Jamie Osborn, MD

The Twenty-first National Conference on Primary Health Care Access will feature initiatives in several states, including a series of roundtables relating to the State of California. (See: 21st National Conference on Primary Health Care Access April 12-15, 2010 in Kaua’i.) One of these will explore “mission-oriented” residency linkages with innovative models of “health care delivery”.

Over the years, the National Conferences have highlighted various innovations in physician residency training in settings that both promote primary health care access for underserved populations and teach them how to provide care to such populations in ways that are culturally sensitive and cost-effective.

Yet, even though such strategic initiatives can be demonstrated as successful, they tend to be financed by disparate revenue streams and may be simultaneously subject to conflicting regulations. Even if one imagines that the follow-up to any federal health care legislation that should pass might prove to be a positive factor for such initiatives, nothing is presently certain.

This roundtable will discuss several innovations that held great promise, some of which are unambiguously successful and some of which are less so.

Doctor Jamie Osborn, director of the Loma Linda University family medicine residency program, will update the successful rural-based residency program in the Central Valley town of Hanford. She will relate her residency program’s transformative experiences with the Patient Centered Medical Home, which she believes has demonstrated its capacity to provide “whole person care”.

Charles Vega, MD

Doctor Osborn will begin a discussion of the positive and negative issues relating to the Community Health Center and Medicaid Health Maintenance Organization models of primary health care delivery. She will be joined by Doctors Charles Vega and Ana Bejinez-Eastman.

Doctor Vega’s residency program at UC Irvine has one of the longest track records of any physician training program located in a federally qualified health center, this one located in the center of Santa Ana, one of California’s largest Latino communities. An extensive discussion of Dr Vega’s outreach program may be accessed at: University of California Irvine’s Family Medicine Residency Program: Outreach to Orange County’s Latino Community.

Selected Interviews from the Coastal Research Group’s Studentdoctor.net website.

This interview was conducted by William H. Burnett and first appeared 10 November 2008.

This is the second interview in the Student Doctor Network series of “community-based medical education” interviews.

(See the previous interview with Gerard Clancy, MD, the Dean of the newly established University of Oklahoma (OU) School of Community Medicine in Tulsa.)

The A. T. Still University School of Osteopathic Medicine in Arizona is located in the Phoenix suburb of Mesa. The structure of the school differs from that of other medical schools in having only the first year of medical school in Mesa, and the remaining three years for each student located in one of 11 participating community health centers.

SDN interviewed four members of the A. T. Still University faculty in Mesa.

SDN: Doctor Wendel, as Associate Provost of the A. T. Still University, please give us an overview of your new community-based medical school.

Dr Wendel: Our understanding of the need for a new medical school grew out of a relationship the A. T. Still University had developed with the National Association of Community Health Centers (NACHC). We realized that there are an estimated 50 million people in the United States with unmet health care needs.

There has been a lot of lip service to the idea of medical schools preparing students to meet that need, but not a lot of programs designed to address unmet needs as part of the educational program.

We plan to recruit people from the community and strengthen their ties to the community in which they were raised. We educate the students we have recruited about the missions and goals of our community-based medical school from Day One.

Because three clinical years are spent in the Community Health Center, we believe that the students and their families establish roots in the communities.

SDN: When doctors graduate from your school, what happens during their postgraduate years?

Dr Wendel: We do expect challenges in this area. Although some residencies exist with compatible goals, it is an open question whether there will be funding for creating more residency positions specifically designed to deliver care within community health center facilities.

That said, our graduates will enter residency programs with far more experience with chronic disease than students educated in most tertiary care-oriented academic health centers. Tertiary care is important, but the great majority of health care is the non-acute treatment of diabetes, hypertension and depression.

As an osteopathic medical school we add public health interventions. And, we are, in fact, a campus with a complex of health professional schools, each committed to interdisciplinary training. We all believe that having a health care team improves the health care system, but there are few places where one can model interdisciplinary health care for medical students. We believe that in most community health centers (CHCs), the interdisciplinary model predominates.

SDN: How did you choose the CHCs that are your partners in this educational program?

Dr Wendel: We started with several hundred CHCs, and developed a sophisticated screening process through which we chose a group to work with directly. We conducted site visits and, utilizing criteria to rate the CHC’s dedication to education, its community ties, its administrative support and the available space, we selected 11 CHCs for the program.

SDN: Dr Kasovac, as a member of the medical school faculty, how do you envision the first year of the A. T. Still University – School of Osteopathic Medicine in Arizona (ATSU-SOMA) in Mesa, Arizona differing from a typical medical school?

Dr Kasovac: The first year will take place on the ATSU-SOMA campus in Mesa, with all of the freshman class taking courses together. All courses will be part of a “clinical presentation” model curriculum, which we adapted from one developed in 1994 at the medical school in Calgary, Alberta, Canada

SDN: Can you describe what a clinical presentation model curriculum is, and how it works?

Dr Kasovac: Unlike the typical school first year, where students take separate courses in the basic sciences – anatomy, physiology, biochemistry, microbiology – the course content will integrate all of these sciences around specific clinical presentations from the very first week. There are approximately 120 clinical presentations that patients go to see a doctor about, such as cough, headache, back pain, chest pain, upset stomach, etc.

For example, during the first year there will be six courses, which will include Principles of Medicine, Musculoskeletal, Neurosciences, Cardiopulmonary, Renal and Endocrine.

SDN: It sounds like you are well along in designing the curriculum.

Dr Kasovac: Yes, there has been considerable work by our faculty. We have had the assistance of the physician who developed the original curriculum in Calgary, who is here for a one year visiting professorship.

Some aspects of the model have been tried at two other osteopathic medical schools, and is expected to be tried at one new MD medical school, but the ATSU-SOMA program is going to fully implement the model with all of the last three years of medical school occurring in one of the 11 participating CHCs, to which Dr Wendel referred.

SDN: Professor Nayeri, you will be coordinator of one of the 11 clinical sites, based at Phoenix Community Campus. What happens in the second year to the students that will be at that site?

Prefessor Nayeri: There are several notable differences between the typical second year medical school in the 2+2 model and the curriculum requirements for ATSU-SOMA students, with the community health centers and population-based medicine being central to the unique differences.

