Implementation Timeline

Reflecting the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act

2010

Immediate Access to Insurance for Uninsured Individuals with a Pre-Existing Condition. Provides eligible individuals access to coverage that does not impose any coverage exclusions for pre-existing health conditions. This provision ends when Exchanges are operational. Effective 90 days after enactment.

Small Business Tax Credit. Initiates the first phase of the small business tax credit for qualified small employers for contributions to purchase health insurance for employees. The credit is up to 35 percent of the employer?s contribution to provide health insurance for employees. There is also up to a 25 percent credit for small nonprofit organizations. Effective calendar year 2010. (Later, when Exchanges are operational, tax credits will be up to 50 percent of premiums.)

Eliminating Pre-Existing Condition Exclusions for Children. Bars health insurance companies from imposing pre-existing condition exclusions on children?s coverage. Effective six months after enactment and applying to all employer plans and new plans in the individual market. (This provision will apply to all people in 2014).

Rebates for the Medicare Part D ‘Donut Hole.’ Provides a $250 rebate check for all Part D enrollees who enter the “doughnut hole”. Currently, the coverage gap falls between $2,830 and $6,440 in total drug spending. Effective calendar year 2010. (Beginning in 2011, institutes a 50 percent discount on brand-name drugs and begins generic coverage in the doughnut hole; fills the doughnut hole by 2020.)

Prohibiting Rescissions. Prohibits abusive practices whereby health insurance companies rescind existing health insurance policies when a person gets sick as a way of avoiding covering the costs of enrollees? health care needs. Effective six months after enactment and applying to all new and existing plans.

Eliminating Lifetime Limits. Prohibits insurers from imposing lifetime limits on benefits. Effective six months after enactment and applying to all plans.

Regulating Use of Annual Limits. Tightly regulates plans’ use of annual limits to ensure access to needed care in all group plans and all new individual plans. These tight restrictions will be defined by the Secretary of Health and Human Services. Effective six month after enactment and applying to new plans in the individual market and all employer plans. (When the Exchanges are operational in 2014, the use of annual limits will be banned for new plans in the individual market and all employer plans.)

Covering Preventive Health Services. All new group health plans and plans in the individual market must provide first dollar coverage for preventive services. Effective six months after enactment.

Improving Prevention Health Coverage. Requires State Medicaid programs to cover tobacco cessation services for pregnant women. Effective Fiscal Year 2011.

Extending Coverage for Young Adults. Requires any group health plan or plan in the individual market that provides dependent coverage for children to continue to make that coverage available until the child turns 26 years of age. Effective six months after enactment.

Bringing Down the Cost of Health Care Coverage. Health plans, including grandfathered plans, must annually report on the share of premium dollars spent on medical care and provide consumer rebates for excessive medical loss ratios. Effective January 1, 2011

Reducing the Cost of Covering Early Retirees. Creates a new temporary reinsurance program to help companies that provide early retiree health benefits for those ages 55-64 offset the expensive cost of that coverage. Effective 90 days after enactment.

Strengthening Community Health Centers. Provides funds to build new and expand existing community health centers. Effective Fiscal Year 2011.

Strengthening the Primary Care Workforce. Expands funding for scholarships and loan repayments for primary care practitioners working in underserved areas participating in the National Health Service Corps. Effective Fiscal Year 2011.

Improving Consumer Assistance. Requires that any new group health plan or new plan in the individual market implement an effective appeals process for coverage determinations and claims. Effective six months after enactment.

Improving Consumer Information through the Web. Requires the Secretary of HHS to establish an Internet website through which residents of any State may identify affordable health insurance coverage options in that State. The website will also include information for small businesses about available coverage options, reinsurance for early retirees, small business tax credits, and other information of interest to small businesses. So-called “mini-med” or limited-benefit plans will be precluded from listing their policies on this website. Effective not later than July 1, 2010.

Improving Consumer Assistance. Requires the Secretary of Health and Human Services (HHS) to award grants to States to establish health insurance consumer assistance or ombudsman programs to receive and respond to inquiries and complaints concerning health insurance coverage. Effective upon enactment.

Cracking Down on Health Care Fraud. Requires enhanced screening procedures for health care providers to eliminate fraud and waste in the health care system. Many provisions are effective on the date of enactment.

Improving Public Health Prevention Efforts. Creates an interagency council to promote healthy policies at the federal level and establishes a prevention and public health investment fund to provide an expanded and sustained national investment in prevention and public health programs. Effective not later than July 1, 2010.

Strengthening the Quality Infrastructure. Additional resources provided to HHS to develop a national quality strategy and support quality measure development and endorsement for the Medicare, Medicaid and CHIP quality improvement programs. Strategy submitted not later than January 1, 2011.

Extending Payment Protections for Rural Providers. Extends Medicare payment protections for small rural hospitals, including hospital outpatient services, lab services, and facilities that have a low-volume of Medicare patients, but play a vital role in their communities. Effective calendar year 2010.

Establishing a Patient-Centered Outcomes Research Institute. Establish a private, non-profit institute to identify national priorities and provide for research to compare the effectiveness of health treatments and strategies. Effective date of enactment.

Ensuring Medicaid Flexibility for States. A new option allowing States to cover parents and childless adults up to 133 percent of the Federal Poverty Level (FPL) and receive current law Federal Medical Assistance Percentage (FMAP) will take effect. Effective April 1, 2010.

Non-Profit Hospitals. Establishes new requirements applicable to nonprofit hospitals beginning in 2010, including periodic community needs assessments. Effective on the date of enactment.

Expanding the Adoption Credit and Adoption Assistance Program. Increases the adoption tax credit and adoption assistance exclusion by $1,000, makes the credit refundable, and extends the credit through 2011. Effective for tax years beginning after December 31, 2009.

Encouraging Investment in New Therapies. A two-year temporary credit subject to an overall cap of $1 billion to encourage investments in new therapies to prevent, diagnose, and treat acute and chronic diseases. Available for qualifying investments made in 2009 and 2010.

Tax Relief for Health Professionals with State Loan Repayment. Excludes from gross income payments made under any State loan repayment or loan forgiveness program that is intended to provide for the increased availability of health care services in underserved or health professional shortage areas. Effective for amounts received by an individual in taxable years beginning after December 31, 2008.

Excluding from Income Health Benefits Provided by Indian Tribal Governments. Excludes from gross income the value of specified Indian tribal health benefits. Effective for benefits and coverage provided after the date of enactment.

Establishing a National Health Care Workforce Commission. Establishes an independent National Commission to provide comprehensive, nonbiased information and recommendations to Congress and the Administration for aligning federal health care workforce resources with national needs. Effective not later than September 30, 2010.

Strengthening the Health Care Workforce. Expands and improves low-interest student loan programs, scholarships, and loan repayments for health students and professionals to increase and enhance the capacity of the workforce to meet the range of patients? health care needs. Effective calendar year 2010.

