This archiving and publishing of the proceedings of the fourth plenary session of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):
Sandral Hullett MD, West Alabama Health Services, Selma, Alabama [Dr Hullett is a Fellow of the Coastal Research Group]: I would like to say hello again and that I’m very happy to be a part of this panel. I chose to be last because I knew that both speakers that we had before would cover many of the issues that I would be concerned about.
The issues of access to care for minorities overlap for all minorities, so the same issues are raised over and over again. The availability of providers is an issue. Having facilities where the care can be given is an issue. How people get to those facilities is an issue.
One of my special concerns is the sensitivity to minority needs of the training programs that the providers are trained in. I graduated from a family practice residency training program that I thought was very sensitive to the issues of the area. I’m from Alabama, but went to medical school in Philadelphia. I started interviewing out West because I really wanted to see the mountains and later come back home. I always wanted to come back home.
But then I thought, why should I train in an area that really would not be similar to the area where I planned to work? So I changed midstream and came back home to interview in the South and then ended up through the National Residency Matching Program in Alabama. I was one of the first women in the program and the first minority woman. I think that probably was a good thing to happen to me.
But as I look at the residents who come through the program now (and I work very closely with that program), I’m really surprised. There are now no minorities at all in this residency program, nor have there been in the last three years. The residency program faculty state they do not have a pool of minority applicants form which to choose. I am concerned about that. But then the majority of residents chosen who supposedly will be working with all people lack a great deal of sensitivity to what the issues are for minorities.
I even had, for the first time in working at my site in 11 years, a physician who was actually attacked by a patient. It was a situation where the patient was Black and the doctor was White. But the issue that caused this problem was truly a lack of sensitivity. If the person had really been instructed a little bit more in the residency program, I think, even if that person did not have common sense (which the person didn’t have), it would have helped a great deal.
My issue with the residency program is faculty orientation. I’m concerned about faculty just as much as I ma concerned about residents. If the faculty members do not have direct contact with the people for whom they are training the residents to become involved with, I think we have a great deficiency.
How many faculty people are going outside of their offices or outside of the group of patients who come directly into their facilities? I think this is something we need to look at.
Another issue of concern are the actual training hospitals that we have. Are we all using public hospitals? Are we using a combination of public and community hospitals and private hospitals? I think we need to use all of them, so the students and residents can have a mixture of all. They should not have just public hospitals. There should be a mixture. Again, this helps us to deal with that issue of culture sensitivity.
Another area of concern in access is that minorities usually use public hospitals. There is a mentality that exists in public hospitals. I call it the “clinic attitude.” IN our area we don’t’ call any of these public facilities “medical centers.” We call them “clinics.” People get “clinic attitudes” even though there are some marvelous clinics – Cleveland Clinic, Mayo Clinic.
But the majority of the country, not just the minority patients, are not accustomed to that word “clinic” used in the positive ways. Special people go to Mayo and Cleveland! The rest end up with this “clinic mentality” which affects the way the care is being delivered affects whether the patients follow through and continue to come.
Rural hospitals are very, very important. In this country, and especially in the Southeast, a very large number of the minorities live in rural areas. The aged especially live in rural areas. We see a large number of public hospitals, both rural and urban, that once primarily delivered care to the minority people in the area, which have closed.
Even more are closing. This will cause a major lack of access to care and is something that as health care providers, administrators, and policy makers, we all should pay attention to, because these places have historically served the underserved and will continue to serve the underserved if properly funded and staffed.
Those are just some brief comments that I wanted to make. The other three speakers have covered many of the issues and I would like for us to have some time for dialogue.
Dr Midtling: This is directed at Hector. One of the things that I discovered as a residency director in California is that we’re dealing with a relatively short period of time, the time a student is in high school until we get him in a medical school. IT could be four years; it could be five years.
Over a ten year period of time, I saw students go from high school, to college, to medical school, to residency, and come back and practice in Salinas, the community that I was in. One of the really successful interventions was that of role models going into the schools, especially the schools that had very high drop-out rates.
We had a similar situation in Salinas where we had one school that had a drop-out rate in excess of 70%. I would like for you to comment on what you’re doing and what you see the place might be for that type of intervention. We’re trying to do that in Milwaukee, but we’ve done it only on a very small scale and I must admit with, I think, very little success. At least I think the opportunity to expand it is much greater.
Dr Flores: Those are good points. I think what we’re trying to do is: first, in a microcosm we, as a program and as an organization, have adopted certain schools. For example, the residency adopted three elementary schools and then all the junior high schools they feed into and the five high schools that they feed into.
