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 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).