The SOMA students will spend sixty percent of their time in small group didactics, orchestrated by the main campus. There will be substantial use of electronic media, including PowerPoint and schemes, supplemented with lectures. The School of Medicine faculty at each site will facilitate the students’ learning by leading structured small group case presentation and discussions.

Our medical students receive course-specific cases, utilizing the Case Presentation (CP) method to deliver didactic education that integrates basic sciences and facts, i.e., anatomy/physiology and pathophysiology, histology, embryology, biochemistry, immunology, pathology, pharmacology, and nutrition.

Another educational opportunity that sets us apart are the weekly CP, related to the courses of study in Osteopathic Principles and Practice followed by laboratory where the medical students receive hands-on training.

The on-site School of Medicine faculty, beyond leading the structured didactic presentations, will act as academic advisor to the medical students, and will recruit and oversee the clinical adjunct professors who will observe and train students in patient care activities.

SDN: Doctor Simon, you have administrative responsibility for evaluation of students’ academic performance, faculty, and the medical school curriculum. Will there be ongoing feedback from the 11 clinical sites on the clarity, quality and relevance of every lecture and every PowerPoint.

Dr Simon: Yes, and that is only one aspect of the evaluation processes. Each student’s progress will be continuously evaluated.

SDN: Describe how students will be evaluated.

Dr Simon: Over the course of the four years, we will use a combination of many traditional methods of evaluation – examinations of students at the midpoints and the ends of all courses.

We will look at individual skills, coupling them with evaluations that are more non-traditional. In the very first year, the students will have structured encounters with a number of standardized patients, and they will manage a number of patients that are represented by the human patient simulators.

In regards to the basic sciences, we want students to demonstrate a grasp of concepts in the most concrete way possible as soon as possible. These early clinical type encounters not only allow them to demonstrate their “book knowledge” and “hands-on” skills, but also the interpersonal skills required for dealing with difficult patients.

Once the students leave campus after the first year they will have a combination of a half -week of didactic coursework in the mornings that will be evaluated by both written and practical exams.

The clinical work in the afternoon will be evaluated daily by their preceptors, much like a traditional third year student. There will be a 360-degree examination from their onsite facilitator.

The 360-degree evaluation will gather information from each student’s clinical preceptor, from nursing staff, and from support staff. Patients will be asked to complete satisfaction surveys. Feedback will come from a much wider group than the physician evaluations that are typical of traditional medical education.

Students will take the “shelf exam” at the end of each year, although any deficiencies in skills will be exposed much earlier. Their onsite evaluator will be observing them in patient encounters taking histories, doing physical exams and providing patient education.

We think that we will have a lot more data to pass along to the residency programs to which they apply. We will have all the quantitative data, such as test scores, but we will have more qualitative data, from the first year exams and the onsite evaluators on interpersonal skills, staff and professional colleagues.

SDN: Let’s return to what happens in the second medical school year.

Dr Simon: The second year for students, regardless of the site to which they are assigned, will consist of an integrated clinical experience (ICE).
Its objective is to provide that core clinical education which is essential to the professional development of every medical student, regardless of his or her eventual choice of specialty.

Each student will have assigned community-based projects that will focus on health professions and wellness.

The individual clinical adjunct faculty members are the students’ clinical supervisors. The clinical patient care activities will comprise about 40% of the second year students’ time. Every student’s clinical activities will include broad training in family medicine, internal medicine, pediatrics, OB/GYN, behavioral health and Emergency Room.

The second year students will be involved mostly in shadowing, and preparing for their third and fourth year clinical preceptorships. However, all students will be assigned ten patients that they will continue to see over the next two years of their medical school training.

By the third and fourth year of medical school, through their preceptorships, the students will be engaged in supervised clinical practice.

SDN: Doctor Nayeri, since you are coordinating the Phoenix Community Campus, please give us some background on the what the medical students based there will experience.

Professor Nayeri: The medical school has established a successful partnership with Clinica Adelante, Inc., a community health center which will be a model of inter-professional medical care and practice. The collaboration fosters medical education and will result in an increase in the number of potential osteopathic physicians who will probably serve in the rural areas caring for the underserved, farm workers, as well as suburban constituents.

This is a wonderful opportunity for our students to gain exposure to a diverse population, each with their own subsets of cultural values, including the Latino/Latina and American Indian communities.

SDN: Would you elaborate on the access issue?

Professor Nayeri: There are remarkable disparities among certain ethnic groups in our communities in accessing healthcare. Historical data show that some members of the lower socioeconomic status and disparate population have higher incidents of morbidity and mortality rates compared with the general population. For example, the average life span of an American Indian is significantly lower than that of the general population. The Hispanic males delay accessing health care and thus present with more severity. These are but a couple of examples of the risk factors that our medical students will have the tangible opportunity to learn about.

SDN: Will the students at the Phoenix site be given special training in delivering care to American Indian and Alaskan Native populations?

Professor Nayeri: Our students may choose to explore the opportunity to gain competency in a number of cultural subsets and the unique challenges in delivering care to them, including the American Indian/Alaskan Native people.

SDN: How will your medical students be involved in addressing these access problems?

Professor Nayeri: The second year, in addition to continued didactics, as mentioned earlier, includes Early Clinical Experience where students are immersed in community health centers in the greater Phoenix area and Central Arizona, when they will focus on health promotion/disease prevention. Medical students in year-two will begin to apply their knowledge of basic sciences acquired through integrated case presentation method and schemes, along with clinical reasoning and skills, in utilizing proper medical attention, that prevents acute episodes within a chronic disease, such as diabetes or cardiovascular disease, and further complication sequlae, hence improved quality of life – wellness being the focal point of the year-two ICE curriculum objective.

SDN: Describe the third and fourth medical school years.

Professor Nayeri: All of the education during the first two years have prepared students for the third and fourth year clinical preceptorships. They are taught basic sciences, OCSE, clinical reasoning and medical skills, beginning in their first year. In second year, they are assigned longitudinal patients, perhaps a family unit, and by knowing the family, the community, and the health care institution in which they are based and given this wraparound background they begin their early clinical experience.

We use the RIME model, on which there is considerable literature. RIME stands for R (reporter) I (investigator), M (manager), E (evaluator) for each progressive phase of the clinical education to systematically train the students, based on their demonstrated knowledge, skill, abilities and other professional attributes at corresponding level when they can diagnose, manage and treat the patient using evidence-based medicine.