So we’re making a long-term commitment, not only be there as role models and promote higher education in addition to health profession careers, but also to do the health education classes and other services that are equally important to the student.
Secondly, we work with the teachers directly to give them any kind of support that they need in order to teach the students and help hem to be critical thinkers. One of the things we do as we analyze the school we participate in is to sit in on some of the classes. A lot of what happens in the classroom is passive learning. You’re dealing with teachers who are either burning out or are working with very limited resources. So again, what we try to do is work with the school districts and identify some of the needs that we think are crucial for these students to have a better chance at succeeding. That is the microcosm.
In the larger picture, we realize California has dropped to 49fth in this country in state expenditures per capita on education. It’s a shame that the state with the most money in this country spends so little on education. What we try to do, then, is work with the larger institutions and the Department of Education in the State to start bringing some of these issues to the forefront. If need be, we will try to shame officials into taking some sort of action but we recognize we must be part of the solution ourselves, rather than just raising issues without doing anything about them.
It has to be a long-term commitment, because by the time we get to college, we’ve lost a lot of those kids already. Even the ones that go to college sometimes are not adequately prepared to succeed in that environment. They become the 7 to 8 year seniors, and have irregular progress many times in medical school as well. It’s going to have to be a long-term solution. There is no quick fix to this.
One of the biggest concerns we have that Sandral and others have mentioned is the dropping applicant pool of minorities applying to medical school. California is no exception. A study of trends over the past five years shows that the number of minority students in the applicant pool has dropped by greater than 20%. The success rate has not changed. Definitely, there needs to be a long-term commitment and we need to become part of it.
Dr Hullett: Something else we should consider is that while the number of students applying to medical school has decreased significantly, in the engineering department at the University of Alabama the number of very bright young minority students has increased significantly. One of the major reasons is that they have an outright push with a full-time recruiter to do nothing but get minorities into engineering.
And what are we doing in medicine? Are we doing anything similar? I don’t know of us doing anything similar in Alabama. I believe having a paid recruiter to do nothing but get the best students into the engineering while the medical applications are dropping. The medical schools don’t make that kid of a full, outright commitment to recruitment. We can send someone to the local schools and talk about the medical school program, but we don’t aggressively look for these young people. That’s something else we need to consider.
Dr Gessert: My question is for John Arradondo. (I was intrigued by your fairy tale of “Dodge City!”) In view of the urgent need give us your judgment of what the principles were that really made significant success possible. I am thinking particularly of the success around utilization and emergency rooms.
Dr Arradondo: This was a fairy tale that has an address. I am talking about Tennessee. I am talking about 1984-85 in Nashville. The Tennessee Association of Primary Care, which was principally an association of community health centers, decided to go after a grant to form an HMO.
That was at a time when we had six or eight years of priming the local government through the Tennessee Primary Care Advisory Board, which I had chaired, which advised the governor and the director of public health in the state. We formed a program called Medicaid Plus. There were some subsidies in the initial organizational planning phase. I had an opportunity to sit on the medical advisory board of that organization, although I knew that my academic institution would probably be one of the providers.
The organization decided that it would use a kind of independent practice association model, since it had contracts with each individual provider or group of providers. What they negotiated with the State Department of Health and Environment, Medicaid Section, was a contract for 95% of the funds that the Medicaid division had thought they would spend during that current year.
They focused on the people who were recipients of Aid to Families with Dependent Children, which was a moderate user category compared to people who were on the Medicare side of the grandparents who were taking care of children who made them eligible for AFDC. I guess there were, as I recall, 160,000 eligibles in the state. The average eligible had gone to the physician the previous year 3.9 times at a take of about $27-29 per visit to the physician, whereas the physicians bill was about $43 per visit. So they were getting form 60% to 2/3 of what they were billing for.
They chose to start in a small town in East Tennessee and after they had some experience there, the next town they would expand to would be Nashville and then they would go to Memphis and Chattanooga.
They had some modest enrollment goals that they wanted to achieve. In Nashville, for instance, they wanted to have 2,000 enrollees within the first six months or so, and they achieved that. Then when they went to Memphis, where they wanted to enroll about 10,000. Although they were delayed going into Memphis, they did achieve that. Then they went beyond those numbers in Nashville and met their target in Chattanooga and then a small county in east Tennessee.
All of those added up to somewhere between 15,000-20,000 enrollees. In Nashville, the eligibles they had were around 20,000, so they were enrolling a small number of the eligibles. But then not all of the people eligible for the services had used Medicaid services in the previous year.
