Sandral Hullett, MD, MPH, Medical Director, West Alabama Health Services, Inc.

Sandral Hullett, MD, MPH; West Alabama Health Services, Selma [Dr Hullett is a Fellow of the Coastal Research Group.]   I work as a Health Services Director in a rural community in Alabama.  The community is called Eutaw, Alabama.

We have a unique problem in dealing with a situation where the service area is about 80% black, is rural, and extremely poor.  And we have many problems that impact on access to care.

The lack of facilities for care and lack of providers are both significant problems.  We have to deal with a low socio-economic population living in an are with poor transportation components.  It’s a real tall task to provide access to care in an area like this.

I am one of those people who Don Weaver was just talking about.  I was a National Health Service Corps provider.  I came there 11 years ago, at the same site where I am now, to fulfill a two-year Corps obligation.  I served the two years obligation and volunteered two years after that.  So I was in the Corps for a total of four years.  I have remained there.

Alabama's "black belt" counties with high proportions of African-Americans; Eutaw is in Greene County near the Western border; map prepard by the University of Alabama

I have continued to be interested in the concerns of people who need care and in the delivery of rural health care.  This has made me become more interested in program planning and policies; and I have a public health degree in Public Health Policy.  I see patients about 50% of the time now because West Alabama Health Services has grown significantly as I will show a little later.

I came to a site that was a two physician site and a satellite was started in 1979, the same year I got there.  We now have a total of six sites, five satellites, 15 full-time physicians and over 150 employees dealing specifically with the health service component.  So we have grown.  And part of what we have tried to do is to look at new and different ways of delivery and accessing care for the people in our area.

Bill Burnett asked me briefly to talk about the use of a health maintenance organization for Medicaid patients which we created and operated as part of the Robert Wood Johnson Foundation program on prepaid managed care for a couple of years.

We were one of the 13 organizations who received a Community Partnership grant from the Robert Wood Johnson Foundation.  We were to develop a rural health HMO that was primarily supported by Medicaid.  And that was a tall, difficult task.

I want to share with you what our goals and objectives were, the patient population demographics that we had to work with, some of our strengths and weaknesses, our enrollment and utilization, and then some of the conclusions that we found in working with this particular program.

The first question is, why would poor people even look at an HMO?  This is a volunteer HMO which has a lot of problems that we might talk about later.  But the objective of this HMO is to provide adequate health care to a low income, rural, Medicaid clientele and to simultaneously reduce the rate of increase of Alabama health costs.

Alabama has one of the lowest Medicaid reimbursement rates of any state in the union, including Mississippi, and we’re always fighting and trying to to be one step above Mississippi.    But we didn’t beat them when it comes to Medicaid reimbursement and we are really pretty pitiful.  Health care is not one one of our main interests in Alabama.  I hate to say that I think our main interest is highways.

We have a serious problem.  When you look at the state, it is a predominantly rural state.  It was once an industrial state in some respects but now it’s not.  We have one of the lowest property taxes in the nation and we have a very large amount of land and everything is in shambles.  Health care is not one of our emphases.  And especially health care for the underserved is not one of our emphases.

Table I compares the demographics for West Alabama Health Services fee-for-service patients with those who are enrolled in the HMO.

As you can see, we have a predominantly (75%) female population, who’s average age is exceptionally high compared to the average which you will find in most HMO’s, which does present problems.

Most HMO’s have younger people who are supposed to have less health problems, and whom you’re supposed to make some money off of.  We have a larger median age group than most.

The demographics of West Alabama Health Services, comparing those enrolled in HMO to all WAHS clientele

We also see that about 83% of the HMO clientele are separated, divorced, single, or widowed, and that falls in that female group and the average educational level is 7.8 years of school.  As we go on to Table II, we are going to see how the area served by West Alabama Health Services compares with the state.  You can see the state has come serious problems also, if you look at the per capita income, at the number of people receiving public assistance, and the health statistics for the state.

Our service area contains a very large number who are receiving public assistance, and the health statistics for the state.  Our service area contains a very large number who are receiving some type of public assistance.  The poverty level there is very, very high.  We also have a large number of babies who are born to women that are not married and who also have a high teen pregnancy rate.  Alabama as a state has also one of the highest teen pregnancy rates in the nation.  The infant mortality rate is a little bit higher than that.

Our HMO is called the West Alabama Health Plan.  Again, it’s a volunteer program and it’s an open panel, independent practice type HMO.

The demographics of the West Alabama Health Services

The state Medicaid program provides for 30 services, and we had to come up with some things that would make people look at us; because we have in our own community a very large number of people who are on Medicaid and who do not want to give up any of those privileges.  Our “carrots” are services provided HMO members which are not covered by Alabama’s Medicaid program:

• (a) preventive medical and dental care,
• (b) unlimited physician visits,
• (c) transportation for medical and dental services, and
• (d) 24-hour health consultation by telephone.

These “carrots” may not look like a lot but to many of our people they’re quite a bit.  The patients were particularly attracted by the privilege of unlimited physician visits for the HMO members.  We have no limit on how many visits they complete.  And they liked having access to transportation, which is a significant problem in our area, and preventive dental services.

We feel that there are strengths are in the program.  Primarily, our patients have a high patient satisfaction and that means that they don’t move around a lot.  We do have a 60-day lock-in right now.  We would like to have a longer period of time, not so much that the patients are jumping in and out, but because of the fact that in the state each person’s eligibility for Medicaid is determined monthly.

The person, in 30 days period of time could be ineligible and go off the rolls; when you have to do all the paperwork, and then they com back, and so it’s a real problem.  We have good coordination of our expanded services, good patient-physician relationships, good preventive care programs with utilization improving.

One of the things that most HMO’s are supposed to do is have a good preventive program.  We had people who had 7th and 8th grade educations who had been accustomed to doing anything they wanted to do and they thought Medicaid would pay for it.  And then all of a sudden we got into offering health education, preventive services that people were not accustomed to, that they didn’t want, and that they didn’t accept initially.

We feel that prevention will cut down on the cost of health care, so that was a major focus of our program.  We have been in action now about four years, going on our fifth year, and we’re now finally beginning to make some headway in that respect with things like walking clubs and exercise groups.  The whole community is walking.  I find that very exciting.

We have a significant problem with hypertension, obesity, diabetes, infant mortality, and teenage pregnancy.  We have noted changes in all these particular areas, especially among the HMO group which we can verify, because it is a small group.

One of the weaknesses in the program is management information.  We worked on it, worked on it, and still are working on it.  The capitation rates are very low.  We are capitated by the State of Alabama and we’re at risk for everything, including hospitalization.  We have five counties involved and the capitation rate is different for each county because it’s based on the experience of the county.

The capitation rates go from $60 to $80 a person.  And remembering all the different things I said about the people, that’s really a relatively low rate considering all the things we have to deal with.  They want to give us 90% of that particular rate.  So we don’t get total cost.  The high number of members lost due to loss of eligibility, as I said before, and the high enrollment of older people, the need for more providers, and the distances that our patients have to travel for specialty services constitute real problems.

Table II looks at hospital stays and shows that for our patients, most of the hospital utilization occurs in the group under 65.  The length of stay is about four days which is really not that bad, even over four days.

A graphical comparison of utilization rates

Interestingly enough, the older population – you would think that the stay of the older people would be longer and then you would have a higher utilization of hospitalization of the older group – but we do not have that.

If we look at our total enrollment, we see that we have about 2000 people under 65 right now.  The enrollment fluctuates.  The highest number that we have ever had is about 5000 people.  This is a small group, but you have to look at the fact that we cover an area of 4000 square miles with an average of 20 persons per square mile.  It’s a very sparsely populated area.

We have to remember that a Medicaid population is not homogeneous.  We like to think it is.  And if you think it is and if you approach it with that respect, you’re going to have serious problems in delivering care.  Self-selection is a real problem when you have a volunteer program.

There has to be some way to encourage people to join the plan, so – we market.  You have to look at your marketing.  You have to be competitive with the private practice people.  If you don’t have different things to make it attractive, then we will continue to lag behind the traditional fee-for-service type situation.

And then, finally, if we have some any regulations that are applied to us by the Medicaid people that make it very difficult to deliver this type of program, it won’t succeed.  And if Medicaid does not make it any different, if they don’t help us make a program like this attractive, it won’t succeed.

I’ll state this here now that to allow the fee-for-service group that it has to operate under more stringent rules to control the cost of care is going to make it very difficult for a program like this to succeed.  The Medicaid agency as a whole for the state has to be told about he advantage of a program like this.

Now this is a model program.  It’s the only one in the state.  The state is about to expand it but it’s still not making the commitment needed to make it work over the long term.  Why has this one worked as well as it has?  Because the West Alabama Health Services is basically a community health center that has the philosophies already intact of serving the underserved as its cause.

Cause has always been a part of what we had to do because of our regular federal mandates.  So promoting the cause and delivering care to the underserved had made it easier for us to do this.  But if a group does not have these principles, then it would be very, very difficult to make a Medicaid HMO work.

Dr Hullett’s presentation was preceded by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 2, Weaver)

All seven groups had the following topic for discussion:

There are many examples of individuals and organizations who are committed to increasing access to quality primary health care, no matter what happens to health care insurance reform. Give examples of how you (or persons whom you admire) are addressing the problems of a population’s ill health or medical needs.

GROUP ONE: Clasen (Leader); Babitz (scribe), Flores, Leong, Renaud and Webster.

The following notes were submitted by Marc Babitz, Group One Scribe. They have been reviewed by Doctors Clasen and Renaud, who have revised and approved the quotes attributed to each of them. 

Doctor Renaud is the 2012 Thomas Brown, Ph.D. Memorial National Conference Scholar

From left, clockwise: Doctors Mark Claswen, Daniel Webster, Hector Flores, Marc Babitz, Daneille Renaud and Darryl Leong; photograph by Marcus Payne

Flores:  expresses admiration for Mark Clasen, great work analyzing demise of FP Residency. [See Measuring the Economic Impact of Closing a Family Medicine Residency: An e-publication of the National Conferences on Primary Health Care Access.]

Leong: seeing changes in HMO practice in his current work.  CHCs always had  tension regarding funding and balance of patients (payor source).

Flores:  difference between publicly traded health insurance companies (for profit) vs. non-profit companies that reinvest into community.

Leong:  CEO and Board determine direction of health plan.  Do what costs the least or do what is best for the patient?

Flores:  health care reform trying to justify profit margins and justify rates.  California has tighter control.  Workforce issues remain a challenge for everyone.  Large employers who don’t care for the poor/Medicaid able to pay top dollar for providers.

Leong:  why does Kaiser cost more if they are an “ideal” plan?

Flores:  Kaiser financial person said that they needed to maintain their reserves.  In the past insurance companies could pass on all increased costs and raise rates as desired.  Kaiser is a model of efficiency.

Babitz:  Intermountain health care is another model of efficiency.

Flores: biggest competitor for providers in California is Kaiser and the prison system (which is paying new FPs $250,000).

Leong: Any changes in training programs in primary care?

Clasen:  big changes over 20 years in students and residents.  Much greater use of computer tools.  Current students can’t sit through a lecture.  Need laptops and devices.

Flores: had residents lamenting that not all their classes were online!

Clasen:  this changes their view of relationships.  Learning a community and the people is slow work.

Webster: continually distracted by something else.  Students don’t have to go to lecture, all online.

Flores:  still hard working individuals, but at different hours and different things.  Many now see medicine as a vocation that is a means to another end.

Babitz:  has this changed relationships with patients?

Flores:  No, the patients are like this too.  Kaiser markets to this population.  Patients like the asynchronous communication.

Clasen: his program was early adopter to electornic health record (EHR).  Big paper charts hard to use, hard to read, hard to find informtion,  EHR can flood provider with data.  Can’t bill for reviewing that data.  Primary care flow/productivity must change.