Special Deduction for Blue Cross Blue Shield (BCBS). Requires that non-profit BCBS organizations have a medical loss ratio of 85 percent or higher in order to take advantage of the special tax benefits provided to them under Internal Revenue Code (IRC) Section 833, including the deduction for 25 percent of claims and expenses and the 100 percent deduction for unearned premium reserves. Effective for tax years beginning after December 31, 2009.

Indoor Tanning Services Tax. Imposes a ten percent tax on amounts paid for indoor tanning services. Indoor tanning services are services that use an electronic product with one or more ultraviolet lamps to induce skin tanning. Effective for services on or after July 1, 2010.

2011

Discounts in the Part D ‘Doughnut Hole.’ Provides a 50 percent discount on all brand-name drugs and biologics in the donut hole and begins phasing in additional discounts on brand-name and generic drugs to completely fill the donut hole by 2020 for all Part D enrollees. Effective January 1, 2011.

Improving Preventive Health Coverage. Provides a free, annual wellness visit and personalized prevention plan services for Medicare beneficiaries and eliminates cost-sharing for preventive services. Effective January 1, 2011.

Increasing Reimbursement for Primary Care. Provides a 10 percent Medicare bonus payment for primary care physicians and general surgeons. Effective January 1, 2011.

Improving Health Care Quality and Efficiency. Establishes a new Center for Medicare & Medicaid Innovation to test innovative payment and service delivery models to reduce health care costs and enhance the quality of care provided to individuals. Effective January 1, 2011.

Providing New, Voluntary Options for Long-Term Care Insurance. Creates a long-term care insurance programs to be financed by voluntary payroll deductions to provide benefits to adults who become disabled. Effective January 1, 2011.

Improving Transitional Care for Medicare Beneficiaries. Establishes the Community Care Transitions Program to provide transition services to high-risk Medicare beneficiaries. Effective January 1, 2011

Transitioning to Reformed Payments in Medicare Advantage. Freezes 2011 Medicare Advantage payment benchmarks at 2010 levels to begin transition. Continues to reduce Medicare Advantage benchmarks in subsequent years relative to current levels. Benchmarks will vary from 95 percent of Medicare spending in high-cost areas to 115 percent of Medicare spending in low-cost areas with higher benchmarks for high-quality plans. Changes are phased-in over three, five or seven years, depending on the level of payment reductions. Effective January 1, 2011.

Increasing Training Support for Primary Care. Establishes a Graduate Medical Education policy allowing unused training slots to be re-distributed for purposes of increasing primary care training at other sites. Effective July 1, 2011.

Expanding Primary Care, Nursing, and Public Health Workforce. Increases access to primary care by adjusting the Medicare Graduate Medical Education program. Primary care and nurse training programs are also expanded to increase the size of the primary care and nursing workforce. Ensures that public health challenges are adequately addressed. Effective July 2011.

Increasing Access to Home and Community Based Services. The new Community First Choice Option, which allows States to offer home and community based services to disabled individuals through Medicaid rather than institutional care. Effective October 1, 2011.

Reporting Health Coverage Costs on Form W-2: Requires employers to disclose the value of the benefit provided by the employer for each employee?s health insurance coverage on the employee?s annual Form W-2. Effective for tax years beginning after December 31, 2010.

Standardizing the Definition of Qualified Medical Expenses. Conforms the definition of qualified medical expenses for HSAs, FSAs, and HRAs to the definition used for the itemized deduction. An exception to this rule is included so that amounts paid for over-the-counter medicine with a prescription still qualify as medical expenses. Effective for tax years beginning after December 31, 2010.

Increased Additional Tax for Withdrawals from Health Savings Accounts and Archer Medical Savings Account Funds for Non-Qualified Medical Expenses. Increases the additional tax for HSA withdrawals prior to age 65 that are not used for qualified medical expenses from 10 to 20 percent. The additional tax for Archer MSA withdrawals not used for qualified medical expenses would increase from 15 to 20 percent. Effective for tax years beginning after December 31, 2010.

Cafeteria Plan Changes. Creates a Simple Cafeteria Plan to provide a vehicle through which small businesses can provide tax?free benefits to their employees. This would ease the small employer?s administrative burden of sponsoring a cafeteria plan. The provision also exempts employers who make contributions for employees under a simple cafeteria plan from pension plan nondiscrimination requirements applicable to highly compensated and key employees. Effective for tax years beginning after December 31, 2010.

Pharmaceutical Manufacturers Fee. Imposes an annual, non-deductible fee on the pharmaceutical manufacturing industry allocated according to market share and not applying to companies with sales of branded pharmaceuticals of $5 million or less. Effective for tax years beginning after December 31, 2010.

2012

Encouraging Integrated Health Systems. Implements physician payment reforms that enhance payment for primary care services and encourage physicians to join together to form “accountable care organizations” to gain efficiencies and improve quality.

Linking Payment to Quality Outcomes. Establishes a hospital value-based purchasing program to incentivize enhanced quality outcomes for acute care hospitals. Also, requires the Secretary to submit a plan to Congress by 2012 on how to move home health and nursing home providers into a value-based purchasing payment system.

Reducing Avoidable Hospital Readmissions. Directs CMS to track hospital readmission rates for certain high-cost conditions and implements a payment penalty for hospitals with the highest readmission rates.

2013

Improving Preventive Health Coverage. Creates incentives for State Medicaid programs to cover evidence-based preventive services with no cost-sharing.

Administrative Simplification. Health plans must adopt and implement uniform standards and business rules for the electronic exchange of health information to reduce paperwork and administrative burdens and costs.

Encouraging Provider Collaboration. Establishes a national pilot program on payment bundling to encourage hospitals, doctors, and post-acute care providers to work together to achieve savings for Medicare through increased collaboration and improved coordination of patient care.

Increasing Medicaid Payment for Primary Care. Requires states to pay primary care physicians the same rate Medicare pays, and fully federally funds any additional state costs.

Limiting Health Flexible Savings Account Contributions. Limits the amount of contributions to health FSAs to $2,500 per year, indexed by CPI for subsequent years.

Eliminating Deduction for Employer Part D Subsidy. Eliminates the deduction for the subsidy for employers who maintain prescription drug plans for their Medicare Part D eligible retirees.

Increased Threshold for Claiming Itemized Deduction for Medical Expenses. Increases the income threshold for claiming the itemized deduction for medical expenses from 7.5 to 10 percent. Individuals over 65 would be able to claim the itemized deduction for medical expenses at 7.5 percent of adjusted gross income through 2016.

Additional Hospital Insurance Tax for High Wage Workers. Increases the hospital insurance tax rate by 0.9 percentage points on wages over $200,000 for an individual ($250,000 for married couples filing jointly). Expands the tax to include a 3.8 percent tax on net investment income in the case of taxpayers earning over $200,000 ($250,000 for joint returns).

Medical Device Excise Tax. Establishes a 2.3 percent excise tax on the first sale for use of a medical device. Excepted from the tax are eye glasses, contact lenses, hearing aids, and any device of a type that is generally purchased by the public at retail for individual use.

