The Third Charles E. Odegaard Lecture, Presented at the Sixth National Conference on Primary Health Care Acces, Colonial Williamsburg, Virginia, March 1996 

Presented by: Mark E. Clasen, MD, Ph.D., Wright State University, Dayton, Ohio:

Mark E. Clasen, MD, Ph.D., Wright State University, Dayton, Ohio

While I recognized the controversial nature of this title, I chose it anyway because it captured most closely the few thoughts that I may put forth regarding this concept. I suppose one could ask the question, how can one be culturally incompetent? Rather, we are considering the “oughts and shoulds” in our yearning for a society that has healthcare as a right, and not a privilege.

The American Academy of Family Physicians, and our constituent chapters, has put forth the noble idea that all Americans should have their own physician- a physician who knows them and their families, whose values and culture lies in the midst of their family units. Taking the concept of the genogram, or the family organ as Jack Rodnick whimsically mused about, and moving its concept beyond the psychosocial data base into the realm of family mythology. Personally, I think the genogram is a powerful tool.

When the genogram is considered at the level of family mythology, we can approach the health belief systems that guide many of our personal decisions in matters of health and illness. These belief systems also guide our notions of adherence with medical authority, or with the teachings and beckonings of health providers.

An entire hour could be devoted to issues of compliance or adherence; yet, we as healthcare professionals know that most compliance occurs in the milieu of a trusting relationship that is culturally competent. In this major thrust, that creating a real change in behavior, occurs best when the message is negotiated in one’s own language, articulated with the proper mixture of science, theology, and always love. There is little doubt that a culturally competent care giver is more valuable than the high priest of technology who possesses 100% knowledge to heal, but who lacks the human translation about how to heal.

Does the title of this presentation suggest that our medical school graduates are inadequately prepared to deal with a diverse population? Does the title imply that interpersonal skills are not fully developed or as finely honed as they should be by graduation? Does it imply that 20th century physicians have been egocentric, dogmatic creature and practitioners of the art? Does it imply that 20th century physicians have not made tremendous strides in conquering disease and delaying premature death? The title was not selected to caste blame, shame, or dispersions on 20th century medical education, it was selected to look forward into the 21st century- pondering the questions about what knowledge, skills, and attitudes are needed to equip the st century physician. What types of educational activities will prepare the medical student of the future to enter this profession, and what are the threats and promises of such a career?

To loosely paraphrase an old adage: “ a physician is frequently in error, but never in doubt.” For those in the audience who are not physicians, I want to assure you that ego strength is required to deal with pain and suffering, and demands a decisive, take charge approach, and is more egocentric than George Patton, especially when life and death matters hang in the balance.

As a consumer of healthcare, we prefer to be clients or customers when the issues are superficial; however, when the issues are weakness, being sick unto death, being rendered helpless, we more likely want to be a patient of a loving, caring physician who will guide us through the storm to the shoreline of restoration , health, and well-being.

We have accepted the culture of medicine that does not like “wimps” but strongly favors the direct approach, aggressive intervention, hard data, hard facts, “heal with steel,” and when in doubt cut it out. The culture of medicine is portrayed on the television series, “ER.” Notice all the language of medicine used to describe the culture of medicine: hard Science, hard facts, conquering the disease and aggressive intervention. I won’t comment on the term physician extender to describe physician assistants or advance practice nurses as part of the psychosexual language used to describe workers in US medical culture.

When my wife’s parents went to the radio-oncologist to enlist his help in addressing my mother-in-law’s inoperable lung cancer, they were asked the following question: Do you want the palliative dose or the curative dose of radiation? My mother in law is a fifth generation Texan, and my father-in-law grew up on the plains of Kansas, both are highly learned people, and how do you expect they answered that question? Suffice it to say that they did not opt for the palliative approach. Four years later, without a trace of cancer on bronchial biopsy, I would say they made the right decision. US medicine gives you the option for the palliative approach or the curative approach. It is the wimp factor versus aggressive intervention, and aggressive intervention wins.

Think of your own family. Rationing healthcare is good in concept, but now for my family. After all, managed care has brought us  coronary artery by-pass surgeries for $9000 in some markets, and the price is still falling. Major coronary artery plumbing jobs are becoming routine, and there is no doubt that carotid endarterectomies improve the potential to live life without stroke complications.

I presume many of you have become acquainted with Dossey’s book entitled “Healing Words.” For those who have not read this or seen the PBS series which devoted time to explore mind/body relationships, I will cite one study which was performed on patients in coronary care units. This was a double blind study with matched control groups and experimental groups. The groups which received prayer had significantly better outcomes than the group not prayed for. Despite the curative approach used by my mother-in-law’s oncologist, she received prayers from the Christian Medical Society and prayers offered from a variety of religious faiths.

There is a meditative tradition in almost every major religion: Buddhism, Christianity, Hinduism, Islam, and Judaism, and these major religions emerge from the same source of power (in my humble opinion).

There is healing in the words and traditions of these faiths because they are connected to the concept of a loving God as we know him or her to be. Ghandi  said,”I am a Hindu, I am a Christian, I am a Jew…Imperfect ourselves, we should be gentle to others.” The notion of healing words, meditation, soft intervention, and gentleness are the entrée to the next addition to the 21st culture of medicine.

There is no question that a pluralism of values which embraces the culture of US medicine will emerge in the next century. I am hoping that women entering medicine will not try to out Patton General Patton. I hope that entering students will already have an acquaintance with sorrow, grief, and human suffering.

Being a creature of the culture of medicine, one day I prescribed an antibiotic to a woman who was suffering from a moderate to severe pneumonitis. In the community health center where I was practicing, we had our own pharmacy. This prescription was costly and on our “use sparingly list.” I told this woman that I was giving her” Gorilla-cillin.” She looked at me and a tear came to her eye. I asked, “what is wrong?”

She replied, “You have cared for my mother better than any doctor ever has, but I thought you were different.” “Different,” I queried? Then she looked at me and asked, “are you calling me a Gorilla… A monkey? Do you think that I am too stupid to know the real name of the antibiotic?” I almost fainted. She cared enough to tell me that I was a culturally incompetent physician who was not sensitive to a racial connotation and too elitist to use the name Augmentin. I told her that now I could see my incompetence, and used the term only to imply the strength of the antibiotic and nothing else.

What I loved the most about working with the African American community in Houston was the dignity and wisdom of people who entrusted their health care in me. I had just enough culture competence to learn from this dear woman. When she understood what I had meant, and that I had meant no harm, our relationship grew even stronger. We brushed tears from our eyes, and I had gained more appreciation for cultural awareness and sensitivity.

In the same community health center, a very ill subset of diabetic patients were getting sicker. In this group hemoglobin A1C’s were climbing, and visual and extremity complications were worsening. The physician group asked our diabetic teaching nurse, Gloria O, to break out of her prescribed protocols, and render this group of patients intensive outpatient care. Listening to her counsel her patients in a new way, I heard her use language and imagery that I had never heard her use before.

With some patients she was gentle, and methodical- teaching life style modification. With others she talked about which dress she would wear when she attended their funeral. Ms. O was culturally competent and effective. By all parameters, this group became healthier. Here was a nurse practitioner who was more powerful therapeutically than a team of physicians. I learned a lot about the power of multi-disciplinary teams, and about cultural competence in changing behavior.

I could turn this into a personal confessional detailing the numerous mistakes that I have made regarding my own cultural naivety, so I will turn to other examples of cultural incompetence. I will relate the story of a second year resident who chased a patient through and out of the waiting area for wanting to discuss a termination of her pregnancy. As he yelled out scripture, the frightened patient ran out and never came back. When I attempted to counsel the resident, he quoted scripture to me. “Thou shall not kill.” I quoted back the first commandment: “ I am the Lord your God. You shall have no other gods before me.” – not even your best definition of me.

These stories illustrate examples of attitudinal incompetence, laced  with elitism, sexism, and intolerance. Gayle Stephens has pointed out wisely that practitioners of medicine’s shortcomings are not usually due to a lack of knowledge; rather, they are the result of character issues deep within. I have even heard the rumor that more reasoning abilities of medical students decline over the course of their medical education. Can this be so? Is a medical education destructive?

Many of us have been through a medical education, and have our own war stories to tell. Can the countless hours, sleepless nights, pimping, roundsmanship, and open harassment mold and inspire the culturally competent physician for the 21-st century? To be a physician for human beings, you must first be a human being. How does medical education care for the personhood of the medical student or resident? What is being done – other than Pelligrino –  to assist students as they poder ethical dilemmas? What is being done to foster true character building experiences which enable our students to encounter illness, evil, death, and violence and render hope, compassion, caring, and maybe even cure.

What will the 21st century be like in medical education? If we know the answers, we could begin our curricular revisions now. We know that our nation is aging, and that Gerontology and Geriatric Medicine begs for compassion in the curriculum. The racial mix of the nation is changing rapidly. We know the race, culture, and ethnicity are such that diversity can be used to make the US the most creative nation on earth. Stratification and separation may preclude us the rich blessings of our diverse heritage. We know that hatred and bigotry have evil roots and tentacles, and the politics of fear may prevail.

We have those that believe that the economic pie is only so large- that if somebody gets something, there is less to go around. This mentality exists among many physicians. The creation of wealth and capital is a concept missed somewhere in the education. We know that different languages will be spoken in this land. We know that HIV to be a sentinel event with other incurable conditions to follow.

And, the re-emergence of infectious diseases will tax our public health systems. We know that environmental pollution, chemical warfare, biologic warfare, and the disposal of nuclear waist will become more intense problems in the next century. We also know that racial disparities as expressed in mortality and morbidity rates largely disappear at the top of the economic scale.

