28th National Conference Program Incorporates Alternate Perspectives of “Access” Theme

The 28th National Conference on Primary Health Care Access is scheduled for April 10-12, 2017 at the Hyatt Regency New Orleans. The conference theme for 2017, “Access”, will be incorporated into each of the National Conference plenary sessions.

Several presenters on the first day will continue to test how well this decade’s major health legislation – the Patient Protection and Affordable Care Act (ACA) – meets the goal of providing high quality, culturally sensitive primary health care to the nation’s population, regardless of socio-economic status, ethnicity or geographic location. [See 28th National Conference Keynote Sessions to be Dedicated to ACA Issues of “Access”.]

Regional Issues in Access

Other plenary sessions are grouped into specific perspectives on access. One will continues the National Conferences’ studies of the consequences of long-term strategic investment by medical schools, postgraduate physician residency programs, community health centers, public health departments and Area Health Education Centers in the creation of a community and family-oriented primary health care workforce and the institutions that workforce supports.

This year’s conference, among other regional studies, will examine such strategic interventions in the State of Louisiana and the Northwestern States, in the Central Valley and other agricultural regions of California and in various urban communities that appear to have sufficient numbers of physicians, but where significant access problems exist.

Memorializing Generations

Peter V. Lee (1927-2016) University of Southern California Faculty Emeritus

Peter V. Lee (1927-2016)
University of Southern California Faculty Emeritus

Another theme will be built on the National Conferences’ remembrance of the founders and early pioneers of family medicine and other strategic primary care interventions. We celebrate the work and mourn the losses of members the generation born before 1930 whose efforts resulted in the momentous mid-20th changes in federal, state, local and regional health care policies, of which Medicare and Medicaid are the most obvious examples.

We will also celebrate the generation born between 1930 and 1950, many of whom were the first physicians to enter the newly created family medicine residency programs and/or to staff the first group of federally-funded community health centers.

Mark E. Clasen, MD, Ph.D. (1947-2015) Wright State University/Boonshoft School of Medicine Faculty Emeritus

Mark E. Clasen, MD, Ph.D.
Wright State University/Boonshoft School of Medicine Faculty Emeritus

We will focus on two of the physicians we lost in the past year – Doctor Peter V. Lee, who was the first Chair of the Department of Family Medicine at the University of Southern California (born before 1930) and Doctor Mark E. Clasen of the Wright State University Boonshoft School of Medicine in Dayton, Ohio (a member of the second group).

Beyond the extraordinary influence that both physicians had on the careers of so many physicians who were inspired by their teaching and professionalism, both were emeritus board members of the Coastal Research Group, which conducts the National Conferences.

The composition and subject matter of individual panels will be announced in future weeks.

“Time Will Tell”: the Proceedings of the 26th National Conference – “Issues in the Training of Primary Care Physicians (Part Three, Kozakowski), Monday April 13, 2015

We gratefully acknowledge the sponsorship of the Charles Q. North, MD of the University of New Mexico Department of Family and Community Medicine for his support of the transcription and editing of this section of the Proceedings of the Twenty-Sixth National Conference


The following transcription is of the first plenary session of the 26th National Conference on Primary Health Care Access, held April 13, 2015 at the Hyatt Regency Orange County. This section follows: Time Will Tell”: the Proceedings of the 26th National Conference – “Issues in the Training of Primary Care Physicians (Part Two, Hansen)”, Monday April 13, 2015.

Stanley Kozakowski, MD; American Academy of Family Physicians

Stan Kozakowski, MD;
American Academy of Family Physicians

Stan Kozakowski, MD, American Academy of Family Physicians, Leawood, Kansas [Dr Kozakowski is the 2015 Norman B. Kahn, Jr, MD National Conference Scholar]: Good morning, I’m Stan Kozakowski and this, I’m a first time attendee here. I’m going to try and realize the challenge.

Bill Burnett asked me to touch on two topics during my ten minutes. One is the American Academy of Family Physicians (AAFP), response to the Institute of Medicine (IOM) report and then give you a brief update on the Family Medicine for American’s Health project. We’re going on a whirlwind tour here.

26phca-1-3-240-0As a matter of disclosure, I’m speaking as an individual today, not as a member of the AAFP because some of the things I have to say may not totally align with the AAFP policies.

The IOM report [see Time Will Tell”: the Proceedings of the 26th National Conference – “Issues in the Training of Primary Care Physicians (Part One, Henderson)”, Monday April 13, 2015] report came out in summer 2014.

26phca-1-3-240-2On September 15 of that year, the Academy presented a position paper on Capitol Hill. There were two campaign pieces that went with this. Essentially the Academy believes that the IOM got it mostly right.