Limiting Executive Compensation. Limits the deductibility of executive compensation under Section 162(m) for insurance providers if at least 25 percent of the insurance provider?s gross premium income from health business is derived from health insurance plans that meet the minimum creditable coverage requirements. The deduction is limited to $500,000 per taxable year and applies to all officers, employees, directors, and other workers or service providers performing services, for or on behalf of, a covered health insurance provider. This provision is effective beginning in 2013 with respect to services performed after 2009.

Fee for patient-centered outcomes research. Annual fee becomes effective on insured and self- insured plans to fund the patient centered outcomes research trust fund.

2014

Reforming Health Insurance Regulations. Implements strong health insurance reforms that prohibit insurance companies from engaging in discriminatory practices that enable them to refuse to sell or renew policies due to an individual?s health status. Insurers can no longer exclude coverage for treatments based on pre-existing health conditions. It also limits the ability of insurance companies to charge higher rates due to heath status, gender, or other factors. Premiums can vary only on age (no more than 3:1), geography, family size, and tobacco use.

Eliminating Annual Limits. Prohibits insurers from imposing annual limits on the amount of coverage an individual may receive.

Ensuring Coverage for Individuals Participating in Clinical Trials. Prohibits insurers from dropping coverage because an individual chooses to participate in a clinical trial and from denying coverage for routine care that they would otherwise provide just because an individual is enrolled in a clinical trial. Applies to all clinical trials that treat cancer or other life-threatening diseases.

Establishing Health Insurance Exchanges. Opens health insurance Exchanges in each State to the individual and small group markets. This new venue will enable people to comparison shop for standardized health packages. It facilitates enrollment and administers tax credits so that people of all incomes can obtain affordable coverage.

Ensuring Choice through a Multi-State Option. Provides a choice of coverage through a multi- State plan, available nationwide, and offered by private insurance carriers under the supervision of the Office of Personnel Management.

Providing Health Care Tax Credits. Makes premium tax credits available through the Exchange to ensure people can obtain affordable coverage. Credits are available for people with incomes above Medicaid eligibility and below 400 percent of poverty who are not eligible for or offered other acceptable coverage. They apply to both premiums and cost-sharing to ensure that no family faces bankruptcy due to medical expenses again.

Ensuring Choice through Free Choice Vouchers. Workers who qualify for an affordability exemption to the individual responsibility policy but do not qualify for tax credits can take their employer contribution and join an Exchange plan.

Promoting Individual Responsibility. Requires most individuals to obtain acceptable health insurance coverage or pay a penalty of $95 for 2014, $325 for 2015, $695 for 2016 (or, up to 2.5 percent of income in 2016), up to a cap of the national average bronze plan premium. Families will pay half the amount for children, up to a cap of up to a cap of $2,250 per family. After 2016, dollar amounts are indexed. If affordable coverage is not available to an individual, they will not be penalized.

Promoting Employer Responsibility. Requires employers with 50 or more employees who do not offer coverage to their employees to pay $2,000 annually for each full-time employee over the first 30 as long as one of their employees receives a tax credit. Precludes waiting periods over 90 days. Requires employers who offer coverage but whose employees receive tax credits to pay $3,000 for each worker receiving a tax credit up to an aggregate cap of $2,000 per full-time employee.

Increasing Access to Medicaid. Medicaid eligibility will increase to 133 percent of poverty for all non-elderly individuals to ensure that people obtain affordable health care in the most efficient and appropriate manner. States will receive 100 percent federal funding for the first three years of this coverage expansion.

Small Business Tax Credit. Implements the second phase of the small business tax credit for qualified small employers.

Quality Reporting for Certain Providers. Places certain providers – including ambulatory surgical centers, long-term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, PPS-exempt cancer hospitals and hospice providers – on a path toward value-based purchasing by requiring the Secretary to implement quality measure reporting programs in these areas and also pilot test value-based purchasing for each of these providers in subsequent years.

Health Insurance Provider Fee. Imposes an annual, non-deductible fee on the health insurance sector allocated across the industry according to market share. The fee does not apply to companies whose net premiums written are $25 million or less.

2015

Continuing Innovation and Lower Health Costs. Establishes an Independent Payment Advisory Board to develop and submit proposals to Congress and the private sector aimed at extending the solvency of Medicare, lowering health care costs, improving health outcomes for patients, promoting quality and efficiency, and expanding access to evidence-based care.

Paying Physicians Based on Value Not Volume. Creates a physician value-based payment program to promote increased quality of care for Medicare beneficiaries.

2018

High-Cost Plan Excise Tax. Imposes an excise tax of 40 percent on insurance companies and plan administrators for any health insurance plan that is above the threshold of $10,200 for self-only coverage and $27,500 for family plans. The tax would apply to the amount of the premium in excess of the threshold. The threshold would be indexed at CPI-U plus one percentage point for 2019 and CPI for years thereafter. An additional threshold amount of $1,650 for singles and $3,450 for families is available for retired individuals over the age of 55 and for plans that cover employees engaged in high risk professions. Employers with higher costs on account of the age or gender demographics of their employees when compared to the age and gender demographics nationally my adjust their thresholds even higher.

The concept of the “medical home” is emerging as an increasingly sophisticated idea, that indeed may promote primary health care access for many of the nation’s most vulnerable persons. What do you see as the promises and the challenges of the medical home as a mechanism for increasing primary health care access?

Team 1. L. Burnett (Lead), Babitz, Fernandez, Hansen, Maudlin, Troy

Family medicine revisited:

• it decreases access
• it decreases reimbursements
• it is hard to meet performance goals unless “cherry picking” [atoemts
• creates "perverse" incentives

Medical home is "designed" to clarify the true role of primary care. It is not defined as care of the "family" - only the patient. It creates a system in which any specialist can be a "medical home".

Community health centers are currently the most effective comprehensive care for underserved communities.

Medical home is stated as an effort to save money, but is based on poor data.

NCQA medical home tiers of certification

Repacking of "gatekeeper" in a more politically correct manner.

CHCs/FMRP Centers. These work most effectively. CHCs will increase in political power as two-tier system becomes legislatively entrenched.

L. Burnett, scribe.

Team 2 W. Burnett (Lead). Baird, Flinders, Hara, North, Vega

The medical home is an evolving concept that many don't understand.

Kaiser has had the Medical Home for decades, especially now with Kaiser's electronic health record.

NCQA payments drive the Medical Home.

The medical home can take more effort. For visits, you need a team to help make care efficient (i.e., an MA gives immunizations prior to an order).

Kaiser has population disease management systems which manage chronic illness remotely, without a physician being present. It has proven to be cost-effective.

Some payers want visit-based care and are closed to new models, such as using e-mail to address patient concerns.

The medical home works well in capitated systems. It's more complex to implement in low-income communities.

Access isn't a natural outcome of Medical Home. Access needs to be addressed proactively.

Medical homes have received bipartisan support, and we'll need to take advantage of that.