Leong: need to move to the patient management payment style, per member/month, pay for chronic disease management.

Flores: there is a retooling of delivery systems across the country to be more efficient.  Community clinic model (paraprofessionals, patient navigators, etc.) to maximize provider productivity.  PCMH rewards that system.  Potential to get paid for doing this.

Babitz: what about cherry-picking of healthier patients by these systems?

Flores: yes, some may do that.

Leong:  costs/visit at CHCs, for example, can be very different.  Not rewarded for efficiency?

Clasen:  elephant in the room is the mental health piece.  A lot of residents just don’t want to go there.  We are losing the unique story of each patient.

Babitz:  doesn’t a third of the population have mental health issues?  Are we going to ignore that?

Leong: Can we do preventive health for mental health problems?  Need to have time to talk to patients.

Clasen:  CEO of one health system bragged about seeing 12 patients/hour.  I told him that the law suits will come later.

Leong: I was taught that 95% of diagnosis was based upon history alone.

Clasen: billing requirements, re. ROS, etc. driving care.  Moving away from a true patient history.

Flores: learning to manage a patient panel without having to see them in the office, yet get paid for avoiding ER visits and other costs.  How can small practices do this?

Clasen: uses a scribe with patients to keep computer from being between him and patient.  Dayton has multiple computer health systems (Air Force, VA, hospitals) that don’t automatically communicate with each other.  Hospitals want to keep them separate.

Webster: still have some small groups in private practice who are working to be PCMH.  Those practices can have increased income with less work.  New graduates not taking Medicaid, despite having 40% of population on Medicaid.  Michigan Medicaid offers enhanced reimbursement for MSU practitioners.

Flores:  challenge of these special programs/FQHC model, is if everyone did it, it would break the bank.

Leong: it would break the bank under current payment plans, but currently 80% of dollars go to the hospital.

Flores: Kaiser model is to squeeze dollars out of hospital costs.  Medicaid has enough money, but hospitals have a powerful lobby.  All elected officials have a hospital in their district.

Leong: hospitals depend on physicians (sub-specialists) to keep them open.  If we could just shift percentage of physicians toward primary care.

Flores: DSH hospitals don’t want Medicare/Medicaid patients in managed care because it hurts hospitals’ bottom line.

Leong: don’t overly subsidize hospitals but don’t let them close.

Flores: need to organize hospital care such as Kaiser.  Every hospital can’t be “center of excellence” for everything like private hospitals.  Kaiser flatters their consumers so that they like/accept that system.

Renaud:  do those patients have choice?

Flores: no, but employers are told pros and cons of Kaiser.  If they don’t like it, employees can pay extra out-of-pocket for another program.  Kaiser is a union program and they use that to go to other unionized businesses to attract more business.  They also use their cost-effectiveness arguments.  President Obama mentioned Kaiser as a model for a national health plan.

Leong: main access point to care remains primary care.

Babitz: what has happened to independent NP practices, drug store primary care?

Clasen: ran PA program.  Many grads went into sub-specialthy care.  ANPs had a very high referral rate which would not occur in FP practice.  NPs no longer wanting to be in solo/private practice.

Clasen:  Health care costs are now comprising a huge percent of the family budget.  This is really a problem for working class families.  Working poor need to rely on charity care systems!  A problem when those patients need specialty care.  Really worries about what will happen if Supreme Court overturns ACA.

Clasen:  childhood poverty level is stunning (increasing).

Leong: hospitals are largest employer in rural areas.

Clasen: imagine Medicare being insurance company for all Americans.  Let other insurance companies just do Medicare advantage.  Then they would really have to compete.

Babitz: no one model is used throughout the country.  Our nation is too different.

Leong: population likes Medicare.

Clasen: as geriatrician, loves Medicare.

Flores:  many don’t know Medicare is a government program.

Leong: in Maryland, legislature told that changing Medicaid to a managed care program would save dollars.  Every specialist has to make a living.

Flores: Gwande’s article about costs in McAllen, TX for Medicare patients.  Costs were three times the cost of the same care in the Rochester system in MN.

Leong: can fee for service continue?

Flores: savings come from fees for global services; a problem for small, independent practices.

Clasen:  need to teach team to do other duties.

Flores: train community health workers.  Malpractice coverage depends on documentation of training and skills.  Uses a Johns Hopkins model for training of assistants.

GROUP TWO: Flinders (Leader); Bachofer, Fredrick, LeRoy (scribe) and Rodos.

The following notes were submitted by Gary LeRoy, Group Two Scribe. They have been approved by Dr Fredrick and approved with revisions by Dr Rodos.

Dr Bachofer is the 2012 Charles Q. North, MD National Conference Scholar

Dr Fredrick is the 2012 Mark E. Clasen, MD, Ph.D. National Conference Scholar

Clockwise from left Doctors Rick Flinders, Sally Bachofer, Gary LeRoy, J. Jerry Rodos and Benjamin Fredrick; photography by Marcus Payne

Our discussion began with a debate about primary care and the recent match for residency training. What do successful medical schools do to have good match results in primary care?:

• Selective admissions process
• Mentorship
• Clerkship experiences which are positive
• Changing social climate

This transitioned to a discussion about the community challenges of providing access to care. We work in a “lousy” system. Where are the individuals who will or can inspire the next generation of teachers of primary care, who will increase access to primary care.

There was a discussion about the history which led us to this point that we have such a broken system.

The group discussed the pros and cons of faculty Balint sesions to identify how we, as professionals, feel about what we do. The participants feel more aware of what we do and the rewards.

Challenges:

• How are we going to pay off loans?
• The desire to always know the answer
• The cost of academic training in the community – it does not pay the bills.

PPACA is an “access to care” bill. It increases the number of Medicaid eligibles, but does not increase the numbers of primary care professionals.

In the pre-1970s (c. 1965) charity hospitals and medical schools cared for the underserved. There was a professional commitment of service to the underserved that seems to have eroded in the 2000s.

What do you do with the patient in “four days” after they have been hospitalized, stabilized, and discharged back into the environment from which they came?

There was discussion about FQHC and community health center missions of productivity and service. There is no mission to educate medical students to become the next generation of family doctors who will serve.

“Provider burn-out” can possibly be relieved by incentivizing physician to be clinical faculty and the ability to teach.

The next generation of physicians will be more interested in lifestyle management.The “Hot 100″ patients who use all/most resources are now being identified by the community to prevent unnecessary hospitalizations and costs. Interventions are being given to these 100 individuals proactively. Students participate in these activities.

There is an increasing loss of appropriate physician to physician communication to sub-specialists for referrals. Now many referrals are triaged by PAs and APNs. There may be referral apps that we will use in the future.

When asked what other specialty of medicine we would do other than family medicine, all participants [in the breakout group said they] would do family medicine because of the perceived value in our work.

GROUP THREE: Hara (Leader); Broderick, Freeman, McCanne (scribe) and Ross.

The following notes were submitted by Don McCanne, Group Three Scribe. They have been reviewed and approved by Dr Hara.

The country needs to have at least 25,000 new family physicians. Yet, there has not been much change or improvement in the last two decades in the expansion of family medicine. There needs to be advocacy for GME reform, especially for family physicians; although there is a risk that changes in GME reform might result in even greater numbers of specialists, when primary care physicians are needed.

Medicare should not be the revenue source for GME funding. The current system produces an inequitable distribution of funds between primary care and sub-specialist physician training programs.  Hospitals are at risk of being disallowed reimbursement by Medicare for GME.

Public hospitals care for the sick young and poor. They have less Medicare and therefore less funding. The Primary Care Access issues raised medically underserved areas and minority populations, including undocumented patients, regardless of whether the health insurance reform legislation is fully enacted, still needs to be addressed.

Medicare should change its reimbursement structure, slashing the reimbursement rates of sub-specialists. The marketplace will produce a shift to family medicine. Even sub-specialists will agree, since there will be less competition for the diminishing sub-specialty market.

Sub-specialists are worried about Accountable Care Organizations (ACOs). (BPs in orthopedists’ clinics being an example of difficulties in coordinating care).

Comparing CHCs and public hospitals: There is contrast between the Kaiser Permanente system that is fully integrated with registry coordinators and an integrated Information Technology system,  compared to the loose coordination of CHCs and public hospitals.

The quality of data is essential for performance reports. FPs are likely to outperform in preventative medicine.

What do we do to get effective population health management systems? Population health requires Medicaid Managed Care, in which a joint effort between primary care, sub-specialty groups and hospitals can create a system. (Look at the example of Klamath Falls, Oregon.)

Hospitals cater to primary care in order to pick up revenue sources from sub-specialists to whom primary care physicians refer.

The health insurance system must be reformed. Eliminate parsasitic passive investors.

GROUP FOUR: Haughton (Leader); Burnett (WH), Geyman, North (scribe), Scherger and Wilke

The following notes were submitted by Charles North, Group Four Scribe. They have been reviewed by Doctors Haughton, Scherger and Wilke and Mr Burnett, who have revised and approved the notes. 

From left, clockwise: Doctors Charles North, Kevin Haughton and Allan Wilke; Mr Burnett; Doctors Joseph Scherger and John Geyman; photograph by Marcus Payne

Examples of increasing access to vulnerable populations:

The NHSC and IHS scholarship programs and FQHC federal programs were seen as the prototypical programs that effectively address the needs of diverse communities for access to medical care.  The programs have been proven over time to meet access needs and now are addressing training needs and sustainability by becoming teaching community health centers.

Native Alaskan health care systems are using dental extenders to provide access for frontier populations to basic dental services traditionally provided (or not) by dentists.  The team-based approach to medical and dental care should not only be practiced but taught from the early years of medical, dental, public health and allied health professional education.

Faith-based organizations should play a role in service and education especially for marginalized individuals, communities  and populations such as undocumented immigrants.  Student organizations can be very effective in helping to staff and provide direct care to such populations through faith-based groups.

We don’t currently have a national health care system in the USA.  We have a free enterprise system that is designed to reward the key stake holders -including insurance companies, hospital systems, big pharmaceutical and medical device companies.  Doctors, especially proceduralists, have also benefited greatly.

Our current non-system is not designed to improve the health of the population nor is it designed to raise health status. Organizations that are designed to improve population health operate at the margins, not in the mainstream.  The federal Indian Health Service and its partner Tribes, Native Corporations and urban Indian organizations are prime examples of entities designed to improve the health status of defined populations, but they have not been held up as examples for reforming a plan for the US population as a whole.

Other innovative examples include a school-based community clinic in partnership with the school of medicine and nursing and the school system in Albuquerque.  Many medical schools sponsor student-based organizations that serve minority populations such as Latinos, African Americans, immigrants and other special populations.  Located in medical clinics and community-based organizations or health fairs, students can participate in reaching traditional under-represented groups.

Who is the medical care system for?  Whom do we serve?  What is the role of faith-based religious organizations in meeting needs that are not adequately met by our systems?

What is the role of “direct care” primary care concierge type practices and the needs of populations to have better heath status?

GROUP FIVE: Henderson (Leader); Hansen (acribe), Olsen, Schwartz and Zuniga

The following notes were submitted by Thomas Hansen, Group Five Scribe. 

Dr Schwartz is the 2012 J. Jerry Rodos, DO National Conference Scholar

Dr Zuniga is the 2012 John Geyman, MD National Conference Scholar

Schwartz: The ATSU Osteopathic Medical School in Arizona has opened regional campuses to help address needs of underserved within the community health center structure. Its possible that the role of the primary care doctor will be radically redefined given the increase in patients needing primary care docs.

Olsen: Board member of community health center under medical clinic in a mental health clinic. Its difficult to find primary clinicians willing to provide medical care in that setting.

Zuniga: There is a diversity of lifespan between Hispanic populations (73 years) and whites (86 years) in California. How to help addres this? There is a psychologist coming to his y medicine residency clinic to provide psychological services to Hispanic populations. Medicare is coming to evaluate their clinics to see if they can receive grants to help increase health information exchange between all primary care clinics to provide better services.

