their neighborhood and have contributions from the neighborhood in what is to be their mission.

In the discussions about access going on, everybody talks about the numbers who are uninsured or under-insured and I won’t dwell on that.  Obviously, it’s a basic goal to have everybody covered by health insurance.  I don’t think that should be of much argument.  And then there will be the discussions of adequate reimbursements for primary care which I guess Dave Sundwall and others are going to talk about.

They are currently under the Medicaid system even in a rich state like California, inadequate.  Bill Burnett and others have cited some of the experiments going on to see if the Medicaid reimbursement system can be made more attractive in its support of primary care.  This group is sophisticated in the knowledge of the many other barriers to access:  transportation, logistics, whether there is child care, language barriers.

I’m very interested in the issues of cultural barriers and won’t dwell on it.  Even when funding is possible, barriers exist for failure of an immigrant to feel welcomed, or failure to know how the system works.  And this has nothing to do with money, nor even the availability of service at a nearby health center, but crossing those cultural barriers that bring the individual and family into primary care.

But I would say that the most significant barrier to access is that there is no primary care system to access.  I’m speaking now nationally.  The problem is really there is no “there” there as Gertrude Stein said about our sister city of Oakland.  And that’s the biggest problem from my vantage point.

And it, of course, reflects, which is of interest to many here, the inadequate numbers of physicians, nurse practitioners, and other health professionals who have been educated to the concept of primary care and decided to devote their careers to primary care.  So, that’s the biggest barrier to the access.

I”m sure you agree with me that when I talk bout such a primary care base, it would provide health education as, for example, HIV education.  It provides preventive care.  It provides surveillance of a family in continuity so that you can intervene early.  It really does have a family overview.

Almost all of our severe problems are ones in which all the family is involved.  We don’t have to say that to this group but you shouldn’t have an individual going through a substance abuse clinic without seeing the entire family, having an overview, knowing all that’s going on with the family.

Primary care providers ideally would be skilled in using community-based organizations and social services and would have some of them on site.  All of those are attributes that you are all familiar with and teach about. The primary care providers would not be limited to the ambulatory care setting or to the acute hospital – and they sometimes have to use it – but would indeed be use home care, and day care services.

Day care for HIV has become as important in San Francisco as day care for the frail elderly.  It has great economy, and is a wonderful way to give care.  We serve the SIDS community best with primary care providers who are champions of day care and who will themselves participate, primary care providers who will work in a variety of long-term care settings and residential settings.

And finally, – again I”m preaching to the converted – primary care providers would be comfortable with the concept of outreach services and would use their primary care base as a way of reaching out into the community.

Now of the new pressures, the area where I think we give the most abysmal service, if any at all, is in the area of substance abuse, which, according to one national report, involves anywhere from 15 to 25 million or, using the high figure, 1 in 10 Americans.

I think IV drug users are estimated around 1.5 million.  But overall drug use is somewhere around 25 million.  The care is really terrible.  For one, it lacks, unfortunately, any strong scientific base, even a research base.  There’s too little understood about addictions.  So, unlike other areas of health care, it rests on on an insecure foundation of basic science knowledge.

The conceptual models are lacking, except some good residential care models.  For the most part it is a separate system.  It’s a parallel system of health care to which you send the individual, so the individual won’t be at your hospital, your office, your neighborhood health center, or wherever.  It can’t thrive in a vacuum; but that’s the way substance abuse is set up in almost all cities.

The worst examples may be the methadone clinics where people go in and get a swallow – out they go – $8.00 reimbursement for that “service.”  There is no health education; there’s no primary care; there’s no seeing the family.

If you haven’t been in a methadone clinic, you have to have a look at them.  Even so there are too few treatment slots.  A lot of people can’t get in who would like to get in and there is not enough money to pay for the services.

I would say substance abuse characterizes the problems that we deal with, in particular the relatively small involvement of primary care and the primary care team, the failure to address the problem as one that require family orientation, and the failure to look at the problem in terms of all the other concurrent health care problems.

Certainly the IV users usually have a raft of other concurrent health problems that need attention.  There is little social or vocational rehabilitation.  Obviously what I am breaking a lance for is that substance abuse services be linked to primary care and family care.  To a modest extent, we are just beginning to do that by saying that our primary care centers should provide substance abuse counseling on-site.

If there is a young woman whom we are following for prenatal care and she has a substance abuse problem, there is drug counseling on-site.  There are mental health services on-site.  More and more we are trying to really provide primary care, rather than continue a system of episodic clinic are for general health problems, mental health over here, substance abuse over there.  OS it’s possible within the public health care system.

For a long time the public health care system – no matter how reimbursements change – will remain one of the important systems of care to those with poor access, and probably in many ways one of the most responsive.

Now, I am going to use AIDS in San Francisco as my example of how the community can come together in terms of health care services and some worthwhile things can ensue.  Recall the presidential commission, the one that almost crashed but then was rescued by Admiral Watkins, and its report that almost got swept under the run.  It was actually an eloquent document when it finally appeared.

It said that HIV provided a lens with which to view the health care system and a lens with which to view society as a whole.  That’s what it has been for us in San Francisco.  You know 30,000 people out of our city of 750,000 are HIV positive.  That’s close to 5%.  There is no higher rate anywhere else in the world, except perhaps in Central Africa.  And if you exclude the very young and the very old and look mainly at the adult male population, you can get up to 1 in 10 of the population.

So it’s an enormous problem and the whole community is aware of it and the whole community has suffered greatly.  SO everyone of whatever background has lost individuals to AIDS and the community has come together in many different respects.  Not that it’s perfect!

For care of AIDS, when the story is written and people look at those who were heroes and heroines and contributed significantly, it will turn out that family physicians played a rather critical role.

For one, it was family physicians in the gay community who were among the earliest of the care providers.  They greatly influenced the model of care that evolved at San Francisco General Hospital.  They related the care to the community.

It incorporated the sensitivity, the needs of psycho-social support, that came form those family physicians.  It was then and remains a quintessentially primary health care problem, one in which the family physician is the most skilled provider working with a health care team that is oriented to the needs of working with the support group.

It requires a care-giver who is comfortable at providing care in the office setting, the home setting, the day care setting, the hospital setting, and in providing continuity across all of those.

Looking at our systems of care – the university largely passed it to San Francisco General.  They were going to contribute by letting their faculty at San Francisco General Hospital handle the problem.

For the first several years of the epidemic, San Francisco General Hospital was the only place to go for care.  The university, in terms of care and research on the care, has had a relatively small role, although obviously a very great role in basic science developments and the interaction via the county hospital in particular has allowed that phenomenon to occur.

One of the underlying themes, I think, of this conference is that interaction between the medical school or university health science center and the health care system in promoting developments we want to see.  Kaiser Hospital, which I told you provides 20% to 25% of the care in San Francisco, was remarkably responsive.  And to this day, I credit them as one of the important factors in the community’s being able to cope with the epidemic.

Whenever they recruited physicians – primary care physicians – they let everyone coming to Kaiser San Francisco know that one of their responsibilities would be care of individuals with HIV and that that was to be part of what they did daily.

They provided continuing education for their staff.  They kept adding to staff as needed.  They even mo0ved some of their services away from the city, that didn’t have to be in San Francisco, so that they could keep up with their commitments to HIV care in the city.

The medical society was very progressive.  The physicians organized a county consortium of physicians interested in HIV care.  I remember when there were 10 or 15 physicians at first, now there are 100.  They, of course, provided one another a good deal of moral support and exchange of information.

They found that one of the ways of stimulating their interest, staying abreast, avoiding burnout, and feeling part of the cause, was involvement in research.  Some of what I would say are the most important clinical drug trials going on in San Francisco are ones in which primary care physicians in the community are working together in various clinical protocols.

It took about four years to convince the NIH that this was the way to do clinical trials, that actually you got a more representative sample of the community if you had practicing physicians in a consortium doing the clinical trials.  They said, “Oh no, no.  It would never work.  We tried it once in cancer and it didn’t’ work there.”  They finally were embarrassed that they were passing up superb opportunities for the clinical trials.

The community was together.  The health department served to bring everybody together for planning purposes and preventive efforts.  We would survey knowledge, attitudes, behaviors, and beliefs about HIV in the white gay community, in the Black community, in the several Asian communities that we have – Chinese, Southeast Asian, Philippine – and in the Hispanic community.

Those are marvelously rich and revealing surveys.  We could tell from year to year how well we were doing educationally within those communities and then share that data with providers.  We have public sector and private sector volunteer organizations, and, as we call them, CBO’s (community based organizations) reaching out to the community with education prevention programs attuned to cultural needs.

Another ingredient was the involvement of the affected community itself – persons with AIDS.  We would not think of having a planning meeting about AIDS in San Francisco or a conference on AIDS without involvement of persons with AIDS.  That has, of course,  influenced how we do the care and has made it responsive to the problems.  It has brought the patient population together with the provider population for purposes of influencing legislation and government in a way that has been quite powerful – certainly quite powerful locally.