At this conference, AJ Henley alluded to the fact that economic disparity and deprivation was more important to good health than access to healthcare. Correcting the economic problems would do more for the health of vulnerable and indigent people than medicine.

Many of us have an inkling that despite our total embracement of private medicine, a public sector will re-emerge as a dominant force in healthcare. The argument for the demise of managed healthcare is one that I won’t make here, but I predict it will happen. However, concepts of accountability, contracts for quality, and continuous quality improvement are here to stay in some form or another. Our students need strategies to incorporate these concepts into their own self-monitoring, self-measuring, and life- long educational strategies.

Evidence based medicine which Al Berg so eloquently described in Maui with the otitis media scenario and population medicine best articulated by capitated payment programs are examples of practicing in new ways. I remember Mark Babbitt articulated the futility of going room to room to room as the community became less healthy. I remember Mark learning about culturally competency when he prescribed  ampicillin to a migrant farm worker who lack refrigeration- because he was living in the car.

The day of the lone ranger, solo practitioner is over, and every small group practice in American is for sale. If solos are gone, then groups and intelligently crafted teams will be the future stage for the practice of medicine. Let us examine the future player.

One of the most enlightening experiences of teaching at a primary care medical school is that our strongest learning lab is the community. The teaching community is the most powerful ally that we have in teaching cultural competence. In Family Medicine our strongest teaching strategy is the teaching family. It is not the “Fam Scam” of the genogram; rather, it is the myriad of appropriate strategies that might be used in the context of this person’s family and health belief system.

In our department we lend teaching expertise to the advanced practice nursing curriculum as well as the physician assistant training program. We participate in the multi-professional course where medical students, nursing students, allied health students, and seminary students work and learn together. We learn cultural competence by learning from a diverse group of people.

Dr. Leroy, who, by the way, was recently  cited as one of America’s top 50 positive role models as a physician, teaches a course entitled “Economics, Society, and Medicine.” He welcomes our students during orientation. He tells them how he learned to be culturally appropriate and sensitive to the many people of the Appalachian culture whom he serves in his community health center. He even listens to and enjoys country western music, which was not the music in the home in which he grew up. In the first week of medical school, students begin their introduction to clinical medicine course, and the Department of Family Medicine has 20% of the curricular time of the first two years.

We have a teaching associates program and a curriculum that we brought to the national predoctoral meeting of the STFM in January 1995. In this program, non-MDs teach students the knowledge, skills, and attitudes needed to conduct a sensitive physical examination on both men and women. An OB resident from another school tried to tell one of our students that a group of feminists was teaching them an impractical approach. Our students were not intimidated because the patients gave them positive feedback. We believe our students do better in early cancer detection for rectal, prostate, breast, and pelvic cancers.

When we needed pediatric patients in order to teach our students the skills of physical examination of children, we were invited into a community elementary school so that our medical students could perform histories and physical examination on 5 and 6 year olds. What a thrilling experience for the medical students, and for the kids who enjoyed the rapport with the medical students. Incidentally, when I came to help precept the experience, a woman approached me and said, “Hello, I am a Community Health Advocate and I want to know how information derived from these examinations will be communicated to the parents and care-givers of these children.” Good question.

These Community Health Advocates were trained in our Center for Healthy Communities, a project led by Cheryl Maurana, and resulted in the empowerment of community advocates who are not afraid to say to a powerful figure in medicine – just a minute, how is this experience going to help our community.  One little boy who was examined by my group of students had a blood pressure of 1388/88. At age 5 ½, this may have been his first access to a comprehensive pediatric examination. Another child had a raging otitis media, while another appeared to have a urinary tract infection.

When our first year students needed patients to interview during their medical interviewing course, a cadre of older hospital volunteers became our willing patients.  Students, patients, and faculty all found the experience authentic, significant, and important. Objective structured clinical examinations (OSCEs) are useful and a powerful device for assessment. But the teaching community has more to offer than scripted scenarios. The HIV, the geriatric, and the human sexuality selectives all use community patients and a host of non-MD teaching personnel. How could we teach geriatrics without Marshall Kapp’s insight into the legal issues of competence and aging? How could we teach community health without the faculty diversity found within that department?

Lest you think that we are soft science haven, I can also cite our trauma service which handles major trauma and has statistics which are half the national morbidity and mortality rates. Directors across the country rate our students as good as and better than graduates from other institutions.

What’s the secret at the Wright State University School of Medicine? Part of it is in the admissions process and the values that stand behind that process. With a 40 to 1 applicant to acceptance ratio, we could fall into the trap of being a mainstream medical school. We look for the student who has the academic base, then we look further. The key is to find the student that has had substantial involvement with community over a long period.

In this look, we seek students who have become acquainted with human suffering and who have made a connection with people who suffer, and who continue their involvement with people in these communities. We also find a racial mix of students who reflect the racial composition of our geographic area of western Ohio. Without students who reflect our community, we could not be evolving into a leading school in producing culturally competent physicians.

Last fall, Carole Bland and Michael Rosenthal assisted all the schools of Ohio when they became visiting faculty at our statewide conference on changing admissions practices of the seven Ohio medical schools. We are looking to change the mix of candidates likely to enter primary care versus specialty care medicine. The conference provided research data that suggests that the medical classes can be manipulated at the front end.

I still have trouble convincing our own admissions committee that we should seek students with science and math GPAs  around 3.5, because those with a GPA higher than 3.75 are more in love with science than with people. Listen to what your own committees would say to the notion of lowering standards, especially when the non-cognitive attributes of the culturally competent physician are still so ill-defined and foreign to the current culture of medical education as well as US medicine.

The emergence of the culturally competent physician also includes in-depth training in medical cultural anthropology and language skills that go beyond medical Spanish or the meager attempts at using a translator. Cross cultural/cross racial advanced doctor-patient communication skills are imperative, and the place to learn these skills is early in the medical education process.

Dr. Leroy has told me that he likes the students to take his course early, before their medical education has jaded them, and the current acculturation process of medical education has taken the wonderment of people out of the equation.  I believe that medical cultural anthropology is more intense and needed than is biochemistry. Memorizing the Kreb cycle for the 7th time does little to wipe tears away from people who need relief from pain and suffering.

The WSU School of Medicine model starts with admissions values, continues with the powerful presence of Family Medicine throughout all years of the curriculum, involves many non-MD educators, and an invested teaching community.

The will to create the conditions for the emergence of the culturally competent physician is an intricate process, and is different at each institution. The team concept of medicine of the future requires excellence in interpersonal and intraprofessional communication abilities. Much of this is driven by personal values and the institutional values that comprise the medical school of tomorrow.

A model that resembles the priestly model of care may be relevant here. The priestly model  involves the concepts of teaching, suffering, and celebrating. Teaching involves patient education and behavioral change. Suffering involves the intimate acquaintance with sorrow, grief, loss, anger, and failure. Celebrating is the essential ingredient for renewal and inspiration found in healing, care, comfort, and cure.

Are we telling our students to celebrate and dance? Do we dance with them? Are we distanced from sorrow and suffering? Have we taught in such a way that behavior changes and outcomes improve? Are we the role models of the culturally competent physician? Are we skilled in low tech, high touch medicine? Are we competent to stand with our patients through the threats and promises of technology and for the omnipresent aggressive approach which promises cure rather than palliation?

As John Mitling has taught us through his eloquent research, a family physician in every count in America means less cost and an improvement in morbidity and mortality statistics. Can this model be so wonderful? I believe the potential for all medical specialties lie in the renewal and transformation of the culture of American medicine that must begin in our medical schools. I have given several examples of what is meant by cultural competence, and have cited our early beginnings at our institution to create the culturally competent physician.

Can this interface between high technology, clinical excellence, and cultural competence occur? Of course, it can and should. Cultural competence is the attitudinal soul of the transformation of the culture of US medicine. Rather than the oak tree which stands fast in the storm, the strength of the future practitioner is that of a willow tree: many branches, the ability to change shape as conditions change, and a tree that can withstand storm and wind. It is the blending of soft and hard sciences, with faculty role models to help US medical students cope with suffering, teach new ways, and to celebrate always.

After all, there will come a time when lions and lambs will graze together, every tear will be wiped away, and there will be no more death. The promise of the parousia is no more or less possible than the cultural transformation of medicine, and the obvious impact this transformation will have on issues of access to health care.

Monday, April 16, 2012

6:30 AM – 8:00 AM Working breakfast in preassigned groups, Avocet Restaurant (conference registrants only) 

8:15 AM – 12:00 PM First Plenary session

8:15 AM Welcome   

      Jay W. Lee, MD; Memorial Hospital Long Beach (California)

8:20 AM Opening Statement of First Plenary Session by Session Moderator:

     Marc E. Babitz, MD; Utah Department of Health

8:25 AM First Roundtable: “Realities and Illusions:  A Discussion National Health Policy, PPACA and Health Care Insurance Reform 2011-2012” 

     Joshua Freeman, MD, University of Kansas, Kansas City

     David Sundwall, MD, University of Utah, Salt Lake City

     Hector Flores, MD, White Memorial Medical Center, Los Angeles

9:00 AM Audience Questions and Comments:

     Lead Question: Cynthia Olsen, MD

9:10 AM Special Presentation: The Primary Care Crisis 

     John P. Geyman, MD, University of Washington, Emeritus, Friday, Harbor, Washington

9:35 AM Audience Questions and Comments: 

    Lead Question: Richard Clover, MD

9:45 AM: Second Special Presentation: “Reconceptualizing the Primary Care Relationship”

     Joseph E. Scherger, MD, MPH

10:10 AM Audience Questions and Comments

    Lead Question: Perry A. Pugno, MD

10:20 AM Break

10:30 AM The 22nd G. Gayle Stephens Lecture

     To Be Announced

11:00 AM Audience Questions and Comments

    Lead Question: Charles Q. North, MD

11:10 Thought Provocateur #1: Caribbean Medical School Graduates and Regional Primary Care Needs

     Peter Broderick, MD, Valley Consortium for Medical Education, Modesto, California

11:30 Lead Question: Jimmy Hara, MD

11:35  Realities and Illusions: Plenary Roundtable and Discussion by the Conference as a Whole on the Days’ Themes: 

     Mark E. Clasen, MD, Ph.D., Wright State University

     Allan Wilke, MD, Ross University, Dominica, West Indies

12:00 Adjournment

Stephen W. Cobb, MD, Medical Director, Exempla Physician Network, Denver

Stephen W. Cobb, MD; Exempla Healthcare, Denver

Good morning.  I’m Steve Cobb from Denver. It’s good to be here. Three years ago I gave up running the family medicine residency at Saint Joseph Hospital in Denver. Now I run our group practice, which has doubled in size in two years. I wonder if that’s happening in your markets too. Hospitals are buying up practices. I met a colleague who’s on the same career path as me. It’s the 90s all over again! It’s a different world!

