ABSTRACT

The authors assessed that the economic impact of closing a family medicine residency and outpatient center in Dayton, Ohio, has cost this community $17,451,000 annually. This cost is the sum of loss of revenue from graduate medical education (GME) Medicare payments to a teaching hospital with residencies, and the absorbed costs from increases in emergency department (ED) visits. The authors argue the displacement of a cost-effective family medicine health center and residency placed an economic burden on an area ill-equipped to absorb and afford it, and this impacted negatively on the health of a community.

BACKGROUND

The greater Dayton, Ohio, area once enjoyed the benefits of a 500+ bed teaching hospital, St. Elizabeth Medical Center, and its integrated family medicine health center (Hopeland) and residency program. For 122 years, St. Elizabeth Medical Center, and for 30 years, Hopeland, served as medical homes for thousands of greater Dayton area families considered as either “urban poor” or as “high risk.”

The St. Elizabeth Family Medicine Residency Program was established in the early 1970’s. This family medicine residency had slots for 12 residents in each of the three training years. Each of its 36 enrollees comprised a diverse and talented group of physicians in-training at a site that quickly earned a reputation for providing premier training in urban family medicine. Archival records indicate more than 270 family physicians completed their residency at St. Elizabeth. This program produced physicians with patient-centered training, which augmented the health and quality-of-life of the greater Dayton area.

This family medicine residency was also well known for encouraging many physicians to establish practices in underserved settings throughout Ohio and the nation. However, in 2000 the hospital abruptly closed and the Hopeland health center was slated for accelerated contraction and closure when the negotiations for a suitable buyer for both the hospital and its ambulatory center broke down.

During the 1990s, the St. Elizabeth Medical Center and Hopeland began to experience financial difficulties. Two of many causes for these difficulties involved poor cash flow from billing practices and an ever growing burden of uncompensated care for the poorest and most vulnerable citizens of Dayton. Consequently, the religious order that managed the hospital and health center decided to sell both.

For several months in 1999 and the first six months of the year 2000, the residency, health center, and community were informed that a for-profit buyer was conducting due diligence analysis and that a quick sale was expected. Relying on this information, a new class of physicians was recruited into the St. Elizabeth Family Medicine residency.

What became a surprise, however, was that negotiations for this sale collapsed in July 2000. While business, community, and civic leaders were interested in saving the hospital, the community was not given the opportunity to make a counter-proposal, and on July 13, 2000, it was announced that the hospital would close in 60 days. The hospital did close on September 13, 2000, but its ambulatory facility did not.

The 12 newly recruited first year family medicine residents and many second and third year residents were able to transfer into other residencies leaving a handful of second and third year residents and some Wright State University School of Medicine, Department of Family Medicine, faculty members behind to wind down the family medicine practice.

The residency program closed completely in 2002, leaving the greater Dayton community to ponder the enormous loss felt among generations of families who relied on this health center for the 122 years of its existence. St. Elizabeth employees were also distraught not only at their job loss, but at their loss of being passionate supporters of the St. Elizabeth mission to care for the poor and underserved. Similarly, Wright State family medicine faculty and 36 residents and their families were distraught, because they too believed in St. Elizabeth’s mission—never believing the hospital, health center, and residency program would be closed so quickly.

The closing of the St. Elizabeth medical complex has raised the question: “What economic perturbations or burdens did the closure of the St. Elizabeth Medical Center and Hopeland bring to the greater Dayton community?”

THE PROPOSAL 

In order to answer the above question, three assumptions were made: (a) the closure of the St. Elizabeth Emergency Center and Hopeland clinic resulted in increased emergency department visits at other Dayton sites; (b) the increase in emergency department visits would immediately emanate from the 40,000 people who annually visited the St. Elizabeth emergency department, as well as incrementally from the 30,000 who annually visited the Hopeland Family Medicine Center; and (c) since 42 capped Graduate Medical Education positions would be lost to the Dayton area permanently, it was proposed to determine whether or not this represented an economic burden to the greater Dayton community.

METHODS

To estimate the financial burden resulting from the loss of a family medicine residency, the authors:

(a) reviewed details of the due diligence documents used by the potential buyers considering purchase of the St. Elizabeth hospital and Hopeland. These documents contained data pertaining to reviews and audits of the federal medical education support payments from Medicare, clinical revenues and expenses, and all personnel costs—including resident and faculty salaries.

Because the “burden of suffering” among users of the St. Elizabeth hospital and Hopeland was large, the residency program received a large hospital disproportionate share (DSH) payment; that plus the combined federal medical education support from Medicare to St. Elizabeth hospital created a total full-time equivalent or FTE revenue stream of $160,000 per resident. (Note: Hopeland itself operated at a loss of $750,000/year, but because of the service revenue and the influx of Medicare dollars, a small surplus for the institution was generated.)

(b) analyzed emergency department (ED) visits throughout the greater Dayton area using data from the Greater Dayton Area Hospital Association (GDAHA). Their data is used by all Dayton area hospitals because of its accuracy and acceptance by area hospitals. The Wright State University College of Science and Mathematics provided statistical assistance analyzing and comparing area ED visits in different years.

Ohio Hospital Association data was used to calculate the average cost of an ED visit in both Montgomery and neighboring Greene counties. This was done to calculate: (a) the average cost of an ED visit which did not result in an admission and (b) the average cost of an ED visit resulting in an admission.

FINDINGS 

(a) When the Dayton community lost all 42 GME slots, this loss in revenue totaled $6,720,000/year. When balanced budget reduction formulae were applied to this amount for the years 2000-2005, the Dayton community had lost $4,805,000 each year without having receipt of federal medical education support from Medicare.

(b) Emergency department usage in the Dayton area had been rather constant from 1990 until July 2000. After 2000 when a significant “safety net of care” was lost and access to culturally appropriate care became constricted, that baseline abruptly curved upward. (Table 1)

Emergency room usage in Dayton, Ohio and surrounding counties

What this suggested to the authors is that without primary, secondary, and tertiary preventive care, through the presence of a family medicine model of comprehensive care, former Hopeland patients became sicker and then sought medical care from area Emergency Departments.

The slopes of ED usage between the years prior to the hospital closure (1998-2000) and those after the closure (2001-2003) differ significantly—and were calculated using GDAHA data. The estimated slope for 1998-2000 was not significantly different than zero (P=0.45). The estimated slope for 2001-2003 was marginally significantly different than zero (P=0.0583). The tests for determining if these two slopes differ significantly is statistically significant (P=0.0091).