One example of how this will help is a common Electronic Medical Record (EMR) so that patients don’t receive duplicate services (e.g., vaccinations), with the health record available to all clinics.

Hansen: Creighton University MC provides 70% of the indigent care in the City of Omaha.

The Family medicine residency program:

• runs a refugee clinic.
• provides care for family doctors at local community clinics

There is a lack of transparency in tuition dollars and in the GME dollars for residency programs. How to establish more FM residency programs with limited resources.

Group Responses: The process for calculating indirect and  direct GME funds is archaic.

Where do tuition and GME funds go? There is a lack of accountability. The administration has a huge gain from the residency generated GME dollars.

Residency programst don’t depend on CMS dollars. Is there a model out there that works?

FQHC – Future will depend on the next administration. Depending on who wins, we might see the dominance of healthcare administration vs. primary care residencies separated from hospital systems. FOr years, how to incentivize health care centers?

Innovations vs ris. To try and innovate how we teach students and residents in a way that makes sense but doesn’t cause financial difficulties.

GROUP SIX: Herman (Leader); Kasovac, Peck (scribe) and Squire

The following notes were submitted by Anna Peck, Group Six  Scribe. They have been approved  by Dr Kasovac and Ms Peck.

Mr. Squire is the 2012 F. Marian Bishop, Ph.D., MSPH Memorial National Conference Scholar.

From left, clockwise: Dr Mitchell Kasovac, Mr David Squire, Dr James Herman, Ms Anna Peck; photograph by Marcus Payne

Examples of Institutions serving the underserved:

FMC in Cedar Rapids Iowa  – Volunteers, staff paid from donations from the community, receives no federal funds

FQHCs are front line safety nets for underserved. These are self-directed and self-sustaining in the beginning. The downside is burnout and lack of continuity training.

Failure of a clinic can be devastating to a community. Once a critical mass of patient care is delivered, often relying on outside funding and volunteers.

Dr Kasovac noted that 2nd, 3rd and 4th year students from A. T. Still College of Osteopathic Medicine of Arizona are sent to work in community health centers across the country as a medical school rotation. Hospitalists associated with the health care centers often supervise the students.

Mr Squire volunteers at a homeless clinic in Salt Lake City. There will still be people who are either not willing or who can’t access the health care system. There are still access issues in health centers in rural and urban settings.

Dr Fredrick discussed global health initiatives: the Global Health Scholars program, helps people realize that thes services are also needed close to home and they need to be “specialize” in providing such care.

Concerns about health insurance reform legislation:

The reform process focused on funding for the uninsured instead of developing a care system that works for patients.

Physician Workforce Issues not solved (and likely exacerbated) by PPACA:

To get a 50/50 mix of generalists and sub-specialists (considered more optimal than the present system) one needs to change the rates of compensation for each. Often generalists cannot pay back loans at current compensation rates.

A need for developing new primary care residency programs.

Mr Squire: 20% of the workforce in any profession ends up being dissatisfied within the profession and looking for other career paths.

How do we help people choose the right careers? For primary care, provide early exposure to primary care practicea, and build awareness of the successful primary care models.

Question: are we successful at training primary care physicians because they choose to become iin primary care, because we are training them to do so? (push vs pull?)

Factors affecting the rate of producing primary care physicians: parents, socioeconomic status, race, and education level.

Rural programs may have students interested in medicine, but they may have family pressure not to leave the local community.

Interdisciplinary health care training is needed. Longitudinal projects could be used to increase interdisciplinary interactions.

Systems with a good history of setting up people to go into primary care, such as Canada, should be studied. Public health should be incorporated into primary care medical training programs.

GROUP SEVEN: Jafri (Leader); Christman, Coleman (scribe), Lee and Testerman

The following notes were submitted by Mary Thoesen Coleman, Group Seven  Scribe. They have been revised and approved by Doctor Coleman and Mr Christman.

From left, clcwise: Mr Scott Christman, Doctors Mary Coleman, Asma Jafri and John Testerman; photograph by Marcus Payne

The Memorial Health System (Long Beach, California) will be operating as a 24/7 health care entity, with more primary care docs than other institutions in the area.

Adventist Heatlh (Roseville, California) established a medical foundation and has shifted focus from perfromance as a hopsital system to a more complete health care system, or integrated delivery network. They are aggressively rolling out Cerner electronic medical record applications to the ambulatory setting.

At Loma Linda University (Loma Linda, California), all services are being tied together through EPIC. There is concern that EPIC doesn’t have the ability to operate registries or primary care effectively. EPIC is using Dr Scott Fields (Oregon Health Sciences University) for data mining.

At San Joaquin General Hospital (Stockton and French Camp, California) they are using data in registries to do population management.

At Loma Linda University, to increase family medicine residents’ interest in serving the underserved, the interview process looks at the record of service. About 60% of the Loma Linda graduates go into underserved areas. Loma Linda is also moving the family medicine residency into an FQHC. The FQHC will provide a funding source for patient-centered medical home services (social work, mental health, dieticians, etc.)

At Louisiana State University (New Orleans), a pilot project is using Social Work students, Pharm. D. students, medical students, and community nursing students to provide care management for high risk diabetic patients.

A new strategy is to use non-physicians to increase access.

There are difficulties with having many insurance companies askng health care providers to do case management.

It would be helpful to bring together all payers and stakeholders to discuss how to do wellness care. Businesses are also into wellness, such as lowering the rate of smoking.

At Loma Linda University, a physician has been hired who who provides care for the homeless. She wears a backpack and visits the homeless wherever they live.

A View of the Grand Hyatt Kaua'i, site of the 24th National Conference on Primary Health Care Access April 7-11, 2013

The National Conferences are a mechanism for bringing together major figures in primary health care policy for the United States, including persons from the health professional, academic and public health communities.

Invitations will sent over the next few weeks to the Senior Fellows and Fellows of the Coastal Research Group’s National Consortium on Community-Based Medical Education, and to registrants for the 23rd National Conference, held at the Park Hyatt Aviara resort April 16-18, 2013.

For those wishing to arrive early or stay after the conference, the Grand Hyatt Kaua’i will offer (on a space available basis) the very favorable Coastal Research Group rate for the nights of April 3, 4, 5 and 6 and the nights of April 11, 12, 13 and 14.

A view of one of the Grand Hyatt Kaua'i concept pools bordering the Pacific Ocean

The registration fee, as with all the National Conferences, includes accommodations for the nights of April 7, 8, 9 and 10 (checking out at noon on April 11th.) Registration fees must be paid in advance and the the pre- and post- nights are master-billed and must be paid in full prior to the conference. Continuing medical education credits will be awarded.

The National Conferences provide an intense immersion in current primary health care policy issues. There is a notable continuity in both the plenary faculty and the invited registrants from conference to conference.

An innovation at the 23rd National Conference, held in April 2012, is the creation of six National Conference Scholar positions, for persons new to the National Conferences, each sponsored by the Scholar’s home institution.

Grand Hyatt Kaua'i guests enjoy the stream pools

Medical or public health school or teaching hospital departments, primary care residency programs, teaching health centers, or public agencies wishing to sponsor one of the six National Conference Scholar positions to be established for 2013 (for a designee of their choice) should contact William H. Burnett, Program Coordinator, The National Conferences on Primary Health Care Access at burnett_crg@hotmail.com.

Preliminary announcements about the 2013 program and the plenary faculty will be made soon, and updated regularly.

A current initiative of the National Conferences is the publication on this website of the proceedings of all of the 23 National Conferences held to date, with the objective of completing this task in time for the 25th National Conference in April, 2014. A perusal of the coastalresearch.org website will highlight some of the past presentations and activities of the National Conferences.

Donald Weaver, MD; Director, National Health Service Corps

Donald L. Weaver, MD, Director, National Health Service Corps:  The National Health Service Corps (NHSC) was formed by the Emergency Health Personnel Act of 1970 (PL 91-623), to address the maldistribution of health personnel in the United States.  Through the placement of Health professionals in underserved areas, access to primary care services would be improved; removing geographic, financial, language, and cultural barriers.

The history of how this legislation was developed and signed into law is recorded in a fascinating book, The Dance of Legislation, by Eric Redman.  Supported by Representative Paul Rogers from Florida and Senator Warren Magnuson from the State of Washington, the NHSC was signed into law on December 31, 1970.

The mission of the National Health Service Corps is to provide health professionals to those communities and populations of greatest need which cannot otherwise recruit and retain health care providers.  To be eligible for NHSC personnel, an area or population must be federally designated as a Health Manpower Shortage Area (HMSA).

An HMSA is a rational service area with a physician to population ratio of 1:3500 (or 1:3000 if there are indicators of unusually high need, such as high levels of poverty or high infant mortality).  Within a given HMSA, a community-based system of care is then sought to be the setting for a NHSC practice.

In January 1972, the initial 17 health care professionals were placed by the NHSC, with the number of NHSC members providing care to the underserved in a given year peaking at over 3,000 in 1986.  Originally, an all volunteer service, the NHSC Act was amended in 1972 by PL 92-585 and in 1976 by PL 94-984 to include a scholarship component.  While the volunteer component of the NHSC continued, the scholarship program grew and became an integral part of the activities of the NHSC.

Since 1974, there have been over 13,000 individuals who have received scholarships from the NHSC.  Approximately 83 percent of the scholarship recipients fulfilled their obligation through service and approximately 13 percent elected to fulfill their obligation through repayment.  Although the law allows repayment as an option, the goal of the NHSC is to have as many individuals as possible fulfill their obligation through service to the underserved.

Over the last five years, the number of NHSC scholarship recipients available for service has markedly diminished.  The decrease was a direct result of the lack of appropriations for the program in the early 1980′s.  The appropriation reduction was in part the result of Graduate Medical Educational Advisory Council (GMENAC) and other studies indicating that there would soon be a surplus of physicians in the country, and that everyone would be within 25 miles of a primary care provider.

It was felt by many that “diffusion” (market forces) would result in physicians moving into the less desirable rural and urban inner city practices.  Given these predictions and concerns about the budget, the scholarship program underwent considerable reductions until there were no appropriations for scholarships in the early 1980′s.

Many felt that the scholarship program had the disadvantage of asking students to make a commitment to a primary care career too early in the educational process.  Some students would incur an obligation to serve the underserved as a primary care provider and then decide to pursue a career in a non-primary care specialty.

In addition, there was increasing recognition that despite the predictions of a physician surplus, the problem of individuals lacking access to primary health care services continued.  With the passage of Public Law 100-177 in 1987, modest funding was made available for a Federal Loan Repayment (FLR) and a State Loan Repayment (SLR) program.

The loan repayment programs have the advantage of selecting individuals for participation who are completing or have completed their training and, therefore, have already made a commitment to primary care.  Both the FLR program and the SLR program, in their infancy, have had some degree of success in getting providers to locate in underserved areas.

Since individuals in the FLR/SLR programs are volunteers until they match to a site, they have the option of saying no to serving in the hardest-to-fill underserved areas.  The scholarship program has had greater success in getting providers to serve in the hardest-to-fill- underserved areas.  The scholarship program has also helped to target disadvantaged individuals who could choose to pursue a primary care health professional career without the prospect of a tremendous loan debt upon completion of their education.

Given the complementary nature of the scholarship and loan repayment programs, funds were identified which allowed 41 scholarships to be awarded in the Fall of 1989.  To help identify the most appropriate applicants, an interview process was instituted.  Potential scholars were evaluated on the following:

1. Did the individual understand that this was a scholarship, not a loan?  The NHSC expected service to the underserved as a return on the scholarship investment.

2. The NHSC was looking for primary care physicians – family physicians, OB/GYNs, general internists, and general pediatricians.  What commitment did the applicant have to pursuing a career in one of these specialties?