At our campus there is an opportunity for students to learn to provide health care to underserved and underinsured persons whose health care delivery has often been like that of the third world countries. An ongoing criticism of medical school students providing care to underserved populations, is that they learn the skills they need and leave, rather than becoming involved with the community and staying there to serve. The common perception among the underserved areas such as Indian reservations are that scientists show up to do studies, publish their findings, get academic promotions back at their institutions, but never give anything back to the community that benefited them. The community sees such behaviors – whether by medical students or their professors – as “taking” and running.

SDN: What will your medical school students do to leave a different impression?

Professor Nayeri: Our CHC-based students will learn from the community, with this difference – that they are especially recruited and encouraged to pay back by caring for the underserved in rural areas of the United States.

SDN: It seems that some of your sites will be good places to learn rural health care.

Professor Nayeri: There will be opportunities at select Indian Health Care Delivery System sites where our medical students will be able to select individual rural experiences. For instance, one particular Indian reservation comes to mind, that due to its isolation and location can only be accessed by pack mules, on foot or by helicopter.

SDN: Does the traditional holistic preference of some osteopathic medical schools resonate with certain ethnic populations your medical students may be serving?

Professor Nayeri: Our four year curriculum integrates the “whole person approach” – embedded in our mission as “Body-Mind -Spirit” – which is the foundation of the osteopathic approach to medicine, and is a traditional theme in the history of ATSU, whose venerable Kirksville, Missouri campus has deep roots in the osteopathic medical profession. The philosophy of the school, in my opinion, is complementary to the holistic spiritual beliefs across cultures, including that of the American Indian and Alaska Native communities.

SDN: How will this “whole person” medicine translate into the medical student’s broader education.

Professor Nayeri: Our medical students will have a chance to appreciate the day-to-day interdependent operational aspects of a clinic as they train with physicians, interface with interdisciplinary clinicians, patients representatives and other staff. The students may further be invited to meet the native healers and may have the opportunity to participate, by invitation from the community, in native ceremonies.

Most physicians, during their medical education, do not get the perspective on how and what the doctor does impacts the community and the other team members.

SDN: Will special attention be given to medical school applicants from American Indian and Alaskan communities.

Professor Nayeri: Yes, ATSU is invested in recruiting American Indian/Alaska Native applicants, as well as those applicants with demonstrated commitment to serving the underserved and rural areas. This year, ATSU graduated the highest number of Dental Students with Native American backgrounds of any health professions school. The Physician Assistant (PA) program graduates about 20% of the nation’s Native American PA students, and the School of Medicine proportionately has a high percentage of Native American medical students.

Traditionally, the third and fourth year clerkships in the affiliated hospital(s) have had medical students, during the year, at different rotation intervals, from a variety of settings. We have found already that the students from the CHCs have exhibited much higher skill levels than the traditional medical student.

SDN: Thank you.

Selected Interviews from the Coastal Research Group’s Studentdoctor.net website.

This interview was conducted by William H. Burnett and first appeared 9 April, 2008.

(Subsequent to this interview, Dr Clancy assumed the presidency of the University of Oklahoma, Tulsa Branch)

With this interview, Student Doctor Network begins a new series of interviews relating to “community-based medical education” and with it a new forum on this subject. To launch the series, we interviewed Gerard Clancy, MD, the Dean of the newly established University of Oklahoma (OU) School of Community Medicine in Tulsa.

SDN: Dean Clancy, how do you envision your School of Community Medicine in Tulsa differing from a typical medical school?

Clancy: First, it is important to recognize that all the students in OU’s Community Medical School in Tulsa will graduate with the same MD degree as the students in OU’s traditionally organized medical school in Oklahoma City. They will learn the basic core information about medicine that they need to be successful as a physician.

But the information will be organized and taught in an entirely different way. Instead of being as a group of discrete subjects the subject matter will be organized around the principals of population medicine and community medicine.

SDN: Would you define those terms for our readers?

Clancy: Sure. Population medicine looks at the frequency of diseases and rates of mortality by disease, either for the general population or a particular subset of it (such as the residents of a geographical area, ethnicity, or income level). Community medicine would look at the disparities between one group and the population as a whole or perhaps another group.

SDN: For those persons not familiar with Oklahoma, is that a place where health disparities between communities are very pronounced?

Clancy: Although I am sure you will find health care disparities in communities everywhere in the United States, we were shocked when we began to study and then comprehend how great the differences in health status are from one part of Tulsa County to another. There is a high level of need throughout Eastern Oklahoma.

SDN: How will your medical school incorporate community medicine into the curriculum?

Clancy: First, we are recruiting faculty who are universally in agreement with the need to have medical students involved in providing care in communities of need from the earliest point in their education. We are collectively organizing a curriculum that “fast tracks” the students out of the medical school into community-based practice sites. As an additional feature, we will have a “loan repayment for service” plan that will give students the option for paying off their loans in a loan repayment system operated by the University of Oklahoma.

We have enlisted the help of experts nationally, and already have had retreats to develop our plans. Also, the new school is not being created out of thin air, but is being built on the existing University of Oklahoma medical school branch in Tulsa.

SDN: Are students to be involved in the development of plans for your school and its curriculum?

Clancy: Yes, OU medical students have been a driving force in creating the school. We have had high levels of student involvement in community health centers operated by the OU Medical School Tulsa Branch. They will continue to be involved in all the major elements of the plans.

SDN: Do funds exist to pay for all of these innovations?

Clancy: We have received a 50 million endowment, which includes 35 million to create endowed faculty positions, and an additional $15 million split between faculty recruitment and a loan repayment fund for the school’s medical students. As the school achieves success, and it will, we expect that our success will be recognized and our efforts supported by the people of Oklahoma and the alumni of the University of Oklahoma.

SDN: How will you implement these ideas?

Clancy: We are determined to select medical school classes that are truly interested in our approach to medical education – to learn the content of medicine, but to understand it in the context of the many factors that affect a person’s health. Those factors can include where the person lives, and how ethnicity, language and family situation.

SDN: Is there a way for persons interested in finding out more about your school?

Clancy: Yes, we will be very happy to respond to questions through the studentdoctor.net forums.