1. Restrict GME Payments to “First Certificate” Programs

We as the AAFP put forth five policy recommendations. The first recommendation has to do with limiting payment for GME to “first certificate” programs.

Over the last decade, there have been a significant number and percentage of additional GME slots funded. If one agrees that we, 26phca-1-3-240-3as a nation, have a need to increase our primary care base and to address other potential specialty shortages, how GME funds are used should be considered.

If the funds for the 7700 existing fellowship positions were shifted to new first certificate programs, that could potentially fund another 7700 new first certificate programs. The AAFP recommendation is that half of those positions go to primary care specialties, and half of those allocated to primary care go to family medicine.

2. Require funding recipients to Meet Primary Care Physician Training Thresholds

26phca-1-3-240-4The AAFP’s second recommendation is that there should be thresholds for receiving these government funds, that relate to production of primary care physicians.

Our recommendation is that a third of the positions that an institution receives are funding primary care positions. We define the primary care specialties as family medicine, general internal medicine and general pediatrics.

This recommendation addresses what has been referred to as the “Deans Lie”. I think about this as a systems issue and not as an intentional lie, but we do have a system designed to produce the results that we have. We know that five years out from a physician’s graduation from residency is a better measure of whether that physician is practicing primary care..

3. Require demonstrated Maintenance of “Primary Care” Training Efforts 

26phca-1-3-240-5The third AAFP recommendation is that for an institution to seek additional slots, there should be a demonstration that those positions going into primary care.

The institution should demonstrate that it is maintaining its primary care effort over the long haul.

4. Provide for for Innovation in Funding Formulas

26phca-1-3-240-6The fourth AAFP recommendation endorses the IOM report’s recommendation that the funding formulas should allow a certain amount of innovation.

If there were an adjustment of the indirect medical education (IME) factor reducing it by a quarter percent, it would free up about $300 million that could be used to fund a workforce commission as well as innovation in community-based training.

5. Fund a National Workforce Commission

26phca-1-3-240-7The fifth recommendation is to fund a national workforce commission. We know that politically that name may be problematic but the concept of an oversight body is important. Somebody has to do it. It’s not being done here in this country. That’s essentially the AAFP position on the IOM.

Now we shift directions!

Update on “Future of Family Medicine” Project

26phca-1-3-240-10Over the past ten years, we’ve seen the development of the Future of Family Medicine efforts. The first iteration we call Future of Family Medicine 1.0.

In 2014 at the annual AAFP assembly we launched the Family Medicine for America’s Health effort.

Stanley Kozakowski, MD; American Academy of Family Physicians

Stan Kozakowski, MD;
American Academy of Family Physicians

I see that one of the challenges here, as compared to the first Future of Family Medicine project is that, if you will, we are building the airplane in the air. The Future of Family Medicine through tactic teams.

We launched this effort in September, 2014, to coincide with an AAFP Assembly was meeting in Washington, D.C., even though it was not fully fleshed out.

In our analysis of the first project a decade ago, we concluded that its communication strategy was ineffective. So an important component of this new project now is a communication strategy, whose theme is “Health is Primary”.

So here’s the report. I would recommend to you the article in Family Medicine, looking at the foundations.

The Seven Core Strategies

26phca-1-3-360-11There are seven core strategies that are found in that report. Essentially,  they articulate our need to connect our nation’s people with a trusted source of care. We need to achieve the Triple Aim; we need to demonstrate value, et cetera.

In order to have a well trained workforce to do that we have to have systems in place to support that, financially and otherwise.

The Six Tactic Teams

26phca-1-3-360-12There are six tactic teams which began  in January. 2015. They are looking at ways to set direction.

Each of these six tactics is important, and each team has been asked to develop a set of initial tactics. Today we will focus momentarily on the workforce, which is where medical education lies.

The Workforce Tactic Team

26phca-1-3-360-13The workforce team here is looking at four initial tactics:

(1) incorporating EPAs (entrustable professional activities) into residency training;

(2) providing the skills needed for population health, (because that’s something new and evolving)

(3) increasing the number of students going into primary care and, particularly, into family medicine; and,

(4) addressing the national problem of  inadequate numbers of preceptors.

The Public Relations Effort

26phca-1-3360-14Supporting this effort is a public relations campaign.

That campaign comprised of press events. Concurrently, a series of rallies are planned that convene people on a local level.


The goal is eventually to create tool kits that can be used in any community.


Workforce and Medical Education Issues

This is the strategy on which we have embarked. But the challenge we have before is to decide whether we asking the right questions?