These data support the hypothesis that Dayton area emergency department visits were relatively stable in the years prior to 2000, but have increased significantly during the years 2001-2003. In fact, they increased at a rate of about 9,000 visits per year. This slope led the authors to predict an increase of 9,000 more ED visits would occur in 2003 over those in 2002. In fact, GDAHA reports there actually were 19,316 more ED visits in Dayton during 2003. Using the actual figure of 19,316 makes the slope line following the Hopeland closure even more significant (P=0.009). By the year 2004, the slope flattens out. (Table I)

(c) The ED visits by former Hopeland patients not only resulted in greater numbers of area ED admissions, but they were more expensive visits than typical non-admission visits. For this study, however, the authors did not mix the visits resulting in admissions with those that did not. Instead, the authors considered all the ED excess visits “non-admissions”—knowing that the average cost of these non-admissions was $788.

This yielded a very conservative price tag for the aggregate value of these additional visits. By the end of 2004, an additional 17,000 ED visits, as tracked by GDAHA, were being made to Dayton area EDs, presumably driven by the closure of Hopeland.

The 40,000 annual ED visits to the St. Elizabeth Medical Center spread quickly into the community upon the closure of the hospital and they did not factor into the area’s trend of experiencing an escalation in ED visits. Rather, it was the Hopeland patients who initially started the increase and, then as they got sicker and sicker, created a wave of new and increasing demand for ED services.

Thus, since a conservative cost for these visits would be $788 and since it can be estimated that an additional 17,000 visits occurred, a community burden for these additional ED visits would be 17,000 X $788 or $13,396,000. The 17,000 visits is the difference between the average visits to ED in the three years before and after closure of Hopeland.

Finally, the authors estimate the annual cost to the Dayton community by the year 2005 had risen to:

(a) $ 13,396,000 (excessive ED usage charges)

(b) $ 4,805,000 (loss of federal support from Medicare with the balanced budget act (BBA) formulae applied) and

(c) <$750,000> (Operating loss of the Hopeland Center, considered a gain in this scenario or $17,451,000)

In 1999 an average visit to Hopeland created a “cost” of $37/visit. In 2004, a visit to an area emergency department has an average “cost” of $788. This ratio is approximately 21:1

($788/37 = 21:1) and represents the excessive cost of an ED visit versus one made to Hopeland.

Discussion

Is such a large economic burden possible? Certainly, the loss of the GME slots is real, and the funds which followed each slot are real. The authors reduced these amounts to reflect the impact of the Balanced Budget Acts (BBA) over the various years since 2000. The additional ED visits are logical since there was little capacity to absorb the Hopeland patients into other Dayton area clinical settings.

The tables in this report argue that it is the expense of ED visits that are driving up area healthcare costs in Dayton, which could have been avoided by having care delivered at a well-established family medicine unit. This leads to speculation about the relationship between health care costs and the paucity of primary care in the USA, and especially whether or not patients should be directed to an urban family medicine training site, such as Hopeland, for much of the care they are currently seeking from ED departments. (Table 2)

National trends in emergency room use

The authors recognize that numerous confounding variables are operative in this analysis, the most important being the interactions between a chaotic health system and vulnerable people needing care from that system.

There is evidence that the number of visits to emergency departments is soaring nationwide (Table 2), as well as in Dayton, and ED departments are scrambling to meet new demands by increasing capacity.

Thus, it would behoove policy-makers and other healthcare decision makers to consider the alternative of a less costly and more effective family medicine model. The implication for America’s health care system is that a safety net, non-triage, comprehensive Family Medicine training and practice model is cost-effective and has great value.

In addition, it is a model whose real value lies in its ability to provide comprehensive and preventive care which results in non-events, i.e., fewer strokes, heart attacks, earlier detection of cancer, etc. For example, heart failure (HF) can be cost effectively managed in an ambulatory setting. When it is, it creates a reduction in the number of visits made to an emergency department, ultimately saving resources.

As an illustration, if heart failure had been treated at Hopeland, it would have generated a revenue stream of $75 per visit; if that same patient had visited a Dayton area ED, it would have generated a cost of $788; however, if that patient was subsequently admitted to a hospital, that original $75/visit becomes an average $19,000+ admission.

Finally, this commentary is a lament for the reality that a financial contribution to a community by one family medicine health center was considerable even by using conservative assumptions, and now it is gone. Unfortunately, the knowledge of this financial contribution has been done long after the Hopeland’s demise, and this knowledge cannot alter history or turn around the escalation in Dayton ED usage.

The perturbations set off by the closing of Hopeland did send people at risk to EDs. Five years later, the increase in ED usage appears to be flattening, but a higher ED baseline average number of yearly visits will likely become a new norm due to the turbulent dynamics of losing a major safety net family medicine center.

Charles Q. North, MD, MS

Dr Charles North is a Senior Fellow of the National Consortium on Community-Based Medical Education, the community of participants in the National Conferences on Primary Health Care Access. Dr North has retired friom the Indian Health Service, and is presently a member of the faculty of the University of New Mexico School of Medicine.

Dr North has reviewed the “time capsule” consensus statement from the Seventh National Conference of 1996 (see Time Capsule: The Consensus Statement of the Seventh National Conference on Primary Health Care Access), and has extracted the following statements from that document for discussion at the Twenty-second National Conference of 2011:

A. Preamble

2. Health care problems often are linked to other fundamental societal problems, including poverty, unemployment, racial discrimination, and poor education. Ultimately, strategies for solving health care problems may require addressing other problems.

D. Family and Community Medicine

1. One of the national health priorities, formally recognized in the mid-1960s, is that every person should have access to a personal physician, who has comprehensive training and the skills to provide continuous care to the individual and family. The reasons for establishing such a national priority remain as valid now as they were at the time.

G. Health Professions Education

2. The central mission of primary care educators must be the creation of a primary care workforce to meet regional and national needs. Public policy should be concerned with how the kinds of financing mechanisms needed to support that mission can be established or enhanced, and how adequate funding to meet that mission can be secured.

15. First year residency positions should be capped at 110% of the graduating medical students in a 50% generalist, 50% subspecialty mix.

20. Health professions education should be financed in part through mechanisms that pay the cost of the student’s education in exchange for public service obligations in underserved inner city, rural or other areas of need. In any emerging funding structure directed to health care reform, meaningful all payor contributions to the funding of primary care education in ambulatory settings is necessary in both predoctoral and graduate education.

26. Physician residency programs should take a proactive role in the placement of physicians in underserved communities, including political support of service corps programs. A placement service for such communities should be instituted by medical schools, where appropriate.

H. Health Promotion

3. The monitoring of quality and outcomes should include the evaluation of access to and effectiveness of primary health care services. “Healthy People 2000? objectives should be incorporated into quality measures for such monitoring activities.

