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 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.
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).