I will present a different perspective on the potential impact of PPACA. Saint Joseph Hospital takes care of the underserved in Denver, now that the University of Colorado no longer serves them. There’s no one left in Denver but St Joseph Hospital to care for that population. Only last year, the hospital got Disproportionate Share Hospital [DSH] money for the first time.

Denver is very different than Hector’s situation in Los Angeles  [see 22nd National Conference: How Will it Work? PPACA and the Community-based Teaching Hospital (Part 1, Flores)]. Saint Joseph Hospital is very much a partner with the Kaiser system in providing care, 80% of the admissions at our hospital are Kaiser patients.

Competition between Denver’s hospital systems

I will describe the three hospital cartels in the Denver market. I use the word “market”, even though I think that’s a bad word in this group. I don’t want to see any stones thrown at me up here, but I think that it might be instructive to hear this.

Mt story will tell how PPACA has provided pressure for cartels to collaborate with one another. The resulting collaboration is affecting the Saint Joseph family medicine residency.

The company I work for is Exempla. We have three hospitals in Denver. If I don’t show you geography none of this is going to make any sense, so I have to use pictures for my story.

Locations of Exempla's Three Denver Hospitals

Our three hospitals employ physicians whose practices support the mission of the hospital. That’s why those practices exist.

We have three major cartels in our market. The first, HealthOne is the Hospital Corporation of America [HCA] by another name. There is a a community partnership with HCA that makes them feel better about being a “for profit” entity, but it’s still just part of HCA. The corporation hosts two family medicine residencies in Denver.

The second cartel, Centura, is a marriage between the Adventist and the Catholic hospitals. They have six Denver hospitals and six “mountain” hospitals as well, with one family medicine residency in Denver and one in Colorado Springs.

The third, Exempla, is the weaker player in town, but I believe being the underdog is a good thing. We are Catholic sponsored [the Sisters of Charity of Leavenworth Health System]. We have a family medicine residency in Denver and our parent company owns one in Grand Junction.

Just to show you are we are the weaker member, below is a map of the geographical reach of the Centura network:

These hospital systems do not like each other. They do not like to collaborate. They do not trust each other. They don’t like to share data.

Medicaid Funding of Cooperative Efforts between Family Medicine Residency Programs

However, the family medicine residencies collaborate with each other, even though we fight over the medical students we recruit to Colorado.

So why do the family medicine residencies collaborate in Colorado? We collaborate because we have leveraged Medicaid money that funds a state commission that was established in 1977 so that we could build a primary care workforce in Colorado.

From this nucleus there is a history of nine family medicine residency directors working with commissioners appointed by the Governor to ensure Colorado has primary care physicians throughout the state. That has proved to be very important. We’ll discuss the commission more fully later.

At our hospital we have four 104 residents in four physician specialties. In the family medicine residency clinic we have 18,000 visits a year, of which 44% are self pay (in our hospital and that means no pay, since patient don’t pay for their care). The Sisters of Charity pay. They very intentionally operate a charity system that funds a lot of health care – at least the primary care.

What we think will happen after PPACA is fully implemented, is that our “self pay” percentage will go down by half and will be converted into Medicaid at some point in time. We think it’s important to be prepared for that.

Collaborative Efforts to Implement Patient-Centered Medical Home Principles

All nine family medicine residencies in Colorado applied for and received a grant from the Colorado Health Foundation, an HCA subsidiary.  HCA, a competitor, is giving us and its other competitors money to implement patient-centered medical home principles in the nine Colorado family medicine residencies. The residency programs are all at various stages in their development and face various struggles.

The goal is to get everyone’s residency program recognized by NCQA [National Committee for Quality Assurance] as a patient-centered medical home, and eligible for the contracts associated with tha designation. The residency in Fort Collins does very well financially and they probably will get some nice commercial contracts out of being a patient centered medical home recognized. At Saint Joe’s we probably won’t get any such contracts.

Medicaid-funded accountable care organizations

Our state Medicaid agency is creating accountable care collaborative organizations. I’ll describe how we’re going to participate in those. We will be developing new competencies for residents, like we do for students. We have to think about what kind of doctor that we will need to produce to be successful in the patient-centered medical home model.

What will this mean for a residency program that historically has produced docs that when they finish can go to work in a Kaiser system and be successful, but also can go out into rural America and be successful? Is that going to change? I think it will.

The Colorado Patient-centered Medical Home Initiative

Colorado’s patient-centered medical home initiative, although funded by the Colorado Health Foundation, will be administered by the University of Colorado and the Colorado Association of Family Medicine Residencies.

Here is what will happen at Saint Joe’s. Now our residents will all complete two quality improvement projects a year based on their patient practice populations. They will have to demonstrate health improvement in their practice population. This they will be required to do in addition to their ICU rotations and their continuity OB clinics.

We are tracking referrals and doing followup, which in the past was not done in this practice. There is intentional, continuous quality improvement in place. Never before were those words uttered in this program. We will have completed implementing EPIQ [Evidence-based Practice for Improving Quality]  in a few weeks. Our patients, who are 44% self pay/no pay patients, are really going to access their charts electronically.  You can imagine that it is a big deal for this population. It’s important that someone is there during the entire period of change, and we’ll be there throughout this process.

The Challenges of Care Management

Those of us who run residency programs all know that team-based care is one of the most difficult administrative challenges. We’re all part-time doctors in that practice, and there is a lot of discontinuity, no matter what our values and principles are. For these reasons, we’ve implemented nurse practitioner-run teams of care and we all work with them. That’s been very successful.

What’s not going well? 1) Care management! Nobody knows how to do it in our program. We don’t know how to fund it.  It’s very difficult to do for the population that we serve, even if you have money. 2) Population management! It is also very, very difficult to manage patients in this situation by registry for a lot of reasons. 3) Self-care! The facilitation of self-care is not going well. These are all resources that we don’t have. No matter how much we ask for the resources, the hospital doesn’t have it either.

We’re on the difficult journey that we hope leads to an effectively operating patient-centered medical home. The other eight residencies have similar struggles.

Medicaid Accountable Care Collaborative Program

The enactment of PPACA has, I believe, increased interest in a separate initiative, the Medicaid Accountable Care Collaborative Program.  There are three elements to this collaborative program: 1) Primary care docs providing patient-centered medical homes, 2) regional care collaborative care organizations which will be important,  and  3) comparative statewide data. A data analytics coordinator position has been established, to enable providers have be able to compare how they are performing with others.

Colorado is still divided into seven regions. In Denver County, where Saint Joe’s is, the Saint Joseph Hospital family medicine residency will be participating in a patient-centered medical home. You get a $4 member per month management fee, but all you have to do in this contract is say yes, I’m committed to patient-centered medical home principles and I commit to work with the regional care collaborative organization. That, at the present time is all you have to commit to. Nobody’s measuring anything. On top of your management fee, you get fee-for-service reimbursement.

What’s interesting though is that in region six (Denver) a contract to create a collaborative care organization was awarded to what’s called the Colorado Community Health Association – a collaboration between the IPA to which all of our primary care doctors in Exempla belong as do those of Centura, a competitive hospital system. Through this collaboration we jointly will address the care of the Medicaid population.

Hector alluded to the cartels in Los Angeles, where there are also emerging Accountable Care Organizations [ACOs] that are comprised of IPAs and competitor hospital systems and residency programs. These cartels are going to try to work together to try to do something that might be helpful for the Medicaid population. Why are the IPAs and hospitals doing that? I think, because they want practice experience, so that when commercial products come along they will have some competency to do this work. Maybe the motivation isn’t pure, but the side effect is that the Medicaid population may get better care.

Developing Residency Faculty Competencies for Quality Assurance 

What probably is more important in the current situation than focusing on resident competencies is the need for better faculty competencies. Our residents have competency, even now, in some of these quality improvement tools. Our faculty doesn’t really know how to manage care. It’s not something that they’ve done.

For this reason, I hired two of my former residents to work in our system. Six months after I hired them, one described three PDSA [Plan-Do-Study-Act] healthcare improvement cycles she has already done in her clinic, where she’s working to make various things better. Up until about five years ago, I didn’t know what a PDSA was. I am really proud of her.

Learning how to be NCQA recognized and what all that means; participating in mandatory Medicare quality initiatives like PQRS [Physician Quality Reporting System] –  are competencies that are new for our residency.  Beyond that, there is a whole new science for patient safety that we’re now teaching in the residency.