Look at this list of initial activities around workforce and education. Are these the right ones that we should be focusing on right now? I’m not so sure. I hope we can talk about that as we get into our Q & A.

26phca-1-3-360-19When considering workforce, do we know what we need and how we’re going to get there?

I would recommend to you Bazemore and Peterson’s article that was published in Family Medicine.

I draw your attention to what they see as a 33,000 primary care physician shortage by 2035.

26phca-1-3-360-21With our current level of production we would need an additional 1700 primary care residency slots in order to produce that workforce.

If there is a reduction in the number of patients cared for by a physician, that number changes and, according to the authors, could be 3,000.

If we play with the retirement age and so on, the numbers shift again. So predicting the workforce needed is certainly a major challenge.

For family medicine, depending on how you slice the numbers and what assumptions you make, it could be as many as 1700 additional slots are needed, given current trends in terms of how general internal medicine is performing.

26phca-360-22Have we really done very well? This graph shows the total number of residency slots, and the number of slots actually filled. It also shows the number of U.S. senior class medical students.

My answer to the question is maybe. We may be producing the numbers of residency graduates in terms of getting us to the increased production that we project we need.

It translates to about 65 additional positions per year. That is about 12 new family medicine residencies would need to come online every year over the next period of time here in order to ramp up to this level; or an increase in current positions at residency by perhaps two per residency program in the current configuration. But U.S. seniors are not finding this attractive, at least based on the last match. We had a net of six additional U.S. seniors select family medicine.

The Center for Interprofessional Education

Do we need to think about our delivery of the workforce differently?

26phca-1-3-360-23I recommend consideration of Barbara Brandt’s work being done at the Center for Inter-professional Education.

She proposes creating new partnerships that bring together the education community with the practicing physician community.


26phca-1-3-360-25Our ultimate goals are improved healthcare and educational outcomes. Should we not be thinking about inter-professional training and inter-professional care delivery in the future in new ways?

With that question, I’ll conclude.

“Time Will Tell”: the Proceedings of the 26th National Conference – “Issues in the Training of Primary Care Physicians (Part Two, Hansen)”, Monday April 13, 2015

We gratefully acknowledge the sponsorship of the Charles Q. North, MD of the University of New Mexico Department of Family and Community Medicine for his support of the transcription and editing of this section of the Proceedings of the Twenty-Sixth National Conference:


The following transcription is of the first plenary session of the 26th National Conference on Primary Health Care Access, held April 13, 2015 at the Hyatt Regency Orange County. This section follows: “Time Will Tell”: the Proceedings of the 26th National Conference – “Issues in the Training of Primary Care Physicians (Part One, Henderson)”, Monday April 13, 2015.

Thomas Hansen, MD, Advocate Healthcare, Chicago [Dr Hansen is a Fellow of the National Conferences]:

Thomas Hansen, MD Advocate Healthcare Chicago

Thomas Hansen, MD
Advocate Healthcare

I’m going to just talk a little bit about my role at Advocate Healthcare and some of the concerns that I have.

For those who are not familiar with Advocate Healthcare, we have 12 hospitals in the system.  After a  merger we will be bringing on four more.

Four of our hospitals are teaching hospitals, all of which became teaching hospitals prior to becoming part of the system. So you know they had their independent culture and identity.

Three of the hospitals are accredited by the Accreditation Council on Graduate Medical Education [ACGME]. Three programs are dually accredited by the  American Osteopathic Association [AOA] and ACGME. One hospital has three programs accredited only by the AOA, all part of A. T. Still School of Osteopathic Medicine’s “Opti”. Those AOA programs are in family medicine, neurosurgery and neurology.

I have responsibility in total for 31 programs, 631 residents, fellows and over 2,000 medical students who are coming through our system on an annual basis.

Illinois Masonic Medical Center, Chicago

Illinois Masonic Medical Center, Chicago

We are a health system, but we don’t operate our own medical school. For the third-year medical school clerkship years, we have three primary medical school affiliates with students coming in from the University of Illinois, Chicago; the Chicago College of Osteopathic Medicine; and the University of Chicago Medical School.

For our fourth-year medical student experiences, we open up to any student who wants to come to our system. I mentioned a possible merger with North Shore University Health System, which, itself, has a primary affiliation with the University of Chicago.

It’s a complex system. My job as the chief academic officer, which I was hired for two years ago is to oversee, encompasses undergrad medical education, GME, CME, the library services, and research.