[ Visit the new SDN Community Medicine forum ]

Both myself and members of the OU faculty and student body expect to participate in the new studentdoctor.net forum on community-based medical education. We certainly will be interested in connecting with medical school applicants that share our vision of how physicians should be trained.

[The National Conferences on Primary Health Care Access highlight local initiatives throughout the United States that are designed to improve the health status of populations within our nation. One of the California's largest Latino barrios, in Orange County, has been served for the past 35 years by the University of California Irvine's family medicine residency program. Current initiatives will be discussed at the Twenty-first National Conference.]

Healthcare disparities faced by the Latino population in the United States have been shown to be related to access, language barriers, and poor communication. At the University of California, Irvine Family Medicine Residency Program, we have had success in addressing barriers to health care.

However, Spanish fluency and cultural knowledge among our trainees and graduates continues to fall short of the needs of our surrounding community. While nearly two-thirds of their patients use Spanish as their preferred language, only 20% to 30% of our residents feel fluent in Spanish. At the same time, half of the residents do not feel competent in cultural issues important to Latinos.

In response, we have developed a longitudinal resident curriculum in Spanish language and Latino culture that incorporates didactic sessions, “language lab” experiences in the residents’ clinic, cultural immersion experiences in the local community, home visits, and community outreach.

Multiple outcome measurements have been or will be employed to judge the success of our efforts. We have performed baseline assessments with 2 validated surveys which assess general patient satisfaction with their physician as well as examine specific cross-cultural skills pertinent to Latino patients. The baseline surveys provided some surprising results. In addition, the UCI Family Medicine Class of 2012 received a completely redesigned objective structured clinical examination, in which each standardized patient case emphasized Spanish language and issues of culture and disparities in patient care.

The most critical outcome to our project is the number of residency graduates who go on to provide high-quality, culturally-sensitive care for poor and disenfranchised Latino communities. Overall, the Health Education and Language for the Latino Community (HEAL-LC) project has the potential to be replicated throughout the country to better prepare physicians-in-training for a multicultural environment and improve health care disparities for Latino and other populations in need.

The concept of an “Educational Health Center” has evolved over several years as a result of collaborative process between the University of Washington School of medicine’s Department of Family Medicine (Department), Community clinics as represented by the Northwest Regional Primary Care Association (NWRPCA) with connection to the National Association of Community Health Centers (NACHC), and the University of Washington Affiliated Network of Family Medicine Residencies (Network).

In short, the concept is to combine the efforts and purposes of residency training and health center service in a more intentional model to serve the interests of both entities while expanding the network of service to the uninsured and the underinsured.

While these affiliations already exist in many forms between Health Centers (HC) and Family Medicine residencies across the country, the current regulatory and accreditation standards pose significant barriers to an efficient and economically sustainable co-location.  That it is accomplished in scores of programs and clinics is a testament to the effort and shared vision the leaders of those residencies and health centers maintain. In other words, it is hard to do and it is heavily dependent on the existing leadership on site.

The current idea is not entirely new.  However it started as a “new” idea in a Network strategic planning session.  Many of our programs and many FM programs across the country were facing economic challenges to their survival.  Approximately 10% of FM residencies had closed in the preceding 7 years, most for economic reasons.  We knew that most of the physicians hired by HCs were FPs and we all considered graduates working in HC practices as a success.

We also knew they had many unfilled FP openings and yet were slated to be expanded by Federal plans as the government’s official way to provide care for the poor.  We also felt that there was a strong overlap in the type of patients seen in residencies by social, insurance, illness, and economic characteristics. We knew the reimbursement for Medicare patients far exceeded our own in the federally Qualified Health centers and felt this adjustment could be a major help in stabilizing the economics of residencies.  We felt residencies had a lot to offer Health Centers in terms of training potential employed physicians, increasing the workforce in the “safety net” for our communities, and possibly stabilizing existing physician workforce in the HCs themselves.  This latter point of view came from our own experience of residencies either in HCs or with satellites in HCs.

We learned a lot! With support from the UW, faculty members performed qualitative research on the cultures of FMRs and HCs.  Structured focus groups run by Dr. Carl Morris explored administrative, economic, service, educational, personnel, regulatory, governance, and cultural issues in these groups.  This work has been published. In short, it revealed the same categories that had made us feel there was a good fit were the areas of barriers to collaboration.  It confirmed that there was a very similar view as to the potential benefits and alignment of values related to service and education.

However, the basic regulatory and accreditation rules posed conflicting measures of successful performance that were critical to each group’s fundamental purpose.  That is, direct clinical service to a defined volume of patients as versus successful provision of educational experiences that included service to patients but required significant elements other than patient service.  There were many apprehensions each group had about the other in terms of erosion of their core commitments and purpose if collaboration occurred.  These areas were explored and defined.

Dr. Morris, Dr. Frederick Chen, and others also reviewed our network’s history in future practice of our grads.  They found that residents trained in a HC environment were significantly more likely to work in a HC after training as well as much more likely to work in a health professions shortage area after graduation. These trends have since been confirmed by other residency networks with similar differences of training sites within them.

Finally, a varied group of residency directors, faculty, health center administrators, and others developed a concept each group could support.  It was felt that this type of entity could help supply an increased number of FPs for HC practice in the future, stabilize FMR finances, and simultaneously increase the role residencies play in “safety net” care in our communities.  It was appreciated that not all HCs and not all residencies could or would wish to transform into this new entity.  It was also appreciated that many legislative and regulatory changes were necessary to implement the Educational Health Center as we envisioned and defined.  A copy of this is appended in what we often call our “one pager”.

Recently, a close version of this was proposed in Senate health reform legislative language as the “Teaching Health Center”.  At the time of this writing, it has disappeared from the bill’s language but another bill creating funding for Medicare Pilots may allow it to be tried.  As you will note, key to this new model clinic working will be allowing GME funding to flow to it for the educational expenses.  Currently the GME funds flowing to residency training sites, or not, is totally dependent on voluntary agreements between the programs and their hospital sponsors.  To stabilize these new programs, a stable funds flow for the educational enterprise will be critical.