This is a very granular picture of the big changes that are occuring in one residency because of PPACA.

A Potential Unintended Consequence of PPACA in Denver

If we ever are going to get the resources to do population management at Saint Joe’s, it’s going to come from collaborating with the Kaiser system. Saint Joseph Hospital doesn’t have the money, but Kaiser does. Kaiser ends up with about half of our graduates every year. They’re very invested in those doctors being competent in population management. So Kaiser is interested in taking over the residency program all together.

Kaiser’s interest in our residency, heightened because of the changes PPACA will bring to health care delvery, may very well affect our rural medicine mission. I’m very proud to tell you that two years ago the family medicine residency program established an OB fellowship and our first graduate completed 120 C-sections. That matters to me. I spent my first five years in practice in rural Oklahoma taking care of Native Americans. My passion is rural medicine.

If Kaiser were to run our program, this is what I think would happen. Kaiser doesn’t really care if family medicine doctors deliver babies, or if they’re competent to work in ICUs, or whether they can do their own C-sections. The program that I built based on my personality and my belief of what a family doc should be won’t continue.

I think we’ll probably end up with an exposure rather than a mastery experience in obstetrics. I think the obstetrical fellowship will go away. Maybe that’s the right thing to do with the program, but these might be the unintended consequences of the impact of PPACA on our little community hospital residency.

I will conclude my story with this picture of Saint Joe’s.

Saint Joseph Hospital Denver with Kaiser Hospital in Background

We have two towers. (There’s a story behind that.)  In the background, right behind Saint Joe’s, is the Kaiser building. That’s how connected we are to them down in Denver.

These are my comments.

The Twenty-Third convocation of the National Conferences on Primary Health Care Access will be held April 16 through 18, 2012 (concluding at noon on April 18th) at the Park Hyatt Aviara Resort in Carlsbad, California. The theme of the conference is “Realities and Illusions”.

Th Park Hyatt Aviara Resort in Carlsbad, California

Background of the National Conferences on Primary Health Care Access

In 1990, a group of persons interested in family and community medicine, medical school reform, and advocacy for rural, inner city and other geographical areas of need, were invited to rural Wisconsin for the First National Conference on Primary Health Care Access. Since then, similar groups have been invited to assemble each Spring.

Over the years, many of the pioneers, key strategists, researchers and policy makers who have promoted the idea of community-responsive medical education have participated in one or more of the National Conferences. (Many have participated in 15 or more of the 22 conferences held through 2011.)

The National Conferences have continuity in the conference faculty from year to year. The conferences are limited to approximately 55 participants. Persons who enroll in the conference series are invited to renew their space in each subsequent conference. For additional information on the series of National Conferences, see: The Background of the National Conferences on Primary Health Care Access.

Continuing medical education prescribed units will be awarded. (For the CME awards of each of the previous National Conferences, see: CME Prescribed Credits for National Conferences on Primary Health Care Access.)

When the National Conferences began in 1990, there appeared to be a consensus among its participants that if legislation was enacted to increase access to primary health care, rural and underserved populations would be the principal beneficiaries of the reform.

A panoramic resort view from a Park Aviara room

That may yet prove to be the case, but many persons who strongly supported changes in national health care legislation have deep reservations about both the processes and the product of the legislation enacted in 2010.

Of course, enacting legislation at the federal level is only the first step in changing the way the health care system works. Not only do different sections of the comprehensive bill become operative at different times, almost every line of the legislation requires new regulations or revision of existing regulations.

Some (maybe much) of what the legislation requires will generate ongoing political debates, which often will be so divisive as to make the particular future policy stands of legislators and other policymakers (or even whom they may be) unpredictable at the present time.

Even so, there is much opportunity for constructive change, and those areas will be a central theme of the Twenty-Third National Conference.

Each of the National Conference sessions begins at 6:30 a.m. and is comprised of early morning breakout groups with assigned topics. (See an example of last year’s breakout session at 21st National Conference – Reports from Monday Breakout Sessions – April 12, 2010.

The Park Aviara - a Five Diamond Resort

Reports of succeeding days are found in the website’s archives for the months of April 2011 and subsequent months.)

All National Conference business ends at noon each day, permitting conferees to enjoy the surroundings of one of the world’s great destination areas for the remainder of that day with family or colleagues.

Information on the National Conference’s plenary sessions will be posted as they are announced.

The posting of the proceedings of previous National Conference plenary sessions relevant to the 23rd National will take place continuously.

This will include a series of presentations on Community-based Medical Education that are preparatory to discussions on this subject at the Carlsbad conference.

For information on the Twenty-Third National Conference, which is invitational, please contact coastalresearch@yahoo.com.

The Adjacent Lagoon and Bird Sanctuary

23rd National Conference Plenary Faculty (announced as of January 11, 2012)

Marc E. Babitz, MD, Utah Department of Health, Salt Lake City

Sally Bachofer, MD, University of New Mexico, Albuquerque

John Boltri, MD, Wayne State University, Detroit, Michigan

Peter Broderick, MD, Valley Family Medicine Residency Program, Modesto, California

Mary T. Coleman, MD, Ph.D., Louisiana State University, New Orleans

Hector Flores, MD, White Memorial Medical Center, Los Angeles

N. Benjamin Frederick, MD, Penn State Hershey Medical Center, Hershey, Pennsylvania

Joshua Freeman, MD, Kansas University Medical Center, Kansas City

John Geyman, MD, University of Washington Emeritus, Friday Harbor

Thomas Hansen, Creighton University, Omaha, Nebraska

Tim Henderson, MPH, George Mason University, Fairfax, Virginia

James Herman, MD, Pennsylvania State University/Hershey Medical Center, Hershey

Mitchell Kasovac, DO, A. T. Still University, Mesa, Arizona

Jay Lee, MD, Memorial Medical Center, Long Beach, California

Darryl Leong, MD, MPH, Care 1st Health Plan, Monterey Park, California

Gary LeRoy, MD, Wright State University, Dayton, Ohio

Don McCanne, MD, Physicians for a National Health Program, San Juan Capistrano, California

Charles Q. North, MD, MS, University of New Mexico, Albuquerque

Cynthia G. Olsen, MD, Wright State University, Dayton, Ohio

Perry A. Pugno, MD, MPH, American Academy of Family Physicians, Kansas City, Kansas

J. Jerry Rodos, DO, Midwestern University, Western Springs, Illinois

Joseph E. Scherger, MD, MPH, Eisenhower Hospital, Palm Springs, California

Frederic N. Schwartz, DO, A T Still University, Mesa, Arizona

David N. Sundwall, MD, University of Utah, Salt Lake City

Daniel Webster, MD, Michigan State University, Traverse City

Allan J. Wilke, MD, Ross University, New Brunswick, New Jersey

_

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Joseph Scherger, MD, MPH; Eisenhower Medical Center; Rancho Mirage, California

Doctors John Geyman and Joseph Scherger return to the faculty of the National Conferences on Primary Health Care Access, at the 23rd National Conference on Primary Health Care Access, to be held April 16-18 at the Park Hyatt Aviara in Carlsbad, California.

The first three hours of the 23rd National Conference will be devoted to overviews of the current issues surrounding 2010′s comprehensive and controversial health care legislation, the Patient Protection and Accountable Care Act (PPACA), to the nation’s seriously deficient primary health care system, and to promising new directions in primary care.

The first plenary panel, which will begin Monday, April 16 at 8:15 .m., will provide an update to the administration’s implementation plans, and to constitutional and political challenges raised against PPACA.

The first plenary panel will be followed by “Breaking Point”, Doctor John Geyman’s lucid analysis of the lack of preparedness of the nation’s current primary care system to meet even current challenges such as the increased prevalence of chronic disease and the aging of the population, without considering how PPACA might be fully implemented. Doctor Geyman is emeritus professor at the University of Washington, and author of seven books on health care policy that includes his latest on the primary care system [see Senior Fellow John Geyman’s New Book on Primary Care Crisis to be Featured at 23rd National Conference.] A reactor panel will follow Dr Geyman’s presentation.

Then, at 10:15 a.m., there will be a presentation entitled “The Future of Primary Care is Now!”  by Dr Joseph Scherger, Vice President of Primary Care and Academic Affairs at Eisenhower Medical Center in Rancho Mirage, California. A reactor panel will follow his presentation as well.

The 23rd National Conference is invitational, with registration strictly limited. For further information, contact coastalresearch@yahoo.com.

Joshua Freeman, MD; Kansas University Medical Center

The scheduled panelists are Joshua Freeman, MD of the Kansas University Medical Center (Kansas City), David Sundwall, MD of the University of Utah (Salt Lake City), and Hector Flores, MD of the White Memorial Medical Center in Los Angeles. Doctors Sundwall and Flores are Senior Fellows of the Coastal Research Group. Dr Freeman is a Fellow.

Last year Dr Freeman critiqued the PPACA legislation as the 2011 Stephens Lecturer. (See Proceedings of the 22nd National Conference: The 21st G. Gayle Stephens Lecture: Dr Joshua Freeman.) He is Chair of KUMC’s Department of Family Medicine and has been involved in issues of social justice and care to underserved populations throughout his career.

David Sundwall, MD, University of Utah

Dr Sundwall, who has served on a committee staff of the United States Senate, and has been served as Administrator of the United States Department of Health and Human Services Health Resources and Services Administration, and also as the Utah State Director of Health.

Dr Sundwall is currently on a national policy committee on  Medicaid and federally financed children’s health programs. (See Activities of the Fellows and Senior Fellows of the Coastal Research Group: Dr David Sundwall is Vice Chair of Federal Panel on Medicaid and CHIP Payment and Access.)