Thomas Hansen, MD

Thomas Hansen, MD, Advocate Healthcare, Chicago

As far as GME is concerned, the executive suite had imagined we could consolidate four family medicine programs, three internal medicine and two OB programs into one program with 210 residents. The thought was that by consolidating we would achieve economy of scale. It quickly became clear that a combined residency was not an ideal situation, especially since the distance between our two furthest hospitals is about 160 miles. We talk about patient safety, but requiring residents to drive between sites through Northern Illinois is in itself an unsafe practice for our residents.

Another executive suite directive was that we move towards a single sponsorship. Although the GME leadership had been very resistant to trying to standardize across the Advocate Healthcare system, the single sponsorship idea does make sense.

In response, I created the Advocate Graduate Medical Education Committees [GMECs]. Each hospital still has its own GMECs at each site, but I created an Advocate GMEC comprised of all the program directors, who come together once a month. This was the first time that our program directors were talking to each other – not only across the system, but within the individual hospital sites. It really was an amazing outcome!

The internal medicine program directors were discussing which metrics we need in order to meet their requirement for clear criteria. They became a force to leverage IT to start working with the residency programs. We had to figure out how do we have a model where we can capture the data for the patients that are residents are seeing.

Soon afterward, the family medicine residency programs came together to start talking about the metrics that they needed. There really was a lot of synergy that was the outcome of the programs talking with each other.

For those who have ever gone towards developing a single sponsorship, you know that it raises the issue of how to develop institutional policies across a system, in which each of the hospitals have their own institutional policies.

The program directors didn’t even know we had institutional policies. Now they’re participating in writing those institutional policies in a way that makes sense for us as a system. How do we address the clear requirements in a way that, that is providing better quality of care? How do we you improve patient safety, etc.?

One nice thing about having an Advocate Hospital GMEC, is that we now at our meetings. we have the head of quality improvement, the head of patient safety, the heads of research, of library, of IT, and other relevant departments participating in our annual and our monthly meetings.

We are able to offer faculty development that makes sense across the system; especially with regard to the Next Accreditation System [NAS] and Milestones. [see Proceedings of the 25th National Conference: April 14, 2014 – Second Plenary Session, Part 1 (Allen)].

We have been looking at the organization chart and the fact that different people at our sites have similar jobs, but they all have different titles and different pay scales. How do we level the playing field for staff, and then address resident salaries?

I believe that there are issues, not only for Advocate Healthcare, that I think will become national issues in the coming years. At Advocate Healthcare our faculty are primarily for residency programs. They are physicians whose productivity is based an RVU model of how many patients they see.

When I was at Creighton, part of my faculty contract was research, clinical productivity and teaching. My physicians – the faculty for the residency programs – don’t have those provisions in their contracts. These same physicians are also faculty for the medical schools with which we’re affiliated. They have these dual functions because of the LCME requirement that you have to be a faculty member in order to teach at the third-year medical student [M3] level.

The physician faculty are starting to say say: “I’m trying to get these milestones finished. I have to be on the CCC. I have to do all these other things. I have only so many hours in the day. Our primary focus has been on GME, but the requirements for ACGME-accreditation have increased significantly.” Our physicians are starting to opt out of being teaching faculty.

The first consequence is that I just can’t take more medical students. Chicago’s a saturated market. We cannot take any more students. Now we’re starting to decrease the number of students that we’re able to educate within our system.

There are also issues around funding and the “cap allotment”. In my system. We have a direct medical education [DME] cap of 598 DME. Last year, for the 2013 cost report I had to claim 620 – that is, 22 FTEs over cap.

My executive team has said we have to be at cap, because we don’t know what’s going to happen over the next couple of years as a result of the IOM report; and because President Obama’s 2016 budget is proposing reducing the IME reimbursement by 10% for 10 years.

In Illinois, we have a new governor who’s trying to reduce our budget. That will affect Medicare and Medicaid reimbursement to our hospitals.

Advocate Healthcare’s primary CFOs are saying that we have got to be very cautious in this time. They are absolutely right. I absolutely support them. We’re looking at decreasing the number of residents in our system. We’re looking at decreasing the number of faculty who are willing to teach in our system, but if we don’t have faculty and residents teaching, we have to decrease the number of students even further in our system.

In the meantime, our service lines are trying to grow, because they know their bottom line is going down. They believe that if they bring on these other service lines, it will enhance their income. The best way to do this is to hire residents, because they’re considered “cheap labor”. There is this duel going on right now between residents being seen as revenue-enhancing cheap labor and the drive to lower our cap. How do we grow the service lines?