]]> http://coastalresearch.org/2009/09/forum-on-educational-health-centers/feed/ 0 http://coastalresearch.org/2009/04/discussion-points-physician-residency-programs-and-los-angeles-countys-safety-net/ http://coastalresearch.org/2009/04/discussion-points-physician-residency-programs-and-los-angeles-countys-safety-net/#comments Fri, 03 Apr 2009 23:35:09 +0000 CRG http://coastalresearch.org/?p=947 One of the scheduled presentations for the Tuesday morning plenary sessions at the Twentieth National Conference on Primary Health Care Access is by Doctor Rick Flinders of the Santa Rosa Family Medicine Residency Program. His topic is “The Family Medicine Residency as Change Agent”.

In preparation for the discussion panel that will follow Dr Flinders’ presentation, Doctor Hector Flores of the White Memorial Medical Center has developed graphical and visual representations of points he will be making about the development of new relationships between local government entities concerned with health care delivery to “safety net” populations and the White Memorial Medical Center family medicine residency program.

The following slides supplement Doctor Flores’ discussion.

Doctor Flores adapts a chart from the policy document Healthy People 2010

Dr Flores the overarching ideas behind key Institute of Medicine reports published during the past decade:

Doctor Flores discusses the major tiers of care in Los Angeles County.

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Dr Flores observes that Los Angeles County cannot properly be called a “system of care” – instead it might be characterized as a “non-system”.

Dr Flores then looks at the impact of public policy initiatives in the study area.

Dr Flores discusses the interaction of different “sectors” in providing care in East Los Angeles

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Dr Flores presents the following policy ideas:

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Dr Flores then raises the prospect of genuine health care reform taking place at the local level, incorporating a much wider group of providers and facilities than is often considered feasible in current policy proposals.

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October 17, 1993

Hyatt Regency Lake Tahoe Resort and Casino

Incline Village, Nevada

A Working Conference presented by the National Conferences on Primary Health Care Access

Norman B. Kahn, MD, moderator: Darryl Leong is currently vice president for Primary Care Systems Inc, a non-profit corporation that focuses on increasing outcomes for underserved populations, particularly through CHC linkages. You may know Darryl better in his previous career as Director of Clinical Affairs for the National Association of Community Health Centers, a position in which he served for three years. Prior to that he was Director of Maternal and Child Health for the state health departments in Hawai’i, Vermont and Iowa.

Darryl is a board certified pediatrician who received his MPH from the University of Hawai’i. He will talk on “Family Practice and the Future of Community Health Centers.

Darryl Leong, MD (National Association of CHCs, Washington, DC)

Just a few words about the Primary Care Systems and what we are trying to do. Its mission is to ensure primary care to everyone in the country. In support of its mission, it is available to provide assistance to CHCs as well as assistance to academic training programs in developing programs to achieve that mission.

Before I get started, I just wanted to mention the context of what we’re here to talk about in terms of primary care teaching and CHCs.

History

I would like to begin with a bit of history of the neighborhood health center program, out of which CHCs developed. The neighborhood health centers were started in 1965, by the Office of Economic Opportunity (OEO), as part of the “War on Poverty”.

Some of the sister programs in the War on Poverty, which are still here today, were Family Planning, Head Start, the Job Corps and VISTA. The principal characteristic of all of these programs is that they include direct federal funding to community agencies. All of these programs provide funds that by-pass health departments, hospitals and medical schools.

The CHC program was established to make an impact on health. There were dismal health outcomes in 1965 when the program started. For example, many of the 600,000 children to enter Head Start had never seen a physician in 1965. One-third had never seen a dentist. These children averaged ten pounds underweight. May of these indicators have not improved. The system has not made much of an impact on some of these populations.

So, what OEO decided, rather than purchase traditional medical services, was, instead to fund a model of care they called a Neighborhood Health Center. These centers would provide health care services, regardless of ability to pay.

They would be a “one-door” facility, readily accessible as to time and place for all services. They would include preventive care and social and outreach services, along with treatment services.

They would use high quality staff. They would create employment opportunities (consistent with their War on Poverty mission). They established their sites right in the middle of target communities.

Count Gibson, MD, Founder of Columbia Point (Massachusetts) Community Health Center

A key feature was that consumers were to be participants in the governing of the centers. Coordination with existing services was promoted. There were several responses by a wide variety of public and private sources. Neighborhood health centers were not there to be operated independently. They were to emphasize community-based and community-oriented health care.

The original OEO grants were made to Doctors Count Gibson and Jack Geiger, then respectively of Tufts University and Harvard University, for two neighbhood health centers – Columbia Point in Boston and Mound Bayou in Mississippi.

An excerpt from that first grant is illuminating. The reason why you had a neighborhood health center, it stated, was to intervene in the cycle of extreme poverty, ill health, unemployment and illiteracy. It was not simply to provide health services. One had to break the poverty cycle.

How does one do that? Provide comprehensive health care based in multi-disciplihary CHCs oriented to maximum participation of each community in meeting its own health needs, as well as the social and economic changes related to health.

Jack Geiger, MD, Founder of Mound Bayou (Mississippi) Community Health Center

Again, this is not just a medical care organization, but is a broad health organization. Its goal was not simply to distribute services to passive recipients. It really wanted the community to be involved in change. Back then, one of the key features for the training of early local personnel was that they would become part of the CHC. This is where the linkage idea comes in – recruiting and training from local CHC areas.

The health center program began as, and still is, a challenge to traditional medicine and public health. They put medical care and public health activities in one operation. These oprations provide care for all residents of a geographic community. In a CHC, you are responsible for all of the residents of the community, whether or not they come to see you. A community-oriented model is a very different model of care.

When I trained, I learned only one model of care, office practice. That is, I would open an office and people would come to see me there. All the people I saw in the office would be the people for whom I cared. In 1965, most physicians were in solo practice, not even in group practice. A physician paid by salary practiced what then was called “socialized medicine”.

At that time, HMOs were just getting off the ground. Direct funding from the federal government for the community was considered radical, because it emphasized community health, as opposed to medical care. It put the consumers, rather than the doctors, in charge. That is where you see a lot of the conflicts between clinicians and communities. It arises from this concern over who is in charge.

Community Health Centers (CHCs)

CHCs are located in rural and urban areas throughout the nation. They provide recruitment and retention of health providers for underserved areas. There is tremenous patient diverstiy. They employ many experienced health professionals, people who have been working five to 20 years in a CHC. Their expertise is in the provision of care, usually in a team model. It is a quality workforce.