3. Would the Applicant be comfortable in providing primary care in rural areas?  This was not meant to imply that all assignments would e in rural America, However, 70 percent of the HMSAs are rural and most medical training programs: a) are located in urban or suburban areas (with individuals wanting to stay close to where they trained); and b) do a comparatively poor job of training physicians for rural practice.

4. Was this an individual who would provide culturally sensitive health care?  The interviewers were asked to look at the individual’s life experiences which might be an indicator of his or her commitment to serve the underserved as a primary care provider.

Just as there are several ways in which individuals are recruited into the NHSC, there are several ways in which providers are employed as NHSC field assignees.  When the first individuals were placed by the NHSC in 1972, they were all federal employees.  As federal employees, these individuals are covered under the Federal Tort Claims Act for malpractice, a significant savings to those systems of care which employ these individuals.  This is of particular significance for individuals who are providing obstetrical care.

As the NHSC grew, the way sin which individuals could be employed to service the underserved expanded.  The three additional ways in which an individual can receive compensation for serving the underserved through the NHSC are:

•  Private practice option: a traditional fee-for-service practice.
•  Private practice salary:  a salary from an entity other than a federally funded community or migrant health center.
•  Private practice assignment:  a salary from a community or migrant health center.

The variety of payment mechanisms has served the NHSC well, allowing the program to use its budget to the fullest extent possible.

As the program expanded, the diversity of sites for placement expanded.  Placements are made into financially viable systems of care, with the caveat that all individuals must be cared for without regard for their ability to pay.  Initially, all NHSC placements were in rural areas.  The NHSC now has practice opportunities in community-based systems of care in the neediest rural and urban areas.

Given the need for a critical mass of age-specific individuals to have a viable practice for OB/GYNs, pediatrics, and internists, the NHSC has recognized the unique ability of family physicians to care for the full range of individuals and has targeted these providers for rural America.  This policy has permitted the NHSC to get maximum utilization of its scarce resources to assure that as many underserved populations as possible are served.

The success of the NHSC over the past 20 years in meeting the needs of the underserved is the result of practitioners who have made a commitment to dedicate part or all of their professional careers to helping those most in need.  Some providers have remained in the community after serving with the NHSC while others have moved on to other practice opportunities.

Many serve the underserved in other community-based systems of care, pursue an academic career and influence health professionals in training to commit part or all of their careers to serving the underserved, or integrate serving the underserved into their private practice.

As recorded in The Dance of Legislation, many felt that physicians and other health professionals would go into underserved areas if they received help in getting a practice started.  It was hoped that once this start up assistance was completed, these individuals would flourish in their practice and remain in the area.  This would allow the NHSC to move into another community and set up other individuals in practice.

To be sure, there continues to be underserved areas where this scenario will work well, given a stable financial base in the community.  But, there is an increasing realization that some other communities will remain NHSC sites for financial, geographic, and a variety of other reasons as long as there is an NHSC.

Unfortunately, diffusion did not occur as anticipated and the need to improve access to primary care services to the underserved has increased.  The Council on Graduate Medical Education (COGME), created by Congress to make recommendations regarding current and future adequacies of physician supply, adopted as their first principle: “The primary concern of the Council must be the health of the American people.  There must be assured access for all to quality health care.”

In COGME’s July 1988 report, it was stated that there “is now or soon will be an aggregate oversupply of physicians  in the United States.”

COGME’s report also stated:

Conclusion B-1.  There is a geographic maldistribution of physicians with too few physicians in many rural and inner city areas.

Conclusion C-1.  Minorities are still underrepresented in the physician manpower pool in the United States

Conclusion D-2.  There is an under-supply of physicians in family medicine.

These conclusions reinforce the need to have programs which focus on meeting the needs of the underserved.  Using data available from the Office of Shortage designation, there are 1,955 primary care HMSAs that would need 4,224 physicians to meet the needs of the undeserved as of June, 1989.

Over the last 20 years, the mission of the NHSC has remained constant although there have been numerous strategies to meet the needs of the underserved.  From an all volunteer organization, the NHSC has included a large scholarship component and the relatively new federal and state loan repayment programs.

From an all federal employee organization to expanded employment options, the NHSC has adapted to serve as many people as possible with the resources available.  When over 1,600 scholars were available for placement in 1985, the major emphasis of the program was placement.

With the limited supply of available primary care providers, the major emphasis of the NHSC turned to retention and volunteer recruitment.  The NHSC’s success has been highlighted by its ability to adapt to the resources available.

The charge for this conference was to list any limitations to meet the needs of the future.  There are three potential limitations to the future of the NHSC:

The first limitation is funding.  The funding for last year’s scholarships and loan repayment enabled the program to award 41 scholarships, approximately 100 FLR contracts, and approximately 120 SLR contracts

The second limitation is the need for an increased awareness of the fact that the dual goals of trying to place providers in the hardest-to-fill areas and trying to retain individuals in these areas will never coincide 100 percent.  The NHSC can improve on its past record, but the factors, in many instances, are not inclusive.

The third limitation is the fact that the NHSC can only be as effective as the primary care providers that are available to provide service.  Given the studies indicating waning interest in primary care specialties as a career choice, the NHSC will have to recruit an increasingly larger share of an increasingly smaller pot.  That could be a real limitation to the program.

In the past 20 years, the NHSC has an outstanding record of helping to meet the needs of the underserved.  There is now considerable interest within the Department of Health and Human Services and the Congress about a revitalized NHSC.  According to Webster, “revitalize” means to “breathe new life or vigor.”  Building on a proud past, the revitalized NHSC will continue to be a partner with other public and private organizations that share the common goal of helping meet the needs of the underserved.

(points of view opinions expressed in this presentation are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Health and Human Services.)

Dr Weaver’s presentation was preceded by:  First National Conference on Primary Health Care Access (1st Plenary Panel, Part 1, Schmidt)

Dr Weaver’s presentation was followed by:  First National Conference on Primary Health Care Access (1st Plenary Panel, Part 3, Hullett)

David Schmidt, MD, University of Connecticut:  I commend those individuals responsible for putting together this conference and thank them for the invitation to participate.  I have spent most of my professional life, which now spans 28 years, working in urban teaching settings that include Boston, Buffalo, Cleveland, and now Hartford.  I believe that the quality of life and the health status of Americans who live in persistent poverty has never been worse than it is today.

David Schmidt, MD; University of Connecticut; photograph courtesy of the AAFP Center for Family Medicine History

Let me share with you and example that occurred the night before I left Hartford for this conference.  In the middle of the night a 50-year-old black female was rushed by ambulance into our emergency room because she was experiencing incapacitating panic attacks.

She has every reason to be falling apart.  Eight months ago her daughter was shot and killed by random gunfire during a gang war.  She is left with two grandchildren to support.  On Easter Sunday her last child, a son, died of AIDS.  Tragedies similar to this occur almost daily in the cities of our nation.

Background of the Access Problem

I have been asked to provide background material which will be a challenge because today’s audience is a group of well informed experts.  I plan to point out some of the major problems that exist in our current health care system and try to portray the urgent cry for change that is coming from all sectors our society.  I will then focus on one suggested plan for change that is exemplified in the current Waxman-Kennedy Bill.

I will share with you my reasons for predicting that in the foreseeable future, (the next five years) virtually nothing is going to be done on the federal government level to address these major health care problems.  This brings us to the central theme of this meeting:  The Challenge and past Responses to the Problems of Access to Primary Health Care.

What can we or other concerned individuals do on the local and regional level to address the problems of access to primary health care by rearranging some of the resources that already exist?  As a partial answer to this question I am going to describe  a couple of successful defenestration projects, mention some of the noble responses from the private sector, and then look at the potential of our family medicine training programs for addressing these issues.

 Impending Bankruptcy of Health Care System

As we all know, the health care system is on the verge of bankruptcy.  Health care costs are out of control.  Partially because of these rising costs, ready access to health care is decreasing.  With decreasing access to care, the health status of our nation is deteriorating.

We are now spending over $750 a year on health care.  Expressed in terms of Gross National Product, this represents 11.5 percent.  There are projections that by the turn of the century this figure may be as high as 14 – 17 percent.

A comparison of the cost for medical care in the United States and Canada is important.  Figures for both nations were very similar until the 1970′s.  This is when Canada introduced a national financing system for medical care.  From that point on, the two nations have diverged.  Canadian costs have been stabilized and 8 ½ percent, while the American costs continue to rise to the current peak of 11.5 percent.  I mention this comparison because we can be assured that health care planners, legislators, and business leaders are tracking these major discrepancies between two similar nations.

It is estimated that there are about 37 million people in the United States without health insurance.  It is important to look at the composition of this group.  Only 18 percent are non-working adults.  Forty-nine percent are employed adults and 33 percent are children.  Two-thirds of these individuals have salaries above the poverty level.  These Americans are at great risk without health insurance.  Should they experience a medical disaster, they could easily experience financial ruin as well.

Fourteen percent of the White population is uninsured.  Twenty-two percent of the Black population is uninsured.  Twenty-nine percent of the Hispanic population is uninsured.  Twenty-five percent of all American children are currently living below the poverty level and 50 percent of all Black children live in persistent poverty.

Deficiencies in Medicaid Program

The Medicaid program was introduced in the 60′s and designed to be a safety net to provide at least minimal health care benefits for those with no other source of financing for their medical care.  In recent years, the eligibility requirements have deteriorated to the point that there are some places in the South where anyone earning more than $75 a week is not eligible for Medicaid benefits.

The Robert Wood Johnson Foundation has recently demonstrated that all segments of society are having problems with access to health care in the United States.  Approximately one in five Americans had no regular source of health care, and a slightly smaller percentage experienced difficulty obtaining care when needed.  The average number of ambulatory visits of patients in fair to poor health was inversely related to the health insurance and economic status.

As the number of individuals in this country living below the poverty level has increased, the number of individuals receiving Medicaid has remained stable.  This health coverage designed to provide minimal insurance for the poor reaches only 65 percent of the households living below the official poverty level.

In 1980, the Surgeon General set a goal for 1990 of having 90 percent of our children fully immunized by age two.  Today, fewer two-year-olds are fully immunized than when that goal was set.  We are moving in the wrong direction.  As a nation we now rank nineteenth in the world in infant mortality.  (the infant mortality rate is the number of deaths per 1000 live births at the end of the first year of life.)

Blacks in this country rank 28th below Cuba, Costa Rica, and Portugal.  These embarrassing figures are exaggerated in selective cities.  Infant mortality rate for Blacks in Boston exceed 25 per 1000!  These rates are similar to those of Third World Countries.

The cry for change is coming form all sectors of our society.  Senator John D. Rockefeller, IV, Chairman of the Pepper Commission:  “There is growing recognition that the American health care system is in total crisis…we are plunging ahead in this country toward health care catastrophe.”  Arnold Rellman, Editor of the New England Journal of Medicine:  “The cost of our present market driven system may prove to be so high, and it’s inequities so onerous, that universal tax supported health insurance may become a far more attractive political option than many now suspect.”  Lee A. Iococa: “The country needs an orderly system, and if that means some kind of national health insurance, then I’m for it.”  Why is a business leader like Iococa rendering an opinion?

The private sector is paying the bill.  Every Chrysler that is sold today had %530 attached to ti’s basic price in order to pay for health care insurance for Chrysler employees.  This figure is four times the amount of dividends that are given to the company’s stockholders.  This figure is four times greater per employee than the competition, Mitsubishi, is paying for health benefits.  Over the past decade the cost of health insurance to Chrysler has increased by 700 percent.

What is happening on a national level to address these problems?  St September, the American Academy of Family Physicians endorsed mandated private health insurance and Medicaid reform.  This is currently embodied in the Kennedy-Waxman Bill.