J. Reimbursement

Reimbursement should continue to move towards prospective payment at an overall fixed amount for providers and plans. Providers and plans should be held accountable for prospective budgets and allocation of resources that maximize access, efficiency and quality.

L. Teaching Community Health Centers

2. Teaching Community Health Centers [TCHCs] are a model for community-based service, education, and research. These TCHCs are expected to improve the quality and outcomes of health professions education by integrating medical education within model community-oriented primary care practices operating in a reformed health care delivery system.

13. Changes should be made in federal and state statutes and regulations that accomplish the following:

a) TCHCs should be eligible to directly receive graduate medical education payments that reimburse these centers for their development and      operational costs.

b) startup funds for planning and development of TCHCs should be identified and made available.

c) TCHCs will be recognized separately from non-teaching community health centers by taking into account the special needs of ambulatory-based    teaching programa.

d) the National Institutes of Health, Agency for Health Care Policy Research, and other federal research agencies should increase their focus on  primary care research by utilizing TCHCs.

e) faculty development, technical assisstance, and support programs for TCHCs should be developed and implemented.

f) loan repayment programs serving medically underserved communities should target residents and faculty of TCHCs.

O. Rural health

2. Public funding of health professional education should be based, in part, on how well this education meets the provider needs of the region. The ultimate success is the number of graduates who practice in specialties and geographic locations of need.

Q. Rural health systems

5. Mental health services and long-term care facilities in rural communities hsould be integrated effectively into the health care systems.

U. Coalition building

7.The goals of coalitions to further access to primary care are: a) developing rational, effective primary care delivery systems responsive to clients, their families and communities; b) enhancing the biopsychosocial education and training of primary care health professionals, including team training; c) developing the primary care research base in health services delivery, clinical outcomes, and training and evaluation methods; and d) reforming health policy and financing systems to reestablish the central role of primary care and to provide adequate service delivery to all our citizens.

16. Nationally, primary care organizations must develop an effective and singular voice on health policy and financing reform. At all levels they should become more effective at presenting the message that primary care is essential to the future health of the nation and can only be provided in a quality fashion by those who are trained and specialize in it. This message must be successfully conveyed to our citizens and our political decision-makers

V. Personal values

1. Certain core personal values (“guiding principles”) are linked closely to effective primary care. Medical trainees choosing primary care specialties tend to rate benevolent personal values (helpfulness, honesty, loyalty and service) significantly higher than trainees choosing non-primary care specialties. Conversely, many subspecialists rate power values (wealth, social standing) significantly higher.

Tim M. Henderson, MSPH, MAMC

Department of Health Administration and Policy, George Mason University, Fairfax VA

Thomas (Tim) Henderson, MSPH George Mason University

States provide important support for the education of physicians in primary care and other specialties.  State and local governments appropriate funds for medical school training ($5 billion in FY2009 [FN1]).  Moreover, Medicaid programs in most states historically have made graduate medical education (GME) payments in teaching hospitals and other settings under their fee-for-service and capitated managed care programs (just under $3.8 billion in 2009 [FN2]), although they are not obligated to do so [FN 3,4].  This represents a total of nearly $9.8 billion annually for physician training.  In fact, Medicaid is the second largest explicit payer (behind Medicare) of GME and the other special missions and services of teaching hospitals.

However, the recent troubled economy and its strain on state budgets and Medicaid spending has begun to have a noticeable impact on Medicaid payments for GME and many other services.  For the first time in recent memory, the number of states making Medicaid GME payments in 2009 declined significantly.  According to the recent study for the Association of American Medical Colleges, eight (8) states reported not making GME payments under their Medicaid programs in 2009—an almost tripling of the number of states not making such payments in 2005.  Three (3) of these states—Illinois, Massachusetts and Texas—are among the top ten states with the largest number of graduate medical education programs.  An additional 11 states reported in 2009 and early 2010 that they have recently considered ending Medicaid GME payments [FN5].

Despite these troubling trends, the study found that Medicaid programs in 10 states require that some or all GME payments be directly linked to state policy goals intended to vary the distribution of the health care workforce.  The number of states with this requirement has remained largely constant over the past several years.  The goal of encouraging training of physicians in certain specialties that are short supply (e.g., primary care) is applied to GME payments by 9 of the states. Six of the states use these payments to encourage training of physicians in non-hospital and certain other settings such as rural locations and medically underserved communities. Seven states link payments to efforts to increase the supply of health professionals trained to serve Medicaid beneficiaries [FN6].

Policy Implications and Opportunities for Primary Care Training

Amidst economic downturn and insufficient numbers of primary care physicians to serve booming Medicaid enrollments in many states, Medicaid programs in collaboration with medical schools and primary care residency programs may be able to offer new incentives for expanding GME of primary care physicians who are more likely to serve in nearby needy communities.

Use of Special Financing to Establish or Expand Medicaid GME Payments

Because of competing demands for public services, especially with recent budget shortfalls, many states exceed their fiscal capability that gives their Medicaid programs the incentive to substitute federal funds for state funds.  The Medicaid program’s Federal-State matching payment structure for covered services provides the mechanism for this substitution.  In general, this process of “Medicaid maximization” allows states to cover services that have traditionally been state or local responsibilities and to receive federal matching funds for the costs of furnishing these services to Medicaid beneficiaries.  The higher the state’s matching rate, the greater the replacement potential.

In particular, states have the flexibility to import federal Medicaid dollars into state-funded university teaching hospitals through the GME reimbursement methodology.  The Medicaid maximization strategy most applicable to employ in this way is intergovernmental transfers (IGTs).  IGTs are fund exchanges between different levels of government and are a common feature in State finance. Many states use IGTs as a way to leverage federal Medicaid dollars to pay higher reimbursement rates to providers or to continue or expand coverage of optional services (e.g., GME).  States can use state (or county) expenditures, such as state appropriations to public medical schools and residency training programs, to generate a federal match to support Medicaid services.  As a mechanism to initiate or expand support for GME, IGTs are now being used by several state Medicaid programs.

States might use such Medicaid funds to support an increase in the number or size of in-state primary care residency programs, as well as provide incentives to:

a) medical school graduates to select in-state primary care residencies as their top GME choices, and

b) primary care residencies to recruit more in-state medical school graduates.

To this end, public medical schools could be encouraged to further expose students to the values and opportunities of in-state residencies, particularly ones located in high Medicaid and medically underserved settings.