Behind all this, of course, is the whole transition within our AOA programs to ACGME. There is some ambiguity about whether the AOA requirements are going to change. I’m saying we’ve got to make sure we’re planning now, cause we’re admitting residents where I have no data that they’re going to be able to graduate in our AOA programs. We see some, I’ve had a couple of conversations where we now have some systems trying to offload AOA programs cause they know that they don’t have the clinical material to be able to continue the programs. They are trying to figure out how to do that.

And so the potential issues moving forward: teaching hospitals are being bought out by healthcare systems, so these kinds of decisions are no longer being made locally. Fewer faculty exist for resident and student education, fewer residents are present to teach medical students. Some consider residents as cheap labor while other are trying to identify  the financial risk to the system of their being.

ACGME education requirements are becoming a disincentive for physicians to teach. Faculty are saying that they can’t do all these things. The AOA transition to ACGME adds further uncertainty.

So, the question that I’m asking myself, is the U.S. creating a medical education system, in which we have impending shortage of attending physicians to teach, a reduced number of residents in training to do for the funding, and then reduced number of medical schools and medical students, due to no teachers and not enough residency spots?

28th National Conference Keynote Sessions to be Dedicated to ACA Issues of “Access”

The 28th National Conference on Primary Health Care Access is to be held April 10-12, 2016 at the Hyatt Regency New Orleans. Each of its three days will focus discussion of issues of access to primary health care, from national, regional and local perspectives.

Each of the last eight National Conferences has begun with plenary sessions that analyze an element of health care access.

John Geyman, MD

John Geyman, MDd critique the enactment and implementation of the Patient Protection and Affordable Care Act (referred to variously and ACA or Obamacare.)

On April 10, 2017, the discussion is resumed with two of the permanent members of the National Conference faculty, Doctor John Geyman, author and member of the University of Washington emertius faculty and Doctor David Sundwall of the University of Utah. [For their most recent discussion on the topic, see “What Should Happen Next”: Doctors John Geyman, David Sundwall discuss Obamacare

Doctor Geyman has been an eloquent critic of the corporate transformation of the medical profession and of the American system of health care.

He has argued that inherent in ACA are fundamental flaws that make the act ultimately unsustainable. A selection of Dr Geyman’s critical appraisals of the legislation may be found at “What Has NOT Changed” – A Critique of the Affordable Care Act: John P. Geyman, MD and Proceedings of the 22nd National Conference: Thought Provocateur Session #1 (John Geyman MD) – “What Will Not Work: The Fundamental Errors in PPACA”.

David N. Sundwall, MD; University of Utah

David N. Sundwall, MD; University of Utah

Doctor Sundwall has previously served as a staff member to the United States Committee on Labor and Human Resources, chaired by Utah Senator Orrin Hatch.

He also served as the Head of the United States Health and Human Services Health Resources and Services Administration under President Ronald Reagan, and more recently as the Director of the Utah Department Health under Governor Jon Huntsman and as a member of the presidentially-appointed Medicaid and CHIP Policy Advisory Commission.

After the keynote presentations by Doctors Geyman and Sundwall, presentations will be made by Doctor Norman Kahn, who is the Executive Officer of the Council of Medical Specialty Societies and Doctor Perry Pugno who is an emeritus Vice President of the American Academy of Family Physicians.

Doctors Geyman, Sundwall, Kahn and Pugno are all Senior Fellows of the National Conferences on Primary Health Care Access.


Confirmed Faculty: The 28th National Conference on Primary Health Care Access

The following members of the permanent faculty of the National Conferences on Primary Health Care Access have confirmed their participation in the 28th National Conference, to be held April 10-12, 2017 at the Hyatt Regency New Orleans. Other confirmations are expected soon. The list will be continuously updated.

The 28th National Conference Faculty (confirmed as of October 8, 2016):

A neighborhood in New Orleans' French Quarter

A neighborhood in New Orleans’ French Quarter

Suzanne M. Allen, MD, MPH, University of Washington WWAMI Program, Boise, Idaho

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

John Boltri, MD, Northeast Ohio Medical University, Rootstown, Ohio

J. C. Buller, MD, Touro University College of Osteopathic Medicine, Vallejo, California

Eileen Chiang, CMA, Family Health Center, Kalamazoo, Michigan

J. Scott Christman, MPDS, Office of Statewide Planning and Development, Sacramento, California

Mary T. Coleman, MD, Louisiana State University, New Orleans

Denise Crawford, MBA, Family Health Center, Kalamazoo, Michigan

Delight F. Erickson, RNC, FNP, MPH, Radius Medicine Group, Andover, Minnesota

Jeremy Fish, MD, Contra Costa County Regional Medical Center, Martinez, California