The AMA has endorsed mandated private insurance and Medicaid reform.  The Pepper Commission suggested mandated health insurance and Medicaid reform.  Recommendations of the Pepper Commission were made by a narrow vote of ti’s members.  The Secretary of Health and Human Services points out that the divergence of views on the commission reflects what is going on in the country.

There is no consensus of how to achieve the kind of health care we specifically want and how to bear the cost.  There is no doubt that mandated health insurance and Medicaid reform represents a quick fix.  However, I predict that even this less than optimal solution to our problem will not be accepted because of its costs.  The price tag for mandated health insurance and Medicaid reform would be in excess of $3 billion for the private sector and $10 billion for the public sector per year.

It is important to compare the relative economic strengths of the United States in the 1960′s and in the 1980′s.  The social reforms that were instituted in the sixties occurred when the nation was enjoying incredible prosperity.  In the 1960′s, the United States had 60 percent of the world industrial production, a trade surplus and small debt.  We had a heavy industry and a unionized work force.

Today, our country has 30 percent of the world industrial production, over a $100 billion trade deficit and a national debt of $3 trillion.  That $3 trillion figure represents $12,000 for every man, woman, and child in the United States.  Heavy industry in this country has disappeared.  The new high tech jobs require a minimal level of education.  Only 22 percent of our work force is currently unionized.  The major strategy for cost reduction is to lower labor costs, which is being done on a large scale.

For every billion dollars of foreign investment, we lose about 25,000 jobs.  There is slowly creeping into our country a Third World population who are willing to work for minimal wages.  There has been a great deal of publicity recently centered around eight million new jobs which have been created in this country.  IN reality, 60 percent of these jobs are with earnings off $7,000 a year or less.  There are many indications that the nation’s economy will worsen and with the recession, access to health care for the persistently poor will become an even greater problem.

It is estimated that the cost to implement the Kennedy-Waxman Bill will be extremely high.  This quick fix, short term solution to the problem of access would concentrate on mandated employer provided health insurance and reform of the Medicaid system.  It is estimated that such a program will cost the private sector $33 billion a year, and the public sector about $9 billion or $10 billion per year.  In the current economic climate, I do not believe such a bill will pass Congress.

This, then, brings us to the generic question, “What can we as individuals do on a local or regional basis to address these health care problems?  What can we do with existing resources to better provide access to care for the persistently poor?”  We do not have to reinvent the wheel.  For the past 20 years, a number of experiments have been going on that have been very successful.  The following are a few selected examples of past successful responses to the problem of access for the poor.

Selected Pilot Projects

THE CALIFORNIA PROJECT FOR OB ACCESS

In the 1970′s, it was discovered that there was an increase in infant mortality in the poorer districts throughout California.  Less than half of the obstetricians were taking Medi-Cal patients.  Increasing the physician reimbursement had no effect on the number of physicians who would care for these patients.  Therefore, the California Department of Health Services targeted 13 counties and defined a comprehensive prenatal care package.

This included a very active outreach effort to bring women into the health care system.  There was a guarantee that this care would continue to until the birth of the child, regardless of eligibility requirements.  Over 7,000 women received care in these comprehensive programs.  When compared to women receiving conventional care, it was demonstrated that there is an increased cost of about five percent for the California OB Access Program.  But for every dollar that was invested, more than $2 were saved in the area of neonatal intensive care alone.  These calculations do not consider the human suffering associated with permanently damaged child.

COMPREHENSIVE SCHOOL HEALTH CARE PROGRAMS

Over 20 years ago the city of St. Paul (Minnesota) introduced a comprehensive health care program in the school system.  This began with education at the seventh grade.  The curriculum included family planning, prenatal classes for pregnant women, and a mother support group.  The medical services included routine medical examinations, personal counseling, family planning, treatment of sexually transmitted diseases, pregnancy testing and prenatal care on the school premises.

St. Paul even established a day care component which allowed the parents to complete high school.  A woman who completes high school is on welfare for an average of two years.  The woman who has a child and drops out of high school is on welfare for 18 years!  The day care component provided field experience with course credit for the high school’s child development classes.

The results of this program were phenomenally successful.  After four years of operation, virtually all the pregnant women received early prenatal care.  There was only one premature birth.  There were no other low birth weight infants.  There was no perinatal mortality. The postpartum drop-out rate fell from 45 percent before the initiation of the program, to only 10 percent.  There were virtually no repeat pregnancies and the baseline fertility rate dropped by half.

MADISON COUNTY, NORTH CAROLINA

Madison county, North Carolina has 450 square miles of land, 17,000 individuals living in 5,000 households, a higher than average number of individuals over age 65, and a median household income that is below the poverty level.

The Hot Springs Health Center; Madison County, North Carolina

Over 20 years ago, the Town of Hot Springs lost its last physician and none could be found to replace him.  Local community leaders developed a non-profit community-owned health care program and hired nurse practitioners to provide care for the people.

Initially, the nurse practitioner was supervised by faculty from the University of North Carolina, Chapel Hill.  Eventually, physicians were hired by the health care program.

Over this period of time, virtually every remaining physician in the county has retired or died and Hot Springs Health Care Program now provides total care for the county.  They employ six primary care physicians, two family nurse practitioners, dentists, pharmacists, and 75 health professionals.  They are the fourth largest employer in the county.

They now have four medical centers.  There is a county-wide home health and hospice agency.  Staff from the Hot Springs Health Program staff the county health department.  Virtually every woman receives free prenatal care.  The deliveries occur at the Asheville Hospital in a neighboring county.  The entire county has enjoyed an incredibly low infant mortality rate: 5 per 1,000!

The six physicians provide 24-hour county call.  One of the centrally located facilities is open until 9:00 pm.  After that hour, if a true emergency occurs, an ambulance is sent to bring the patient to the medical facility.  By organizing health care for the entire county, it is now possible to recruit young physicians to work in this rural area.  The six physicians enjoy professional companionship and share night and weekend coverage.  The Hot Springs Health Care Program is financially solvent.  In fact, this program recently declined acceptance of federal funding.

Responses from the Private Sector

Across the country, office-based private physicians have been forced to reduce the number of Medicaid recipients they care for because of low level Medicaid reimbursements.  In some areas, the introduction of primary care management for Medicaid recipients has reversed this trend.

In the State of Washington, a physician legislator sponsored a successful bill for $19 million which allowed the state to buy health care from the Puget Sound Cooperative (a closed staff HMO) for Medicaid recipients.  The benefit package was somewhat reduced.  This is clearly and example of rationing of health care.  The “frills” were not included, such as prolonged mental health care and drug rehabilitation.

In Rochester, New York, physicians, Blue Cross/Blue Shield, and hospitals work together to create a health insurance program for low wage earners.  The cost of this insurance to the individual was 50 percent the cost of regular Blue Cross/Blue Shield programs.   Here, again, the benefits were trimmed.  The physicians agreed to accept 65 percent of the regular and customary fee for their services.

In Orange County, California, a constituency of academic leaders and practicing physicians became an effective advocacy group for the uninsured.  Orange County is known for its affluence with a mean annual income of over $48,000.  However, there are 5,000 homeless, 150,000 non-documented aliens, and about 250,000 people without health insurance in that county.

The county hospital, which is owned by the medical school, attempted to insist on advance payment for their services.  This advocacy group has been very effective in preventing the county hospital from decreasing patient services.  IN fact, the number of women receiving comprehensive OB care at this institution has increased.

The Potential for Training Programs to Help Address

The Problem of Access to Medical Care

It is difficult to quantitate how much care for the underserved is provided by training programs.  The number of residents in training is over 80,000.  This person power works in institutions that add up to over 300,000 beds.  This represents 60 percent of all the medical beds in the United States.

In family medicine alone, there are 380 residency programs.  If an average family medicine center has 15,000 visits per year, this resource provides six million visits.  I am not aware of any means of estimating what percentage of these visits are made by Medicaid recipients or patients without health insurance.  Nevertheless, this must be a significantly high percentage.

I will end this presentation by focusing on a new and promising training program in East Los Angeles.  Over 300,000 Hispanics live in East Los Angeles within the shadow of the affluent downtown skyscrapers.  In 1985, there were only 65 elderly non-residency trained primary care physicians in this community.

The story begins a few years ago when an 8-year old boy named Hector Flores and his family moved from Mexico to the United States.  No one in the family spoke English.  They settled in the East Los Angeles area.

Eventually, Hector went to Stanford University and received his medical degree from the University of California, Davis.  During his college and medical school days, Hector became involved with the California Chicano Medical Student Association.  This group today has 12,000 pre-medical, 300 medical students, 3,000 residents, and 12,000 alumni in its membership.

In 1985, the University of Southern California was granted AHEC money to create a Hispanic education training initiative.  It was decided that a new family practice residency program would be the centerpiece of this initiative.  Dr. Peter Lee, the Chairman of the Department of Family Medicine at the University of Southern California, began searching for a hospital that might house such a residency program.

White Memorial Medical Center in East Los Angeles is a full service tertiary care facility that was previously the University Hospital, Loma Linda Medical School.  As a university hospital, it had little community involvement and virtually none of the East Los Angeles primary care physicians had admitting privileges to the hospital.  Loma Linda build an entirely new university, hospital at some distance.  Suddenly this full-service hospital was left without a mission.

Dr. Sanford Bloom, who had retired from a distinguished career as the family practice residency director at Santa Monica Hospital Medical Center, agreed to do a feasibility study for the White Memorial Medical Center and later developed the curriculum and the Residency Review Committee accreditation application.

When it came time to recruit a faculty, Hector Flores seven of his friends form the Chicano Medical Association.  Six of these seven physicians had their roots in East Los Angeles.  Through the California Chicano Medical Association, it was easy to recruit a group of bright residents.

This is not an ordinary residency program.  The Faculty and the residents have become heavily involved in the community.  These Hispanic role models are trying to encourage the younger students at the elementary school level to consider health careers.  They have organized a teenage pregnancy program in the high school and there is a great deal of one-to-one mentoring occurring.

The program has set up a number of satellite practices throughout East Los Angeles.  At present, there are three such practices.  Faculty receive 50 percent salary from the hospital and they earn the rest of their living through community practice.  There is a separate practice corporation.  The hospital and the practice corporation are prepared to help each resident set up a new practice in East Los Angeles upon graduation.

This is another example of crating a system in which an individual need not be isolated when providing care to the underserved.  This type of arrangement provides professional companionship and a reasonable night and weekend call schedule.

At present this project is funded almost equally by the hospital, extramural grants, and patient income.  Bill Burnett (through the Song-Brown Family Physician Training Act that he administers for the State of California) is helping the program create new funding methods to provide long-term viability.  The areas that are being explored include a primary care capitation program with Medi-Cal and application for designation as a National Health Service Corps site.

This is an example of existing resources being brought together in a vision that has the potential of providing a sufficient number of well trained family physicians for the entire 300,000 population.

Dr Schmidt’s presentation was preceded by: The First National Conference on Primary Health Care Access. April 20-21, 1990 (Opening Remarks)

Dr Schmidt’s presentation was followed by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 2, Weaver)

William H. Burnett, MA; California Office of Statewide Health Planning and Development

William H. Burnett, Office of Statewide Planning and Development, State of California [Mr Burnett is a Senior Fellow of the Coastal Research Group.]: Others at this conference have presented, or will be presenting, evidence that problems of access continue to stalk us as a nation.  My comments will speak to three main areas of concern – fragmentation of public policy relating to primary health care, the looming deficits of physicians in key segments of medical practice, and the precariousness of funding for primary care training programs.

The Evolution of “Primary Care” as a Concept

As we contemplate what policy options should be taken to promote health care access in the next ten years, much of the conceptual framework we will be using will date from the mid-1960′s through early 1970′s.  The term “primary care” dates from that period – a vestige of an attempt to impose the language and principles of systems analysis in describing health care delivery in the United States.  The term “tertiary care” also survives from this scheme, more often than not in pejorative contexts, to describe the circumstances that favor sub-specialization, bench research, and procedures in the academic medical centers.