________________

Footnotes:

¹ Such funds are non-Medicaid appropriations and include support from parent universities of medical schools. Association of American Medical Colleges. 2008-2009 Financial Tables on U.S. Medical Schools, Table 1.  http://www.aamc.org/data/finance/

² T. Henderson. “Medicaid Direct and Indirect Graduate Medical Education Payments: A 50 State Survey,” for the Association of American Medical Colleges. (Washington, DC: 2010).  The report is available online at https://services.aamc.org/publications. Financing for Medicaid (including payment for GME costs) is shared by the states and federal government.

³ Beyond the services that state Medicaid programs are required to cover, states have the option to support additional services such as DGME and IME and receive matching federal funds for them.

⁴ Contrary to Medicare, the federal government has no explicit guidelines for states on whether and how their Medicaid programs should or could make DGME and IME payments.  However, a provision included in health reform legislation passed by the U.S. House of Representatives in 2009, but not part of the final law enacted in 2010, clarified that state Medicaid programs may receive federal matching payments for the costs of graduate medical education, and directed the Secretary of the U.S. Department of Health and Human Services to specify program goals for the use of such funds based on workforce needs in the states (Section 1744 of the Affordable Health Care for America Act of 2009, H.R. 3962).

⁵ T. Henderson. “Medicaid Direct and Indirect Graduate Medical Education Payments: A 50 State Survey,” for the Association of American Medical Colleges. (Washington, DC: 2010).

⁶ T. Henderson. “Medicaid Direct and Indirect Graduate Medical Education Payments: A 50 State Survey,” for the Association of American Medical Colleges. (Washington, DC: 2010).

Coastal Research Group — Policy Statements

Title : Public Health Impact of Family Medicine Residency Programs

Keywords

Public health impact

Public health benefits

Community

Community context of care

School health

Population-based health

Policy/Position Statement

In an environment of economic constraints, declining resources, and increasing public health needs, support for a collaborative relationship between family medicine residency programs and their communities’ public health infrastructure will ultimately benefit the public and protect the health of the community.

Practice styles and techniques taught in family medicine residency programs, including comprehensiveness, community-orientation, and coordination of resources for their patients, should be used to advance federal, state and local public health priorities.

Background

Introduction to the National Project

Since 2000, the Coastal Research Group National Project on the Community Benefits of Family Medicine Residency Programs has amassed a robust database on the services provided by a diverse sample of family medicine programs.  That sample reflects the distribution of residency program characteristics nationally.  From this database has been derived a detailed taxonomy of the services delivered to the patient populations served by those programs.  In addition, in collaboration with the University of Louisville School of Public Health and Information Sciences, the taxonomy and data set are undergoing detailed analysis to demonstrate the relationship between family medicine residency programs’ clinical contributions to their communities and the meeting of local public health needs.

Pertinent Data

Data from this project support the observation that family medicine residency programs contribute to the public health priorities of communities in:

The “sentinel” physician role (community health assessment and protecting the health of the public)

Care of special populations (school-based health, low-income elderly)

High-quality disease prevention services

Training of a professional workforce in appropriate models of care

Curriculum in breadth of care

Curriculum in public health and epidemiology

Care in the context of community

“Community” as part of FMRP mission statements

Conclusions

Family medicine residency programs make material and substantive contributions to meeting the public health needs of the communities they serve through the training of generalist physicians with an “adaptive skill set”.

Future Considerations

Physician workforce issues including numbers, training and distribution.

The benefits of community partnerships with health systems.

The use of family medicine residency programs as sentinel practices.

The integration of school health in residency curricula.

References

1.      Starfield B, Shi L, Macinko C — Contribution of Primary Care to Health Systems and Health.  The Milbank Quarterly 83(3):457-502 (2005)

2.      IOM Report — Crossing the Quality Chasm — (http://www.iom.edu/CMS/8089.aspx)

3.      Goldberg W, Goldfrank L, Smith PC, Green LA, Lanier D, Yawn BP – The Ecology of Medical Care Revisited.  N Engl J Med 345:1211-1212 (2001)

4.      Green LA, Fryer GE — The Development and Goals of the AAFP Center for Policy Studies in Family Practice and Primary Care.  JFP 48:905-908 (1999)

5.      IOM Report — The Future of Public Health in the 21st Century – http://www.iom.edu/?id=15246

6.      Gerberding J — 10 priorities

Glossary

Comprehensive care — Care of women, men, and children that meets all of their health care needs.

Adaptive skill set — The clinical skills of a physician that can be applied to a variety of medical problems through the extrapolation of current training.

Sentinel physician — That member of the medical community most likely to have early/initial contact with a threat to the public health.

________________________________

This policy statement is a product of the Coastal Research Group (CRG) Policy Analysis Committee, Task Force on Family Medicine Center Benefits

Chair, Working Group on Public Health Impact of FMRPs: Richard Clover, MD

Last Updated (18 May 2006 07:51)

Coastal Research Group – Policy Statements

Title: Family Medicine Residency Impact on the Medical Community

Keywords

Physician workforce

Quality of care

Quality assurance

Standard of care

Patient safety

Medical community

Distribution / Mal-distribution

Policy/Position Statement

Family medicine residency programs generate favorable impacts in their medical communities, including the raising of quality standards and the rejuvenation/replenishment of the physician workforce.

Background

Introduction to the National Project

Since 2000, the Coastal Research Group National Project on the Community Benefits of Family Medicine Residency Programs has amassed a robust database on the services provided by a diverse sample of family medicine programs.  That sample reflects the distribution of residency program characteristics nationally.  From this database has been derived a detailed taxonomy of the services delivered to the patient populations served by those programs.

Pertinent Data

Data from this project supports the observation that the impacts of a family medicine residency program on their local medical community include:

o       Residency programs have increased the number of family physicians in their communities.

o       Graduates have established practices in these communities, and replaced older and retired GPs with board-certified family physicians.

o       Impact on the composition of…

o       Impact on the demographics of…

o       Impact on the systems-based proficiencies of…

o       Impact on the recruitment of…

A.     Hospital’s medical staff

B.     Community physician workforce

o       Workforce multiplier effect (call schedule coverage, admission of unassigned patients, obstetrical deliveries “feeding” pediatrics, etc.)

o       Family medicine programs and their graduates differentiate themselves to meet unique community needs.

o       Expands local/regional primary care base.

o       Introduces and maintains evidence-based medicine and enhanced standard of care.

Conclusions

Family medicine residencies benefit both the physicians and patients of their communities.

Future Considerations

Physician workforce issues including numbers, training and distribution.

The benefits of community partnerships with health systems.

The use of family medicine residency programs as sentinel innovators for health care delivery.