But I would say that much of the most effective lobbying nationally has come out of this coalition approach developed in San Francisco.  Dave Sundwall will remember from his HRSA days that San Francisco leaned on government to give money to HRSA, so that it could be distributed for community-based programs – and leaning on the CDC so that we could do surveillance in our community – and leaning on the NIH so we could get funds for research – and leaning on the FDA so we could get parallel tracks on hasten drug trials that were community-based.

That became a quite powerful coalition and would be for me reason for optimism.  IF we can take some lessons from that and apply them more generally, in the decade ahead, we may see some nice surprises.


Dr Werdegar’s presentation was preceded by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 4, Rodos)

Dr Werdegar’s presentation was followed by: First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 2, Burnett)


First National Conference on Primary Health Care Access (1st Plenary Panel, Part 4, Rodos)

This archiving and publishing of the  proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) is made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.


J. Jerry Rodos, D.O. Midwestern University, Western Springs, Illinois [Dr Rodos is a Senior Fellow of the Coastal Research Group]: Let me make some global comments.  I think that we’re seeing a rash of meetings, of conferences about the issue of access to primary care and producing family physicians.  I think that’s good!  As many of you know, I am a family physician by roots and a psychiatrist by evolution.  Clearly, we are all so frustrated by group meetings.  We need to talk about the things we don’t control, that frustrate us, and we did a little of that this morning.  I think we need to understand that we don’t have a problem that is isolated from the rest of the society in which we work.

The two speakers earlier this morning alluded to that and passed over it quickly and I want to emphasize it again.  The status of our society, and its health is simply one issue in that society, is not going to be resolved, improved, changed, altered, without consideration of what is going on around us.  What we have seen, which I think is very interesting, is a whole group of very local projects in which you and I and colleagues have control and can produce responses that serve the needs of our community.

But Sandral Hullett pointed out a very important issue and that is the issue of standards, controls, and bureaucracy.  Those are projects, when they’re locally managed and that meet the standards and that meet the needs of that community.  If we have a national set of standards, as many of us have experienced over and over again, because of our pluralistic society, we get into difficulties trying to mandate those in other parts of the country, no matter how good they are in basis.

For example, it is wise to deal with the issue of the use of psychotropics as restraining agents in nursing homes.  But it is not reasonable to have a psychiatrist review records every six months when there are large parts of our country, as there are large parts of rural Illinois that do not have a psychiatrist available to perform that function.

And while we’re thinking of solutions and while we communicate with each other, we need, I think, to consistently keep in mind some basic principles.  We need to look at errors we have made in the past because one of the things about our society and about our government is that it is not prone to admit its mistakes.  It is not prone to say, “We developed Medicare and Medicaid to solve some very specific problems.

We believed that the disincentive for access at the tome was financial.  If we could remove the financial disincentive, people would get the care.”  Well, what have we discovered in the evolution of 25 years of this program  – we’re going to focus a little more on that tonight – we have, in fact, taken what was tier care, said we’re going to eliminate it, and 25 years later have tier care that is more intense than we had when we set out to solve the problem.  So there are some national issues.  We’re going to have a chance to look at these issues.  And then we have some local opportunities.

Here I think is where we can shine.  Here I think is where you, all of  us who have influence (and we in education do have influence) can weave into the fabric of our programs a reestablishment of what physicians’ roles are – what it is, in fact, to serve society.  Because remember we didn’t have to do this.  We stopped 25 years ago.  There was no underserved.  Remember, we eliminated it.  There was no difficulty in access to care because we said we had taken care of it.

I’m old enough now and I have been involved in the issue of drug abuse, probably since 1957.  I’m a veteran of more wars against drug abuse than I would like to count and I don’t think we’ve won a damned one.  But we keep declaring war!  We need to look at those issues and translate them from our ability to manage the national scene, which we can’t give up on, and continue to sharpen and focus our approaches to what we can do in the roles in which we play on a local level.

As part of that, I guess I want to share with you a fairy tale.  I want you to have a fairy tale before lunch.  But even before I start the fairy tale, let me point out that I think it is good that we have this meeting.  And I want to compliment Dr. Midtling and Mr. Burnett for bringing us together, because I hope that there will be, in theses mall kinds of meetings, ongoing focus and sharpening of approaches that we can take both locally and nationally.

Once upon a time, because remember fairy tales have to start with “once upon a time,” in a section of this country which comprised six states, there was a group of physicians who came together because they were concerned about the fact that their average age was 66; that they were having difficulty getting students whom they had gotten interested in practicing in their region into medical schools; that for large parts of this region they were providing the only medical care in most of the rural areas and some of the urban areas; and that it seemed to them that no matter how hard they tried, the graduates of existing schools didn’t diffuse into their region.  Those that did were ill-equipped to practice.

So they decided to develop a medical school in their region (remember this is a fairy tale!) with no public money and with only two of the 12 members of this board having any academic medical experience.  They set about to meet monthly – I am, because this is a fairy tale, going to skip all the organizational issues that went along with it, to skip all the fund raising, all the efforts in site selection, all the activities that went about to gain professional support to prepare for accreditation, the necessary state charters, or public relations and legislative support, all of which are fascinating stories, each a fairy tale by itself.  But I am standing between you and lunch.

And this inexperienced group of folks established some principles.  Very easy to do when you have no biases based on knowledge and experience and that was the description of this group.  So they wanted to produce family physicians and that was the description of this group.  So they wanted to produce family physicians that would serve their area.  That was their mission.  They were going to do this by creating a curriculum that would focus on that goal.

The faculty would consist primarily of practicing family physicians in that region; the admissions committee would be composed of a majority of practicing family physicians; and applicants to the school would be encouraged from the region.  Because their focus and mission was family practice, they wanted applicants focused on family medicine, even recognizing that applicants will tell you whatever it is you wish to hear.  That much experience they all had!  And early on, they indicated, as part of their principles, that the basic science faculty that they would hire would have to spend at least 50 hours with a family physician on the college opened and that that requirement would be continued for all new basic science faculty.

Now, because they had no experience and could meet monthly and you had to do something with this monthly meeting, they established a curriculum committee which consisted of four family physicians – one family physician would become a pathologist; one retired internist, who was an early gastoenterologist, practiced in the City of New York but had the experience of being an internal medicine department chairman at a college; and one family physician who was also part psychiatrist.

I often think that they keep psychiatrists in medical school administrations primarily to deal with the faculty.  They made some decisions – again based on all of the inexperience that they could muster:  that they would use a systems approach, that family physicians with a basic science faculty would be the coordinators of these systems, and that a majority of the clinical faculty teaching in these systems would be family physicians in the area.  They did this, by the way in the selection of the systems approach as a mechanical issue of how to get people from their offices to be able to teach on the institution’s campus and get back to their offices in some reasonable plan because, (if some of you are beginning to smell a pre-Flexnerian model) they did not see whole-time physicians as an advantage.  But the, again, this is a fairy tale!

They wanted early exposure of the student in their school to the health care delivery system.  And so emergency rooms, rescue squads, public health clinics, visiting nurse programs, well-baby clinics, venereal disease clinics, other health agencies, practitioners’ offices (practitioners in the broad sense from podiatrists to dentists to a variety of physicians) attendants at the hospital, utilization review committees, quality assurance, time with the administrator, even participation in prison health care was part of the program in community medicine that began in the first quarter of the freshman year four hours of each week.

These programs all had learning objectives for each site and a small group debriefing which occurred monthly.  The student was expected to conduct himself or herself in a professional manner in terms of dress, in attendance, and demeanor.  The students were to study who was served, why they were served, and was to study carefully doctor-patient relationships in these environments.

An associate dean for basic science was brought on.  He was asked to be innovative and develop no-traditional roles as he hired faculty, which he did extremely well.  And so we really need to look at the end of this fairy tale and see what happened.  The things I described to you occurred between 1972 and 1978.  Making it that recent is hard to make it a “once upon a time” fairy tale.

And this institution, this make believe institution, that I have described opened in October, 1978.  Because it’s a fairy tale, I can leave out all the problems that occurred between ’72 and ’78 or, in fact, between ’72 and ’90.  But that’s the advantage of fairy tales.  But this fairy tale did some interesting things.  They did a survey to find out what happened to their graduates?  I was hoping to update it beyond January, 1987, but, unfortunately, they do not have additional data.

They graduated 289 people.  If you take out the 66 who are still in internships in our fairy tale school, there are 223 that are left.  IF any of you are concerned, by the way, this is not Chicago.  Now, of the people practicing in their region of those who graduated, 32% are practicing in their region; 13% in the state in which the medical school finally decided to live.  Of those graduated, 66% are family physicians.  And if one adds primary care to that as we traditionally define primary care, 87% of the graduates are in primary care.