“Primary health care” and “primary health care access” are related, although not identical concepts.  But we rarely use the term “primary care” without an explicit or implicit reference to some problem of access.  For 20 years it has been a principal mental construct to aid in the devising and promoting of policies to counter the inexorable process fragmenting medicine into sub-specialties.  It becomes the matrix for corollary constructs – the ideas of comprehensiveness of care and of continuity of care.

Consider several important movements of the past two and a half decades – each advance to promote access to comprehensive, continuous primary health care (each represented by one or more members of this conference’s faculty).

1. The idea of expanding urban health departments beyond such traditional roles as immunization, vector control, and food inspection to incorporate comprehensive health services to the medically underserved.

2. The idea of establishing consumer-controlled neighborhood health centers, now usually referred to as community and migrant health centers and promoting them with federal support.

3. The idea that the U.S. Public Health Service, whose patient clientele had once been limited to the Merchant Marine and to Native American tribal communities, should assume direct patient care responsibilities in certain defined geographical areas of need, most notably through the establishment of a National Health Service Corps

4. The idea of creating a new medical specialty which came to be called family medicine whose elements – including the structure and content of training and requirements for board certification and periodic re-certification – were based on normative theories of what primary care training should be like.

The latter initiative, family medicine training, addresses the improvement of access for the underserved to quality primary care at two points in the career continuum of physicians.  One is during the physician’s residency training when model primary care delivery would be provided in the residency programs themselves through the  family health centers, family practice inpatient services, home care, and community-based satellite practices.

The second interaction is through the practices of the residency program graduates – those who have mastered family medicine in training and who are duly certified by the new primary care-oriented specialty board.  Those graduates, it is envisioned, would collectively practice the enunciated principles of “ideal” primary care.

Delivering Primary Care

I have listed five kinds of primary care deliverers, each kind invented to promote access to care.  Again, the five are:  comprehensive health services by local health departments; community and migrant health centers; the National Health Service Corps; the family medicine residency programs; and family medicine residency program graduates.

Each of these kinds of primary care deliverers have had their detractors over the years.  Many of the detractors, during the 1980′s, came to be convinced that a surplus of physicians would emerge in the United States, making these initiatives of the 1960′s superfluous since sub-specialists would be forced to enter primary care and a diffusion of physicians into ever smaller and less desirable communities would occur.

During the 1980′s, many who had been concerned with issues of primary care access found themselves on the defensive.  Concepts of primary care, comprehensiveness, and continuity may have influenced each of these initiatives strongly, but the evolution of each occurred in relative isolation.

Systemic Linkages between Primary Care Entities

In two ares formal linkages do exist.  One obvious kind of linkage is that between the family medicine residency programs and their graduates – an outcome, I think, of accreditation requirements, that encouraged community physicians to be participants in the residency programs as attending faculty, often an effective antidote to “town and gown” controversies.

A second kind of linkage is one promoted by federal policy, that the National Health Service Corps would become a principal means for assuring physician manpower for community and migrant health centers.

In a longer presentation I would suggest examples of other kinds of linkages, usually local, such as we have heard of in San Francisco.  Between other deliverers in my list of five, but thinking in national terms with the exceptions noted, each has evolved independently.  Characteristically, in an era when public policy formulation is so often a fragmented and episodic activity, each of the kinds of primary care deliverers noted has fought its own political battles.

I propose that we think of the five kinds of primary care deliverers as a partially connected pentagonal figure, showing the previously describe family medicine residency program-residency graduate linkage and the NHSC/community-migrant health center linkage.

Deficient Numbers of Primary Care Physicians

The concept of looming deficits in the supply of physicians in the United States may be an unfamiliar one in some policy circles.  We were accustomed in the early 1980′s to consider our principal physician manpower dilemma to be an impending surplus of physicians over levels of adequacy enunciated by the Graduate Medical Education National Advisory Council.

I will not speak to whether or not the analytical approaches to forecasting physician need and supply advanced by the Graduate Medical Education National Advisory Council [GMENAC] were fundamentally sound. But too often predictable manpower deficits, which should have been of paramount concern to policymakers, were either unrecognized or assumed to be temporary problems which would abate as the “surplus” physicians searched for things to do.

I am not one who argues that we may be heading for an absolute shortage of physicians, although the 1960′s provided us with lessons that the predicted surpluses of teachers and engineers, which led to cutbacks in numbers being admitted to teaching and engineering schools, led in time to the recognition of national shortages of teachers and engineers.  I suppose a devil’s advocate might note that our population is increasing, our health status by some important measures is declining, and our number of medical school places has ceased to grow and may be in long-term decline.

But two areas of physician supply seem to be grossly inadequate as we enter the 1990′s – physicians entering rural practice and physicians who deliver babies.  Arguments for family medicine residency funding often have included the idea of the “bimodal curve” of family physician ages – that is, that most board-certified family physicians are either those trained since the early 1970′s who, therefore, are about 45 or younger, or are those trained just after World War II who typically are over 65 and nearing retirement.

We currently are living through the long-predicted period of retirement of the older hump in the bimodal curve.  This is profoundly affecting health care patterns in rural America.  Many rural towns are simultaneously seeking physicians to replace their long-time community doc and are finding the competition very rough.  Typically, their small rural hospitals’ fates are themselves tied to their community’s ability to attract physicians.

Competition for Family Physicians

But the family physician, whose training is precisely designed to be the most useful physician for rural areas, apparently has become the physician of choice for a whole range of settings, vastly increasing the number of would-be recruiters of family physicians.  Dr. Marc Babitz of NHSC’s regional office in Denver recently presented the information that every family practice medicine graduate has an average of 20 serious job offers to choose from.

Given the advantage that a region, rural or urban, that is host to a community-oriented family medicine residency program has in recruiting graduates of that training program, the difficulties that a rural area which has not had a long-term strategy for recruiting and retaining physicians can be formidable.

Even more ominous if the impending crisis in obstetrical manpower.  Only two physician specialties – OB/GYN and family medicine – are trained to deliver babies, and physicians in both specialties have enough within their normal scope of practice that they can build busy practices without offering obstetrics.  In fact, with the high cost of liability insurance for physicians who perform obstetrical services, and the practice time that delivering babies consumes, it is plausible that physicians in either specialty might actually increase practice income by dropping obstetrics.

It is apparently the preference of some medical communities that family physicians not deliver babies at all regardless of skill and training.  This, and the specter of litigious patient clienteles, has caused larger numbers of family physicians and, for that matter, some graduates of OB/GYN residencies, to resolve from the first day of practice not to deliver babies.

But a poorly understood fact is that a large percentage of physicians who deliver babies give up their obstetrical practice in the period between ages 42 and 45 which suggest that, if we as a society wish to assure ourselves an adequate supply of physicians to deliver babies, that we be constantly producing a number of physicians who will give us a dozen or so years that we can count on them for this important purpose.

It is quite likely that we have not come close to producing that right amount of physicians trained and willing to deliver babies in the period since 1985 and that, if this is true, it will become increasingly obvious as the decade unfolds.

Funding of Primary Care Physician Training Programs

My final concern relates to the funding of primary care physician training programs.  I believe one of the intellectual achievements in the public policy debates of the 1960′s was the application of educational theory to the societal need of producing a particular kind of physician who could perform specific skills in just the right way.  I think both the family physician and the family medicine residency program are living embodiments of a truly great pragmatic vision – the primary care physician trained in an ideal curriculum to perform an ideal role in the United States health care system.

There are now hundreds of family medicine residency programs, many of which are genuinely interesting and inspiring endeavors, and tens of thousands of their residency program graduates properly certified by their guardian specialty board.  Great numbers are performing exactly as the inventors of the specialty dreamed they would and, as noted above, they have become a “hot item,” intensely recruited by private practices, community clinics, HMO’s and their residency programs themselves.

Lauding the programs cannot mask a fundamental weakness in the concept of “idealized” primary care training.  Partly by necessity, partly by tradition, they were planned as something that teaching hospitals would sponsor.  An accreditation body was organized to assure that the programs would contain all of the essentials of an “idealized” primary care program.  However, the administration of the sponsoring hospital might well have a quite different view of what the hospital’s mission is and what it regards as proper priorities.

Consider for a moment what a hospital administrator might regard as the hospital’s mission – the emphasis on the very sick and concentration of resources on life-threatening illnesses, accidents, and acute care.

Consider the special features of a family medicine residency program that might be imposed upon that teaching hospital.  These may very well contain requirements that are not considered to be part of the hospital’s mission – comprehensive care; three years of specified rotations that may be on services that that hospital doesn’t routinely choose to provide; continuity of care, getting the hospital into ambulatory care in a very specific, precisely defined way; behavioral sciences, requiring an interdisciplinary faculty that may not be the kind of staff that that hospital would normally have; community linkages which require resident time out of the hospital.

So you could imagine that with the figure in the center suggest that the hospital management might represent a narrower view of what a family medicine residency program should do within that hospital, and that the residency review community might  well have a much more expansive view of what society needs that family practice residency program to do.

Well, no hospital can pay for all of the components that a properly operating family medicine residency program must have to maintain accreditation by means of revenues generated by the residency program.  Thus, every family practice residency program operating in the United States is subsidized from one or more sources and ultimately it is the sponsoring institution, the hospital, that must absorb the shortfall between what the residency program generates in revenues and what external subsidies it can garner.  This can lead to a tension between hospital administration and the accrediting society as to how much of the hospital’s resources the residency program should command.

The accessibility of residency program subsidies mitigates this potential tension.  External subsidies usually exist as federal, state, and local grants for family medicine training.  (The Medicare “pass-through” subsidy for teaching hospitals, though technically an external subsidy, operates more often than not as a resource whose use is discretionary with the hospital administrator and, therefore, is often perceived as an internal subsidy).

Beyond these governmental subsidies and residency program income, any shortfall in the costs of the family medicine training has to be paid for out of surpluses in other parts of the hospital.  But the internal subsidies (the other services of the hospital) may very well be squeezed by price inflation in the health care sector, reimbursement by DRG’s, reductions (actual and proposed) in the Medicare pass-through, and the increases in uncompensated care that affect the hospital’s bottom line.

Meanwhile the government and non-profit sectors are affected as well – the concern of the federal deficit, the effect of the taxpayers’ revolt on state and local government revenues and expenditures, the philosophies of economic limits that affect resource allocations – all have affected particular hospitals, and particular states that squeeze their subsidies and, therefore, squeeze the hospitals.  What you get is the simultaneous effect of the cost squeeze on hospital’s financial resources and the cost squeeze on the government, affecting both the internal and external subsidies of the hospitals.

The 1990′s will be a decade when strategic thinking as how to address problems of training the right kinds of providers will be required.  As perplexing as it is likely to seem at times, we are indebted to the intellectual work of 25 years which has led to workable models of health care delivery that promote access.  It is our task to preserve and improve upon this legacy.

J. Jerry Rodos, D.O. Midwestern University, Western Springs, Illinois [Dr Rodos is a Senior Fellow of the Coastal Research Group]: Let me make some global comments.  I think that we’re seeing a rash of meetings, of conferences about the issue of access to primary care and producing family physicians.  I think that’s good!  As many of you know, I am a family physician by roots and a psychiatrist by evolution.  Clearly, we are all so frustrated by group meetings.  We need to talk about the things we don’t control, that frustrate us, and we did a little of that this morning.  I think we need to understand that we don’t have a problem that is isolated from the rest of the society in which we work.

The two speakers earlier this morning alluded to that and passed over it quickly and I want to emphasize it again.  The status of our society, and its health is simply one issue in that society, is not going to be resolved, improved, changed, altered, without consideration of what is going on around us.  What we have seen, which I think is very interesting, is a whole group of very local projects in which you and I and colleagues have control and can produce responses that serve the needs of our community.