References

1.      Starfield B, Shi L, Macinko C — Contribution of Primary Care to Health Systems and Health.  The Milbank Quarterly 83(3):457-502 (2005)

2.      IOM Report — Crossing the Quality Chasm — (http://www.iom.edu/CMS/8089.aspx)

3.      Goldberg W, Goldfrank L, Smith PC, Green LA, Lanier D, Yawn BP – The Ecology of Medical Care Revisited.  N Engl J Med 345:1211-1212 (2001)

4.      Green LA, Fryer GE — The Development and Goals of the AAFP Center for Policy Studies in Family Practice and Primary Care.  JFP 48:905-908 (1999)

5.      25+ Years: Oklahoma Physician Manpower Training Commission — Oct. 2001

Glossary

Medical community — The medical environment in which health care professionals work, in both ambulatory or inpatient settings.

________________________________

This policy statement is a product of the Coastal Research Group (CRG) Policy Analysis Committee, Task Force on Family Medicine Center Benefits

Chair, Working Group on FMRP Impact on Medical Community: Charles Henley, DO

Last Updated (18 May 2006 07:40)

Coastal Research Group — Policy Statements

Title: Care of Underserved Populations

Keywords

Underserved

Uninsured

Underinsured

Publicly funded

Safety-net

Special populations

Disenfranchised

Policy/Position Statement

The range of services delivered in family medicine residency programs provides comprehensiveness and continuity of care for “safety net” populations.

Background

Introduction to the National Project

Since 2000, the Coastal Research Group National Project on the Community Benefits of Family Medicine Residency Programs has amassed a robust database on the services provided by a diverse sample of family medicine programs.  That sample reflects the distribution of residency program characteristics nationally.  From this database has been derived a detailed taxonomy of the services delivered to the patient populations served by those programs.

Pertinent Data

Data from this project supports the observation that the benefits of family medicine residency programs to safety-net populations include:

High-quality fundamental medical services

High-quality disease prevention services

Appropriate access to needed specialty services

Coordination of social services that complement care

Multidisciplinary team care

Training of a professional workforce in appropriate models of care

Conclusions

Comprehensiveness and continuity of care delivered to underserved populations provide a roadmap to an efficient and effective system of care that benefits society in general.

Future Considerations

Physician workforce issues including numbers, training and distribution.

The benefits of community partnerships with health systems.

The use of family medicine residency programs as sentinel innovators for health care delivery.

References

1.      Starfield B, Shi L, Macinko C — Contribution of Primary Care to Health Systems and Health.  The Milbank Quarterly 83(3):457-502 (2005)

2.      IOM Report — Crossing the Quality Chasm — (http://www.iom.edu/CMS/8089.aspx)

3.      IOM Reports (6 during 2001-2004) on the Consequences of Uninsurance —  (http://www.iom.edu/CMS/3809/4660/4356.aspx)

4.      Goldberg W, Goldfrank L, Smith PC, Green LA, Lanier D, Yawn BP – The Ecology of Medical Care Revisited.  N Engl J Med 345:1211-1212 (2001)

5.      Green LA, Fryer GE — The Development and Goals of the AAFP Center for Policy Studies in Family Practice and Primary Care.  JFP 48:905-908 (1999)

Glossary

Safety-net population — Segment of the US population that includes recipients of Medicaid health coverage, the, publicly-subsidized medically indigent, the uninsured, and those under-insured who would be financially decimated by catastrophic health care costs … those whose access and means to care is either discontinuous, insufficient or non-existent.

Comprehensive care — Care of women, men and children that meets all of their health care needs.

Continuity of care — Health care to an individual by a specific medical professional or team over an extended period of time.

________________________________

This policy statement is a product of the Coastal Research Group (CRG) Policy Analysis Committee, Task Force on Family Medicine Center Benefits

Chair, Working Group on Care of Underserved Populations: Peter Nalin, MD

Last Updated (18 May 2006 07:41)

THE SEVENTH NATIONAL CONFERENCE ON

PRIMARY HEALTH CARE ACCESS

Williamsburg Lodge and Inn

Colonial Williamsburg, Virginia

March 28-31, 1996

CONSENSUS STATEMENT

[A] PREAMBLE

1. Whether access to health care services is viewed as a right or an entitlement, a community should be concerned with the health of all its members.

2. Health care problems often are linked to other fundamental societal problems, including poverty, unemployment, racial discrimination, and poor education. Ultimately, strategies for solving health care problems may require addressing other problems.

3. Our nation should be comprised of communities where differences between persons are respected and self-esteem is built.

4. Continuous, comprehensive primary care should be available to everyone.

5. Linkages and exchanges between professionals in academic settings and other professionals (such as community health centers, managed care organizations and government entities) interested in these issues need to increase.

6. The following recommendations have been developed in hope of influencing federal and state policy makers, and the leadership of health professional associations.

[B] POVERTY AND HEALTH CARE NEEDS

1. Poverty cuts across all racial and ethnic lines. While issues of race and ethnicity are experienced by certain groups, poor people of all races share common problems.

2. Separate health care systems for those who are affluent and those who are impoverished should not exist.

3. Impoverished inner city populations have health behaviors which are inappropriate for maintaining health and they use the health care system in inefficient ways. Investments in behavior change strategies are essential to improve health status and system efficiency.

4. Even when we try to think globally, there is a general tendency to compartmentalize groups and problems, e.g., rural versus inner city. Although geographically disparate, in terms of access rural and inner-city people share many of the same problems.

[C] CULTURAL ISSUES

1. Behavioral and cultural traditions and attitudes that cause some people to seek care only in the most extreme emergencies, are also barriers to health care access.

2. Health care delivery systems need to incorporate cultural sensitivity and responsiveness to both the individual and community health beliefs of diverse populations, emphasizing that healing encompasses mind, body and spirit.

[D] FAMILY AND COMMUNITY MEDICINE

1. One of the national health priorities, formally recognized in the mid-1960s, is that every person should have access to a personal physician, who has comprehensive training and the skills to provide continuous care to the individual and family. The reasons for establishing such a national priority remain as valid now as they were at the time.

2. To provide comprehensive care, a primary health care provider should have the clinical training and expertise to provide health care to all members of the family, should incorporate the behavioral sciences into the practice of medicine, should understand and utilize the health and social resources of the community, and be knowledgable about and comfortable with the cultural heritage of the patients served.

3. Community-oriented primary care [COPC] should be promoted in medical schools and the COPC model integrated into health care delivery systems.

[E] RESOURCES

1. Increased resources should be allocated for primary care and comprehensive health education.

2. Public policy should promote health education programs. Advertising agencies should be enlisted in health education activities.

3. Prioritization of health services, when necessary, should be based on patient medical need, rather than patient income.

4. The profits of any organization, industry, or agency which provides health services, should be limited to appropriate levels.

5. A process for rigorously evaluating new technologies and the use of existing technologies should be instituted. A national consensus on the allocation of health care resouces should be sought.