Now, I have shared this fairy tale with you because it means that you can create institutions that do what it is you set out to do.  Because one of our focuses is, in fact, the production of family physicians, and I am not going to be lulled into using that primary care piece, not as a slight to anyone else but because, in fact, what we need is family physicians.

Dr.  Midtling’s studies, if nothing else, should alarm most of us that within the next five years, ten years at most, we are going to have a serious problem, a crisis problem – although I hate to use that term because we use it for everything – in family physician supply in this country.  But you can, in an institution, create a program doing that which you know that will work.

And so, what’s the moral of our fairy tale?  The moral of the fairy tale is that if you do what you say you are going to do and do what we know will work, it does.  But then, again, this is a fairy tale!

Schmidt: Can we take some time to have some interaction between the panel and the audience?  Questions.

David Kindig, MD: [The wording of Dr Kindig’s question is currently unavailable.]

Schmidt: My message, the bottom line, is that since we will not have a national health insurance program, whatever we do will have to be done on the local level and there are a half a dozen samples that we can choose from, a menu that we can choose from, that will fit into our local needs.

Rodos: Can I respond to both the issues that you raised?  I think that the statement that needs to be made, without the chemical terms, is that there are parts of this country that will never have access to care because of the nature of that particular community – whether it is isolated, whether it is low population, whether it is inner city – and have special risks at issue.  And that although you can reduce access problems, and I think Corps is probably going to go through several more changes if it becomes the focus of addressing that mission, that eventually we will decide how we’re going to care for and provide service to that group.

Now, by the way, without, I hope, some continued concern on all of our parts that health care is simply one issue.  Prevention in inner city Chicago and in Eutaw, Alabama, and rural Illinois are very different issues.  And prevention on the north side of Chicago is very different from all of those.  Secondly, I think there is a message about local initiatives and local care.  I happen to be becoming more and more convinced that we get into more and more difficulty by trying to find national solutions in a very pluralistic society.  And we continue to ignore the principle  of economics that I will mention again tonight.

The utilization of curative services rises to the level of the availability of those services.  That’s not a new principle and it certainly isn’t Rodos’ principle.  It has been around a long time.

If you visit Russia – and many of you have – where they don’t have access problems and manpower is not one of their problems, utilization is one of their problems.  And how do they reduce utilization where it’s a problem? They post all the appointments on a blackboard outside in the waiting room.  It has some impact.  Some people shifted to use the emergency help service which, as you know, in the cities is excellent.  And they finally had to redefine how the were going to give that service.

So unless we keep in mind some things as we design programs, we are constantly going to be in the position of having to make changes, which is what we’re doing now.  We are ratcheting down physicians’ payments.  We’ve already ratcheted down hospital payments.  Without recognizing that the basic issues were created by the program to begin with, we’ve now maybe created problems that ten years from now we’ll be spending even more money to try to balance and correct them.

Dr Rodos’ presentation was preceded by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 3, Hullett)

Dr Rodos’presentation was followed byFirst National Conference on Primary Health Care Access (2nd Plenary Panel, Part 1, Werdegar)


First National Conference on Primary Health Care Access (1st Plenary Panel, Part 3, Hullett)

The archiving and publishing of the  proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.


Sandral Hullett, MD, MPH, Medical Director, West Alabama Health Services, Inc.

Sandral Hullett, MD, MPH; West Alabama Health Services, Selma [Dr Hullett is a Fellow of the Coastal Research Group.]   I work as a Health Services Director in a rural community in Alabama.  The community is called Eutaw, Alabama.

We have a unique problem in dealing with a situation where the service area is about 80% black, is rural, and extremely poor.  And we have many problems that impact on access to care.

The lack of facilities for care and lack of providers are both significant problems.  We have to deal with a low socio-economic population living in an are with poor transportation components.  It’s a real tall task to provide access to care in an area like this.

I am one of those people who Don Weaver was just talking about.  I was a National Health Service Corps provider.  I came there 11 years ago, at the same site where I am now, to fulfill a two-year Corps obligation.  I served the two years obligation and volunteered two years after that.  So I was in the Corps for a total of four years.  I have remained there.

Alabama’s “black belt” counties with high proportions of African-Americans; Eutaw is in Greene County near the Western border; map prepard by the University of Alabama

I have continued to be interested in the concerns of people who need care and in the delivery of rural health care.  This has made me become more interested in program planning and policies; and I have a public health degree in Public Health Policy.  I see patients about 50% of the time now because West Alabama Health Services has grown significantly as I will show a little later.

I came to a site that was a two physician site and a satellite was started in 1979, the same year I got there.  We now have a total of six sites, five satellites, 15 full-time physicians and over 150 employees dealing specifically with the health service component.  So we have grown.  And part of what we have tried to do is to look at new and different ways of delivery and accessing care for the people in our area.

Bill Burnett asked me briefly to talk about the use of a health maintenance organization for Medicaid patients which we created and operated as part of the Robert Wood Johnson Foundation program on prepaid managed care for a couple of years.

We were one of the 13 organizations who received a Community Partnership grant from the Robert Wood Johnson Foundation.  We were to develop a rural health HMO that was primarily supported by Medicaid.  And that was a tall, difficult task.

I want to share with you what our goals and objectives were, the patient population demographics that we had to work with, some of our strengths and weaknesses, our enrollment and utilization, and then some of the conclusions that we found in working with this particular program.

The first question is, why would poor people even look at an HMO?  This is a volunteer HMO which has a lot of problems that we might talk about later.  But the objective of this HMO is to provide adequate health care to a low income, rural, Medicaid clientele and to simultaneously reduce the rate of increase of Alabama health costs.

Alabama has one of the lowest Medicaid reimbursement rates of any state in the union, including Mississippi, and we’re always fighting and trying to to be one step above Mississippi.    But we didn’t beat them when it comes to Medicaid reimbursement and we are really pretty pitiful.  Health care is not one one of our main interests in Alabama.  I hate to say that I think our main interest is highways.

We have a serious problem.  When you look at the state, it is a predominantly rural state.  It was once an industrial state in some respects but now it’s not.  We have one of the lowest property taxes in the nation and we have a very large amount of land and everything is in shambles.  Health care is not one of our emphases.  And especially health care for the underserved is not one of our emphases.

Table I compares the demographics for West Alabama Health Services fee-for-service patients with those who are enrolled in the HMO.

As you can see, we have a predominantly (75%) female population, who’s average age is exceptionally high compared to the average which you will find in most HMO’s, which does present problems.

Most HMO’s have younger people who are supposed to have less health problems, and whom you’re supposed to make some money off of.  We have a larger median age group than most.

The demographics of West Alabama Health Services, comparing those enrolled in HMO to all WAHS clientele

We also see that about 83% of the HMO clientele are separated, divorced, single, or widowed, and that falls in that female group and the average educational level is 7.8 years of school.  As we go on to Table II, we are going to see how the area served by West Alabama Health Services compares with the state.  You can see the state has come serious problems also, if you look at the per capita income, at the number of people receiving public assistance, and the health statistics for the state.

Our service area contains a very large number who are receiving public assistance, and the health statistics for the state.  Our service area contains a very large number who are receiving some type of public assistance.  The poverty level there is very, very high.  We also have a large number of babies who are born to women that are not married and who also have a high teen pregnancy rate.  Alabama as a state has also one of the highest teen pregnancy rates in the nation.  The infant mortality rate is a little bit higher than that.

Our HMO is called the West Alabama Health Plan.  Again, it’s a volunteer program and it’s an open panel, independent practice type HMO.

The demographics of the West Alabama Health Services

The state Medicaid program provides for 30 services, and we had to come up with some things that would make people look at us; because we have in our own community a very large number of people who are on Medicaid and who do not want to give up any of those privileges.  Our “carrots” are services provided HMO members which are not covered by Alabama’s Medicaid program:

  • (a) preventive medical and dental care,
  • (b) unlimited physician visits,
  • (c) transportation for medical and dental services, and
  • (d) 24-hour health consultation by telephone.

These “carrots” may not look like a lot but to many of our people they’re quite a bit.  The patients were particularly attracted by the privilege of unlimited physician visits for the HMO members.  We have no limit on how many visits they complete.  And they liked having access to transportation, which is a significant problem in our area, and preventive dental services.

We feel that there are strengths are in the program.  Primarily, our patients have a high patient satisfaction and that means that they don’t move around a lot.  We do have a 60-day lock-in right now.  We would like to have a longer period of time, not so much that the patients are jumping in and out, but because of the fact that in the state each person’s eligibility for Medicaid is determined monthly.

The person, in 30 days period of time could be ineligible and go off the rolls; when you have to do all the paperwork, and then they com back, and so it’s a real problem.  We have good coordination of our expanded services, good patient-physician relationships, good preventive care programs with utilization improving.

One of the things that most HMO’s are supposed to do is have a good preventive program.  We had people who had 7th and 8th grade educations who had been accustomed to doing anything they wanted to do and they thought Medicaid would pay for it.  And then all of a sudden we got into offering health education, preventive services that people were not accustomed to, that they didn’t want, and that they didn’t accept initially.