But Sandral Hullett pointed out a very important issue and that is the issue of standards, controls, and bureaucracy.  Those are projects, when they’re locally managed and that meet the standards and that meet the needs of that community.  If we have a national set of standards, as many of us have experienced over and over again, because of our pluralistic society, we get into difficulties trying to mandate those in other parts of the country, no matter how good they are in basis.

For example, it is wise to deal with the issue of the use of psychotropics as restraining agents in nursing homes.  But it is not reasonable to have a psychiatrist review records every six months when there are large parts of our country, as there are large parts of rural Illinois that do not have a psychiatrist available to perform that function.

And while we’re thinking of solutions and while we communicate with each other, we need, I think, to consistently keep in mind some basic principles.  We need to look at errors we have made in the past because one of the things about our society and about our government is that it is not prone to admit its mistakes.  It is not prone to say, “We developed Medicare and Medicaid to solve some very specific problems.

We believed that the disincentive for access at the tome was financial.  If we could remove the financial disincentive, people would get the care.”  Well, what have we discovered in the evolution of 25 years of this program  – we’re going to focus a little more on that tonight – we have, in fact, taken what was tier care, said we’re going to eliminate it, and 25 years later have tier care that is more intense than we had when we set out to solve the problem.  So there are some national issues.  We’re going to have a chance to look at these issues.  And then we have some local opportunities.

Here I think is where we can shine.  Here I think is where you, all of  us who have influence (and we in education do have influence) can weave into the fabric of our programs a reestablishment of what physicians’ roles are – what it is, in fact, to serve society.  Because remember we didn’t have to do this.  We stopped 25 years ago.  There was no underserved.  Remember, we eliminated it.  There was no difficulty in access to care because we said we had taken care of it.

I’m old enough now and I have been involved in the issue of drug abuse, probably since 1957.  I’m a veteran of more wars against drug abuse than I would like to count and I don’t think we’ve won a damned one.  But we keep declaring war!  We need to look at those issues and translate them from our ability to manage the national scene, which we can’t give up on, and continue to sharpen and focus our approaches to what we can do in the roles in which we play on a local level.

As part of that, I guess I want to share with you a fairy tale.  I want you to have a fairy tale before lunch.  But even before I start the fairy tale, let me point out that I think it is good that we have this meeting.  And I want to compliment Dr. Midtling and Mr. Burnett for bringing us together, because I hope that there will be, in theses mall kinds of meetings, ongoing focus and sharpening of approaches that we can take both locally and nationally.

Once upon a time, because remember fairy tales have to start with “once upon a time,” in a section of this country which comprised six states, there was a group of physicians who came together because they were concerned about the fact that their average age was 66; that they were having difficulty getting students whom they had gotten interested in practicing in their region into medical schools; that for large parts of this region they were providing the only medical care in most of the rural areas and some of the urban areas; and that it seemed to them that no matter how hard they tried, the graduates of existing schools didn’t diffuse into their region.  Those that did were ill-equipped to practice.

So they decided to develop a medical school in their region (remember this is a fairy tale!) with no public money and with only two of the 12 members of this board having any academic medical experience.  They set about to meet monthly – I am, because this is a fairy tale, going to skip all the organizational issues that went along with it, to skip all the fund raising, all the efforts in site selection, all the activities that went about to gain professional support to prepare for accreditation, the necessary state charters, or public relations and legislative support, all of which are fascinating stories, each a fairy tale by itself.  But I am standing between you and lunch.

And this inexperienced group of folks established some principles.  Very easy to do when you have no biases based on knowledge and experience and that was the description of this group.  So they wanted to produce family physicians and that was the description of this group.  So they wanted to produce family physicians that would serve their area.  That was their mission.  They were going to do this by creating a curriculum that would focus on that goal.

The faculty would consist primarily of practicing family physicians in that region; the admissions committee would be composed of a majority of practicing family physicians; and applicants to the school would be encouraged from the region.  Because their focus and mission was family practice, they wanted applicants focused on family medicine, even recognizing that applicants will tell you whatever it is you wish to hear.  That much experience they all had!  And early on, they indicated, as part of their principles, that the basic science faculty that they would hire would have to spend at least 50 hours with a family physician on the college opened and that that requirement would be continued for all new basic science faculty.

Now, because they had no experience and could meet monthly and you had to do something with this monthly meeting, they established a curriculum committee which consisted of four family physicians – one family physician would become a pathologist; one retired internist, who was an early gastoenterologist, practiced in the City of New York but had the experience of being an internal medicine department chairman at a college; and one family physician who was also part psychiatrist.

I often think that they keep psychiatrists in medical school administrations primarily to deal with the faculty.  They made some decisions – again based on all of the inexperience that they could muster:  that they would use a systems approach, that family physicians with a basic science faculty would be the coordinators of these systems, and that a majority of the clinical faculty teaching in these systems would be family physicians in the area.  They did this, by the way in the selection of the systems approach as a mechanical issue of how to get people from their offices to be able to teach on the institution’s campus and get back to their offices in some reasonable plan because, (if some of you are beginning to smell a pre-Flexnerian model) they did not see whole-time physicians as an advantage.  But the, again, this is a fairy tale!

They wanted early exposure of the student in their school to the health care delivery system.  And so emergency rooms, rescue squads, public health clinics, visiting nurse programs, well-baby clinics, venereal disease clinics, other health agencies, practitioners’ offices (practitioners in the broad sense from podiatrists to dentists to a variety of physicians) attendants at the hospital, utilization review committees, quality assurance, time with the administrator, even participation in prison health care was part of the program in community medicine that began in the first quarter of the freshman year four hours of each week.

These programs all had learning objectives for each site and a small group debriefing which occurred monthly.  The student was expected to conduct himself or herself in a professional manner in terms of dress, in attendance, and demeanor.  The students were to study who was served, why they were served, and was to study carefully doctor-patient relationships in these environments.

An associate dean for basic science was brought on.  He was asked to be innovative and develop no-traditional roles as he hired faculty, which he did extremely well.  And so we really need to look at the end of this fairy tale and see what happened.  The things I described to you occurred between 1972 and 1978.  Making it that recent is hard to make it a “once upon a time” fairy tale.

And this institution, this make believe institution, that I have described opened in October, 1978.  Because it’s a fairy tale, I can leave out all the problems that occurred between ’72 and ’78 or, in fact, between ’72 and ’90.  But that’s the advantage of fairy tales.  But this fairy tale did some interesting things.  They did a survey to find out what happened to their graduates?  I was hoping to update it beyond January, 1987, but, unfortunately, they do not have additional data.

They graduated 289 people.  If you take out the 66 who are still in internships in our fairy tale school, there are 223 that are left.  IF any of you are concerned, by the way, this is not Chicago.  Now, of the people practicing in their region of those who graduated, 32% are practicing in their region; 13% in the state in which the medical school finally decided to live.  Of those graduated, 66% are family physicians.  And if one adds primary care to that as we traditionally define primary care, 87% of the graduates are in primary care.

Now, I have shared this fairy tale with you because it means that you can create institutions that do what it is you set out to do.  Because one of our focuses is, in fact, the production of family physicians, and I am not going to be lulled into using that primary care piece, not as a slight to anyone else but because, in fact, what we need is family physicians.

Dr.  Midtling’s studies, if nothing else, should alarm most of us that within the next five years, ten years at most, we are going to have a serious problem, a crisis problem – although I hate to use that term because we use it for everything – in family physician supply in this country.  But you can, in an institution, create a program doing that which you know that will work.

And so, what’s the moral of our fairy tale?  The moral of the fairy tale is that if you do what you say you are going to do and do what we know will work, it does.  But then, again, this is a fairy tale!

Schmidt: Can we take some time to have some interaction between the panel and the audience?  Questions.

David Kindig, MD: [The wording of Dr Kindig's question is currently unavailable.]

Schmidt: My message, the bottom line, is that since we will not have a national health insurance program, whatever we do will have to be done on the local level and there are a half a dozen samples that we can choose from, a menu that we can choose from, that will fit into our local needs.

Rodos: Can I respond to both the issues that you raised?  I think that the statement that needs to be made, without the chemical terms, is that there are parts of this country that will never have access to care because of the nature of that particular community – whether it is isolated, whether it is low population, whether it is inner city – and have special risks at issue.  And that although you can reduce access problems, and I think Corps is probably going to go through several more changes if it becomes the focus of addressing that mission, that eventually we will decide how we’re going to care for and provide service to that group.

Now, by the way, without, I hope, some continued concern on all of our parts that health care is simply one issue.  Prevention in inner city Chicago and in Eutaw, Alabama, and rural Illinois are very different issues.  And prevention on the north side of Chicago is very different from all of those.  Secondly, I think there is a message about local initiatives and local care.  I happen to be becoming more and more convinced that we get into more and more difficulty by trying to find national solutions in a very pluralistic society.  And we continue to ignore the principle  of economics that I will mention again tonight.

The utilization of curative services rises to the level of the availability of those services.  That’s not a new principle and it certainly isn’t Rodos’ principle.  It has been around a long time.

If you visit Russia – and many of you have – where they don’t have access problems and manpower is not one of their problems, utilization is one of their problems.  And how do they reduce utilization where it’s a problem? They post all the appointments on a blackboard outside in the waiting room.  It has some impact.  Some people shifted to use the emergency help service which, as you know, in the cities is excellent.  And they finally had to redefine how the were going to give that service.

So unless we keep in mind some things as we design programs, we are constantly going to be in the position of having to make changes, which is what we’re doing now.  We are ratcheting down physicians’ payments.  We’ve already ratcheted down hospital payments.  Without recognizing that the basic issues were created by the program to begin with, we’ve now maybe created problems that ten years from now we’ll be spending even more money to try to balance and correct them.

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

Hector Flores, M.D.: I want to thank John Midtling and Bill Burnett for inviting me to come and speak today.  This certainly is an area of personal interest to me and also of interest to my organization, the Chicano/Latino Medical Association of California, which is a network of over 1,000 Latino physicians, primarily trained in California schools, but mainly trained in the United States.

I think that’s important because there’s a history that goes along with that.  If I have some time, I’ll get into that later.  Both John and Bill asked me to come and speak on the Hispanic experience, I guess, in the issue of access to health care.  I want to talk bout the demographics in this country and particularly in California and also how that relates to the barriers to health care and the level of access that our people achieve.  Then I will make some recommendations on what we should all be focusing on.

Demographically, in the United States Hispanics are the fastest growing ethnic minority group and, depending to whom you talk, approximately 8% of the U.S. population is now Hispanic.  At the rate it is growing, by the year 2000 it will reach the 10% mark.  That’s due in part to high fertility rates, but also the the large level of immigration that, depending on political and economic pressures in Central and Latin America, tends to fluctuate but usually is on the increase.

If we look at the 20 million or so Hispanics in this country, 63% are of Mexican-American descent; 11% are of Puerto Rican descent; 18% are Central Latin American and the remainder are Cuban, Caribbean, or Spanish ancestry.  That’s important because part of my message today is that we’re not a homogenous group.  Although culture and language unite us, there are some basic differences in terms of our history.  13 million Hispanics in this country live in the Southwestern United States and 53% of those live in California.  Because I live in California.  Of the 6.8 million Hispanics in California 80% are of Mexican-American descent.  The total Hispanic population in California is 24% of the population.

I think we need to look at some of the issues that have already been addressed quite eloquently by John Arradondo and some of the other folks yesterday in terms of the health care access.  But I want to give you some idea of the economic background of the Latina community in California.  The median family income is $22,000 which is 25% lower than the Anglo counterpart in California.

It translates to a poverty rate that is two times greater than the rest of the community in California.  IT also translates to unemployment rates that are almost twice the rest of the community.  I think that’s important because when we talk about access that really leads to people who have very little expendable cash on hand to access health care.