Dr Flores, who is nationally recognized as an expert on the provision of health care to disadvantaged communities, is one of the founders of the White Memorial Medical Center’s family medicine residency program in East Los Angeles. He has taken part in several federal committees and task forces relating to health care access.

Hector Flores, MD; White Memorial Medical Center, Los Angeles

Doctors Freeman, Flores and Sundwall will each speak to the issues and then will engage in an exchange first among themselves and with National Conference participants.

The National Conferences on Primary Health Care Access have taken place each Spring since April 1990. They are invitational conferences limited to around 50 persons. This is the third consecutive National Conference which has examined the efforts to develop and implement a comprehensive federal health care reform legislation.

Professionals interested in primary health care public policy who would be interested in receiving an invitation to the National Conferences should send an e-mail to coastalresearch@yahoo.com.

Plenary sessions concentrated on the student pipeline for the primary care workforce will take place on the second day of the 23rd National Conference on Primary Health Care Access (Tuesday, April 17, 2012) at the Park Hyatt Aviara Resort in Carlsbad, California

Perry A. Pugno, MD, MPH; American Academy of Family Physicians

Leading the principal session on student interest in primary care will be Doctor Perry Pugno, Vice President of the American Academy of Family Physicians (AAFP), who will examine student interest in family medicine careers, addressing the question as how student interest has changed over time.

Dr Pugno will describe the AAFP’s re-design of its strategic approach to student interest in response to new studies, new trends, and now new input from a diversity of stakeholders.

Dr Pugno asks: “Is there a “magic bullet” that will trigger the choice of family medicine as a specialty?” and answers “Probably not”.  But the use of a portfolio approach to address multiple factors and decision-points for individual medical students (or even pre-meds) can indeed make a difference in the pipeline for family medicine’s future.  Innovative residency training models, value-added curricula, and diverse training settings are only a few of the many approaches now beginning to demonstrate their favorable impact on student interest.

The presentation by Dr Pugno will be followed by a responder panel that will be announced soon.

The posting of the proceedings of this plenary session is part of a series of previous presentations on Community-based Medical Education that will be highlighted on this website. Such presentations are preparatory to discussions on this subject scheduled for the Twenty-third National Conference on Primary Health Care Access at the Park Hyatt Aviara Resort in Carlsbad, Caloifornia April 16-18, 2012. 

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From the Third Plenary Session of the 21st National Conference on Primary Health Care Access:

Robert Ross, MD, Oregon Health Sciences University/Cascades East Family Medicine, Klamath Falls (Moderator):  I’d like to welcome Dr. Daniel Webster, from Michigan State University, Traverse City, to give us our first topic of the morning, “Strategic Interventions in the State of Michigan”.

Daniel Webster, MD; Michigan State University, Traverse City

Daniel Webster, MD, Michigan State University, Traverse City: I’d been encouraged for many years by Doctors Bill Wadland, MD, George Smith, MD,  and Beth Burns, MD, who have all attended the National Conferences before, as has Dr Linda Garcia-Shelton. All have spoken very highly of them, so last year I attended a National Conference for the first time.

Introductory Comments

Officially, I’m a family physician who graduated from Northwestern University in 1979, attended Michigan State University (MSU)  College for Human Medicine, and then trained in a family medicine residency in Grand Rapids, Michigan.

I entered practice in a town called Traverse City and ran a family practice there for 14 years. Then in 1996 I left private practice to start a dually accredited (MD and DO) family practice residency.

I was director of that residency for 14 years. Dr Perry Pugno (Director of Education at the American Academy of Family Physicians and a Senior Fellow of the National Conferences) has been my mentor since 1995.

About two years ago, we started the seventh campus for MSU’s College of Human Medicine. I am the Assistant Dean in Traverse City for the MSU campus, my third career in the same town  - as family physician, residency director and now assistant dean.

I will speak about the consequences of Michigan’s strategic initiatives for medical student education. First, I will provide some general information about the growth in medical student education in the State of Michigan and then talk specifically about growth in the  College of Human Medicine (CHM). I’ll discuss some success stories and also some stories yet to be evaluated as success stories.

Earlier in the conference we talked about the Baby Boomers, This is a generation that we in Michigan are looking at too.   I’ll present this in little chronological steps going back to 2005, look at the present, 2010, and forward to 2015, as to what worked and what didn’t go so well.

Michigan’s Geography and its Medical Schools

When you look at the geography of the state of Michigan, you can see there is a lower peninsula and an upper peninsula.  News media reports sometimes forget the upper peninsula is actually part of Michigan. The upper peninsula is not a separate state.

I will give you some driving distances – Traverse City to Lansing,  the main campus of MSU CHM, is a three hour drive. To drive to Lansing for several hours of meetings, then return home to Traverse City is a good day’s journey. We have a campus in Marquette, eight hours away, as well. The other campuses are in Grand Rapids, Kalamazoo in Southwest Michigan, Flint and Saginaw.

The stakeholders in this effort are Wayne State University, University of Michigan and MSU.

MSU has two medical schools on the same campus – CHM (allopathic), and the College of Osteopathic Medicine. Both are housed in East Lansing. The others are Wayne State in Detroit and the University of Michigan at Ann Arbor. These produced 581 students per year in total, as of 2005.

I alluded to the MSU CHM campuses. The allopathic four year campus is in East Lansing. The two year campuses (where specific students do their third and fourth years of medical school) are in Lansing, Kalamazoo, Flint, Saginaw, Marquette, Traverse City and Grand Rapids. MSU’s College of Osteopathic Medicine has their first two years in East Lansing as well. But then the students spread out and do the preceptorship model and the base hospital model, with the students going to approximately 17 hospitals in the state of Michigan. The University of Michigan’s activities are located mostly around Ann Arbor and Wayne State around Detroit.

In 2004-2005, there was a Michigan workforce study that showed that the ratio of primary care physicians to specialty care at that time was 34 to 66. 39% of physicians practicing in Michigan had attended a Michigan medical school, and 61% had completed a Michigan residency. Michigan ranked fourth in the United States of students in a public medical school. The study projected a State shortfall of 4500 physicians over all and a State shortfall of 600 Family Physicians.

These figures seemed low to me at that time. However, this drove some of the State’s medical schools to increase their enrollment sizes, which they were already in the process of doing. The study was revisited at in 2008. The percent of primary care to specialty care hadn’t changed. The study found that in 2008 almost 80% of the physicians were planning to maintain their current practice patterns or to increase their hours of practice.The study also that the female/male physician ratio was  50/50, and that, as in all other states, the population was aging.

Meanwhile, Michigan has its  economic problems, with an unemployment rate at almost 15% in April 2010. Because of severe shortfalls in the general fund for supporting medical education, these original stakeholders have been told to absorb state funding cuts of 23% over three years. Yet, there greater numbers of uninsured, who are increasingly seeking medical care in Emergency Rooms.

Currently, there are 1,051 graduate medical education (GME) positions in Michigan, with roughly one-third being in primary care medicine. Of these 317 primary care GME positions only 99 are in family medicine, comprising only 10% of Michigan’s GME positions.

The next slide clearly shows the impact of medical school expansion. In 2010, the total has increased from 2005′s 581 to 925 medical students per year. Through this increase of 344 medical school positions, Michigan’s physician workforce is being redesigned – although perhaps not for all the right reasons.

Only the University of Michigan stays at the same level, but Wayne State increases rapidly from 200 to 300 graduates. Michigan State’s CHM jumps from 106 to 200, opening one new campus and expanding the combined Midland-Saginaw campus. The College of Osteopathic Medicine (COM) has increased as well from 100 to 250. COM’s growth is towards Detroit, so they’ve entered the competitive market for clinical sites in Ann Arbor (home of the University of Michigan) and Detroit (home of Wayne State).

The next slide shows where the campuses are. Wayne State (labelled WSU) and Michigan (UM) are in the Southeast and MSU’s four year osteopathic medical school (COM) and College of Human Medicine (here, labelled CH) are on  the main campus in East Lansing.

But simultaneously, MSU’s CHM, is launching a four year campus.  Thus, MSU will have two four year campuses, one in Grand Rapids and one in Lansing. They’ll split the students equally between those two campuses in the first two years. The MSU CHM Dean, Marsha Rappley, MD, divides her time equally betwen the two campuses. (It’s an hour’s drive between them.)

Expansion of Community-Based Medical Education raining into New Areas

The students will then be distributed for the next two years to the other community campuses, and will either be assigned to Marquette, Traverse City, Kalamazoo, Flint, the combined campus of Saginaw-Midland, or they’ll stay in either East Lansing or Grand Rapids.  COM, I’ve already mentioned, is expanding to Southeast Michigan, towards Detroit.

Also in 2010 some new stakeholders have entered the scene. These include Western Michigan University, Central Michigan University, and Oakland University. Oakland University’s medical school in Oakland County (in the greater Detroit suburbs) is on board to start partnering with William Beaumont Hospital, admitting 50 medical students starting in Fall 2011.

I visited Central Michigan University in Mount Pleasant just a couple weeks ago. They will  have 100 students starting in 2012.  Western Michigan University (Kalamazoo) is planning for 50 students, although they don’t have a start date as of  yet.

Impending Shortage of Medical Student Preceptors

One of the concerns is that when you start adding more students and more medical schools, as you all know, you only have so many preceptors to go around. There is now competition in  Michigan for the development of training centers for all of these medical students. The map gets a little busier. We still have CHM and COM primarily in East Lansing, but CHM’s four year campus in Grand Rapids is added.