We feel that prevention will cut down on the cost of health care, so that was a major focus of our program.  We have been in action now about four years, going on our fifth year, and we’re now finally beginning to make some headway in that respect with things like walking clubs and exercise groups.  The whole community is walking.  I find that very exciting.

We have a significant problem with hypertension, obesity, diabetes, infant mortality, and teenage pregnancy.  We have noted changes in all these particular areas, especially among the HMO group which we can verify, because it is a small group.

One of the weaknesses in the program is management information.  We worked on it, worked on it, and still are working on it.  The capitation rates are very low.  We are capitated by the State of Alabama and we’re at risk for everything, including hospitalization.  We have five counties involved and the capitation rate is different for each county because it’s based on the experience of the county.

The capitation rates go from $60 to $80 a person.  And remembering all the different things I said about the people, that’s really a relatively low rate considering all the things we have to deal with.  They want to give us 90% of that particular rate.  So we don’t get total cost.  The high number of members lost due to loss of eligibility, as I said before, and the high enrollment of older people, the need for more providers, and the distances that our patients have to travel for specialty services constitute real problems.

Table II looks at hospital stays and shows that for our patients, most of the hospital utilization occurs in the group under 65.  The length of stay is about four days which is really not that bad, even over four days.

A graphical comparison of utilization rates

Interestingly enough, the older population – you would think that the stay of the older people would be longer and then you would have a higher utilization of hospitalization of the older group – but we do not have that.

If we look at our total enrollment, we see that we have about 2000 people under 65 right now.  The enrollment fluctuates.  The highest number that we have ever had is about 5000 people.  This is a small group, but you have to look at the fact that we cover an area of 4000 square miles with an average of 20 persons per square mile.  It’s a very sparsely populated area.

We have to remember that a Medicaid population is not homogeneous.  We like to think it is.  And if you think it is and if you approach it with that respect, you’re going to have serious problems in delivering care.  Self-selection is a real problem when you have a volunteer program.

There has to be some way to encourage people to join the plan, so – we market.  You have to look at your marketing.  You have to be competitive with the private practice people.  If you don’t have different things to make it attractive, then we will continue to lag behind the traditional fee-for-service type situation.

And then, finally, if we have some any regulations that are applied to us by the Medicaid people that make it very difficult to deliver this type of program, it won’t succeed.  And if Medicaid does not make it any different, if they don’t help us make a program like this attractive, it won’t succeed.

I’ll state this here now that to allow the fee-for-service group that it has to operate under more stringent rules to control the cost of care is going to make it very difficult for a program like this to succeed.  The Medicaid agency as a whole for the state has to be told about he advantage of a program like this.

Now this is a model program.  It’s the only one in the state.  The state is about to expand it but it’s still not making the commitment needed to make it work over the long term.  Why has this one worked as well as it has?  Because the West Alabama Health Services is basically a community health center that has the philosophies already intact of serving the underserved as its cause.

Cause has always been a part of what we had to do because of our regular federal mandates.  So promoting the cause and delivering care to the underserved had made it easier for us to do this.  But if a group does not have these principles, then it would be very, very difficult to make a Medicaid HMO work.


Dr Hullett’s presentation was preceded by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 2, Weaver)

Dr Hullett’s presentation was followed by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 4, Rodos)

First National Conference on Primary Health Care Access (1st Plenary Panel, Part 2, Weaver)

 The archiving and publishing of the  proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.


Donald Weaver, MD; Director, National Health Service Corps

Donald L. Weaver, MD, Director, National Health Service CorpsThe National Health Service Corps (NHSC) was formed by the Emergency Health Personnel Act of 1970 (PL 91-623), to address the maldistribution of health personnel in the United States.  Through the placement of Health professionals in underserved areas, access to primary care services would be improved; removing geographic, financial, language, and cultural barriers.

The history of how this legislation was developed and signed into law is recorded in a fascinating book, The Dance of Legislation, by Eric Redman.  Supported by Representative Paul Rogers from Florida and Senator Warren Magnuson from the State of Washington, the NHSC was signed into law on December 31, 1970.

The mission of the National Health Service Corps is to provide health professionals to those communities and populations of greatest need which cannot otherwise recruit and retain health care providers.  To be eligible for NHSC personnel, an area or population must be federally designated as a Health Manpower Shortage Area (HMSA).

An HMSA is a rational service area with a physician to population ratio of 1:3500 (or 1:3000 if there are indicators of unusually high need, such as high levels of poverty or high infant mortality).  Within a given HMSA, a community-based system of care is then sought to be the setting for a NHSC practice.

In January 1972, the initial 17 health care professionals were placed by the NHSC, with the number of NHSC members providing care to the underserved in a given year peaking at over 3,000 in 1986.  Originally, an all volunteer service, the NHSC Act was amended in 1972 by PL 92-585 and in 1976 by PL 94-984 to include a scholarship component.  While the volunteer component of the NHSC continued, the scholarship program grew and became an integral part of the activities of the NHSC.

Since 1974, there have been over 13,000 individuals who have received scholarships from the NHSC.  Approximately 83 percent of the scholarship recipients fulfilled their obligation through service and approximately 13 percent elected to fulfill their obligation through repayment.  Although the law allows repayment as an option, the goal of the NHSC is to have as many individuals as possible fulfill their obligation through service to the underserved.

Over the last five years, the number of NHSC scholarship recipients available for service has markedly diminished.  The decrease was a direct result of the lack of appropriations for the program in the early 1980’s.  The appropriation reduction was in part the result of Graduate Medical Educational Advisory Council (GMENAC) and other studies indicating that there would soon be a surplus of physicians in the country, and that everyone would be within 25 miles of a primary care provider.

It was felt by many that “diffusion” (market forces) would result in physicians moving into the less desirable rural and urban inner city practices.  Given these predictions and concerns about the budget, the scholarship program underwent considerable reductions until there were no appropriations for scholarships in the early 1980’s.

Many felt that the scholarship program had the disadvantage of asking students to make a commitment to a primary care career too early in the educational process.  Some students would incur an obligation to serve the underserved as a primary care provider and then decide to pursue a career in a non-primary care specialty.

In addition, there was increasing recognition that despite the predictions of a physician surplus, the problem of individuals lacking access to primary health care services continued.  With the passage of Public Law 100-177 in 1987, modest funding was made available for a Federal Loan Repayment (FLR) and a State Loan Repayment (SLR) program.

The loan repayment programs have the advantage of selecting individuals for participation who are completing or have completed their training and, therefore, have already made a commitment to primary care.  Both the FLR program and the SLR program, in their infancy, have had some degree of success in getting providers to locate in underserved areas.

Since individuals in the FLR/SLR programs are volunteers until they match to a site, they have the option of saying no to serving in the hardest-to-fill underserved areas.  The scholarship program has had greater success in getting providers to serve in the hardest-to-fill- underserved areas.  The scholarship program has also helped to target disadvantaged individuals who could choose to pursue a primary care health professional career without the prospect of a tremendous loan debt upon completion of their education.

Given the complementary nature of the scholarship and loan repayment programs, funds were identified which allowed 41 scholarships to be awarded in the Fall of 1989.  To help identify the most appropriate applicants, an interview process was instituted.  Potential scholars were evaluated on the following:

  1. Did the individual understand that this was a scholarship, not a loan?  The NHSC expected service to the underserved as a return on the scholarship investment.
  1. The NHSC was looking for primary care physicians – family physicians, OB/GYNs, general internists, and general pediatricians.  What commitment did the applicant have to pursuing a career in one of these specialties?
  1. Would the Applicant be comfortable in providing primary care in rural areas?  This was not meant to imply that all assignments would e in rural America, However, 70 percent of the HMSAs are rural and most medical training programs: a) are located in urban or suburban areas (with individuals wanting to stay close to where they trained); and b) do a comparatively poor job of training physicians for rural practice.
  1. Was this an individual who would provide culturally sensitive health care?  The interviewers were asked to look at the individual’s life experiences which might be an indicator of his or her commitment to serve the underserved as a primary care provider.

Just as there are several ways in which individuals are recruited into the NHSC, there are several ways in which providers are employed as NHSC field assignees.  When the first individuals were placed by the NHSC in 1972, they were all federal employees.  As federal employees, these individuals are covered under the Federal Tort Claims Act for malpractice, a significant savings to those systems of care which employ these individuals.  This is of particular significance for individuals who are providing obstetrical care.

As the NHSC grew, the way sin which individuals could be employed to service the underserved expanded.  The three additional ways in which an individual can receive compensation for serving the underserved through the NHSC are:

  •  Private practice option: a traditional fee-for-service practice.
  •  Private practice salary:  a salary from an entity other than a federally funded community or migrant health center.
  •  Private practice assignment:  a salary from a community or migrant health center.

The variety of payment mechanisms has served the NHSC well, allowing the program to use its budget to the fullest extent possible.