Rick Flinders, MD, Sutter Hospital, Santa Rosa, California

Donald Frey, MD, Creighton University, Omaha, Nebraska

John Geyman, MD, University of Washington Emeritus Faculty, Friday Harbor, Washington

Ivan Gomez MD, California Statewide Area Health Education Center, Fresno, California

Derrick Gruen, Adventist Heatlh Systems, Hanford, California

Jimmy H. Hara, MD, Charles R. Drew University, Los Angeles, California

Steven Harrison, MD, Natividad Medical Center, Salinas, California

Charles Henley, DO, Marian University, Indianapolis, Indiana

James M. Herman, MD, MSPH, University of Oklahoma School of Community Medicine, Tulsa

Norman B. Kahn, MD, Council of Medical Specialty Societies, Chicago, Illinois

Gary LeRoy, MD, Wright State University, Dayton, Ohio

Dennis E. Means, MD MMM, CPE, Family Health Center, Kalamazoo, Michigan

William A. Norcross, MD, University of California, San Diego

Charles Q. North, MD, MS, University of New Mexico, Albuquerque

Keosha Partlow, Ph.D., MPH., Charles R. Drew University, Los Angeles, California

Perry A. Pugno, MD, MPH, American Academy of Family Physicians Emeritus, Lebanon, Ohio

Adalberto Renteria, MD, Adventist Health Systems, Hanford, California

Janice Spalding, MD Northeast Ohio Medical University, Rootstown, Ohio

David Sundwall, MD, University of Utah, Salt Lake City

Allan Wilke, MD, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan

The National Conferences on Primary Health Care Access: background

In 1990, a group of persons interested in family and community medicine, medical school reform, and advocacy for rural, inner city and other geographical areas of need, were invited to rural Wisconsin for the First National Conference on Primary Health Care Access. Since then, similar groups have been invited to assemble each Spring.

Periodically, landmark national legislation is enacted  (Medicare and Medicaid in the mid-20th century; the Affordable Care Act in the 21st), each of which has proven to have unintended consequences that exacerbate access to care.

Over the years, many of the pioneers, key strategists, researchers and policy makers who have promoted the idea of community-responsive medical education have participated in one or more of the National Conferences. (Many have participated in twenty or more of the 27 conferences held through 2016.)

The National Conferences have continuity in the conference faculty from year to year. The conferences are limited to approximately 55 participants. Persons who enroll in the conference series are invited to renew their space in each subsequent conference.

Public Policy and Access to Primary Healthcare

Lack of access to health care is a problem in most rural, inner-city, lower socioeconomic, and minority communities. That lack of access is in part due to the decline in the numbers of general practitioners and family physicians and the increase in medical subspecialists, who typically do not locate in inner city or rural areas.

The subspecialization of medicine increased in every decade of the 20th century and continues in the 21st. That specialization appears to be accelerating, and with it the decline in percentage of primary care providers when compared with subspecialists. (Many areas continue to experience an absolute decline in numbers of primary care providers.)

Trends suggest that current levels of funding for primary care activities are inadequate for turning the tide of subspecialization, and such new resources as might be commanded are marginal.

Hopeful approaches include the encouragement of strategies for increasing the cost-effectiveness of current levels of effort and the forging of strategic linkages between health care sectors such as primary care training programs, community-based health care delivery systems and primary health care professionals specifically trained to practice in communities of chronic physician shortage.

Such strategies and such linkages are the content of the National Conferences.

The National Conferences’ Named Lectures

G. Gayle Stephens, MD (right) with 12th Stephens Lecturer John Geyman, MD

The Coastal Research Group has sought to honor major intellectual leaders in the Family and Community Medicine movements.  Typically, each of the National Conferences on Primary Health Care Access has one of three named lectures associated with the conference.  One honors G. Gayle Stephens, MD, one honors the late Charles E. Odegaard, Ph.D. and the third honors J. Jerry Rodos, DO.  The lecturers in each series include many eminent figures in these movements.

The National Conferences have established named lecture series to honor three colleagues who have achieved prominence in their professional careers, and have additionally made significant contributions to the National Conferences. Continue reading

28th National Conference – John Geyman MD on Health Care Reform 2017: What are our Options Now?

John Geyman, MD

John Geyman, MD

Doctor John Geyman’s insightful analyses of what he believes are the fundamental errors in the Patient Protection and Accountable Care Act [ACA] have been highlights of the National Conference on Primary Health Care Access over the past half decade, will be a featured speaker at the 28th National Conference on Primary Health Care Access, to be held April 10-12, 2017 at the Hyatt Regency New Orleans.