Two of these campuses – Grand Rapids and East Lansing – are providing identical services and an identical curriculum. Oakland University (OU) is in Rochester, and Central Michigan University is located in Mount Pleasant. Meanwhile, Western Michigan University is in Kalamazoo, one of our community campus sites. That creates some friction as well.

The problem with finding preceptorship sites is not so much the case in the Traverse City area, because we’re a brand new area for CHM. Although we have been a base hospital for the MSU College of Osteopathic Medicine, with regard to CHM, we have a lot of volunteer faculty that are eager to teach the students. But there is more competition for community preceptors in Kalamazoo and Saginaw and, obviously, in the Detroit area.

Faculty Development for Community Preceptors

All of the campuses, including ours, are engaged in faculty development programs for our preceptors. The last thing we want to do is ask somebody to teach and not help them with the skills they need to teach. The preceptors want that information.

MSU and Medical Education

Next, I will discuss MSU’s progress over the the last couple of years.

As the slide above indicates, MSU is a land grant institution in an auto producing state – an industry that has created some of our major current economic problems.

CHM is a college of Michigan State University, which is a land grant institution. CHM was founded in the 1960s and 1970s to encourage the training of primary care physicians. At one time we had 25% of our graduates going into family medicine. That has changed. Of the 46% entering primary care in 2010, only 9% went into family medicine.

41% remain in the state 43% entered primary care in 2008 and you can see the results down to 2010.

Sometimes it’s confusing as to which medical college you’re looking for, because they’re all in the same building.  (At MSU they say we have three medical colleges because they include the veterinary school.) There is no hospital on the MSU campus itself, although we have hospitals in each of our community sites.

The photograph is of East Fee Hall. When Dr Allan Wilke (a Senior Fellow of the Coastal Research Group) and I were undergrads, that was a dormitory. All of the COM’s offices used to be old dorm rooms.

That’s where we are now with the CHM – the school I’m associated with at this time. I was its residency director as well. We had a family practice residency network that had nine residencies located across the state.

These are the players in my culture right now. There’s a fair amount of friction because Central Michigan University is talking about expanding north, so they would be expanding into where my preceptors come from. We have Kalamazoo Western potentially starting a medical school, and if they do, MSU will pull out of Kalamazoo. Where those students will go, I’m not exactly sure, although I think some of them will end up in Traverse City.

Meanwhile, Saginaw and Midland have plans to combine into one campus as well.

All of the campuses have teaching hospitals, rather than having just one major academic teaching hospital. In Traverse City our teaching hospital, Munson Medical Center, is the hospital where I have had privileges for over 30 years.

This slide gives you a few statistics. Munson Medical Center is a major employer in the area. It currently is going through affiliation talks with Grand Rapids Spectrum Hospital. Whether that’s good or bad, I haven’t determined yet.

When we pose the question to our board as to why should we have a clinical campus in Traverse City, they cite that previous Michigan work-force study that I referred to. The board thought it was good for recruitment, retention and academic stimulation and provided an opportunity to meet rural health care needs. They thought it would help the institutional reputation, as well.

For the first two years – the year starting July 2009 and the coming year starting in July 2010 –  students had already been assigned to clinical campuses. For that reason, we had to recruit pilot students. We have six pilot students for the current year. Four of them are from California, two of them are from Michigan – actually one of them is from Traverse City, and she plans to go into primary care and stay in Traverse City. The four from California plan on going back to California.

Eight months later they’re still happy, and having a good time.

The slide below describes the Traverse City curriculum, which is similar to most medical school curricula, with basic science in the first year and problem-based learning in the second.

 Then in the third year, we have six clerkships, each that are eight weeks long, using the same curriculum across all clinical campuses.  Our campuses are based on a model called Regional Medical Campuses or Disseminated Medical Campuses. (The Canadians use the term “Fully Distributed Medical Campuses”).

Each campus has a clerkship director for each of these specialties and coordinating them is a lead clerkship director for each of these specialties.  This creates a network that delivers the same curriculum across all community campuses. We are fortunate in our family medicine programs to have the students for eight weeks. I take them myself, and am also the family medicine clerkship director in Traverse City.

In Traverse City, I place them in both the rural sites and in sites in Traverse City. They work in the hospital for a week. They are in the Traverse City Health Clinic, which is a free clinic, serving migrants and Native Americans. I try to expose them to all aspects of primary care, similar to Marquette, which does the same thing

The Marquette training site is fortunate to be located in the Upper Peninsula. It geographic situation and curriculum are similar to the rural sites used in the Minnesota program described yesterday by Doctor Macaran Baird. Both the Upper Peninsula and Minnesota rural students have 12 weeks of family medicine.

The Marquette site has a higher percentage going into family medicine, as well as a higher percentage of family docs staying in the Upper Peninsula. They also either go through the residency in Marquette or they go to another residency and return to the area.

(In this morning’s breakout session, Doctor Baird confirmed that the Minnesota data parallels our findings about those training in Michigan’s Upper Peninsula.)

Then in the fourth year we have four week required clerkships in advanced medicine or senior surgery, and then they choose their electives.

The CHM Longitudinal Curriculum

I’ve been in residency education for 14 years and I’ve only been in medical student education for about 16 months. So it’s taken me awhile to learn it. But what’s really nice about the CHM curriculum is the longitudinal component.

The curriculum includes gateway assessments, which are simulation labs, back in Lansing or Grand Rapids. Gateway assessments related to physical exams occur in the second and third years. There is also an Evidence-based Medicine gateway exam as well.

There’s a huge curriculum on professionalism included in our evaluation forms as well. Patient safety is a curriculum component, as is the ethics curriculum, and these subjects are integrated in the curriculum from the first year through the fourth year.

A new requirement is community service (which most of the students have been doing anyway, but now it’s an educational requirement, for a minimum of 40 hours over the four year curriculum. There is a research project in the third year as part of their Evidence-based Medicine curriculum.

To give you an example, our students are doing a medication error reduction research project, by means of a survey of pharmacies to see what rate of medication errors there are in prescription writing, whether from an electronic FAX, email or hand-written prescriptions.

For community service, we paired up with our local high school. The slide below shows one of our third year students, co-teaching anatomy and physiology. (I heard from several of you at this conference that this is being done at other medical schools also.)

Student Demographics, Tuition and Debt

This slide presents some of our demographics, with 66% of the students across all campuses coming from Michigan and 34% from out of state. The general distribution is as noted below, although the tuition is actually higher. Tuition is now up to about $30,000 a year for instate students, and closer to $60,000 per year for out of state students. I’ve been told it’s the highest tuition in the nation for a public institution.

One reason for the high tuition is that part of the tuition comes back to operate the medical school. When you have that many campuses, with that many levels of administration and that many requirements across the state, it’s not an inexpensive way to deliver medical education.

I’ve been told by the six students I have in Traverse City, that their average debt approaches $210,000 at this point.

Summary and Issues for Further Consideration

When considering the future needs of medical education in Michigan, we need more slots for primary care, specifically family medicine. We need something to help with loan repayment for students, just as do those of you from other states. We need some help with our insurance reimbursement for primary care. Hopefully, that is coming through the healthcare reform bill, although not until 2014.

You’ll find, as I did, students like their electronics. They want a practice that has electronic medical records. The generation of students we are teaching is looking for the quality of life (not that those of us who have been in practice for thirtysome years aren’t looking for it also). The students will want to limit their call. So those are all concerns we’re going to have to deal with.

Much of this increase in student medical education has occurred in a nonsystematic manner. Each school took it upon themselves to increase their medical school class size. The increase in CHM medical schools’ class size was driven by the desire of the Grand Rapids’ community to have their own four year medical school in partnership with MSU.

That’s why we have two parallel tracks, East Lansing and Grand Rapids, that are only 58 miles apart.The fact is that CMU, Western and Oakland are each developing medical schools with no workforce plan connected to the other three institutions speaks to that.

I’ve noticed in working with medical students is that when they come into medical school, they want to take care of the whole patient. They want to enjoy the practice of medicine, and they want to provide some value or trust to the culture of medicine. Myself, CHM, and all of us in this room just need to figure out how we can do that best. Thank you!

George Smith, MD; Michigan State University/Sparrow Hospital, Lansikng

George Smith, MD, Michigan State University/Sparrow Hospital, Lansing: I’m substituting today for Doctor Sandral Hullett, who was required to testify in a legal case back in Alabama. In her place, I’ve been asked to be a reactor, observer and commentator on what Hector and Steve have talked about and to relate it back to own  environment.

Compared to what Doctors Flores and Cobb deal with in Los Angeles and Denver, I almost feel like I’m in the backwoods. Lansing is a small market, if you will. The population is about 130,000, with a metropolitan area that’s probably 300,000. It has virtually no managed care whatever.

What  managed care we had in the past crashed in the backlash from the managed care movement that happened a few years back. The institution at which I work is a private, not-for-profit hospital, which is the dominant healthcare system in the city, with about 65% market share. (There’s one other healthcare system that has  a niche in cardiac care that has the rest of the business.)

But beyond commercial insurance, what does the payer situation in the Lansing area look like?

In Michigan, Medicaid is “managed care capititated”, although I use that phrase very loosely. There’s no straight Medicaid in Michigan to any extent. If you get on the Medicaid roles, you are enrolled in some kind of “managed care product”.

There are two other entities – 1) the Physicians’ Health Plan, which is really an IPA that Sparrow Hospital owns, and 2) a physician health organization, Sparrow Physicians Health Network (SPHN), in which Sparrow Hospital is a partner. And that’s the landscape that I work with! We have a lot of the same kind of challenges that Hector and Steve are talking about, although to me it seems much less complicated than everything that they have to deal with.