They were very clear about the voluntary aspect. The client had a list of providers. The client would choose and the client would sign on for a year. If the client moved and there was a provider nearby or if the client preferred a new provider, it was easy to change. But the intention was that people who were providing the service would market this program to their patients. Rather than taking the 3.9 visits at $27 per reimbursement, the physician would opt to get this person to enroll and receive $5 per month for this person, which is $60 per year. This, participating providers were guaranteed $60 per year without having to bill (although there was a routine alternate billing to do a quality check.
Even though prepayment had replaced fee-for-payment reimbursement, those records from the alternate billings would be compared. A few people felt they would do that since who would determine if some providers’ patients were high users and others low users. A number of people did, in fact recruit some of their patients. The Meharry Medical College did that, and a couple of smaller primary care clinics, one of which was in the housing project most nearly like “Dodge City” except it was several blocks south, and, rather than being 97% Black, it was about 18% Black.
The traditional patterns of Nashvillians, where they would live, was demonstrated in the different demographics of those tho housing projects, either of which actually could be called “Dodge City.” There was a private kind of health clinic ultimately funded by 330-331 funds. “Dodge City” which was right on the edge of it had a public health clinic that operated about four days a week.
That was the setting in that part of the city where this small practice existed (a building that had about 6,000 square feet on one floor, a number of exam rooms, a common room in the middle, and a multi-purpose room in the back). Actually, it was set up to be a teaching practice, should the university want to use it for that purpose. But the five of us set it up with the permission of the medical practice plan. (Individual faculty members were permitted to set up a practice to set up a practice that was not controlled by the medical practice plan fully.
Certain payments would be made to the medical practice plan pursuant to income and other factors. These were the practices in which the medial practice plan didn’t invest very much for the start up and had a modest return. It was a “win/win” project. Five full-time faculty members who used a part of their time to run a part-time practice were running this practice at about 2 FTEs, if you added up all of our time. We had psychologists and social workers. OF course, we had medical assistants and nurses.
We had a few other health providers who came. There was a dentist upstairs. There was a laboratory upstairs – a professional laboratory. This was on Main Street. Two blocks to the north was a modest neighborhood of four by four blocks of single homes and duplexes or triplexes and then a few small apartment buildings of 6 to 20 apartment units – but all kinds of lower-middle class and upper-lower class people, in an ethnically mixed, but increasingly Black, neighborhood. Four to five blocks to the northeast was “Dodge City,” which covered an area of about seven blocks long by about five blocks wide. It shared a basketball court with a new 5th through th grade middle school that had been established pursuant to a 29 year old NAACP court case that was settled by a consent decree. The middle school had as an admission policy, a ratio of two Whites to one Black.
There were other criteria. You had to be gifted and tested or recommended or your parents had to believe you were gifted. Those were the three ways you could get int. The waiting list, obviously, was white in Nashville which has only about 30% Blacks, 8% Hispanics and Native-Americans. That was kind of a new development in the neighborhood. But the rest was kind of like “Dodge City” and then what is right next to “Dodge City” – Oprah Winfrey’s dad as a matter of fact. That was kind of the neighborhood. IT had its pluses and minuses. All of that was just a few blocks north of Main Street, eight blocks east of the river, then blocks east of the Capitol.
Those people went to the practice voluntarily, because it was there. They didn’t recognize me or any of the other four practitioners. A few of them recognized my name, not many. A few of them recognized the name of one of our practitioners because in another practice of his located against the number one community hospital in the city, had recognized him as the doc who had an ad on the back cover the the Yellow Pages.
If I were to call him right now all I would have to remember is 800-HELPDOC, and that’s his number. I can dial that number wherever I am in the country and I can get him by telling them that I am Doc Arradondo. They recognize my name on his switchboard. But anyone of you could dial him and you would get some assistance and he would tell you where to get care wherever you happened to be. It was aimed at local people but it is a national 800 number. So they recognized him and a few people came to that practice because of him, but basically they came to the practice because of where it was located. A beautiful upscale practice!
After we had been there six months, 12 members of the Tennessee General Assembly out of 99 m embers were our clients. Nine members of the House and three members of the 33 member senate were our clients. Almost half of these people were Black but not all were. We had other people who became clients, from the historic Edgefield neighborhood. We had clients where the current mayor lives. So it was a mixed practice of about 30% Medicaid, including these patients, and about 25% to 30% Medicare. The rest were basically Blue Cross/Blue Shield, but with very few self-paying patients. The practice was about 50%-60% Black. We provided a fair amount of prenatal care.