[F] TECHNOLOGY

A disproportionate share of health care resources goes to high technological health care, even though much less costly and more effective health care services often are available.

[G] HEALTH PROFESSIONS EDUCATION

Assumptions

1. The current education system for health care fails to produce persons who serve those most in need.

2. The central mission of primary care educators must be the creation of a primary care workforce to meet regional and national needs. Public policy should be concerned with how the kinds of financing mechanisms needed to support that mission can be established or enhanced, and how adequate funding to meet that mission can be secured.

3. Medical schools now rely on federal research funds and patient care reveneus derived from academic medical center hospitals. The value to academic medical centers of the primary care disciplines will increase in the future due to shifts in capitated revenues and increased funding of patient based research.

Medical School Curricula

4. The major forces of change in the medical school are external: rapid changes in health care delivery and payor need to improve access and control costs. Medical schools must develop a primary care base in order to maintain referrals practice to subspecialty faculty and trainees and to increase primary care physician graduates. Family medicine academic units are being asked to develop extensive primary care delivery programs for these purposes. While improving the power base of family practice in the medical school, this role is not without danger of adversely impacting the teaching and reserach roles of these units.

5. Though required family medicine clerkships are now the mode, most medical education is still based in the tertiary care medical center, where students, regardless of their initial orientation, are attracted to the glamour of tertiary care and the attendant role models. Students see limitation of graduate training opportunities as an infringement of their freedom of choice.

6. There is little emphasis in medical school curricula on the economics of health care, future changes in the health care delivery system, health care financing or health policy. Thus, the “pipeline” to primary care graduate training is slow to develop.

7. In the face of a physician surplus, defining minimal requirements may be less important than defining how many physicians can be gainfully employed.

8. Health professions schools should include training in understanding and communicating with persons from dissimilar backgrounds. Students should be taught about such values as compassion.

9. Increased flexibility to allow for rural training experiences should be permitted by physician residency review committees and family nurse practitioner and physician assistant training program accreditation bodies.

10. In any emerging reform of federal health care funding, increased resources (say, ten percent of federal health care expenditures) should be directed to support primary care education in ambulatory settings.

11. Predoctoral and graduate physicians should be exposed to managed care settings and systems, both in didactic and clinical experiences.

12. Traditionally hospital based, medical education must now reflect a model of ambulatory care, and embrace outpatient, continuity settings for training, beginning in the first or second year of predoctoral training.

Nurse Practitioner and Physician Assistant Education

13. Primary care physicians should play leadership roles in the education of physician assistants and nurse practitioners.

Residency Education

14. The inflow of graduates of foreign medical schools into graduate medical education should be capped at the 1993 level or below.

15. First year residency positions should be capped at 110% of the graduating medical students in a 50% generalist, 50% subspecialty mix.

16. An all-payer Graduate Medical Education payer pool should be developed to support national workforce goals with payments made directly to the applicant program.

Continuing Education

17. With movement of student training into community ambulatory settings, community clinical faculty development should be a high priority.

Student Admissions

18. Medical school admission and retention policies should favor students who are familiar with and sympathetic to persons from low income communities, especially those persons whose dominant culture and language differ from the mainstream society.

Financing

19. The financing of postgraduate medical education should be reformed to favor the production of more clinically and culturally competent primary care physicians. Culturally sensitive members of ethnic and racial minorities should be among the mentors and role models that interact with medical students.

20. Health professions education should be financed in part through mechanisms that pay the cost of the student’s education in exchange for public service obligations in underserved inner city, rural or other areas of need. In any emerging funding structure directed to health care reform, meaningful all payor contributions to the funding of primary care education in ambulatory settings is necessary in both predoctoral and graduate education.

21. All managed care systems and other health plans, whether public or private, should be expected to invest a portion of their resources in health professions education.

22. Subspecialist dominated medical schools are behind the market relative to managed care alliances. This is eroding the ability of the academic medical center to generate clinical dollars and to ensure an appropriate teaching base for students and residents.

23. Present levels of funding for primary care are insufficient to influence the adoption of primary care curricula in medical schools. Prestige, tradition, and the perceived requirement for maintenance of accreditation are strong barriers.

24. While state legislatures and other external sources of funding for medical schools long have favored family practice and primary care as principal medical school missions, they have become skeptical about the ability of medical schools to effect such missions on their own volition. Direct funding to family medicine departments, residency positions, third-year clerkships, rural training tracks and other “pro-primary care” strategies are now preferred in many state.

25. As research support wanes and clinical income declines, innovative mechanisms to fund ambulatory care education should be developed. The public and payor intermediaries must be convinced of the need to support medical education.

26. Physician residency programs should take a proactive role in the placement of physicians in underserved communities, including political support of service corps programs. A placement service for such communities should be instituted by medical schools, where appropriate.

Governance

27. Primary care physicians should be members of all influential medical school committees such as admissions, curriculum, faculty appointment and promotion, long term planning, and maintenance and expansion of the primary care patient base.

Outcomes

28. Health professions schools should be accountable to the communities in which they exist. Health professions schools should be responsible to produce a certain number of graduates who go into primary care and practice in underserved communities.

[H] HEALTH PROMOTION

1. Health education begins with the family. Resources devoted to health promotion should encourage families to educate family members on how to maintain good health.

2. Physicians and other health professionals should take positions of community leadership with the objective of promoting good health.

3. The monitoring of quality and outcomes should include the evaluation of access to and effectiveness of primary health care services. “Healthy People 2000″ objectives should be incorporated into quality measures for such monitoring activities.

4. Hospitals and physicians who work in a community should invest in the community’s health and economic well-being.

[I]  PRACTICE GUIDELINES

Guidelines should be established for appropriateness of care. the development of these guidelines should involve patients as well as health care providers. Primary care authorship of those dealing with health promotion and common medical problems is preferred.

[J] REIMBURSEMENT

Reimbursement should continue to move towards prospective payment at an overall fixed amount for providers and plans. Providers and plans should be held accountable for prospective budgets and allocation of resources that maximize access, efficiency and quality.

[K] MANAGED CARE

1. The managed care market should be regulated in a way that assures that providers increase services to the presently uninsured and underinsured. Providers should not be able to profit by limiting their enrollment to those who are in good health.

2. National health policy should promote the positive elements of managed care, including cost containment and quality assurance.

3. Case mix adjusted premiums and provider reimbursement should be developed and implemented to distribute resources more appropriately.

[L] TEACHING COMMUNITY HEALTH CENTERS

1. Community health centers should be a part of community centers. A multidisciplinary team approach for the delivery of services should be established.