As the program expanded, the diversity of sites for placement expanded.  Placements are made into financially viable systems of care, with the caveat that all individuals must be cared for without regard for their ability to pay.  Initially, all NHSC placements were in rural areas.  The NHSC now has practice opportunities in community-based systems of care in the neediest rural and urban areas.

Given the need for a critical mass of age-specific individuals to have a viable practice for OB/GYNs, pediatrics, and internists, the NHSC has recognized the unique ability of family physicians to care for the full range of individuals and has targeted these providers for rural America.  This policy has permitted the NHSC to get maximum utilization of its scarce resources to assure that as many underserved populations as possible are served.

The success of the NHSC over the past 20 years in meeting the needs of the underserved is the result of practitioners who have made a commitment to dedicate part or all of their professional careers to helping those most in need.  Some providers have remained in the community after serving with the NHSC while others have moved on to other practice opportunities.

Many serve the underserved in other community-based systems of care, pursue an academic career and influence health professionals in training to commit part or all of their careers to serving the underserved, or integrate serving the underserved into their private practice.

As recorded in The Dance of Legislation, many felt that physicians and other health professionals would go into underserved areas if they received help in getting a practice started.  It was hoped that once this start up assistance was completed, these individuals would flourish in their practice and remain in the area.  This would allow the NHSC to move into another community and set up other individuals in practice.

To be sure, there continues to be underserved areas where this scenario will work well, given a stable financial base in the community.  But, there is an increasing realization that some other communities will remain NHSC sites for financial, geographic, and a variety of other reasons as long as there is an NHSC.

Unfortunately, diffusion did not occur as anticipated and the need to improve access to primary care services to the underserved has increased.  The Council on Graduate Medical Education (COGME), created by Congress to make recommendations regarding current and future adequacies of physician supply, adopted as their first principle: “The primary concern of the Council must be the health of the American people.  There must be assured access for all to quality health care.”

In COGME’s July 1988 report, it was stated that there “is now or soon will be an aggregate oversupply of physicians  in the United States.”

COGME’s report also stated:

Conclusion B-1.  There is a geographic maldistribution of physicians with too few physicians in many rural and inner city areas.

Conclusion C-1.  Minorities are still underrepresented in the physician manpower pool in the United States

Conclusion D-2.  There is an under-supply of physicians in family medicine.

These conclusions reinforce the need to have programs which focus on meeting the needs of the underserved.  Using data available from the Office of Shortage designation, there are 1,955 primary care HMSAs that would need 4,224 physicians to meet the needs of the undeserved as of June, 1989.

Over the last 20 years, the mission of the NHSC has remained constant although there have been numerous strategies to meet the needs of the underserved.  From an all volunteer organization, the NHSC has included a large scholarship component and the relatively new federal and state loan repayment programs.

From an all federal employee organization to expanded employment options, the NHSC has adapted to serve as many people as possible with the resources available.  When over 1,600 scholars were available for placement in 1985, the major emphasis of the program was placement.

With the limited supply of available primary care providers, the major emphasis of the NHSC turned to retention and volunteer recruitment.  The NHSC’s success has been highlighted by its ability to adapt to the resources available.

The charge for this conference was to list any limitations to meet the needs of the future.  There are three potential limitations to the future of the NHSC:

The first limitation is funding.  The funding for last year’s scholarships and loan repayment enabled the program to award 41 scholarships, approximately 100 FLR contracts, and approximately 120 SLR contracts

The second limitation is the need for an increased awareness of the fact that the dual goals of trying to place providers in the hardest-to-fill areas and trying to retain individuals in these areas will never coincide 100 percent.  The NHSC can improve on its past record, but the factors, in many instances, are not inclusive.

The third limitation is the fact that the NHSC can only be as effective as the primary care providers that are available to provide service.  Given the studies indicating waning interest in primary care specialties as a career choice, the NHSC will have to recruit an increasingly larger share of an increasingly smaller pot.  That could be a real limitation to the program.

In the past 20 years, the NHSC has an outstanding record of helping to meet the needs of the underserved.  There is now considerable interest within the Department of Health and Human Services and the Congress about a revitalized NHSC.  According to Webster, “revitalize” means to “breathe new life or vigor.”  Building on a proud past, the revitalized NHSC will continue to be a partner with other public and private organizations that share the common goal of helping meet the needs of the underserved.

(points of view opinions expressed in this presentation 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.)

Dr Weaver’s presentation was preceded by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 1, Schmidt)

Dr Weaver’s presentation was followed by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 3, Hullett)

First National Conference on Primary Health Care Access (1st Plenary Panel, Part 1, Schmidt)

The archiving and publishing of the  proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.


David Schmidt, MD, University of Connecticut:  I commend those individuals responsible for putting together this conference and thank them for the invitation to participate.  I have spent most of my professional life, which now spans 28 years, working in urban teaching settings that include Boston, Buffalo, Cleveland, and now Hartford.  I believe that the quality of life and the health status of Americans who live in persistent poverty has never been worse than it is today.

David Schmidt, MD; University of Connecticut; photograph courtesy of the AAFP Center for Family Medicine History

Let me share with you and example that occurred the night before I left Hartford for this conference.  In the middle of the night a 50-year-old black female was rushed by ambulance into our emergency room because she was experiencing incapacitating panic attacks.

She has every reason to be falling apart.  Eight months ago her daughter was shot and killed by random gunfire during a gang war.  She is left with two grandchildren to support.  On Easter Sunday her last child, a son, died of AIDS.  Tragedies similar to this occur almost daily in the cities of our nation.

Background of the Access Problem

I have been asked to provide background material which will be a challenge because today’s audience is a group of well informed experts.  I plan to point out some of the major problems that exist in our current health care system and try to portray the urgent cry for change that is coming from all sectors our society.  I will then focus on one suggested plan for change that is exemplified in the current Waxman-Kennedy Bill.

I will share with you my reasons for predicting that in the foreseeable future, (the next five years) virtually nothing is going to be done on the federal government level to address these major health care problems.  This brings us to the central theme of this meeting:  The Challenge and past Responses to the Problems of Access to Primary Health Care.

What can we or other concerned individuals do on the local and regional level to address the problems of access to primary health care by rearranging some of the resources that already exist?  As a partial answer to this question I am going to describe  a couple of successful defenestration projects, mention some of the noble responses from the private sector, and then look at the potential of our family medicine training programs for addressing these issues.

 Impending Bankruptcy of Health Care System

As we all know, the health care system is on the verge of bankruptcy.  Health care costs are out of control.  Partially because of these rising costs, ready access to health care is decreasing.  With decreasing access to care, the health status of our nation is deteriorating.

We are now spending over $750 a year on health care.  Expressed in terms of Gross National Product, this represents 11.5 percent.  There are projections that by the turn of the century this figure may be as high as 14 – 17 percent.

A comparison of the cost for medical care in the United States and Canada is important.  Figures for both nations were very similar until the 1970’s.  This is when Canada introduced a national financing system for medical care.  From that point on, the two nations have diverged.  Canadian costs have been stabilized and 8 ½ percent, while the American costs continue to rise to the current peak of 11.5 percent.  I mention this comparison because we can be assured that health care planners, legislators, and business leaders are tracking these major discrepancies between two similar nations.

It is estimated that there are about 37 million people in the United States without health insurance.  It is important to look at the composition of this group.  Only 18 percent are non-working adults.  Forty-nine percent are employed adults and 33 percent are children.  Two-thirds of these individuals have salaries above the poverty level.  These Americans are at great risk without health insurance.  Should they experience a medical disaster, they could easily experience financial ruin as well.

Fourteen percent of the White population is uninsured.  Twenty-two percent of the Black population is uninsured.  Twenty-nine percent of the Hispanic population is uninsured.  Twenty-five percent of all American children are currently living below the poverty level and 50 percent of all Black children live in persistent poverty.

Deficiencies in Medicaid Program

The Medicaid program was introduced in the 60’s and designed to be a safety net to provide at least minimal health care benefits for those with no other source of financing for their medical care.  In recent years, the eligibility requirements have deteriorated to the point that there are some places in the South where anyone earning more than $75 a week is not eligible for Medicaid benefits.

The Robert Wood Johnson Foundation has recently demonstrated that all segments of society are having problems with access to health care in the United States.  Approximately one in five Americans had no regular source of health care, and a slightly smaller percentage experienced difficulty obtaining care when needed.  The average number of ambulatory visits of patients in fair to poor health was inversely related to the health insurance and economic status.

As the number of individuals in this country living below the poverty level has increased, the number of individuals receiving Medicaid has remained stable.  This health coverage designed to provide minimal insurance for the poor reaches only 65 percent of the households living below the official poverty level.

In 1980, the Surgeon General set a goal for 1990 of having 90 percent of our children fully immunized by age two.  Today, fewer two-year-olds are fully immunized than when that goal was set.  We are moving in the wrong direction.  As a nation we now rank nineteenth in the world in infant mortality.  (the infant mortality rate is the number of deaths per 1000 live births at the end of the first year of life.)