In these CHCs, arbitrary barriers between prevention, public health, and medical care, which developed in this century, have been eliminated. CHC providers do not see the difference between medical care versus prevention in public health. They provide comprehensive primary care services, which are more than just medical services.

The financial administrators of these health centers have well developed systems for running these centers, some in place for over 25 years now. (One comment, when you start talking about whom you link with, look closely at existing FQHCs or “look-alike” CHCs. Staring your own FWHC or CHC is a tremendous administrative undertaking.)

Recently, the Pew Health Professions Commssion listed 17 competencies that should be incorporated into the education of all health professions students by the year 2005. Topping the list is attention to the community’s health. A CHC provides every single one of those 17 competencies well. I actually wrote the authors of the Pew Commission study and said, “Somehow, you described CHCs without even referencing them.”

What is a CHC? It is a non-profit entity which provides a set of services to a community. It may do so either through staff and/or supporting resources or through contracts and/or cooperative arrangements with other public and private entities. If the CHC receives funds through the United States Public Health Service Act, it agrees to provide a set of services required by law.

Section 330 of the Title III of the Public Health Service Act funds CHCs, Section 329 funds migrant health centers, Section 340 is for homeless health projects and secction 348 for public health in housing projects, all of which are considered primary health programs administered by the Bureau of Primary Health Care. Training program faculty are all familiar with Title VII training grants, which is another part of the PHS Act.

Besides providing primary health services, CHCs also may provide supplemental services, which may include case management, including outreach counseling, referral and follow-up, and translation services. Many CHCs at their inception were involved with the provision of environmental health services, and still conduct such case studies as pesticide poisoning of farm workers.

Most people probably think of primary care as only medical care. The Public Health Service Act provides a statutory definition of primary health services. That definition (which, of course, affects the grants awarded under the Act), includes the services of physicians, physician assistants and nurse clinicians. It provides for diagnostic, laboratory and radiology services, and preventive health services – including prenatal, well-child immunizations, and family planning services.

The definition also speaks to emergency medical care, transportation, preventive dentistry and pharmaceutical services. This definition suggest that, although we talk about primary care a lot, we do not have a consensus in this country as to what it includes.

A CHC may provide a wide range of supplemental health services. Most of them do provide more than just medical services. As an example, I know of at least two CHCs that run nursing homes. You cannot with certainty predict, from just the health center’s name, what it is actually doing.

A community or migrant health center provides most of medical care as well as special services. They serve a medically underserved population. “Medically underserved” is an official legal term. To receive a grant you have to serve a medically underserved area (MUA) or medically underserved population. You have to apply for that designation following a defined process.

CHCs are private, non-profit corporations, organized similarly to group practices, but financially supported by grants as well as patient fee revenues. Presently, about 40 percent of the support of those CHCs designated as FQHCs come from the Public Health Service Act grants, 60 percent through other means.

All officially recognized CHCs are non-profit corporations with a governing board. At least 51 percent of the members of the governing board must be users of that CHC. They have a community service mission. They exist to improve health outcomes for that community. Not just health, but community health outcomes.

The CHCs are there to reduce all barriers to health care, especially financial and cultural barriers. They provide quality health care. A point that I made while I was medical diretor at the Naitonal Association of CHCs was that health centers are not there to provide second rate services for people, they are there to provide the very best care possible.

CHCs employ a team of professionals to do that. They certainly provide cost-effective care. They are part of a national system. They provide culturally sensitive care and respond to community needs. That is why CHCs conduct an assessment of the community’s needs.

Through the needs assessment, the community board members, the CHC administration and others in the community, produce a health plan which outlines what they are going to do and the resources available for doing it. They organize themselves to make an impact in that particular community, and that is the reason that no two health centers will look alike.

I will present a quick overview of the health career program. In 1991, there were about 550 grantees nationally, operating at 1500 clinic sites, most with more than one site. They are represented in every state in the country.

Whom do they serve? According to data from the National Association of Community Health Centers (NACHC), 44 percent of the users of CHCs are under age 29. Historically, CHCs have tended to serve a much younger population. But today, there is a fast growing population of elderly in need of primary health care services.

Only 39.2 percent of CHC patients are classified as White/Non-Hispanic. 28.8 percent are African-American, 26 percent are of Hispanic origin, and the remaining are Asian/Pacific Islander, American Indian and “other”.

Although the urban origin of the CHC’s cause some people still to think of the CHC program as an urban program, in fact the majority of grantees are in rural areas, and half of the 6.4 million patients served nationally in 1991, were served in rural areas.

We saw minorities in both rural and urbaOf the people served, about 44 percent have no health insurance whatsoever, not even Medicaid or Medicare; about 40 percent have Medicaid or Medicare, and the remaining 16 percent have private insurance.

The NACHC surveyed health centers in 1991, as to the most urgent health problems in their communities. For both rural and urban centers, teen pregnancy was considered the most urgent health problem in that community, followed in order by substance abuse, infant mortality, and family violence.

Thus, from the viewpoint of the responding CHCs, none of the four most urgent problems are medical problems. All of them are complicated social problems, social and health problems combined.

Who works in them? I do not think the CHC workforce data is great, but I estimate that there are about 3300 physicians in CHCs, about 2500 full-time and 800 part-time. Approximately 45% of the physicians are family physicians or general practitioners, 25% are internal medicine, 20 percent pediatricians and ten percent OB/GYN. The aggregate number of nurse practitioners, Pas and certified nurse midwives is around 1300, which means that there is one of these practitioners for every two full-time equivalent physicians. The data show that NPS and PAs are distributed proportionately in urban and rural areas.

All CHCs provide preventive as well as primary care. There are another 8,700 other health professionals, including such “health care team” members as dentists, dental hygienists, nutritionists, social workers, health educators, and community workers.

Workforce and Hospital General Information

The Bureau of Health Professions [BHPr] made projections of the expected growth in the number of United States physicians between 1986 and 2020. In 1986, the United States had 28.3 percent primary care specialties of family practice, general internal medicine and general pediatrics.

For the year 2020, BHPr has projected that there will be 800,000 physicians of whom26.4 percent will be in primary care. Thus, if the projections hold true, the nation will have a declining percentage of primary care physicians during the next two decades.