We, in this particular practice, provided the services since we decided that since these people were coming to us because of where we were located, not because of who we were, that maybe we could get them to buy into what we were doing. So we set out to do several things right away. Anytime a person would call, we would make sure that we would return the call right away. Our guideline was 15 minutes. The HIO’s guideline was soon.
Our first six months, it turns out, was seven minutes by their clock. All that was required was that it be less than 15 minutes. So the first thing the people discovered was that if you called one of us, you got an answer back right away. At that time I didn’t have a phone in my car, but I had plenty of quarters and I knew here the pay telephones were as I was driving from East Nashville back to Meharry of from my home in the west part of the city to wherever I would come in the central part of the city. All of us did the same thing, including the two members of our practice who did have phones in their cars.
When people would go to the emergency room, we would always make sure we talked to the patient unless the patient was super sick – in trauma for instance. We should always talk to the patient, just as if the patient had called us. That, of course, set a precedent among the emergency rooms. They quickly learned that the approval for admission and for services lay with the designated physician.
We could have let them come under the emergency clause and the HIO would have paid for it. But the idea was to contact the patient. What a more wonderful teachable moment than the moment when the person says I want service and I want it now. Here is some ignoramus professional provider saying, “I need to talk to you.” We did it in various ways. It was amazing how happy the patients were to talk to us. They weren’t getting talked to by the people in the emergency room.
Rather quickly the people in the emergency room learned who we were and learned that when the patient came in with a pink card, that meant Medicaid Plus, as opposed to the green card that was regular Medicaid. There was somebody who was going to be calling. Typically, it was the person whose name was on the card. But they knew somebody was going to be calling and that’s how we began to educate people in the emergency room and in the admissions sectionof the public hospital, the three small community hospitals, and the very large No. 1 community hospital which also got a few of our clients.
Of course, we would almost invariably tell the patient to go ahead and get service or get the patient to make a joint decision.
Would you believe that in the first 32 times I did that, that 18 of the patients decided to leave the emergency room and to come to my office the next day, including one on a Sunday morning? We weren’t open on Sundays. We were open a half day on Saturday. But I dutifully met that person there before church. That impressed her.
She was about a 45 year old lady taking care of two of her grand kids. It just impressed her no end. Needless to say, I wouldn’t’ want to set that as a precedent. I had other things to do on Sunday. But that was the characteristic of the five person practice. We would really go over backwards to meet the patient. We were marketing to them.
Initially, 306 people signed up. Before long we were at 700. Before the end of the year I had 1000 that had my name on it and I think our total was about 1400-1500. It ended up being almost half of the numbers in Nashville, drawn mostly from “Dodge City” and secondarily from the neighborhood center and a few people who were living in private areas but who were on AFDC.
Those were some of the things we did. We tried to get people in to teach them things. There was more health education literature in our office than you could shake a stick at. In fact, I guess the fire marshall probably would have declared it a fire hazard if he came by to approve the premises, after we got going, rather than before. In all the rooms, in the waiting room, on the TV, was all the health education literature that we preach in family medicine. The place was nice and plush and people loved it.
Dr Gessert: One detail on that. When the patient arrived at the emergency room, would you be talking to them on the phone before they were seen?
Dr Arradondo: Whatever the procedure of that emergency room was. If the admissions person in the emergency room figured out that this was Medicaid Plus patient and knew what that meant, she would call. Of course, it surprised the emergency room staff that we would be calling back in such a short period of time. Not just the patients! It surprised them because we would call back just as rapidly for them as we would for the patient.
But sometimes they wouldn’t see that. They would just see the number and they didn’t realize what the pink card meant, didn’t read it, hadn’t been oriented although the HIO had visited all of the hospitals and had agreements with most of them in principle, not in writing. They would send the person on back to wait or to get lab or whatever the procedure was. Sometimes people had seen the nurse of the doctor before they would call us. I talked to a number of physicians, some of whom took umbrage at the conversation.
But the payment mechanism was very clear. I had to O.K. it. IT was as simple as that. I didn’t mind them giving care if they thought it was necessary. If I agreed, I would sign off. And the HIO could overrule me at any time before or after I spoke. But I exercised that quite routinely and that was the most educational matter.
The orientation given was fine, but after a couple of calls from one of my colleges, the people in the emergency room knew about the “pink card” and they knew what it meant. They would call us then fairly early. When a new employee would come in, they would go through the old procedure. IF somebody had been on vacation, doctors and nurses would get on their case because the doctors knew quite readily what all that meant.