Team 3 Wilke (Lead), Bejinez-Eastman, Fort, Hines, Osborn, Webster

Promises:

• transparency, portability of information
• efficiency in record-keeping
• relationship builds over time
• quality as an group, individual measure
• team approach, with members having an equal vision
• better quality level for all rather than have a few motivated patient
• relationship of patients to patients and providers to providers

Challenges:

• obtaining reimbursement for time spent by all
• obtaining buy-in of all players as Medical Home "members"
• the financial risk for providing a Medical Home
• obtaining equal access for all
• applying a small paradigm of care to a larger group of people
• minimum standards for all vs maximum standards for a few
• system development for task completion
• home members training on how to live in "home"
• receptive approach to patients to have interns in the "home"
• control of staff behavior

Team 4 Herman (Lead), Casey, Fowkes, Kasovac, Palafox

• payment reform has to support the medical home
• medical home means changing the way you practice
• team home visits an important part of access

Fowkes, scribe.

Team 5 Ross (Lead), Coleman, Freeman, Kimball, Peck

• Will likely not improve access unless system changed, but will improve systems of care for those already “in”.
• May reduce pressure on physicians and PCP by downloading less complex care to other members of the team in the home, thereby freeing time to increase patient numbers cared for in the home.
• It may open up other access points for care such as phone and/or computer/e-mail access, but the poor rarely have the access to technology nor the knowledge/sophistication to use this form of access.
• May be able to take the care to the patients home by using mobile clinics and other innovations
• We will need to improve social responsibility to improve access and care-Josh says: “We don’t care for or about each other in the United States”

Ross, scribe.

Team 6 Clover (Lead), Erickson, Frey, Lee, Pugno

• The fact that Family Medicine (FM) has taken a lead in the Primary Care Medical Home (PCMH) has been lost to the rest of the world
• Major strength of PCMH: it is so well-designed that people like it however they conceive it
• the challenge today: the force out there in the workplace not sufficient enough to deliver
• misconception that PCMH allows for less FM docs for more pateints
• not a more efficient healthcare system
• dilemma: we may have created a false misperception with the public that we are not able to fulfill
• reimbursement will need to support a change in practice to make this successful
• other specialties have taken up the PCMH to gain the reimbursement associated with it
• many family physicians feel that they are being asked to do more and more without compensation
• medical students are expecting this - but do we have a model of PCMH?
• increased enrollment medical students, but decreased FM residency positions
• need fo increased general Internal Medicine docs as well, but they are dying out
• AAPA has been great partner with AAFP, but there is no national nurse practitioner group. Whom do we talk to? How do we get good data?
• AARP in favor of PCMH, but has not been visible with this
• but, we cannot raise public expectations that we cannot deliver
• payment levels and bureaucratic rules will determine how successful PCMH will be
• How to model PCMH in a Family Medicine Center (FMC), when FMC is not able to make the dollars required to run it
• PCMH model will deliver primary care [in communities where] Emergency Rooms and “docs in a box” also deliver primary care
• Need an enlightened team; PCMH requires abstract thinking, and physicians typically are linear thinkers

From your experience, describe models of community-based medical education that have had a positive impact in a geographical area’s primary care workforce and community health. Identify sites for training physicians whose accomplishments you believe deserve national recognition?

Table 1. Frey (Lead), Lee, Osborn, Palafox, Vega

Group Health (Washington)

Critical Access Hospital

Song-Brown grants (California)

What effect of ALOS/Integrated Care Models? Leadership Training

Public perception i s8important

Problem-based benchmarking

Community-based —-> primary care workforce

University programs –  scholarly activism

2. Kasovac (Lead), Casey, Coleman, Hara, Kimball

Kentucky – Skycap, Lay health visitors –> Kentucky Homeplace; C entering Pregnancy Project; ___ visits for ____ dental cleaning and flouride –> postnatal bonding, breastfeeding education

Latino Health Access – promontores in Orange County, California; UCLA Mobile Clinic; Venice Family Clinic; White Memorial Family Medicine Residency; Kaiser Community Medicine fellowships; Albert Schweitzer Fellowship for health professional students; X-rays read by Kaiser for Skid Row Los Angeles

Home exercise programs in areas where the neighborhood is dangerous

Omaha: all professional schools provide a day of health screening

Phoenix – high school physicals continued by Phoenix Sun’s team physician – 2000 physicals by medical students and residents

Louisville – self management program

3. Troy (Lead), Erickson, Fernandez, Freeman, Webster

Define positive impact. What are the incentives? How do we know there has been positive impact? Methods for evaluating behavior change are okay. But how do we define outcomes?

–> one measure: where do they end s p  practicing (in those communities?)

[Freenan] one model: open up a four year campus in a ___ area. Selina (Lake Wichita) —> Problem Based Learning (PBL) model with teleconferencing —> Family medicine residency that meets the LCME mrequirement for resident presence —> first class = 2011?

[Webster] MSU: for two years students go to community campuses. Using outcomes measure of where grads practice indicates that a significant proportion go to rural sites.

Discussed student lead/driven instructive and volunteer efforts.

Primary care workforce – easier to measure the impact on this, but no s o easy to extrapolate its impact on community health. There is data, but it’s less generalizable.

4. Fowkes (Lead), Baird, Fort, Hines, Hixon

A. Community-based educational program deserving national recognition:

Rural Primary Associate Program (RPAP) —> Kathleen Brooks, MD, University of Minnesota

The WWAMI Program of the University of Washington

University of Western Ontario

B. Worries that current budget crises – state by state – will undermine the efforts to engage “voluntar” community-based teachers.

5. Maudlin (Lead), Bejinez-Eastman, Flinders, Hansen, North

Sonoma County, California:

Santa Rosa Family Medicine Residency program works in underserved areas; graduates woften will go to underserved areas to practice, both long-term and short-term.

Anchorage Native Health Center, Alaska:

Nurse case manager —> teamlets.

Routine care going on all the time;  care is being provided by everyone on the health care tea, all of the time. There is a consortium of native tribes. The health services are owned by its customers with open access to care.

The family medicine residency in Anchorage, not necessarily in the same clinic.

Most all residency programs have a positive impact on the community in which they are located.

- – -

The following conference participants were engaged elsewhere:

Boardroom: Pugno (Lead), Babitz, Clover, Herman, Ross, Wilke, W.H. Burnett (Executive Board Meeting, Coastal Research Group)

You are developing an Internet-based program designed to interest medical and pre-medical students in family medicine and community-based primary care. What kinds of information would you bring to their attention to encourage them to consider primary care and family medicine as a career choice? What would you like students to know about what family doctors do and how they interact with their patients?

Team 1. Hines (Lead), Bejinez-Eastman, L. Burnett, Erickson, Ross, Wilke

[Ross] Promotion of lifestyle of FM-“Do what you want to do” the wide variety of choice in career paths..