Blacks in this country rank 28th below Cuba, Costa Rica, and Portugal.  These embarrassing figures are exaggerated in selective cities.  Infant mortality rate for Blacks in Boston exceed 25 per 1000!  These rates are similar to those of Third World Countries.

The cry for change is coming form all sectors of our society.  Senator John D. Rockefeller, IV, Chairman of the Pepper Commission:  “There is growing recognition that the American health care system is in total crisis…we are plunging ahead in this country toward health care catastrophe.”  Arnold Rellman, Editor of the New England Journal of Medicine:  “The cost of our present market driven system may prove to be so high, and it’s inequities so onerous, that universal tax supported health insurance may become a far more attractive political option than many now suspect.”  Lee A. Iococa: “The country needs an orderly system, and if that means some kind of national health insurance, then I’m for it.”  Why is a business leader like Iococa rendering an opinion?

The private sector is paying the bill.  Every Chrysler that is sold today had %530 attached to ti’s basic price in order to pay for health care insurance for Chrysler employees.  This figure is four times the amount of dividends that are given to the company’s stockholders.  This figure is four times greater per employee than the competition, Mitsubishi, is paying for health benefits.  Over the past decade the cost of health insurance to Chrysler has increased by 700 percent.

What is happening on a national level to address these problems?  St September, the American Academy of Family Physicians endorsed mandated private health insurance and Medicaid reform.  This is currently embodied in the Kennedy-Waxman Bill.

The AMA has endorsed mandated private insurance and Medicaid reform.  The Pepper Commission suggested mandated health insurance and Medicaid reform.  Recommendations of the Pepper Commission were made by a narrow vote of ti’s members.  The Secretary of Health and Human Services points out that the divergence of views on the commission reflects what is going on in the country.

There is no consensus of how to achieve the kind of health care we specifically want and how to bear the cost.  There is no doubt that mandated health insurance and Medicaid reform represents a quick fix.  However, I predict that even this less than optimal solution to our problem will not be accepted because of its costs.  The price tag for mandated health insurance and Medicaid reform would be in excess of $3 billion for the private sector and $10 billion for the public sector per year.

It is important to compare the relative economic strengths of the United States in the 1960’s and in the 1980’s.  The social reforms that were instituted in the sixties occurred when the nation was enjoying incredible prosperity.  In the 1960’s, the United States had 60 percent of the world industrial production, a trade surplus and small debt.  We had a heavy industry and a unionized work force.

Today, our country has 30 percent of the world industrial production, over a $100 billion trade deficit and a national debt of $3 trillion.  That $3 trillion figure represents $12,000 for every man, woman, and child in the United States.  Heavy industry in this country has disappeared.  The new high tech jobs require a minimal level of education.  Only 22 percent of our work force is currently unionized.  The major strategy for cost reduction is to lower labor costs, which is being done on a large scale.

For every billion dollars of foreign investment, we lose about 25,000 jobs.  There is slowly creeping into our country a Third World population who are willing to work for minimal wages.  There has been a great deal of publicity recently centered around eight million new jobs which have been created in this country.  IN reality, 60 percent of these jobs are with earnings off $7,000 a year or less.  There are many indications that the nation’s economy will worsen and with the recession, access to health care for the persistently poor will become an even greater problem.

It is estimated that the cost to implement the Kennedy-Waxman Bill will be extremely high.  This quick fix, short term solution to the problem of access would concentrate on mandated employer provided health insurance and reform of the Medicaid system.  It is estimated that such a program will cost the private sector $33 billion a year, and the public sector about $9 billion or $10 billion per year.  In the current economic climate, I do not believe such a bill will pass Congress.

This, then, brings us to the generic question, “What can we as individuals do on a local or regional basis to address these health care problems?  What can we do with existing resources to better provide access to care for the persistently poor?”  We do not have to reinvent the wheel.  For the past 20 years, a number of experiments have been going on that have been very successful.  The following are a few selected examples of past successful responses to the problem of access for the poor.

Selected Pilot Projects


In the 1970’s, it was discovered that there was an increase in infant mortality in the poorer districts throughout California.  Less than half of the obstetricians were taking Medi-Cal patients.  Increasing the physician reimbursement had no effect on the number of physicians who would care for these patients.  Therefore, the California Department of Health Services targeted 13 counties and defined a comprehensive prenatal care package.

This included a very active outreach effort to bring women into the health care system.  There was a guarantee that this care would continue to until the birth of the child, regardless of eligibility requirements.  Over 7,000 women received care in these comprehensive programs.  When compared to women receiving conventional care, it was demonstrated that there is an increased cost of about five percent for the California OB Access Program.  But for every dollar that was invested, more than $2 were saved in the area of neonatal intensive care alone.  These calculations do not consider the human suffering associated with permanently damaged child.


Over 20 years ago the city of St. Paul (Minnesota) introduced a comprehensive health care program in the school system.  This began with education at the seventh grade.  The curriculum included family planning, prenatal classes for pregnant women, and a mother support group.  The medical services included routine medical examinations, personal counseling, family planning, treatment of sexually transmitted diseases, pregnancy testing and prenatal care on the school premises.

St. Paul even established a day care component which allowed the parents to complete high school.  A woman who completes high school is on welfare for an average of two years.  The woman who has a child and drops out of high school is on welfare for 18 years!  The day care component provided field experience with course credit for the high school’s child development classes.

The results of this program were phenomenally successful.  After four years of operation, virtually all the pregnant women received early prenatal care.  There was only one premature birth.  There were no other low birth weight infants.  There was no perinatal mortality. The postpartum drop-out rate fell from 45 percent before the initiation of the program, to only 10 percent.  There were virtually no repeat pregnancies and the baseline fertility rate dropped by half.


Madison county, North Carolina has 450 square miles of land, 17,000 individuals living in 5,000 households, a higher than average number of individuals over age 65, and a median household income that is below the poverty level.

The Hot Springs Health Center; Madison County, North Carolina

Over 20 years ago, the Town of Hot Springs lost its last physician and none could be found to replace him.  Local community leaders developed a non-profit community-owned health care program and hired nurse practitioners to provide care for the people.

Initially, the nurse practitioner was supervised by faculty from the University of North Carolina, Chapel Hill.  Eventually, physicians were hired by the health care program.

Over this period of time, virtually every remaining physician in the county has retired or died and Hot Springs Health Care Program now provides total care for the county.  They employ six primary care physicians, two family nurse practitioners, dentists, pharmacists, and 75 health professionals.  They are the fourth largest employer in the county.

They now have four medical centers.  There is a county-wide home health and hospice agency.  Staff from the Hot Springs Health Program staff the county health department.  Virtually every woman receives free prenatal care.  The deliveries occur at the Asheville Hospital in a neighboring county.  The entire county has enjoyed an incredibly low infant mortality rate: 5 per 1,000!

The six physicians provide 24-hour county call.  One of the centrally located facilities is open until 9:00 pm.  After that hour, if a true emergency occurs, an ambulance is sent to bring the patient to the medical facility.  By organizing health care for the entire county, it is now possible to recruit young physicians to work in this rural area.  The six physicians enjoy professional companionship and share night and weekend coverage.  The Hot Springs Health Care Program is financially solvent.  In fact, this program recently declined acceptance of federal funding.

Responses from the Private Sector

Across the country, office-based private physicians have been forced to reduce the number of Medicaid recipients they care for because of low level Medicaid reimbursements.  In some areas, the introduction of primary care management for Medicaid recipients has reversed this trend.

In the State of Washington, a physician legislator sponsored a successful bill for $19 million which allowed the state to buy health care from the Puget Sound Cooperative (a closed staff HMO) for Medicaid recipients.  The benefit package was somewhat reduced.  This is clearly and example of rationing of health care.  The “frills” were not included, such as prolonged mental health care and drug rehabilitation.

In Rochester, New York, physicians, Blue Cross/Blue Shield, and hospitals work together to create a health insurance program for low wage earners.  The cost of this insurance to the individual was 50 percent the cost of regular Blue Cross/Blue Shield programs.   Here, again, the benefits were trimmed.  The physicians agreed to accept 65 percent of the regular and customary fee for their services.

In Orange County, California, a constituency of academic leaders and practicing physicians became an effective advocacy group for the uninsured.  Orange County is known for its affluence with a mean annual income of over $48,000.  However, there are 5,000 homeless, 150,000 non-documented aliens, and about 250,000 people without health insurance in that county.

The county hospital, which is owned by the medical school, attempted to insist on advance payment for their services.  This advocacy group has been very effective in preventing the county hospital from decreasing patient services.  IN fact, the number of women receiving comprehensive OB care at this institution has increased.

The Potential for Training Programs to Help Address

The Problem of Access to Medical Care

It is difficult to quantitate how much care for the underserved is provided by training programs.  The number of residents in training is over 80,000.  This person power works in institutions that add up to over 300,000 beds.  This represents 60 percent of all the medical beds in the United States.