If the specialty choices of seniors graduating from allopathic medical schools between 1981 and 1992 are charted to show the percentage choosing primary care specialties as a percentage of the total choices, one notes a declining slope in the choice of primary care.

I did my own blasphemous projection that showed that if this trend continues on the slope of 1981 and 1992, within five years the number choosing primary care would drop to zero (laughter)!

Clearly, as of this date, that negative trend is starting to reverse and so the trend line appears likely to plateau. But I think the point is clear that over recent years we have experienced a drastic decline in primary care physicians.

If one charts revenue trend, one notes that in 1970, 12.2 percent of the income came from fee-for-service reimbursements, but, by 1991, 45 percent came from patient fees. There was a decline in federal research dollars from 25 percent to 20 percent. Interestingly, 3.7 percent from tuition and fees in 1970, but that percentage had only rise to 4.3 percent by 1990 – not an appreciable difference, even though the cost of medical education is considered very high, with the average debt of medical school graduates now exceeding $50,000 per student.

Using data from the American Association of Medical Colleges (AAMC), I calculated the differences in expenditure patterns between public schools and private schools. Public schools tend to spend more on teaching, 36 percent of each dollar, less on service and less on research.

Graduate Medical Education Financing

Many persons have argued that graduate medical education   (GME) financing is hard to understand, but I think the concepts are easily understood. The principal source of general financial support for teaching hospitals is Medicare. Currently, there are about 7,000 hospitals. 52 percent of these are in urban areas and 48 percent are rural.

Of the 7,000 hospitals, only 20 percent of hospitals are teaching hospitals. The 80 percent of hospitals that are not classified as teaching hospital, get no GME dollars. However, both teaching and non-teaching hospitals are eligible for disproportionate share payments [DSH].

There are four categories of Medicare funds available to teaching hospitals. Teaching hospitals are elgible to get direct medical education dollars (DME) and indirect medical education dollars (IME). They additionally are eligible to get “disproportionate share” payments. Teaching physicians are also allowed to bill for patient care services, provided these based on a “services were involved in teaching under part B of Medicare.

The DME and IME payments comprise the GME. 98 percent of GME goes to urban teaching hospitals and two percent goes to rural teaching hospitals. 65 percenet of the payments for IME goes to hospitals with greater than 400 beds.

There are additional funds paid hospitals that have more than their fair share of Medicaid patients and other low-income patients. DME is based on a “reasonable cost” reimbursement methodology. It is analogous to the “reasonable cost” reimbursement mechanism for FQHCs.

There are four allowable costs teaching hospitals can claim: (1) resident stipends, (2) faculty salaries, (3) administrative expenses and (4) overhead costs. The overhead costs are also known as indirect costs (a term I avoid because it immediately invites confustion with the IME category of Medicare funding.) Medicare paid 5.2 billion dollars for GME in fiscal year 1992. Of this, $1.6 billion was for DME and $3.6 billion for IME.

In 1983, Congress amended the Medicare Act to adjust the prospective payment system for hospitals in ways that increased the reimbursement to teaching hospitals. Four adjustments to the prospective payments were established: First, formulas were revised to account for wage level differences between geographical areas; second, reimbursements for teaching hospital were enriched to offset their inherently higher costs of providing services to Medicare patients; third, reimbursements for all hospitals with a disproportionately larger share of low-income patients were increased to offset their higher costs; and fourth, reimbursements for “outlier” (very high cost) cases were increased. All four of these adjustments proved advantageous to urban teaching hospitals.

How much is a teachibng hospital reimbursed by Medicare for heaving interns and residents? To estimate this, you first need to know what is called the Intern and Resident to Bed [IRB] ratio. To calculate that ratio, you divide the number of interns, residents, and fellow, by the number of approved Medicare beds. For example, for a hospital with a total of 100 physicians in training (residents, interns and fellows) and 400 Medicare approved beds, you divide 100 by 400 to establish the hospital IRB (in this example, .25). For every .10 of IRB, a teaching hospital receives roughtly 7.7 percent more Medicare payments than they would normally be reimbursed through the prospective payment system.

In our example, the IRB of .25 is first multiplied by 10 to yield a factor of 2.5, which is then multiplied by 7.7. Thus, the teaching hospital in our example receives an additional 18.75 percent for Medicare. So, if this hospital had 10 million dollars in Medicare payments through the prospective payment system, it would get an additional $1.875 million for a total of $11.875 million.

There indeed are hospital that approximate both the numerator and programs that are wholly based in ambulatory seettings. I think that one prediction that can be made for this round of medical education reform is that there will be a shift away from hospital-based training towards community-based training.There are multiple questions that can be raised about community-based training sites. Who will run these sites? Where are these sites going to be? What will be the quality of treatment?

I am excited about being with family medicine educators, because I think that family medicine is the one field that will be able to expand quickly into ambulatory sites. Remember, we are talking about a massive shift when this all ends. In terms of context, we are talking about a re-forumlation of primary care itself.

I think you have seen mention of it in the health care reform plan. But in the reform plan, the discussion of changes in primary care are all related to health care cost containment. That is not the reason I would favor a new societal emphasis on primary care. I think primary care is better for the people, and supports outcomes supported by the general population.

I will try, in the time I have, to convince you of three points. First, that primary care is actually what I would call an essential community service – a service that no community can do without. Second, that our method of financing graduate medical education needs to be reformed fundamentally. To this, I will provide an overview of how we finance graduate medical education today and how we might finance it in the future. And third, I hope to convince you that the CHC is the best place to teach primary health care.

Essential Community Service

Our goal must be to have primary health care recongized as an essential community-based service. There are several examples of community services that we now deem to be essential that previously were not. As an example, during th eearly parts of this century, electricity was only available to those who could afford it, the service was of variable quality and it was not available in many rural communities. Today, in all communities, rural and urban, reliable electricity is considered a lifeline or essential community service.

When will primary health care come to be recognized as an essential universal community service, that needs to be available 24 hours a day, 365 days a year, in all communities? How can reliable primary health care services be organized and who should be responsible? How would a commitment to primary health care services as an essential community service drive the health care system?