Target areas which historically produce FP’s-Community focused (target rural and local communities)

Reaching out to rural areas:

• 4H (careers in health-special interest groups)
• Scouts-School outreach
• FFA Career counselor
• Grass roots
• Make sure residency programs have FM docs/residents at career days at school, offer in –residency experiences
• Booth at residency program meetings in KC-including AFMRD and Annual Conference of students and residents-all PD’s are worried about FM and want something to improve our applicant pool.
• Local “SON” (?) group need a champion at each location to be successful
• Package pre-selected materials for community outreach activities, and address immediate as well as long-term needs
• Show people what a career in FM looks like: daily activity journal, international medicine, many and any others. Show them exciting aspects of the career,  including packaged on-line content (through Studentdoctor.net)
• Coordinate with the State chapters and State/local orgs and Chapters

“The closer you get to the kids/local level, the better the response”

1. Have a doctor keep an online journal that gives a glimpse of being a family doctor

2. Create YouTube clips, perhaps of interactions with a few patients, like a mini-reality TV show. Could subsstitute for shadowing for those students who do not have good opportunities to shadow a doctor.

3. Connect students with local physicians. Lunch with a family doctor program, outreach to high schoolers, local mentoring. Maybe send local residents to do community outreach (schools, junior colleges), possibly partner with community-based nonprofits and campus groups for undergrads.

4. Arrange shadowing experiences at community health centers.

5. Keep things local if possible; encourage personal contact

6. Provide advising for students without resources at their schools

7. Invite family physicans to submit articles, ideas to www.studentdoctor.net (existing forum users)

8. Feature medical mission work.

10. Feature global health partnerships.

11. Physician’s personal and inspiring stories – their own.

12. Tell why we went into family medicine.

13.Talk about choice of procedures and flexibility in designing your own practice (USIM?)

14. What FP docs do that students might find exciting and interesting.

15. Information to bring to students’ attention:

Focus on long term relationships with patients.

“Brand” family medicine and address the fit with student interests.

Show that FM docs see a variety of patients with t a variety of disease states = not just the same procedures over and over.

Feature FP docs working in global health or in high level positions, in order to inspire and show that these opportunityes do exist.

Highlight patient stories about their FP doc and show the value and benefit from the relationships.

Ask community health center residents to write about their experiences.

Show us having FUN at work.

Relationships, fun, trust, and community leadership.

Basic exposure to role models, practice content, mentoring

International work feature

Health policy issues and food policy

How FPs can influence policy development.

Team 2. Babitz (Lead), Clover, Fowkes, Frey, Hara

What  impact of teaching students:

* Not necessarily the content of the message is important, but how teaching is delivered and relating to the new pedagogy for the millenial student, i.e. group teaching, podcasts. Family medicine can be leaders in this.

Fowkes, session scribe.

Team 3. Herman (Lead), Baird, Fernandez, Kimball, Lee, Maudlin

[Below: Team Three discusses Internet Web-based Student Interest; from left front, clockwise are James Herman, MD, MSPH; Betsy Kimball; Macaran Baird, MD; Enrique Fernandez, MD; Jay Lee, MD and Robert Maudlin, Pharm. D.]

Tuesday April 13, 2010 Team 3 Breakout Sessions

Media: Mayo/ABC News Primary care spot

Politics: Workon on institutional level (Buy-in)

Medical Student interviews Clips

Emergy  <—> New physicians/residents

Blog feeder. Social justice

PCMH/LEAN

Wihi

Personal statement by your besdie

Idealistic/optimistic/courageous vs cynical

Fuzzy logic vs concrete-operational

Negotiation techniques

CAQs: geriatrics, sports, adolescents

“Family physician of the month”

Facebook fan page

Technology

Longitudianl experiences

How do I become the doctor that I want to be

Public Policy Education.

Team 4. Freeman (Lead), Casey, Flinders, Fort, Osborn, Troy

Look at your patient with both eyes (science and mystery/art; biology and spirituality)

Do it like a dating service to do intake of the student and match them to FPs for shadowing/networking

Find out why students don’t come and address it: (Salary and benefits; mission and values)

Is this the wrong question? Shouldn’t we be asking how to get students into medical school that are prone to be in primary care?

Make it relational! It’s about the Love.

Tell them we’re nicer and happier.

What if the medical school admissions committee has to reflect workforce needs? (50% primary care/generalist physicians)

Tell students that their loans will be forgive if they practice in a Health Professions Shortage Area for three years (go, hope! go!)

Address the myths

FAQ; put in positive way. If you love seeing a variety, and are not afraid to get out of bed at night to watch a miracle happen.

As Jamie Osborn for her poem “I am a Family Physician” and put it on YouTube.

Team 5. North (Lead) Coleman, Hixon, Peck, Vega, Webster

Team 6. Pugno (Lead), W. H. Burnett, Hansen, Kasovac, Palafox

[Below: Team Six discusses Internet student interest websites at Dondero's; from left, clockwise, Perry A. Pugno, MD, MPH; Thomas J. Hansen, MD, Mitchell Kasovac, DO; William H. Burnett, MA; and Neal Palafox, MD.]

Tuesday April 13, 2010 Team 6 Breakout Sessions

This already exists through the virtual family medicine interest group, through the unprotected PowerPoint presentation “Your Future In Family Medicine”. The traffic is enormous, usually looking for CME. The newest area of contact is premed students.

There is a national organization of pre-health guidance counselors. There is a guide for all of the health sciences.

A concern expressed by the American Academy of Family Physicians: many people in rural areas don’t consider a career in medicine. The AAFP has products down to the seventh grade.

AAFP links with Facebook, twittering, tweeting, and readily built connections and relationships.

On www.studentdoctor.net, there are online discussions of career paths. There is sharing of information among the two websites www.studentdoctor.net and www.coastalresearch.org. All of the articles that appeared on studentdoctor.net that are relevant to coastalresearch.org exist on this website also.

Vision for Hawai’i. IMIHOLA: Seekers of health; socially disadvantaged. Allows those in the neighboring Hawai’ian islands that there is a career in medicine in Hawai’i for them, leading to them returning to their home islands. Native Hawai’ians constitute 20% of the population of the state, but have only 3% of the physicians.)

How to dialogue and connect on curricula.

Regular leadership: those trying to get with medical schools, residency programs.

The University of Hawai’i has to Maui campuses. There are many private colleges, mostly doing things on-line.

Success of mini-clinics: they have immediate results and reflect desires of consumers.

AHEC  (area health education center networks).

Schools of osteopathic medicine have a heavier emphasis on primary care. The basic science faculty are socialized to primary care, and have been involved in admissions paired with primary care physicians.

The underlying philosophy of osteopathic medicine includes touching and the emphasis on body, mind and spirit, and the body’s ability to heal itself. There is great role modeling in DO schools on patient/physician relationships.

The American Association of Medical Centers appear committed to preserving the status quo, whereas AAFP promotes a heavy push into primary care. The AAFP sponsors forums and groups to address bigger questions. The AMA is not really representatative of physicians (only 11% of physicians belong to the organization).

We need to determine how many medical students actually go into primary care five years post-graduation, to eliminate the counting of those going into sub-specialties and hospitalist positions.

New legislation will be available to train physicians and nurses in the community health center system.

OB/GYN has shifted from arguing it is a primary care specialty to positioning itself as a surgical specialty, due to the latter’s greater reimbursement rates.