2. Teaching Community Health Centers [TCHCs] are a model for community-based service, education, and research. These TCHCs are expected to improve the quality and outcomes of health professions education by integrating medical education within model community-oriented primary care practices operating in a reformed health care delivery system.

3. TCHCs are entities that have a mission of improving the health of the community through: a) service, b) education, and c) research. They are public or non-profit agencies that provide comprehensive primary health care to medically underserved communities.

4. TCHCs in both urban and rural areas in all parts of the country should be developed and funded: a) to improve access to quality primary care services, and 2) to increase the number and distribution of primary care providers coming from and returning to underserved areas.

5. TCHCs should have administrative structures and systems that assure financial, clinical, and academic accountability and stability.

6. TCHCs should provide primary care across the life cycle in a continuous and coordinated fashion to a defined target population representing a diversity of diseases and conditions. Services should be provided as part of an integrated health care delivery system facilitating ready access to all levels of care with a coordinated multidiciplinary team approach.

7. TCHCs should focus on improving the health of the community through the application of the principles of community-oriented primary care.

8. TCHCs should be accredited as an ambulatory primary care provider by the appropriate accrediting body.

9. Physician training located within a TCHC should be sponsored by at least one accredited primary care residency program with a separate match number either as a free-standing organization or an affiliation with an established teaching institution. Such primary care residency programs must be in family practice, general internal medicine or general pediatrics. In addition, the TCHC provide post-graduate training for nurse practitioners, nurse clinicians, physician assistants, or certified nurse midwives.

10. The sponsoring institution must recognize and allocate suffiicient education time distinct from patient care responsibilities in accordance with accreditation requirements.

11 Research on improving the health of the community should be encouraged through participation in clinical trials and the development of databases for community health issues, clinical guidelines and health outcomes.

12. Evaluation of TCHCs should gauge the impact of the program on the community’s health; track its graduates working in underserved areas; and document the costs associated with these outcomes.

13. Changes should be made in federal and state statutes and regulations that accomplish the following:

a) TCHCs should be eligible to directly receive graduate medical education payments that reimburse these centers for their development and      operational costs.

b) startup funds for planning and development of TCHCs should be identified and made available.

c) TCHCs will be recognized separately from non-teaching community health centers by taking into account the special needs of ambulatory-based    teaching programa.

d) the National Institutes of Health, Agency for Health Care Policy Research, and other federal research agencies should increase their focus on  primary care research by utilizing TCHCs.

e) faculty development, technical assisstance, and support programs for TCHCs should be developed and implemented.

f) loan repayment programs serving medically underserved communities should target residents and faculty of TCHCs.

[M] TORT REFORM

Tort reform should be achieved, so that fear of malpractice suits does not dictate inappropriate medical practice.

[N} PRIMARY CARE WORKFORCE

1. There is need to include definitions of primary care (American Academy of Family Physicians and Society of Teachers of Family Medicine) that distinguish the primary physician from the generic term of primary care provider that has been sought after by many of the subspecialty organizations to promote their self interest in the era of health care reform.

2. Predoctoral and graduate physicians should be exposed to health care teams and leadership functions necessary to coordinate teams developed.

3. The family medicine community should place high priority on retraining programs for subspecialists who desire to obtain credentials and certification in primary care.

4. There seems consensus that there are inadequate numbers of primary care physicians, although this is by no means an established fact. Other proposed configurations of health care providers including augmented utilization of nurse practitioners and physician assistants in provision of first contact medical care might even allow the reduction of medical school class size. However, there is consensus that there are too many physicians in the United States and that they are geographically maldistributed.

5. Though exactly how the reconfiguration of health care delivery will occur in an atmosphere of health care reform, there seem relentless forces forging rapid movement on the short term toward a managed, integrated system based on primary care. Though a different array of providers is possible, it is almost a certainty that primary care will continue to be delivered and controlled by physicians. If, as many believe, there is a serious geographic and specialty maldistribution, and that our educational programs have produced too many narrow specialists, then their redirection into primary care will likely occur in the future. With this redirection, the need for physician assistnats and nurse practitioners may be reduced. However, it is quite likely that there will be a continued significant role for nurse practitioners and physician assistants in managed care.

[O] RURAL HEALTH ISSUES (GENERAL)

Financing innovations aimed at equalizing access to health care likely would benefit both rural and non-rural communities. However, service delivery innovations that rely on the development of a competitive environment do not fit the situations of most rural communities, and may exacerbate the physician shortage problem.

[P] RURAL WORKFORCE ISSUES

1. Greater numbers of primary care providers are needed in rural communities than are presently practicing there. Some rural communities are unable to attract and retain physicians, given their remoteness, geography, and/or lack of amenities. Another important cause of the rural provider shortage is the United States health provider training system that produces too many subspecialists.

2. Public funding of health professional education should be based, in part, on how well this education meets the provider needs of the region. The ultimate success is the number of graduates who practice in specialties and geographic locations of need.

3. Optimal models for training rural providers should be developed and tested. Residency review requirements should be modified to accommodate the special training needs of rural providers. Financial support must be made available for more community-based training. Curriculum should be expanded to teach community medicine needed to practice in small town settings. Community and migrant health centers should have an increasing role in training future rural providers.

4. The number of training positions for health care professionals should be based on population needs.

5. Medical school selection preferences should be given to students from rural areas, and particularly to those from needy rural areas who plan to return to their home communities after training.

6. States, including their state offices of rural health, should play stronger roles in creating and supporting programs to recruit and retain health care providers. Hospital and clinic administrators and boards of directors need development of their management skills and ability to work with health care providers, preferably before new providers move into the community.

7. Program should be expanded to alleviate the debt burden of young rural providers.

8. Mechanisms should be developed to decrease the after-hours burden of many rural providers. Successful strategies include (1) facilitating cross-coverage arrangements, and (2) creating a pool of locum tenans providers to provide more extended respite.

9. Despite the effects of various programs, some particularly remote and impoverished rural communities will continue to experience primary care provider shortages. These communities will require ongoing support from the National Health Service Corps, financial incentive programs, and other programs specially designed for th emost challenged communities.

10. The National Health Service Corps should give preference in scholarship awards to individuals from areas likely to require future NHSC placements.

11. More funds should be allocated to Public Health Service regional offices to support NHSC and other rural and urban providers. Partnerships between regional and state offices of rural health should be fostered.

[Q] RURAL HEALTH SYSTEMS

1. Rural health systems should provide the infrastructure (support) for determining the mix of specific services that should be available in 1) all rural communities, 2) some rural communities, and 3) only in regional referral centers.

2. The process for developing rural health systems should involve consumer and community participation.

3. The optimal design of health services delivery and financing in rural areas is not now understood. Consequently, research on rural health service models should be developed and funded.