But what are some of the things that we’re doing related to PPACA and to addressing some of the issues around recruitment money and integrated care? I will highlight three themes:

Residency ties with the clinical years of medical school

From the standpoint of integrated care, we have a very unique medical school. Michigan State University (MSU) is a community-based medical school in that it has no university hospital, per se. Phase two, let’s call it, which would be the clinical years – the third and fourth school of medical school – are done in seven communities around the state of Michigan.

Dr  Linda Garcia-Shelton (who is part of this 22nd National Conference) knows this because she’s a link to the past at MSU. Lansing, where MSU is located, is, of course, one of those communities, but there are several other cities as well. [For a presentation on this subject, see: Proceedings of the 21st National Conference: Consequences of Michigan’s Strategic Initiatives for Medical Student Education.]

Creating an Accountable Care Organization for Lansing

That creates an opportunity – something that we’re looking at right now – for our hospital to create an Accountable Care Organization (ACO) that would be vertically integrated. We would be taking the entire MSU health team group of physicians and bringing them together with the private and employed physicians in the SPHN group  to form one large multidisciplinary integrated group in the Lansing community.

It’s a huge task! I don’t think, however, it’s nearly as contumacious as what Hector and Steve have talked about, because we would be starting with less people that have their fingers in the pie, whether you want to call them cartels or competition or whatever else .

That would be the initial venture. I don’t know when exactly it’s going to happen, but the CEO of our hospital and the MSU Provost and President are very interested in working together and making it happen.

Creating a Teaching Health Center

There is another integrated example of care in the community. This may be very strange for many of you who work with community health centers, FQHCs, FQHC look-alikes. We have been asked by our Sparrow Hospital and are in a position to partner with the health department, MSU and Sparrow, to create an FQHC community health center in a part of Lansing that’s pretty underserved and that has lousy health outcomes. We’ve never done anything like this before.

I have done some research on how to make sure that I don’t step in any cow pies (because I understand from talking to some of my colleagues that have done this, that when you create a residency site that’s an FQHC, if you do not do that correctly, it’s a mess that you will regret. It can be a “lose, lose” for everybody.

There was a really good article in the 2009 Annals of Family Medicine by Carl G. Morris, MD, MPH of the Group Health Cooperative in Seattle and Frederick M. Chen, MD, MPH of the University of Washington, entitled “Training Residents in Community Health Centers: Faciltators and Barriers”.  I was surprised to find that there are only 38 family medicine residency-CHC affiliations in the entire country. Therefore, the barriers to this must be substantial to doing this kind of venture, because the number hasn’t changed much in 20 years.

We’re pursuing the CHC linkages, which we think is an exciting opportunity. We would probably downsize our current residency. We have two family health centers right now; one in Lansing proper, one in a small town south of Lansing. We will take some of the resources from these FHCs to apply to this new site.

We hope that the teaching health center will be a recruitment tool as well. We have lots of resident applicants that come through every year and the first thing many of them ask is “do you have an underserved clinic in a neighborhood where we serve the population that comes to the clinic?” When we answer “No”, we never see or hear from them again. They are often underrepresented minorities from Wayne State University or other schools that would be interested in training in a site like that. That’s something that looks like it’s going to happen. I just need to make sure that it’s done right.

In terms of recruiting people into family medicine, I shuddered a little bit yesterday when I was looking at the ranking list of the different medical schools, because MSU’s up there in family medicine. We may be living off some of our older laurels. I can remember not too long ago when, out of a class of 100, 30 students went into family medicine.

The last two years, even at “good ol’ MSU”, the total in family medicine  of 200 students is about 20. The biggest problem is that out of those 20 students, only three stayed in the State of Michigan. Most of those people came from outside and were returning to their home state. To be honest with you, we have some kind of a connection with California. One of our graduates, who graduated in February, is going to a community health center in Modesto as we speak. I’m going to visit her in a couple of days from now.

We need to do something about our retention problem. We’ve adopted a program, that we call The Integrated Program (TIP). It’s not a new idea. The University of Missouri Columbia Department of Family and Community Medicine started this. The idea is to have a prestigious program for third year students who apply for this opportunity to have a linked fourth year of medical school with the residency, while they’re still in medical school. Even though they are not residents yet, they have a special fourth year. It’s become highly competitive.

We just started this program last year. We have one TIP student in our program beginning in July. We have four people that are interested in the program for next year. In return, they get modest help with their tuition reimbursement and they also have a guaranteed spot in the MATCH the following year if everything works out well for them. We’ve tried that and it seems to be very successful.

The last issue I wanted to mention, with regard to recruiting more students for family medicine, is the impending mismatch between medical school positions and residency slots. I thought of this yesterday when we were talking about the increased numbers of medical students.

It is true that the number of students in medical school classes is exploding. But my Director of Medical Education, Dr. William Gifford, has worked out the math on GME numbers on what happens with all of these students are trying to match up in the number of residency slots that are actually available. There’s a line that will be crossed around 2015, when, even if you take all the IMGs out of the equation across the country, there will be 500 graduates of U. S. schools that will have no home – nowhere to go, because there will be so many students and not enough GME slots. By 2020 that will be 3,000 students without residency positions.

I see PPACA as requiring the need for creating more slots for primary care and family medicine.  This is absolutely crucial, because right now we’ve got this mismatch in which more and more students are coming out of the shoot. If anything residency slots have stayed static or even sagged, because there is no federal support for increasing the number of residency positions. This is a scary problem that we really have to address.

Thank you!

Robert Ross, MD; Oregon Health Sciences University/Cascades East Family Medicine:  Thank you very much for your excellent presentation.

Hector Flores, MD; White Memorial Medical Center, Los Angeles

Hector Flores, MD, White Memorial Medical Center, Los Angeles: Good morning! Our charge this session is to talk about community-based teaching hospitals. I am the co-director of the family medicine residency program at White Memorial Medical Center. White Memorial is an inner-city hospital, and certified as a “disproportionate share hospital [DSH]” that actually has been successfully growing its Medicare book of business.

But it’s still heavily dependent, like most inner city hosptals, on government program subsidies. 50% of our admissions are Medicaid, 35% of our admissions are Medicare and 15% are a mixture of the other payers, including the uninsured.

The Benefits of PPACA

I’m going to quickly go over some of the other issues, because Dr. Kahn, in the previous hour, did a really good job of sort of highlighting some of the benefits Dr Norman Kahn, in an earlier presentation this morning, showed a slide of a convoluted statue (see 22nd National Conference Proceedings: How Will it Work? The Physician Workforce and Medical Education (Part 1, Kahn)).

However, my remarks will be in the context of a teaching hospital and highlight some of the components I think are enabled by PPACA and a related “Medicaid Waiver” that has been authorized for the State of California.

First, improved coverage for patients: About 25% of our emergency room visits are uninsured patients. Roughly 5% of those that we admit ultimately end up being uninsured. The hospital does a good job of trying to find payers, at least on an emergency basis, to cover patients who are uninsured, but PPACA definitely will cut by half both the visits by the uninsured to the Emergency Department and their admissions to the hospital.

The Medicaid Waiver  that California received is in part catalyzed by the Accountable Care Act thinking. We call it the “bridge to reform” The Waiver is focused on enrolling virtually all patients (with a couple of excepted categories) into managed care. It creates a patient-centered medical home model for patients, regardless of whether they are Medicaid or uninsured. I’ll talk about those programs in a second.

Because the State of California also knows that this Medicaid Waiver is conceived as a bridge to reform, it approved the creation of a special fund for private hospitals, like White Memorial, which it called a “hospital fee”. Such a mechanism allowed the hospitals to then set up a fund that could get a federal match through the intergovernmental transfer (IGT) authority.

This was important because, since 2005, private hospitals could not benefit from the IGTs available to the University of California hospitals, or county hospital systems. Instead, private hospitals were told that they had to come up with their own funds. They did so, through this hospital fee and the state legislation required to implement it. By following through with that process, Disproportionate Share Hospital (DSH) funding was preserved for private hospitals. [For a previous discussion of educational activities funded through Intergovernmental Transfers, see Proceedings of the 22nd National Conference: Tim Henderson – The Funding of Graduate Medical Education through Medicaid Dollars.]

Second, the insurance exchange: The insurance exchange will be a benefit to hospitals like White Memorial because participating plans – pretty much every plan – are saying that they need to participate with the insurance exchange. The hospitals understand that if there is going to be two or three million new privately insured patients along with two or three million new Medicaid patients, if they want to access those privately insured patients, then they will need to play ball with the exchange.

The legislation that establishes California’s insurance exchange requires that if you want to access that newly insured commercial patient base, then you also have to also deal with Medicaid. That allows a hospital like White Memorial to seamlessly contract with a single health plan, as opposed to carving out who’s going to give me my Medi-Cal patients, and who’s going to give me my Medicare and who my commercial patients.

There’s a prominent rule for “local initiative HMOs”, which are the Medicaid managed care plans who are always seen as historically aligned with both the public hospitals and the private sector DSH hospitals.  The problem is that the 2013-14 rates are only guaranteed for two years. After that, the states are supposed to pick up the tab. Given where we all are, especially in California, it’s not likely to happen. I’ll return to that subject.

Third, increased numbers of FQHCs and funding for teaching health center models: There will be a session after us that will explore these models further, so I won’t spend any time on it.

Fourth, the expansion and reallocation of GME slots: This feature presents an opportunity for a hospital like White Memorial, which is in the inner-city to benefit. Even though rural communities will get the preference, inner-city and critical access hospitals will be second in line.

Fifth, the accountable care organizations: The ACO authority provides the ability to begin to integrate the medical staff physician workforce, with hospital imperatives around Medicare and around commercial plans also. In California, this really helps a hospital like White Memorial envision a new model of delivery where the physicians are truly aligned with the hospital’s mission. In California we have a corporate bar that prevents hospitals from employing physicians, but the medical foundation model as an ACO strategy would get past some of those barriers.