COMMENTS

This was an amazing meeting.  Thank you for the invitation.  Ilook forward to next year!

Thomas J. Hansen, MD, Creighton University

The enactment of 2010’s health reform legislation was the consequence of a contentious political whose result left many dissatisfied. As the legislation moves to the implementation phase, what should we look for, over the next few years, to judge whether the health reform act’s consequence will be a substantial improvement over the present system?

The following responses were developed by each team

Team 1. Clover (Lead), Baird, Coleman, Fort, Hansen, Hines:

[Below: Team One discusses health care reform legislation at a meeting at Dondero's Restaurant; from left, clockwise, Thomas Hansen, MD; Macaran Baird, MD; Richard Clover, MD; Mary T. Coleman, MD; Thomas Hines, MD and Arthur Fort, MD.]

Monday April 12, 2010 Team One Breakout Sessions

1. The worry exists that the “new” system could repeat the problems experienced with capitation in the health care reform initiatives of the 1990s.

2. In Massachusetts, its state reform has improved access to care, but costs have increased and now they face rising state budget deficits.

3. We know that public health measures must be implemented to really improve population-based health measures.

4. Individual care makes a difference, but will payment reform help support the time and effort needed to help people adapt?

5, We have hope that this new legislation will be a good first step in the “long and winding road” to sensible health care/prevention nationwide.

6. the current “winners” in the health system will do everything possible to block meaningful change.

Macaran Baird, MD, session scribe.

Team 2. Bejinez-Eastman (Lead), Babitz, Herman, Osborn, Webster

• Receiving lots of questions from patients on impact of legislation
• Most patients don’t appreciate the fact that their health insurance is tied to employment and that when that is lost, their health insurance is lost.
• This insurance reform has been designed to serve insurance companies.
• Revisited question of whether health care in the U.S. is a right or privilege.
• One view is that health care coverage is one’s reward for working hard and earning this benefit – which should not be the case.
• Good points of the reform include not losing benefits because of job loss and eliminating coverage denial for pre-existing conditions.
• Concerns raised about health manpower being inadequate to support successful reform.
• Motivation for expanding residency slots examined.  Deans run hospitals and medical centers to be profitable which means utilizing lots of sub-specialty fellowships.
• Don’t expect changes in manpower distribution (by specialty) without meaningful reimbursement reform.  Medical students are smart (can figure out if it’s better to earn $150K vs. $350K per year over their career, especially when faced with $200+K in debt.
• How to judge the consequences of reform?  Standard measures:  Cost (overall), Quality, and Access.
• Glad that something was passed.  Hopefully a first step.
• This legislation will be tested in Fall 2010 by the elections.  Many congressional candidates will try to focus on opposing reform, after all, polls show majority of Americans opposed this legislation.
• Workforce discussion:  medical students remain idealistic upon admission but much changes during their 3^rd year during specialty rotations taught by sub-specialists.
• Student exposure to poverty care and global care and rural care tends to reinforce interest in primary care careers.
• Again, student debt vs. potential earnings a major issue in specialty choice.
• Students may see FPs in negative settings (overworked, frustrated, unhappy).
• Ultimate change will follow the money.
• Reform as recently passed is unlikely to be successful without workforce reform and reimbursement reform.
• Transformation of Family Medicine suggests practices that see fewer patients, have better outcomes and offer higher reimbursement.  But, how is that possible under current system?  This reform will serve to increase the demand for services of family physicians with no better reimbursement (at least, initially).
• Ontario, Canada, did some comprehensive reform that included better reimbursement for primary care and community-based training.  This has resulted in increased interest in primary care.

Marc Babitz, MD, scribe.

Team 3. Fowkes (Lead), Erickson, Freeman, Lee, North

We would like to see the residents trained in sites side by side with mid level providers and others that will be part of PCMH teams.  One of the barriers to training now is the lack of coordination and integration of mid level curriculum and practice experience.  We need to model what we expect learners to actually do in practice.

Health equity is the main issue to address access to care, not having access to health care payBabitments.

Register patients to vote at clinics.

Charles North, MD, session scribe.

Team 4. Hara (Lead), Kimball, Pugno, Vega, Wilke

[Below: Team four discusses the health reform legislation at a meeting at Dondero's Restaurant; from left, clockwise, Perry Pugno, MD; Charles Vega, MD; Allan Wilke, MD; Jimmy Hara, MD; Betsy Kimball.]

Monday April 12, 2010 Team Four Breakout Sessions

1. The legislation is not revolutionary. Like affirmative action, it will be a five to ten year process.

2. The second steps in the legislation are the bills to follow.

3. There shoulod be an increase in interest in primary care, in the improvement of primary care compensation, and in progress towards the medical home and team concept.

4. The following should be seen in the market: 3 year medical schools, and increase in medical schools and primary care interest. Changes towards non-profits like Kaiser-Permenente where 3% of revenues go towards graduate medical education.

5. Attacks (on the legislation) will follow dollars – on costs, abuses, the focus will shift from quality to insurance and pharmacy charges. All of this will require more legislation.

6. We will be talking about all this next year.

Jimmy Hara, MD, session scribe.

Team 5. Maudlin (Lead) L. Burnett, Casey, Flinders, Kasovac

1. Will parts of the bill be repealed? Who knows?

2. Can a workforce commission make a difference, and, if so, how? Is the Utah model relevant?

3. If primary care docs can convince insurance companies that family medicine cast save companies money, it might decrease the likelihood that the current opponents of the legislation might try to repeal it. Data must be collected and used.

4. It might lead to a shift in graduate medical education dollars from hospitals to primary care residency programs.

Donald Frey, MD, session scribe.

Team 6. Ross (Lead), W. H. Burnett, Fernandez, Frey, Peck, Troy

Did the process actually satisfy anyone? It doesn’t seem so. Despite this it may turn out to be transformable.

Indices that should be Measured:

• Increase in raw numbers of people who have access to insurance, are insured, and/or have health care
• Increase in absolute number and percentages of real PCP’s
• Increase in the number of people say in medical homes and/or managed care
• Reduction in the rate of inflation of costs of health care in the long term (not short term) maybe 9 or more years hence (2020)
• Decreased ED visits for manageable chronic diseases and non-emergent care
• Decrease in so-called “covered” people who cannot get access
• Increase in the number of people in the country who with one phone call can name their care provider/family doctor
• Is there a powerful Office of Health Care Effectiveness that can actually make and enforce policy?

Observations:

• Very difficult for a for-profit managed care plan to do good work and survive.
• Possible that there should be a shake-out and some for-profits may figure out how to do good work and survive in a changed environment.
• Most of US population IS covered, but due to a large set of perverse incentives.
• Are the proposed policies and enacted legislation actually going to be followed?
• Federal government also pays now for many futile treatments and some things which we probably don’t even know about, vis-à-vis specialties. For example, Hyperbaric O2 for chronic wounds, which is not proven evidence-based medicine

Quotable Quotes:

“ Adding rights to risk pools (an insurance mechanism) distorts the original intent of insurance” W. H. Burnett

COMMENTS

Bill,  Really enjoyed the conference.  Bright people full of ideas.  Thanks for including our department once again in the proceedings.  All the best,  Chip

Allen L. Hixon, MD, University of Hawai’i

The Senior Fellows of the National Consortium are persons who have participated in ten or more of the National Conferences on Primary Health Care Access and who have made at least one plenary presentation at one of the National Conferences.  The Fellows have participated in from five to nine of the National Conferences with at least one plenary presentation.