Consider a fictional community. If you plot over time the capacity to deliver primary care, and then assume that there is an ideal level, we could probably agree that there is some level that we would consider ideal and we could probably agree that there was some minimal level that would not be ideal. If you plotted a diagram for every single community today, particularly in rural communities, there would be an “ideal” capacity line, above which services exceed need.

If you drop to less than ideal, you may quickly drop further to a crisis level which would generate a response to try to return to the ideal level. This is the kind of system we have today. Every single community goes through cycles of surplus and shortages and some communities, medically underserved communities, have chronic shortages. The challenge to the current system is how to reorganize it to assure that it stays near the ideal level.

In closing, these are some of the characteristics that we have learned from the community Kellogg fellowships – a program that is still ongoing – characteristics which indicate whether the CHC is really going to be successful. First, is that the CHC seriously takes an equal responsibility for teaching, service and research. My advice to health centers has been that teaching is not something to do on the side. If you are going to teach, then you must do it well. That is one message. I think that the teaching CHCs that are successful, as Norm Kahn has already mentioned, are those that are fully invested in the teaching mission.

Second, they are certainly community driven. Third, successful linkages are truly partnerships (and I hardly use the term linkage anymore, because partnership is the right term). I don’t think anyone is going to be successful in coming to CHCs saying we need you, because we need an ambulatory training site, and we need you because we need access to your patients for research. That is not going to fly in most CHCs. It will fly if they understand what is in it for them and the community. There is a lot in it for the CHC, but it has to be clearly identified.

To summarize my predicitons, primary care will become an essential community service. We will revitalize health care in this country. Creating an effective primary care system is one way we are going to do it. There will be major changes in the medical education system, marked by a massive shift in resources from hospital based training to ambulatory based training. This is going to start today in this room and beyond from existing models that are out there. We have heard in this conference about several models – East Dayton, Sequoia, Sea Mar – that I believe will become the standard in the future and be successful from these new partnerships.

Thank you.

Dr Kahn: Thank you very much Dr Leong. Darryl has covered a tremendous amount of material. I know that there may be some issues or questions you wish to raise at this time. I would like to take seven or eight minutes at this point for questions for Dr Leong and then we will move on to our next speaker.

I will ask the first question. Darryl, what is your prediction about the probability of a major new initiative to provide for graduate medical education financing in ambulatory settings in general and CHCs in particular, either through pasage of any bills now before Congress or through implementation of the Clinton health reform plan? Will it happen or not?

Dr Leong: That sounds like a loaded question. The answer is that it will not happen very fast. That is why the FQHC funding mechanism will become increasingly important. The hospitals are controlling those dollars right now. Yes, Norm, your family practice residency programs are getting a big piece of that. But I do not think that the support for proposals to move those dollars into new entities called consortiums or to move funds directly to residency programs is as strong as it needs to be. To tell the truth, the shift in financing from hospitals to ambulatory teaching sites is not going to happen without advocacy. So that is the message, it will not happen right now.

Alvin Jones, MD (West Texas Family Medicine Department, Lubbock, Texas): The rural hospitals in West Texas are having difficulty surviving and we are looking at the possibility of becoming hospital-based “look-alike” rural health centers. Is there a way that rural hospitals in that situation could be designated as teaching hospitals?

Dr Leong: We do have rural hospitals that have rural residency training programs. Once you have an approved program from the Residency Review Committee, that hospital becomes a teaching hospital.

Dr Jones: Thank you very much.

John Payne, MD (Stanislaus Medical Center, Modesto, California): I thank there is a minimum size a hospital must be to qualify for the Medicare pass-through. Does it have to be at least a 100 bed hospital?

Dr Leong: No, the key is that he hospital has to have an approved program through Accrediting Council on Graduate Medical Education (ACGME). That is all you need.

Dr Payne: You talked quite a bit about changing the basis of payment from a hospital-based payment system to a CHC or to a community outpatient system based mechanism. But you said not to expect it right away. Can you give us any more precise definition of the time line we are working with?

Dr Leong: I think that time line is totally dependent on advocacy. You have to realize how much money we are talking about. I think it was Senator Kennedy who said this to one of his staff onece, that they have to understand that we are talking about taking billions of dollars from people who have it and giving it to people who do not. I mean this is really a change in policy. (laughter).

John Testerman, MD, PhD (Family Practice Residency Program, Loma Linda University, Loma Linda, California): I wanted to clarify somtheing I thought I heard you say, whtether CHCs can currently claim and pass through costs that they may expend on a resident’s salary or a resident’s malpractice coverage rather than expenses associated with having residents in their facility. Can they pass those through?

Dr Leong: The answer is yes. But, it is not the panacea because, again, if they called it a teaching cost it would get rejected. To the extent that they can show that these residents and faculty were also providing a service, they can claim that. The DME dollars are weighted to the number of Medicare patient days. Only ten percent of the patients in a community hospital are Medicare patients so they would only get back ten percent of their costs, but still it is new money. The answer is yes, but you have to be careful about how you claim it.

Gabriel Smilkstein, MD (Department of Family Practice, University of California, Davis): I am in the process of establishing a community-based educational center primarily for medical students, but also for residents, and I have run into a problem with funding. I wonder if you could help me with it.

Whereas the existing system of reimbursing care for service to the poor rewards you through fee-for-service, which is higher for those who are sicker, we soon will become part of a managed care program. In a managed care program, the sicker the patient is (and sickness goes along with being poor), the program is not reimbursed in a manner that compensates for the sicker patients. The University is very concerned about taking on a group of patients who will require much hospitalization and much care. Is there any mechanism being considered now that will compensate for the managed care system?

Dr Leong: You’re saying tha the managed care patients are sicker? Is that what you said?

Dr Smilkstein: No, the poor patients that we’ll be seeing will be sicker and because it will be in a managed care system, the University is concerned that these individuals are going to cost them a great deal in terms of hospital care and services.

Dr Leong: What I think it comes down to is the bidding process of how much you are going to get per patient. The same thing goes for the CHCs – we have the same concern. The answer is noI think the only program right now that is subsidizing indigent patients is the disproportionate share program for teaching hsoptial and CHC programs. I cannot answer your question.

Dr Kahn: Thank you, Dr Leong. Perhaps you can’t answer that, but the next speaker can. I cannot think of a better question to lead into our next speaker than the one just asked.

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