In many of the small hospitals, the ER was contracted out and the doctor billed. If the doctor didn’t get his bill, that hurt his take. It was a very serious educational matter for the staff of those hospitals. After maybe three months we would get calls right up front from the admitting people in the ER. Also, we began to have fewer people going to the emergency room because the word began to spread, particularly in “Dodge City,” that these doctors were over here.
The practice had a little catchy name on it, and had a nice sing out front that had some family on it, plus the “digs” were nice – as good as any physician I’ve ever had and I’ve had doctors for 30 years. And the word began to spread. So we began to have people sign up. And people would come before they would sign up. We weren’t taking anybody just as a Medicaid patient in general. IF you came to us, we would sell Medicaid Plus vigorously if you were eligible, because we thought that was much better. The $5.00/month was predictable. We knew that you weren’t going to go to the hospital as often, because most of the hospitalizations were superfluous and unneccesary. So we sold it vigorously and I’m sure that the second half of our patient numbers were really referrals and a result of our marketing.
The first half were mostly people signing up because of where we were. But shoe were just some of the factors. Also, occasionally people would bump into one of the state senators or state representatives or somebody from historic Edgefield just up the way, or sometimes they would see the cars out front. They realized that they were getting the same treatment as everybody else. Or they would see somebody coming in dressed how we’re dressed here today and they were never dressed quite like that. It was amazing how many patients began to get all scrubbed. I used to have to tell some of them not to wipe away evidence. (You know how sometimes the patients get all fixed up for the doctor.) But we really tried to educate the patients. Many of them, when we changed the location of the practice, followed, which was at est of patient loyalty.
Mr Burnett: I had question of Jerry related to the efforts of persons who are trying in their region to increase the representation of underrepresented minorities. It seems that if one has an ongoing strategic organization like the Chicano organizations and support groups in training institutions and schools, why it’s fairly easy to get more resources to Hispanic students. There are also similar Black organizations.
The question for the Native-American, is ti possible or appropriate to be pro-active there and does a group like the Association of American Indian Physicians have programs ongoing that some of us aren’t familiar with yet?
Is it logical to, for example, to be working with say, Morongo Valley Health Clinic which has a nearby residency program, and to be thinking in terms of trying to get Banning High School which has a large percentage of Morongo Indian students to try to build some program there? Do you have to wait for there to be an equivalent of Hector in the Morongo community or can one do something about it if you come from a larger society?
Gerald Ignace, MD, American Association of Indian Physicians, Wauwatosa, Wisconsin: As far as trying to recruit students, presently the Association of American Indian Physicians [AAIP] is one of, I think, two groups active in doing that. The other group is the INMET program for nursing.
The AAIP does have ongoing programs. Primarily, we hold three or four workshops for undergraduate pre-medical students every year, each workshop consisting of about 30 to 35 students who are interested in health career opportunities. These are rotated around the country to try to incorporate different regions so you don’t leave certain folks out.
In these workshops there is a two-day session about the steps you go through to get into medical school, including mock interviews. I think these have been successful. We have been doing this for over ten years. On occasion, the budgeting is limited and the budgeting tends to be decreased every time we get near our goal.
We have been able to, on a limited basis, go to those Indian reservations which have requested support for a health careers day or associated activities. Limited staff and budget restraints impede progress in this area. Part of the problem is that the Indian country is so diverse and so scattered with so many small communities that for them to be able to put together a program is often not really feasible. It is the larger tribes that do.
Sundwall: I just wanted to comment. Everything I heard from all of you underline the failures of the system of health care. Although they were culturally specific, there were problems with the system making it unfriendly to the minorities in particular.
I”ll just quote from a Bob Heisel lecture which impressed me. In Baltimore, after the passage of Medicaid, there was concern that the infant mortality rates were still high, even though Medicaid was available for all. The decision was made to survey the Medicaid cardholders.
These are the kinds of comments that those conducting the survey received. That the Medicaid cardholders regarded the Medicaid card as a very valuable piece of property because they used it for check cashing, food stamps, and incidentally for securing drugs.
These are some of the reasons they stated as to why they didn’t seek care: “They didn’t know they were supposed to.” “They were afraid to tell their mothers.” “They were afraid they would get kicked out of school.” “They were afraid of the large institution; they were afraid of doctors.” “They had a bad experience in clinic.”
Heisel’s point is that unless you have a culturally sensitive, user-friendly delivery system, that’s less threatening and more appropriate to the community environment, all the money in the world doesn’t help.
This presentation was preceded by: First National Conference on Primary Health Care Access (4th Plenary Panel, Part 2, Flores).