[Below, right: the induction of the first six Senior Fellows in April, 2000. From the left, David Sundwall, MD; Ludlow B. Creary, MD, MPH; F. Marian Bishop, Ph.D.; J. Jerry Rodos, DO; William H. Burnett, MA; and John E. Midtling, MD.]

THE SENIOR FELLOWS  OF THE NATIONAL CONSORTIUM ON COMMUNITY-BASED MEDICAL EDUCATION

Marc E. Babitz, MD

Salt Lake City, Utah

*F. Marian Bishop, Ph.D., MSPH

Salt Lake City, Utah

John G. Bradley, MD, MMM

Decatur, Illinois

+William H. Burnett, MA

Granite Bay, California

+Mark E. Clasen, MD, Ph.D.

Dayton, Ohio

Ludlow  B. Creary, MD, MPH

Los Angeles, California

Hector Flores, MD

Los Angeles, California

+Virginia Fowkes, FNP, MHS

Stanford, California

William C. Fowkes, MD

Stanford, California

Paul Juarez, Ph.D.

Nashville, Tennessee

Charles E. Henley, DO, MPH

Tulsa, Oklahoma

+Gary L. LeRoy, MD

Dayton, Ohio

Patricia Matthews-Juarez, Ph.D.

Nashville, Tennessee

John E. Midtling, MD, MS

Memphis, Tennessee

Charles Q. North, MD, MS

Albuquerque, New Mexico

Cynthia G. Olsen, MD

Yellow Springs, Ohio

Perry A. Pugno, MD, MPH

Leawood, Kansas

+J. Jerry Rodos, DO, D.Sc.

Western Springs, Illinois

David N. Sundwall, MD, MPH

Salt Lake City, Utah

Allan J. Wilke, MD

Freeport, Grand Bahama, The Bahamas

John A. Zweifler, MD, MPH

Fresno, California

THE FELLOWS  OF THE NATIONAL CONSORTIUM ON COMMUNITY-BASED MEDICAL EDUCATION

Bruce Behringer, MPH

Johnson City, Tennessee

John Boltri, MD

Macon, Georgia

Thomas C. Brown, Ph.D.

Auburn, California

Lee A. Burnett, DO

Southern Pines, North Carolina

J. Scott Christman

Sacramento, California

Richard Clover, MD

Louisville, Kentucky

James E. Cruz, MD

Los Angeles, California

Patrick T. Dowling, MD, MPH

Los Angeles, California

Ana Bejinez Eastman, MD

Whittier, California

Joshua Freeman, MD

Kansas City, Kansas

Donald Frey, MD

Omaha, Nebraska

John Geyman, MD

Friday Harbor, Washington

Jimmy H. Hara, MD

Los Angeles, California

James Herman, MD, MSPH

Hershey, Pennsylvania

Tim Henderson, MSPH

Washington, D.C.

Thomas C. Hines, MD

Boston, Massachusetts

Cornelius L. Hopper, MD

Oakland, California

Sandral Hullett, MD

Birmingham, Alabama

Norman B. Kahn Jr, MD

Chicago, Illinois

Mitchell Kasovac, DO

Phoenix, Arizona

Kathleen M. Macken, MD

Saint Paul, Minnesota

David W. Marsland, MD

Richmond, Virginia

Samuel C. Matheny, MD, MPH

Lexington, Kentucky

Robert Maudlin, Pharm. D.

Spokane, Washington

Don McCanne, MD

San Juan Capistrano, California

Marianne McKennett, MD

Chula Vista, California

William A. Norcross, MD

San Diego, California

*Charles E. Odegaard, Ph.D.

Seattle, Washington

John Payne, MD

Nairobi, Kenya

Michael D. Prislin, MD

Irvine, California

*Jonathan C. Rodnick, MD

San Francisco, California

Robert Ross, MD

Klamath Falls, Oregon

Joseph E. Scherger, MD, MPH

San Diego, California

G. Gayle Stephens, MD

Birmingham, Alabama

Warwick Troy, Ph.D., MPH

Pasadena, California

Terrell W. Zollinger, DrPH

Indianapolis, Indiana

*Deceased
+Participated in 15 or more National Conferences on Primary Health Care Access

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[Take a tour of each of the four days of the National Conference plenary program. A post for each conference day, and links to relative webpages on this site, precede this post. Tour Day One at 21st National Conference on Primary Health Care Access – First Conference Day (April 12, 2010). Tour Day Two at 21st National Conference on Primary Health Care Access – Second Conference Day (April 13, 2010). Tour Day Three at 21st National Conference on Primary Health Care Access – Third Conference Day (April 14, 2010). Tour Day Four at 21st National Conference on Primary Health Care Access – Fourth Conference Day (April 15, 2010).]

CME 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.)

Joshua Freeman, MD

The Twenty-first National Conference’s “consequences” theme is especially relevant to the debates that surrounded the enactment of federal  health care insurance reform. Despite the political rhetoric heard during the past year, the  existing American health care system is the product of myriad federal, state and local subsidies and mandates. It is now certain that the legislation will impact most of the existing system in consequential ways.

The political debate obscured the reality of how the current system actually works. The first two panels of Day One will be asked the question, “What are the likely consequences of the enactment of federal legislation to change the health care system?”

[Note: hear the podcast of a presentation made by Doctor Philip Lee, President Lyndon Johnson's highest rank health official on the development of Medicare and Medicaid at Podcast: Doctor Philip Lee discussing the unintended consequences of the creation of Medicare and Medicaid]

Panel One: the Consequences of the Federal Health Care Reform Legislation – Overview

Perry Pugno MD MPH

The first panel will address the elements contained in the final form of the legislation signed by President Obama, and the issues that relate to its implementation. (For a discussion of the roundtable, see the article, at: Josh Freeman, Perry Pugno, Enrique Fernandez to Lead Off 21st National Conference on Primary Health Care Access With “What Just Happened?” Roundtable.

Panel Two: the Consequences of the Federal Health Care Reform Legislation – Impact on the Primary Health Care Workforce

The second panel will address the issues of our “physician workforce” in light of proposed legislative changes.

Doctor Donald Frey of the Creighton University School of Medicine will moderate the second panel, which will include Doctor James Herman of Penn State Hershey Medical Center and Doctor Thomas Hines from Boston University. Doctor Hines will discuss the impact of the recent Massachusetts experience with health care reform mandated at a state level.

For a description of the second plenary session, see: 21st National Conference Plenary: Health Reform Legislation Consequences for the Nation’s Primary Care Physicians

[Below: a view of the grounds of the Grand Hyatt Kaua'i.]