In family medicine alone, there are 380 residency programs.  If an average family medicine center has 15,000 visits per year, this resource provides six million visits.  I am not aware of any means of estimating what percentage of these visits are made by Medicaid recipients or patients without health insurance.  Nevertheless, this must be a significantly high percentage.

I will end this presentation by focusing on a new and promising training program in East Los Angeles.  Over 300,000 Hispanics live in East Los Angeles within the shadow of the affluent downtown skyscrapers.  In 1985, there were only 65 elderly non-residency trained primary care physicians in this community.

The story begins a few years ago when an 8-year old boy named Hector Flores and his family moved from Mexico to the United States.  No one in the family spoke English.  They settled in the East Los Angeles area.

Eventually, Hector went to Stanford University and received his medical degree from the University of California, Davis.  During his college and medical school days, Hector became involved with the California Chicano Medical Student Association.  This group today has 12,000 pre-medical, 300 medical students, 3,000 residents, and 12,000 alumni in its membership.

In 1985, the University of Southern California was granted AHEC money to create a Hispanic education training initiative.  It was decided that a new family practice residency program would be the centerpiece of this initiative.  Dr. Peter Lee, the Chairman of the Department of Family Medicine at the University of Southern California, began searching for a hospital that might house such a residency program.

White Memorial Medical Center in East Los Angeles is a full service tertiary care facility that was previously the University Hospital, Loma Linda Medical School.  As a university hospital, it had little community involvement and virtually none of the East Los Angeles primary care physicians had admitting privileges to the hospital.  Loma Linda build an entirely new university, hospital at some distance.  Suddenly this full-service hospital was left without a mission.

Dr. Sanford Bloom, who had retired from a distinguished career as the family practice residency director at Santa Monica Hospital Medical Center, agreed to do a feasibility study for the White Memorial Medical Center and later developed the curriculum and the Residency Review Committee accreditation application.

When it came time to recruit a faculty, Hector Flores seven of his friends form the Chicano Medical Association.  Six of these seven physicians had their roots in East Los Angeles.  Through the California Chicano Medical Association, it was easy to recruit a group of bright residents.

This is not an ordinary residency program.  The Faculty and the residents have become heavily involved in the community.  These Hispanic role models are trying to encourage the younger students at the elementary school level to consider health careers.  They have organized a teenage pregnancy program in the high school and there is a great deal of one-to-one mentoring occurring.

The program has set up a number of satellite practices throughout East Los Angeles.  At present, there are three such practices.  Faculty receive 50 percent salary from the hospital and they earn the rest of their living through community practice.  There is a separate practice corporation.  The hospital and the practice corporation are prepared to help each resident set up a new practice in East Los Angeles upon graduation.

This is another example of crating a system in which an individual need not be isolated when providing care to the underserved.  This type of arrangement provides professional companionship and a reasonable night and weekend call schedule.

At present this project is funded almost equally by the hospital, extramural grants, and patient income.  Bill Burnett (through the Song-Brown Family Physician Training Act that he administers for the State of California) is helping the program create new funding methods to provide long-term viability.  The areas that are being explored include a primary care capitation program with Medi-Cal and application for designation as a National Health Service Corps site.

This is an example of existing resources being brought together in a vision that has the potential of providing a sufficient number of well trained family physicians for the entire 300,000 population.


Dr Schmidt’s presentation was preceded by: The First National Conference on Primary Health Care Access. April 20-21, 1990 (Opening Remarks)

Dr Schmidt’s presentation was followed by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 2, Weaver).


The First National Conference on Primary Health Care Access. April 20-21, 1990 (Opening Remarks)

The archiving and publishing of the introductory remarks and the proceedings of the first plenary session of the First National Conference  on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.

The First National Conference on Primary Health Care Access


April 20-21, 1990: The American Club; Kohler, Wisconsin

John E. Midtling, MD, MS; Chair, Department of Family Medicine; Medical College of Wisconsin; Senior Fellow, Coastal Research Group

Welcome – John E. Midtling, MD, MS, Medical College of Wisconsin [Dr Midtling is a Senior Fellow of the Coastal Research Group.]Good morning!  On behalf of the Department of Family Medicine at the Medical College of Wisconsin, I would like to welcome you to our special invitational conference on “Access to Primary Health Care in the 1990’s.”  With more than 37 million Americans now without needed health insurance, this issue is sure to become one of the most prominent political issues of the next decade.

It is an issue that has now become a mainstream issue in the United States as the lack of health insurance has now impacted on the many middle class Americans and American business has become increasingly concerned about the cost of financing health care benefits.

We are now in a global economy competing with Japan and Western Europe which, to a large extent, factor the cost of health care into the tax structure.  American business must factor those costs into product costs, placing American business at a significant competitive disadvantage.  At the same time costs of health care have far outstripped the consumer price index.

We  have a technology that is totally out of control and in many cases applied with minimal ethical or effectiveness considerations, creating a system about to collapse of it’s own weight.

As Charles Gessert will point out in this morning’s session, the access problem has been a problem that has always been with us.  It is a problem that just will not go away.  It is a problem that has come to the forefront of the national consciousness crying out for solutions.

Despite massive increases in total health care expenditures and massive increases in physician manpower, the access to health care problems has indeed not gone away.  In fact, some would argue that physician specialty and maldistribution, access for the inner city and rural poor, and access for under served minorities have actually worsened over the past decade.  That is why I believe it is so important for us to do careful policy analysis of why er are where we are, what have been the successes and limitations of past programs to address this problem, and what programs or interventions hold special promise for the future.

We will be developing conference proceedings which will capture the essence of this conference and its recommendations.  These proceedings will be distributed to interested policy leaders around the country.  In this regard, I would ask that each of the presenters provide us with a description of your prepared comments and we will be recording the discussion of sessions.  These recordings and prepared comments will be synthesized into a document for distribution to the interested individuals unable to attend.  I believe such a distribution will greatly magnify the impact of this conference, its work, and its recommendations.

It is my hope that each of our invited guests will participate as well with comments and questions and I would ask that as you address the panel, you identify yourselves so that the proceedings will properly reflect credit for your comments.  I believe that the real target audience will be those who receive the proceedings.  We purposely wanted a small, intimate working group that could discuss and analyze this access issue and come up with some recommendations.

We divided the conference into several sessions that I believe dissect this problem into its key elements.  Today’s sessions include:  “Access to Primary Health Care:  The Challenge and Past Responses,” led by David Schmidt; “Emerging Problems in our Management of Primary Care Access,” led by David Werdegar; and “The Impact of Changing Reimbursement on our Ability to Manage Access to Primary Care,” led by David Sundwall.

Tomorrow’s sessions will include: “Improving our Management of Access to Primary Health Care for Minority Populations,” led by John Arradondo, and “Policy Options for the 1990’s, “led by Bruce Behringer.

Before we begin this morning’s session, I have asked Charles Gessert, Vice-Chair of the Department of Family Medicine at the Medical College of Wisconsin, to lead off the conference with some introductory comments.  Charles was the Project Director of the California Area Health Education Center (AHEC) and a Senior Medical Officer with the Bureau of Health Professions in Washington before coming to Wisconsin.  I believe that he has a unique longitudinal and historical perspective on the access problem.  Charles.


Charles E. Gesssert, MD; Vice-Chair, Department of Family Medicine, Medical College of Wisconsin

Introductory Comments –  Charles E. Gessert, M.D. It’s a real pleasure to see so many old friends and new friends who are able to join us at this conference and I think that we’re going to have an excellent group.  I think that we ought to be willing to stretch our minds and look for a new perspective on the problems we’re going to be discussing.

Many of the problems we’re discussing are new new.  I look around  the room and see a lot of old hands, people who have been working with these issues for a long time.  And that’s one of the two bookends that I want to provide for our discussions this morning.  I’m hoping to provide  for our discussions this morning.  I’m hoping to provide some perceptions on the past and perhaps a few comments on what I perceive to be special issues for the future.

For the comments from the past, you have just received an article that’s from the June, 1927 issue of The American Mercury, which is a journal that I became aware of because of my enthusiasm for H.L. Mencken.  If anybody wants me to, I could spend a little time apologizing for him.  His obvious insensitivity to a lot of issues, including racial issues, is legend.  But he nevertheless was a great commentator on his era.

I’ll give you a couple of quick quotes out of this article:  “The new generation of American doctors are specialists.”  “There is a smaller and smaller supply of the old style general practitioners who looked after most of the ills of the family and were often friends and counselors in other affairs as well.”  “With the predominant tendency toward specialism, the expensive medical services become more and more burdensome.”  “These findings are ominous.  They indicate a rapid and dangerous disappearance of country doctors.