Dr Geyman’s presentation will be keynote on Monday morning April 10th.

Dr Geyman will be joined by a reactor panel enlisted from the permanent faculty of the National Conferences on Primary Health Care Access.

The National Conferences are invitational, and consist of approximately four to five dozen drawn from experts on health care policy, public health, community health centers and teaching health center projects, and academic health sciences center faculty. The National Conferences are conducted by the Coastal Research Group, a 501c-3 non-profit corporation devoted to healthcare workforce issues.

For information on the invitation process, contact William H. Burnett, Coordinator of the National Conferences at whburnett@coastalresearch.org.

The 28th National Conference on Primary Health Care Access to be held in New Orleans, April 10-12, 2017

For the first time, the Coastal Research Group will host the invitational National Conferences on Primary Health Care Access at the Hyatt Regency New Orleans. The National Conference will take place April 10 through 12, 2017. Invitations and registration forms will be mailed to invitees during the summer of 2016.

The Hyatt Regency New Orleans

The Hyatt Regency New Orleans

The theme of the 28th National Conference will be “Access”.

The founding of the Coastal Research Group 33 years ago and the establishment of the National Conferences on Primary Health Care Access in 1990 were both based on the premise that the American health care system was in need of substantive reform.

Although there are many admirable features of American medicine and comprehensive reform has been attempted through 2010’s Patient Protection and Affordable Care Act (PPACA), very serious deficiencies still exist in how American health care is organized and financed.

Over the past 27 National Conferences, much of the discussion has not only identified what should be changed in the health system, but has assessed the intended and unintended consequences of past federal legislation (i.e, Medicare, Medicaid and the prescription drug benefit).

PPACA, to which the media have assigned the nicknames “ACA” and “Obamacare” has had a transformative impact on some aspects of the health care system. Yet, although the ACA, at the time of the 28th National Conference will have been enacted for more than a half-decade, its ultimate efficacy and impact is still a source of intense debate.

Whatever its ultimate impact, the problems that brought forth the National Conferences – the geographic and specialty distribution of physicians, the lack of an appropriately functioning system of primary care, the lack of effective integration of medicine and public health – all remain concerns.

These concerns are at the center of discussion of each of the National Conferences.

The Political Climate in 2016

The Patient Protection and Affordable Care Act has yet to gain the widespread popularity predicted by the legislation’s proponents.

The strategic decisions of the two political parties to stake their political fortunes on support or opposition to the act as a whole has made, at least for the time being, the legislative process for modifying the Act in any significant way seemingly unlikely.

A principal concern for the plans’ proponents would be if participating health care plans, as many predict, were to increase rates substantially to cover their costs, and if such cost increases were to erode ACA’s political support among the electorate in such a way to complicate the implementation process.

A Brief History of the Concept of Primary Health Care Resources

Over a half century ago (1964), the treatise “Health Care is a Community Affair”, called the Folsom Report, was published. The next year (1965), the two principal federal programs for funding health care, Medicare and Medicaid passed, followed in the subsequent year, by the publication of the reports of the Millis and Willard Commissions.

The three reports and two financing mechanisms have had profound results, the former on development of public and private sector policies the latter on how the structure of American health care evolved.

The reports resulted in such familiar concepts as the idea of primary and tertiary health care, programs to address geographic and specialty maldistribution of physicians, especially in rural and “inner city” areas, and creation of new primary health care personnel.

In the meantime, multiple efforts to address poverty in America at the federal level led to the creation of the Office of Economic Opportunity, which promoted such ideas as Neighborhood Health Centers.

With the change in administrations at the federal level in 1968, many of the OEO ideas were institutionalized (made politically more “acceptable”) in federal legislation supporting the Community Health Centers and the National Health Service Corps. Legislation funding the new primary care discipline of Family Medicine passed at the same time as the other “safety net” programs, that had consequences for the evolution of training the family physician.

The effects of the two financing mechanisms were outsized, impacting the structure and organization of any entity that received funding from either. Neither Medicare and Medicaid were developed in concert with the policy recommendations of the Commissions, and thus a half-century of accumulated evidence suggests that the policy bases of health care financing do not synchronize with the policy bases would underlie a rational American health care system.

Some issues for consideration by the 28th National Conference 

The following questions, all of which were posed for and discussed at the previous National Conferences, are posed for the faculty and invited participants for the 28th National Conference as well.