4. A telemedicine infrastructure to support rural practice should be developed, and reimbursement for telcommunicated consultation should be provided.

5. Mental health services and long-term care facilities in rural communities hsould be integrated effectively into the health care systems.

6. Rural health infrastructures do exist, but are much more decentralized than in urban areas. Much more flexibility should be allowed in rural communities in establishing rules and regulations governing health care.

[R] RURAL HEALTH FINANCING

1. Private and public financing of rural health care should assure continued viablity of essential health access points for rural patients.

2. Differntial provider reimbursement between urban and rural areas which result in the maldistribution of providers should be eliminated.

[S] INDIAN HEALTH SERVICES

Special notice needs to be drawn to the fact the Indian tribes are sovereign nations and there exists a special Federal trust relationship that must be honored in health policy consideraitons.

[T} RESEARCH ON PRIMARY HEALTH CARE

1, An NIH Instiute of Family Health and Rural Primary Health Care should be established and adequately funded.

2. Although it would facilitate the growth of primary care disciplines, creation of an NIH Insitute of Primary Care in the near future appears not politically feasible. One named a Family Health Institute might be more realizable.

3. There is need for a forum that will promote discussion of a) policy issues, b) program development and evaluation, c) impact of health systems changes (e.g., managed care) on the delivery of services to populations of special interest, de) how groups interested in the changing health care systems are coping in their local service areas and e) faculty development of the ability to perform scholarly studies related to these topics (e.g., funding and exploration of collaborative activity.)

[U] COALITION BUILDING

1. We must find out how to involve all groups in health care decisions, rather than just those with “speical interests”.

2. Coalitions of groups intrested in healt care reform, such as corporations, unions and consumer groups, should be encouraged.

3. A broader coalition of ersons interested in healt and primary care should develop mechanisms to influence government policymaking positively over a long period of time.

4. The groups and individuals participating in the National Conference Series on Primary Healt Care Access share a commitment to improving access to high quality primary health care services, and support the development of coalitions to advance this goal. The inclusion of individuals and groups who are currently delivering high quality primary care services in such coalitions is recommended, as well as representatives of health services systems that share a commitment to and responsibility for primary care. Coalitions should be guided by the needs of the patients and the communities that should be served.

5. Coalitions, like treaties, arise when parties decide that the benefits of joining forces to advance their common agendas outweigh the potential costs and compromises required to maintain them separately. The current crisis in access to primary care is of such a serious magnitude that such coalitions are now necessary.

6. Those attempting to build such coalitions must remain vigilant for deterrents arising from different histories and cultures of participating groups.

7.The goals of coalitions to further access to primary care are: a) developing rational, effective primary care delivery systems responsive to clients, their families and communities; b) enhancing the biopsychosocial education and training of primary care health professionals, including team training; c) developing the primary care research base in health services delivery, clinical outcomes, and training and evaluation methods; and d) reforming health policy and financing systems to reestablish the central role of primary care and to provide adequate service delivery to all our citizens.

8. The specific coalitions for each of the above goals will be differnt and should be established on both local and larger (state and national) levels.

9. Local coalitions should include representatives of each cultural group being served, to ensure that services desired by such groups and cultural sensitivity of systems will increase. Such interaction will also foster population-based primary care goals and facilitate beter measurement of progress.

10. Foundations interested in health care should be included as they often foster and finance creative new approaches. Finally, local governments, managed care organizations and insurers may be involved to create multi-partner solutions to local delivery problems.

11. National coalitions should be formed with large consumer groups such as the AARP, NRHA, NACHC, the Children’s Lobby, major labor unions and others. Such coalitions should facilitate local cooperation and influence national policy.

12. Locally, coalitions should start among MDs and DOs in general internal medicine, general pediatrics and family practice and expand quickly to include nurse practitioners, physician assistants, registered nurses and other health professionals engaged in delivering primary care services.

13. Such coalitions should focus on evaluation and revision of curricula and training, assessing the competency of generalists, joint faculty development, disseminating the primary care curriculum proposed by PCOC, implementing such curricula, and advancing the primary care knowledge base through collaborative research.

14. A suggested method is to survey the local environment to find those with ideas, vision, power and common interests who might be “brokers”. Nationally, the primary care organizations should establish structures that will facilitate collaboration. As they become more familiar with each other’s cultures they will find new, mutually beneficial ways to collaborate productively.

15. Local coalitions can help facilitate local changes in primary care priorities.

16. Nationally, primary care organizations must develop an effective and singular voice on health policy and financing reform. At all levels they should become more effective at presenting the message that primary care is essential to the future health of the nation and can only be provided in a quality fashion by those who are trained and specialize in it. This message must be successfully conveyed to our citizens and our political decision-makers

17. Dialogue should be increased between leaders of organizations that represent physicians in family practice, general pediatrics, and general internal medicine, and between practitioners in those three primary care specialties.

18. The contributions of each of the major primary care specialties to primary care research should be better understood through increased communication and collaboration among leaders and researchers in those specialties. For example, the contributions of general internists to studies of the doctor-patient relationship, of family physicians to family health systems and of pediatricians to child development should be diffused throughout all three specialties.

19, More extensive dialogue should be encouraged between researchers in the primary care medical specialties and the mental health specialties.

20. The Primary Healt Care Access conference series should include among its invitees increased numbers of representatives from general internal medicine, general pediatrics, nurse practitioners, physician assistants and certified nurse midwives.

21. The conference should define primary health care by content and function rather than by the specific kinds of health professionals who perform primary care services. Consensus should be reached as to the content of primary care, including definition of comprehensiveness and continuity of care, and skills needed for delivering primary health care. Primary care’s relationship to the larger health care system should be defined.

22. The knowledge base of the primary care specialties should be augmented to include greater understanding of the behavioral sciences and preventive medicine. Funding of studies of the behavioral and biopsychosocial aspects of health care should increase.

[V] PERSONAL VALUES

1. Certain core personal values (“guiding principles”) are linked closely to effective primary care. Medical trainees choosing primary care specialties tend to rate benevolent personal values (helpfulness, honesty, loyalty and service) significantly higher than trainees choosing non-primary care specialties. Conversely, many subspecialists rate power values (wealth, social standing) significantly higher.

2. Family physicians whose personal values for benevolence are high and for power low have been found to be more satisfied with their work.

3. Many physicians enter medical school with benevolent personal values, which often become distorted by the educational process.

4. Selection of medical students with benevolent personal values is recommended, as well as educational strategies that reinforce and preserve attitudes of helpfulness, service, honesty, compassion, loyalty, kindness and respect.