Sixth, comparative effectiveness research: Should this initiative get funded, it will present an opportunity for community-based teaching programs to participate.

Challenges that Inner City Community-based Teaching Hospitals Face

First, the elimination of Medicare Disproportionate Share [DSH] Hospital Funding:  The scheduled elimination of Medicare DSH dollars, starting next year, and the reduction of Medi-Cal DSH funding in 2014 really worries – even scares – hospitals like White Memorial, because we would not exist today – we would of closed, if it were not for the fact that DSH funds existed in 1989 and subsequently.

Second, accelerated enrollment of MediCal patients into HMOS: Accelerating the enrollment of nearly all Medi-Cal patients into HMOs is a worry for us as physicians and also as part of the hospital. This is because we don’t feel we’re “ready for primetime”.  By mandating the enrollment of the most complicated patients into managed care, into systems serving those communities (i.e. community clinics) that are either already overextended  or into private hospitals and physician practices who also are overextended. Now we’re going to be charged with the responsibility for everything that happens, and for every cost that they incur.

The Medi-Cal Waiver includes the Low Income Health Program (LIHP), which consists of dollars that go to the counties to help them foster relationships with private safety net hospitals, like White Memorial. However, this creates a “shotgun wedding”, because we have to figure out how we’re going to work together very, very quickly. The clocks are already ticking on that!

The Medi-Cal HMO rates do not reflect actuarial costs. They are, I think,  really underfunded. There’s a reason Kaiser Permanente limits the number of Medicaid patients they take. Back in 1992 Kaiser went on record saying the dollars are not actuarially sound, they were not going to do an imprudent thing that would end up penalizing the other already covered Kaiser members. I give the Kaiser leadership credit for having already stepped up to state that. In a moment I’ll describe ways that we found  to try to end run the limitations of the funding, but it’s not really constructive for the long term.

Third, uncertainty of future levels of Medi-Cal funding: The Medi-Cal rates beyond 2015 are a big question mark. Bundle payments, ACOs and other events will have winners and losers. Our hospital is trying to be one of the winners, but if we don’t get our act together, we will be one of the losers. We’ll come back to those themes as I finish.

Well-funded private hospitals already have a head start on all of this. We want the Center for Medicare and Medicaid Innovation and found that they are reluctant to invest in Medi-Cal ACOs. Their response to us was that they already paid through the Medicaid Waiver. They said for us to talk to our state officials about “transformation dollars” or pilot programs through the state, but not through CMMI. But then, the corporate bar that I mentioned earlier impacts this.

Yesterday, I made comment (see Proceedings of the 22nd National Conference: Thought Provocateur Session #1 (Geyman Q and A)) and I appreciate the chance to explain it. But you know, one person’s advocacy group is another person’s cartel. We all belong to cartels whether we like it or not. Donald H. Crane, who is the CEO and President of another cartel, the  California Association of Physician Groups, raised the question “Will ACA stand for the Affordable Care Act, or for Advancing the Cartel Agenda?” Dr. Geyman mentioned yesterday there’s a lot of game playing.

Dr Norman Kahn, in an earlier presentation this morning, showed a slide of a convoluted statue (see 22nd National Conference Proceedings: How Will it Work? The Physician Workforce and Medical Education (Part 1, Kahn)), which, I think, is symbolic of people playing the game behind the scenes. They “made nice” publicly  - “while we support this, we want to be proactive”. But behind the scenes, they’re going back to their old ways and they’re carving out their own special deals.

Fourth, Poorly Coordinated Efforts to Provide Care to Uninsured

How will all of this work in Los Angeles County, the “non-system of care”? We have a public system that is really underfunded for the obligation that it’s given. In L. A. County there’s about $50 billion worth of resources that come into the county, but only about $4 billion earmarked for the Department of Health Services – the public health department that includes public health, county hospitals, and some oupatient facilities.

The bulk of the dollars comes into the private sector. The private sector receives 10 times more money, but the private sector doesn’t have 10 times the obligation. If you look at the uninsured on the bottom, the majority of the uninsured get their care through the County – either as their only source of care or episodically. But that’s where they end up. Sadly, catastrophically ill patients enter the system through the Emergency Department and through the  county hospital system, rather than through primary care.

We’ve tried to create some bridges between the public and private sector, most notably with the entities that are friendliest with the public sector – the community health centers in the county. We created a program called public/private partnership, and now the Low Income Health Program (LIHP), that uses funds given to the county to create these important community relationships.

We also set up similar linkages to share the LIHP money with private hospitals. After the Martin Luther King Hospital closed, a trauma system called Metrocare was created in which several private hospitals and the emergency medical services system participate. Even non-trauma hospitals get paid some county dollars to be part of a fabric of services for the community. But this funding is very thin. It’s not really funding a system of care. The efforts are just more patchwork attempts to fix the problems of the uninsured.

Fifth, the self-protective behavior of health care cartels

We all have our business model. Even those whom we would call traditional providers who see some Medicaid patients, limit the number of uninsured patients. I will include our group in that. Only about 8% of our patients are uninsured. We have the capacity to see a lot more patients, but we just don’t have the resources to be able to see them. I do believe in tithing. If everybody did their 10%, we wouldn’t have the problems we have today. But our ethos is “just say no” to the uninsured. Find some way to unload it onto somebody else.

I remember that when I was in medical school, I attended conferences where I would talk about working with underserved communities. Many attendees told me, “That’s what you pay taxes for.  Let someone else worry about that when you go into your own practice.” The greatest tragedy in the United States is that most teaching hospitals are in underserved areas and their graduates can’t wait to get out of there. The ethos that many of their faculty express encourages that.

The private nonprofits have the FQHCs and other kinds of supplemental funding to help them fulfill their missions. The private hospitals spend a lot of their time lobbying for DSH and supplemental funds, even though they might bicker amongst themselves. As an example, the hospital fee was not universally adopted by all hospitals in California. Some, when talking to their own peers, were very vocal about saying, “I’m doing well without this fee. I don’t want to subsidize a loser hospital”. Then the county hospitals have to protect their access to what we call the MIA (Medically Indigent Adult) Fund, as well as their own version of Medi-Cal, DSH and the Medicaid Waivers.

This is how the cartels protect their turf. If we’re going to have real progress in redesigning healthcare – with community-based teaching hospitals as part of the fabric – we need to get past those behaviors. Part of that is understanding. In the medical practices we sometimes have the California Medical Association, the American Medical Association, the California Association of Physician Groups, and even our own specialty society, at odds with each other, each lobbying the same individuals with a different message. Yet we’re all supposed to be physicians doing the right thing!

The private nonprofit community has similar issues. The California Primary Care Association (CPCA) and the National Association of Community Health Centers (NACHC) both represent the community health centers. Many times physicians and clinics are at cross purposes with each other, when in fact we should be trying to build alliances. Then the hospitals through the California Hospital Association, the American Hospital Association, and the California Children’s Hospital Association, each has its own lobbying force and special concerns.

Back in 1992, a very colorful California State Assembly member, Richard Alatorre, who (for those of you who might know him) was Chair of the Assembly Committee on Health, held a hearing on health services to needful populations. Three health care entities, among others, came in to testify. Alatorre finally threw up his arms and said, “You know the hospitals come in and say we’re doing God’s work. Just give us more money we’ll fix the problems of the world. Then the community clinics come in and say we’re doing God’s work. Just give us more money and we’ll fix the problems of the world. Then the doctors come in and say the same thing. If we’re all doing God’s work, then why are we in healthcare Hell?”

It’s true!  We’re all beating up on each other with our lobbying. The counties have their own public hospital associations. The health plans have their own lobbying firms and their own cartels. Then we also have the academic medical centers. Then we have organized labor playing both sides.  We need to unite ourselves.

I like what Jay Lee said, “If we’re not at the table, we’re on the menu”. That so often is what happens! We can have CPCA working with CMA on one particular issue, but they’re at odds on another. We have to get past that!

To begin to build a unified system, we must understand the politics of the situation. Soon the ACOs  will be coming. This is a major concern to me from a policy perspective. Our hospital, among others, is trying to build an ACO around Medicare and commercial patients. At some point they’re going to say “we’re saturating our capacity with our commercial payers. Let the county system worry about the indigent and Medicaid”. That’s the flaw in the system. We’re allowing people to carve out what they want to be their market. What will end up happening is that we all work in our own silos.

HMOs and IPAs would prefer to do business with Medicare and employer-provided insurance, but they’ll dabble with Medicaid as sort of a loss leader for some people that age into Medicare. (They call it “aging in populations”. They focus on 64 year old Medicaid patients to get them into their business as 65 year olds.)

We’re all trying to figure out, how do we make all of these disparity programs work towards a unified system that will ultimately improve quality and reduce cost? I see an opportunity with the ACOs as reducing costs if we really, truly have ACOs that expand into the uninsured and Medicaid populations.

Somehow we need to tweak the healthcare legislation to mandate that –  just like the insurance exchange provision that specifies that if you’re a health plan you participate with Medicaid as well as commercial populations.We should support a mandate that ACOs do the same thing.

The vision for us, and this is a collaborative initiative we’ve been working on for the past year, is to begin teasing out what our cartels are telling us to do and putting it aside when it doesn’t make sense.  We should be moving together – with what our heart tells us to do – to create a new system of care.

There are something like 17 different proposed agreements we’ve got to come up. Hopefully, next year we’ll have executed agreements.Perhaps next year I’ll have better news around this issue. Thank you very much!