Essayist H. L. Mencken (1880-1956) of The American Mercury

The doctors upon whom the rural districts are chiefly depend for medical service are a group  of old men who are getting toward their end with nobody in sight to take their places. The high cost of medical education peculiarly influences the distribution of rural doctors.  The rural districts today cannot pay the price of money that present medical service demands.  Especially, they cannot pay the price in cultural advantages that our present graduates demand – city conveniences and accessories, things of that sort.  We are turning out now what President Butler of Columbia has called ‘the country club type,’ but the actual country has nothing to offer them.”

In other points the article it makes observations about the specific problem of the diminishing access to obstetrics in rural areas, the role of medical education as a root cause  and potential solution to the problems, the medical school faculties are being poor role models for future practitioners in view of their specialization and their lack of practice experience, and the growing disruptive role of research.   This was in an era well before the NIH as we know it today.

To me the interesting aspects of this article are that it illustrates that many of the problems that we perceive to be so challenging to our generation have been with us for a long time and they promise to be with us for the foreseeable future.  This observation should guide us in our understanding of the nature of these issues and what we might regard as a perfect solution to them.

Somehow I derive a calming and sort of comforting feeling from these observations in the sense that these problems have been with us for such a long period of time.  My father used to  periodically, if you got him mad enough, refer to the world as going to hell in a handbasket.  It may be true but it may not be going to hell in a handbasket quite as quickly or quite as uniquely in our generation as we sometimes think.

Some of the more specific observations, though, on this line of thought would be rural areas have enduring generic characteristics which will “always” impact upon their ability to attract professionals.  Medical education will always be urban based in view of the great interdependency of professionals within an academic community and will always create a culture of its own which will be difficult for young physicians to separate from.  The tendency to develop highly technical specialized medical care has always, in a sense, competed with the need for generalists and has always had a particularly pernicious effect on the supply of physicians for under-served areas.

Lastly, in these general observations, you say that the high cost of medial education and other financial factors have always served as disincentives to getting physicians to work in less technologically advanced, undeserved communities.

Now, if you take this group of observations and pull them together, what does this mean?  The principal  thing it suggests to me is that some of our access to care issues are borne of the nature of our culture and are not peculiar to our generation, nor peculiar to our situation.  And to the degree that this is true we will be frustrated in solving these problems.  These are not particularly susceptible to solution.  The underlying lay of the land which creates our access to care issues must be understood and policies which enable us to manage these problems must be identified.

I think that many of you may have observed the rather “contrived” titles of our panels.  We have tried to insert the concept that we’re not asking people to sit down and tell us how they’re going to solve these problems.  We’re asking people to sit down and help us think through how we can manage these problems better.  Some of our problems have been with us throughout time and we need to learn to manage them.

The distinction between a public program as a solution and as a management tool is not trivial.  With apologies to people like Don Weaver and David Sundwall who have worked much more intimately with the management of public policy than I have, I would like to submit a specific example – the National Health Service Corps.  Again apologizing for oversimplification, the National Health Service Corps was created and to some degree sold to congress as a solution to access to care problems in underserved areas.  We know this because of what the way that we measured its success or failure.  We measured it down to the concept of the eventual elimination of the underservededness of a number of communities around the country.  People were going to lose their designation as underserved areas.  They weren’t going to be underserved any more, implying that we’re going to solve the problem.

Physicians under this model would serve their time in underserved  communities and then remain there as a new graft which has taken in the host.  As a solution to access to care problems in underserved areas, the National Health Service Corps has failed at least to the degree that physicians have generally served their time in underserved communities and moved on.  It has failed because the expectation was flawed.  A keener application of the appreciation of the enduring nature and root causes of underservededness might have led to the early advocates of the National Health Service Corps to promote it as a management tool and, as such, the expectations would have been that we’re going to need to implement this tool clinically.

Moreover, the people who managed the National Health Service Corps  could and should have promised no more than what they controlled, that is to say the placement of individuals in communities for the duration of their obligation.  From the outset the National Health Service Corps would have been recognized universally as a public policy success and as an important ongoing part of our Public Health Service.

I think we have come to that point of view, specifically in the last few years.  I think it’s a very good thing, but we have had to go through a long period of adjusting expectations of the National Health Service corps.  I think the National Health Service Corps, in my sense, is the kind of organization that could serve as an excellent management tool on an ongoing basis.

Well, having provided one bookend for our discussions in this conference drawn from the past,  I’d love to quote an article published in the year 2050 and tell you a little bit about the future and use that as a basis.  However, the closest I can do is to recommend that everyone read, as a number of you have heard me say before, Daniel Callahan’s new book, “What Kind of Life.”  In lieu of an article, I have selected what I see as a fundamental change in our culture, which I would like to have us focus on for a few moments.

This is a reiteration of some of what John said in his opening comments.  I am referring to what I see as the beginning of a new examination of man’s relationship to natural forces, man’s relationship to natural laws.  Not too long ago I finished reading Barbara Tuchman’s book, “A Distand Mirror.”  It’s about the 1400’s.  It’s a very helpful and educational book.  Taking from that point of time to the present over the last 500 to 600 years, I think it’s very clear that our perception of our relationship to natural forces has been dominated by the fact that life has always been – up until the very recent past – short, unpredictable, brutal, unproductive, and dangerous; and that the conquest of natural fores has unquestionably made life safer, more predictable, longer, and more productive.

Generally there has been no need to question whether or not the conquest of natural forces is of benefit to mankind.  As a matter of fact, what we call civilization or progress has largely been measured in our ability to control natural forces.  This has been true, I would say, until recently.  Our teeming population, our concerns for the environment, our new awareness of the downside of our growth and progress have all stimulated, in many, a reflection of the longer term subtler effects of the conquest of nature.

In many there is a new awareness of man’s dependence on a healthy environment and on a healthy nature in which to live.  Some of this new awareness is unfocused.  We have the sense that we are dependent upon a healthy functioning of natural checks and balances even though we don’t necessarily understand what all those checks and balances are.

This, I think, is leading us to a fundamental shift in our perception.  We are beginning to move from the view that the conquest of nature is a good thing for mankind to one in which there is a new appreciation of our dependency on natural processes.  There is a direct application of this rather broad thinking in medicine.  Most directly, in what we call bio-ethical ethics, I see a growing willingness to question the wisdom of medical interventions in natural processes.  Considerations of costs, quality of life, the non-medical aspects of health, and for that matter the non-health aspects of well-being, are all being raised and brought to the door of the medical citadel.

We are being reminded that health is not wholly or even predominantly comprised of medical care and that well-being is not wholly or predominantly comprised of health.  I believe that the growing interest in these considerations should be encourage.  If we are ever to move to a more modest or realistic allocation of our society’s resources to medical care or curative medical care, we’re going toh ave to make a lot of changes.

I believe that to the degree that these kinds of reconsideration or reexaminations of medical care can be brought into the public domain for the public debate, we may see some lessening of demand.    Restraint on demand – through more judicious or selective or circumspect use of medical resources – carries far fewer political and societal consequences and problems than restrain on supply, which has been our principal approach up until the present time.

I hope that we will develop a new – what you would call default – position in that non-intervention may be assumed to be superior until proven otherwise.  The burden of proof may shift to making sure that what we do not only makes sense in the short-term biological sense but that it also makes sense in a holistic sense in terms of its effect on the family, and also its effect on the community, including the distributed effect that is felt broadly in society through the bearing of the cost of care.

In this conference we are focusing on access to care issues.  The considerations I just reviewed suggest that we should be asking, “Access to what kind of care?”  Is not the overspecialized, overly technical medical empire sagging under the weight of the costs?  Its ethical dilemmas?  Of the disaffection which the public is beginning to feel from some of the imbalance in our allocation of resources for the society?  Is this the empire to which we are trying to improve access as we debate access to care issues?

For many of us, and I think of my old colleagues sitting around the room, this interface between cost issues and access to care issues is all too familiar.  It seems that access to basic care has been sacrificed before what I would call the insatiable god of curative medical care.  If we would look at both sides dof the issue there isn’t really a conflict.  We must assure basic nutrition, if you will, to all before anyone can gorge themselves at the banquet.

The analogy to feeding, I think, is apt.  It is hard, or even silly or cruel, to try to convince a starving man that he ought to eat just nutritious stuff.  And we have the same situation in our health care system.  Our underserved communities cannot be expected to join in any general consensus on efforts to restrain health care costs until their basic needs are met.  We must expand coverage or access for basic services so we can have a better basis for universal restraint.  We are analogous to population workers in the Third World who find it difficult to get people to restrain their birth rate through birth control until infant mortality is brought under control.

With these thoughts and two doses of humility – one dose drawn from our knowledge that our problems are not unique to our generation and the other one drawn from the sense that there are distant rumblings of thunder on the horizon that may change some of the rules under which we operate – I’d like reiterate our welcome to all of you and I look forward to unique conference.

Thank you very much.


 The opening remarks of the First National Conference on Primary Health Care Access were followed by:  First National Conference on Primary Health Care Access (1st Plenary Panel, Part 1, Schmidt).