  1. What were the changes in American Health Care intended by passage of the “ACA”? To what extent have such changes been effected, with the likelihood that the change is permanent?
  1. Are there unintended changes that have occurred through passage of the “ACA”? Are those changes good or bad?
  1. Because Medicaid historically has differed significantly from state to state, ACA attempted to impose a more consistent approach to the financing of Medicaid recipients between states. To what extent has this effort been successful, and where do problems still exist?
  1. Insurance companies, which evolved historically to assess and contain risk, have been assigned the task of advancing the “rights” of health care recipients to care (who are now obligated to enroll in a health plan) while charging them with the plan’s actuarial costs. Is this the best way to increase access to health care?
  1. Has the “ACA” enhanced or impeded primary health care access in rural communities, and to “underserved” and disadvantaged populations? What is the anticipated impact of the November 2016 election on the ACA’s progress in providing care access?
  1. What are the effects of changes being implemented in the accreditation of medical schools and postsecondary physician training programs?
  1. How are such innovations as primary care medical homes, teaching community health centers, rural training tracks, hospital-centered community health plans, and accountable care organizations faring? Are there examples of programmatic successes (or failures) that would be of general interest?

Invitations to the 28th National Conference will be sent out in Summer 2016. Those interested in the National Conference and the Invitation Conference should e-mail the conference coordinator, William H. Burnett, at whburnett@coastalresearch.org.

27th National Conference Fourth Day’s Breakout Session Topic (Thursday, April 7, 2016)

On Thursday morning, April 7, 2016, at Dondero’s Restaurant at the Grand Hyatt Kauai, the breakfast breakout groups will assemble. 

The assigned topic for discussion is the following quote of the Doctor Mark E. Clasen from the Third Charles E. Odegaard Lecture, “The Culturally Incompetent Physician” presented March 29, 1996 at the Seventh National Conference on Primary Health Care Access, held at the Williamsburg Inn and Lodge, Williamsburg, Virginia.

Dr Clasen will be memorialized at the 28th National Conference on Primary Health Care Access, on April 10, 2017 at the Hyatt Regency New Orleans.

Mark Clasen, MD, PhD

Mark Clasen, MD, PhD

“[Health belief systems] guide many of our personal decisions in matters of health and illness. These belief systems also guide our notions of adherence with medical authority, or with the teachings and beckonings of health providers.

“An entire hour could be devoted to issues of compliance or adherence; yet, we as healthcare professionals know that most compliance occurs in the milieu of a trusting relationship that is culturally competent. In this major thrust, that creating a real change in behavior, occurs best when the message is negotiated in one’s own language, articulated with the proper mixture of science, theology, and always love. There is little doubt that a culturally competent care giver is more valuable than the high priest of technology who possesses 100% knowledge to heal, but who lacks the human translation about how to heal.

“Does the title of this presentation suggest that our medical school graduates are inadequately prepared to deal with a diverse population? Does the title imply that interpersonal skills are not fully developed or as finely honed as they should be by graduation? Does it imply that 20th century physicians have been egocentric, dogmatic creature and practitioners of the art? Does it imply that 20th century physicians have not made tremendous strides in conquering disease and delaying premature death? The title was not selected to caste blame, shame, or dispersions on 20th century medical education, it was selected to look forward into the 21st century – pondering the questions about what knowledge, skills, and attitudes are needed to equip the 21st century physician. What types of educational activities will prepare the medical student of the future to enter this profession, and what are the threats and promises of such a career?

“To loosely paraphrase an old adage: ‘a physician is frequently in error, but never in doubt.’ For those in the audience who are not physicians, I want to assure you that ego strength is required to deal with pain and suffering, and demands a decisive, take charge approach, and is more egocentric than George Patton, especially when life and death matters hang in the balance.

“As a consumer of healthcare, we prefer to be clients or customers when the issues are superficial. However, when the issues are weakness, being sick unto death, being rendered helpless, we more likely want to be a patient of a loving, caring physician who will guide us through the storm to the shoreline of restoration, health, and well-being.”

The Assigned Discussion Groups

Group One (Freeman, Lead; Pugno, Scribe; Allen, Boltri, Chiang, Erickson)   

Group Two (Christman, Lead; Norris, Scribe; Babitz, Baird, Bejinez-Eastman, Clarke)

Group Three (Flinders, Lead; Partlow, Scribe; Buller, Crawford, Goodman, Smith)

Group Four (Burnett WH, Lead; Rush-Kolodzey, Scribe; McGaha, Means, Renteria, Sawyer)

Group Five (Wilke, Lead; Flores, Scribe; Burnett (Lee), Hansen, McKennett)

Group Six (Haughton, Lead; Carriedo, Scribe; Fowkes, Norcross, Osborn)

Group Seven (LeRoy, Lead; Woolsey, Scribe; Herman, Lee, Spalding