Meanwhile, the Coastal Research Group website will reprise many of the past presentations at its National Conferences Each day of the National Conference will be devoted to looking at the consequences of the quest for health care reform on the American commonwealth.

Monday, April 12, 2010: The 21st National Conference will be convened by Doctor James C. Herman of Penn State University’s Milton S. Hershey Medical Center. After his introductions the three plenary panels described above will take place.

A Lesson in History: the Consequences of the Flexner Report of 1910

Observing the 100th anniversary of the Flexner Report that had a transformative effect on American medical education, the National Conference will analyze how changes in national policy can have unexpected consequences whose impact can be seen a century later.

Tuesday through Thursday, April 13-15, 2010: The Consequences of Strategic Interventions for Rural, Low Income and Vulnerable Populations and for Community-Based Medical Education (Part One).

Donald Frey, MD

The second day will begin withthe third major plenary overview of the health reform proposals.  That plenary will address the nation’s public health needs (see 21st National Conference Focus on Nation’s Public Health System: What Happens Now?)

Dean Richard Clover of the University of Louisville School of Public Health will be joined by Doctors Marc Babitz of the Utah Department of Health and Charles Q. North of the University of New Mexico.

Over the several days of the National Conference, initiatives for decentralizing medical education in the states of California Hawai’i, Michigan, Minnesota, New Mexico, Kentucky and Louisiana will be analyzed. These will begin with a presentation by Dean Daniel Webster of Michigan State University’s Traverse City campus, described at: The 21st National Conference’s “Consequences” Theme: Strategic Interventions in the State of Michigan.

In addition, we will discuss initiatives to create Educational Health Centers within community health centers and other federally qualified health centers (see the accompanying forum by Doctor Kevin Murray of Tacoma General Hospital on this website’s frontpage and the description of cross-cultural, linguistic curriculum at University of California Irvine).

Subsequent National Conference plenary sessions will continue the discussions of these initiatives, and, in addition, will have the first presentation on impact of Caribbean medical schools on the nation’s supply of primary care physicians,  that discusses the multiple campuses and educational activities of that institution.

The fourth day (April 15) will include a celebration of the four decades since its founding of the American Board of Family Medicine, which pioneered and implemented the concept of ongoing certification of primary care physicians.

The fourth day will also observe the 20 G. Gayle Stephens Lectures, with a panel including previous presenter of the National Conference’s Stephens, Odegaard and Rodos Lectures.

In recognition of the lively Armageddon metaphor that Doctor Stephens has used to describe the battle of Medicare and Medicaid and of Doctor Patrick Dowling’s Fifteenth Stephens Lecture  (see The Fifteenth G. Gayle Stephens Lecture – Patrick Dowling, MD) which updated the Armageddon theme to comprise the fight for universal health care in the United States, a panel, entitled “Skirmishes at the Armageddon Battlefield: Correspondent Reports on Health Care Reform Initiatives” will take place in the final hours of the National Conference.

This webpage, to be continuously updated, will be the source of the latest information on the 21st National Conference

Conference invitees will be able to secure up to four additional days before and/or after at the Grand Hyatt Kaua’i at the advantageous National Conference rate. Registration will INCLUDE four nights accommodations at the Grand Hyatt, and will be based on the category of room each registrant selects. Although registration fees and payments for extra nights are non-refundable, full credit towards future National Conferences will be given if circumstances require withdrawal from the National Conference and the Coastal Research Group is notified by April 7, 2010.

[Below: a view of the one of the Grand Hyatt pools.]

21st National Conference Faculty (confirmed as of April 1, 2010)

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

Macaran Baird, MD, University of Minnesota, Minneapolis

Lee A. Burnett, DO, www.studentdoctor.net, Southern Pines, North Carolina

William H. Burnett, MD, Coastal Research Group, Granite Bay, California

Baretta Casey, MD, University of Kentucky, Lexington

Richard Clover, MD, University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky

Mary Coleman, MD, Ross University, Dominica, West Indies

Ana Eastman, MD, Presbyterian Intercommunity Hospital, Whittier, California

Delight Erickson, FNP, MPH, Memorial Hospital, Los Banos, California

Enrique Fernandez, MD, Ross University, Miami, Florida

Richard Flinders, MD, Santa Rosa Family Medicine, Santa Rosa, California

Virginia Fowkes, MHS, Stanford University, Stanford, California

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

Donald Frey, MD, Creighton University, Omaha, Nebraska

Jimmy Hara, MD, Kaiser Permanente, Los Angeles, California

James C. Herman, MD, Pennsylvania State University, Hershey, Pennsylvania

Thomas Hines, MD, Boston University Medical Center, Boston, Massachusetts

Allen Hixon, MD, University of Hawai’i, Mililani

Robert Maudlin, University of Washington, Tacoma Family Medicine

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

Jamie Osborn, MD, Loma Linda University, Loma Linda, California

Neal Palafox, MD, University of Hawai’i, Mililani

Anna Peck, studentdoctor.net, Iowa City, Iowa

James C. Puffer, MD, American Board of Family Medicine, Lexington, Kentucky

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

Robert Ross, MD, Cascades East Family Medicine, Klamath Falls, Oregon

Warwick Troy, Ph.D., Shueman-Troy Associates, Pasadena, California

Laura Turner, MD studentdoctor.net, Southern Pines, North Carolina

Charles Vega, MD, University of California, Irvine

Daniel Webster, MD, Michigan State University/Munson Healthcare ,  Traverse City, Michigan

Allan Wilke, MD, Ross University, Freeport, Grand Bahama, The Bahamas

The 21st National Conference will begin with assigned breakfast groups at Dondero’s Restaurant at the Grand Hyatt Kaua’i (which will be open only for conference registrants).

The assigned breakfast question for Monday will be posted in the first week of April, 2010.

Supplementary information on Monday morning’s activities may be found through the following hyperlinks. The first roundtable is described at:  Josh Freeman, Perry Pugno, Enrique Fernandez to Lead Off 21st National Conference on Primary Health Care Access With “What Just Happened?” Roundtable.

The second roundtable is described at: 21st National Conference Plenary: Health Reform Legislation Consequences for the Nation’s Primary Care Physicians.

Background information on the plenary discussion of Ross University is found at: National Conference Plenary Presentation on the Contributions of Caribbean Medical Schools to Meeting the Nation’s Primary Care Needs.

For a discussion of the Senior Fellows and Fellows of the National Consortium on Community-Based Medical Education, see: Fellows and Senior Fellows.

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For a discussion of the third roundtable, see: The Consequences of Strategic Intervention: Providing Health Care for Rural America.

For further discussion of the Odegaard and other Named Lectures, see: Doctors James Puffer, Macaran Baird, Neal Palafox to Present Named Lectures at 21st National Conference in Kaua’i.

For a discussion of the Fourth Roundtable, see: 21st National Conference Focus on Nation’s Public Health System: What Happens Now?

For a discussion of Dr Troy’s “thought provocateur” session, see: Dr Troy’s “Thought Provocateur” Session on Advancing Family Medicine through Geriatrics and Long Term Care.

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