The median family income figures tell us that even those who are employed are usually working poor – people who don’t have access to employer provided insurance.  Approximately 30% of Hispanics in California are uninsured.  Many of them work, but as I mentioned, they are working poor.  There is evidence that a lot of Hispanics in California are also under-insured, so that even if they have some insurance through employment, the deductibles and co-payment involved are quite prohibitive and limit their access to health care.

Age is also another barrier.  We don’t often think of it as such but among the Hispanics in California the median age is 22 years old as compared to 34 years old for the rest of the community.  Typically, the medically indigent adults in our state come from the age groups between 18 and 45 and that certainly represents a lot of our community.  Lack of formal education is another access problem.  John Arradondo touched on it, but unfamiliarity with using health care systems and bureaucracies is a big limitation to access.  That’s certainly part of the Hispanic experience.

But more than that, I just want to touch on the fact that Hispanics in California have about nine years of school as an average to 12 years for the rest of the community.  That tends to decrease as the level of immigration increases, because most of the folks, coming in California have lower levels of education.  In addition to that, inner city schools have a greater than 50% dropout rate.

In some cases such as John Locke High School in South Central Los Angeles, there is a greater than 85% dropout rate.  What’s even more distressing are statistics from the junior high schools in the area.  Bethune Junior High School which feeds into John Locke High School and two other high schools, has a 90% dropout rate when the students reach high school.  Of the 10% that finish, you probably can count on your hand the number who go to college.

Legal problems are also another barrier for Hispanics, especially the fear of arrest and deportation.  Penalties that threaten amnesty applicants certainly are a big deterrent to looking for health care, particularly in the Southwest.  Then there are the cultural and linguistic barriers that we have touched on already.  In Los Angeles County, a survey last year showed that 47% of Hispanic respondents declared that they had difficulty with the English Language.  That’s fully half of the population.

In L.A. County about 40% of the population are new immigrants from Latin America, mainly Mexico.  So we’re dealing with people who have a very clear problem with language and also with cultural issues.  We talked about the cultural concept of disease, and communicating not only in language but experientially and culturally are equally important.  And the poor coordination of services that John touched on already is itself a barrier.

I think when we look at the level of access not only are the barriers important but we should look at the access to primary care – basically what we’re touching on in this particular conference.  According to the Office of Statewide Health Planning Development in California, 50% of Hispanics in California live in primary care physician shortage areas.  As they define it, that’s one primary care physician for every 2,200 residents.

That translates to a shortage that obviously leads to poorer health outcomes, to a lack of intervention at the appropriate time leading to consequences of severe complications or even death in many situations.  This is also evident in the Secretary’s report on Black and minority health in 1985 which showed that Hispanics have a higher disproportionate representation among chronic complications and deaths in cardiovascular disease, violence, and certain cancers.

Also important are the issues of infant mortality, perinatal complications and low birth weights.  As John mentioned about Houston’s Hispanic population, an interesting phenomenon that is also occurring in Los Angeles County is that among Hispanics in general the low birth rates and infant mortality rates are quite surprisingly low.

One of the things we have noticed, though, in L.A. County is that among acculturated Hispanics – that is second or third generation Hispanics – there is a rapid rise in the number and percentage of low birth rates and infant mortality.  Preliminary data show that a lot of them smoke and a lot of them drink.  In a sense they’re adopting or responding to the heavy marketing that goes on in minority communities in terms of some of the lifestyle and habit decisions that are promoted through commercials and other endeavors by cigarette and alcohol industries.

I think the other parameter of shortage is the number of Hispanic physicians there is for our population.  If you look in California, although Hispanics are 24% of the population, only 2.9% of practicing physicians are Hispanics.  What that translates to is one Hispanic physician for every 4,000 Hispanic residents in California. We compare that to the Anglo population, where there is one physician for every 400 Anglo residents.  That to me, when we deal with the cultural and linguistic issues of access to health care and quality of care, certainly has relevance.

In the United States the numbers are similar.  Although Hispanics are 8% of the U.S. population, Hispanic physicians are only 3.7% of practicing physicians.  Fewer of them are primary care physicians.  It also translates to shortages in other health professions, particularly nursing.  In California, only 5.5% of nurses are Hispanic and only 3.5% of dentists are Hispanic.  It translates to similar impact on the access to care and on the quality of care that’s provided to them.

We talked about the uninsured.  In California there are 5.5 million uninsured residents.  One-third of them are Hispanic.  The reasons this is mentioned is because a lot of them are undocumented, unfamiliar with utilizing the systems, and also because state cutbacks have limited eligibility to the entitlement programs such as Medicaid and because a lot of them are the working poor.  They work in the service industry.  They work in jobs that many people don’t want and, consequently, they work in the industries that can ill afford to provide them with health care benefits.

Well, what does that translate to in terms of what we must do?  I think first we must recognize that despite the predicted physician glut, there is still a maldistribution of physicians and California is no exception;  hat the physician diffusion model or the market forces model for providing access to primary care physicians is not working.  We look at that in Southern California where I Have reviewed some of the data recently and we look at a community like Glendale, for example, which is an affluent community.  It’s about 10 minutes away from White Memorial where I practice.

The ratio of physicians to patient population is 1:3000 and about ten minutes away in Santa Monica the ratio is 1:3000 also.  So we can see that even though geographically physicians are located close to underserved areas, there still is a resistance to go and practice in those areas.  So diffusion has really not worked in our communities.

I think we’ve talked about the issue of medical students selecting less and less the primary care specialties, perhaps the cost of education being a big factor.  We need to recognize that we should not be complacent about that.  In fact, we should do something about it.

I think it’s important to recognize that Hispanics are primarily an urban based population.  In this country, about 90% are urban based and California is no exception.  90% in California are also urban based.  I think that relates a little bit to what we talked about with the National Health Service Corps yesterday that when we look at providing primary care services, particularly family practice, to Hispanic populations, we’re really talking about providing family practice to urban underserved populations.

A corollary problem is the lack of Hispanic health providers in academia.  Dr. Arradondo alluded to that.  We look at how many faculty there are in our country.  According to the AAMC, 1% of all medical school faculty in United States medical school are of Mexican-American or Puerto Rican descent.  Those are two groups that I am going to be focusing on who enter into medical school have very few role models to help them academically, to be their advisors, and to be the people who guide them on into their health centers.  That’s a very important issue when we talk about the admission to and retention in medial schools.

I am going to give you some data that demonstrate that Hispanics tend to choose the primary care fields more than their counterparts, but it’s important for us to recognize also we need to support those Hispanics when they look at academia and becoming professors and faculty in medical schools because it is medical school faculty who will become the deans of admissions and deans of medical schools and who will sit on boards that make very important decisions as far as future health manpower needs.

I think also we do need to pay attention to the level of indebtedness that  minority students are encountering.  Dr. Midtling mentioned that yesterday and that is particularly true for minority students.  The average minority medical student graduates from medical school with a $45,000 debt.  There is evidence that not only does the cost of medical education deter talented young minorities from pursuing careers in medicine, but that once they are in medical school it deters them from choosing primary care fields.

The other issue is the fact that we also are beginning to recognize that minorities tend to return to their communities which are often underserved and with a great preponderance tend to establish practice in underserved areas.

Two papers that come to mind are papers by Dr. Stephen Keith in the New England Journal of Medicine in 1985 and by Drs. Davidson and Montoya in 1987 in the Western Journal of Medicine  addressing that very issue.  I think the other important point to remember is that among Hispanics, in particular among Mexican-Americans, there is a great preponderance of choosing primary care fields.

If you look at the California experience, where we have quite a network that allows us to access most – if not all – of the Hispanic students in California medical schools.  Over the past three years, 30% of graduating Hispanic students have gone into family practice.  If we look at primary care involving family practice, internal medicine, pediatrics and OB, over 80% of those students are graduating into those fields.  I think that has some important implications in terms of the strategies that we begin to develop for providing the health manpower needs of underserved communities, particularly the Hispanic community.

But above all, I want to make sure that we remember that the numbers coming out are quite small.  We need to really work to develop ever larger pools of applicants as well as larger numbers of students entering and graduating from medical school.  I think we need to look at the experience of the Black medical schools and see them as role models for what can be achieved for Hispanics.

Not that it would take away the responsibility of our state supported schools and other institutions from fulfilling their commitment to minority opportunities, particular Hispanic opportunities.  Yet, if you look at the Black medical schools, each year they graduate about one-fifth of all new Black physicians.  I think the time is coming where we need to look at developing a medical school for Hispanics that begins to address the same issues.

We have some exemplary models in Morehouse, Drew-UCLA, Meharry, and Howard that should be replicated for Hispanics as well.  That relates to what I am doing now in working with the White Memorial Medical Center Family Practice Program.  Our residency program is part of the Hispanic Medical Education Center.  [HISMET] initiative that originally was seeded by the California Area Health Education Center.

HISMET was directed towards the manpower needs of Hispanic communities.  It seeks to develop a comprehensive program of recruitment into the health professions among college students up to postgraduate training and residency.  Part of the HISMET programs was to develop pre-baccalaureate support programs for MCAT preparation, for academic support during pre-med years, on to post-baccalaureate programs for those young Hispanics who failed to gain admission to medical the time that they applied.  It also involved bringing in medical student support by means of HISMET clerkships. Those link up minority students with physicians already in practice in shortage areas so that they can model that fee-for-service or other types of practice are indeed possible and that viable practices are indeed possible in underserved areas.

One of the socializing problems that we run into in medical school is that we’re told constantly that practice in shortage areas is going to burn us out and economically we’re never going to make it.  That’s part of what we’re trying to do at White Memorial.

Beyond medical school retention and support, the centerpiece of the entire HISMET initiative has been developing a residency oriented to training young physicians in shortage areas and particularly addressing the health care needs of the Hispanic community.  This residency came about as a result of a two-year feasibility study, that told us there was a commitment to make sure that this was a quality program from the very beginning.

The right kind of consultants were brought in, not the least of whom was Dr. Sanford Bloom who had run the Santa Monica program in family practice for 14 years and brought it to national prominence.  Basically, he brought the blueprint for that residency and adapted it to the multi-cultural population of East Los Angeles, a community of 300,000.

About 80% of the residents of East Los Angeles are Hispanic.  About half of those are monolingual Spanish speaking.  Dr. Bloom adapted it in such a way that it would take into account the type of payer mix that was not like Santa Monica as I mentioned earlier, but certainly would incorporate strategies to make sure that it became financially successful.

The next task was to recruit a faculty that was basically oriented to the HISMET mission.  Having been part of the HISMET committee that planned this residency, it was not difficult for me to see that there was a place for me in that residency as well.  I’ve always had an interest in teaching and always had an interest in serving in that community where I grew up.

There were several other individuals whom I knew who would also be interested in joining us in this project.  The bottom line was that seven of us came together to become physicians and faculty in that area.  It’s interesting that up until that point there was only one other family practice residency trained physician practicing in East Los Angeles.  So when we came in, we basically increased the number by 700% of residency trained family physicians.  Particularly, we were all bilingual.

I think what’s really important is we all grew up in the area and we all had an interest in returning to that community.  This really relates to the issue of health manpower development.  We can’t expect people who are not culturally and experientially affiliated with a community to leave everything and suddenly decide that they want to practice there.  They must have an incredible commitment in order to do something like that.  I give a lot of credit to the folks who have been practicing in those types of areas for many years.

I think what’s much more natural and much more cost effective is to start identifying students, young people in those communities who have an aptitude and an interest in health careers and nurture them as early as junior high and high school, because of the dropout rates, and nurture them throughout their  entire education, supporting them in any way that we can so that they can succeed.  We know that they will return to their communities as the data have begun to show and that our group as a microcosm has already shown.

What’s equally important for us is that we want to model successful inner city practices to young physicians who have similar goals.  One of the things we have done is developed a practice management curriculum for our residents, basically modeled on what we have been able to achieve.  Coming into that community, we know that a large percentage of the community was uninsured, cash-paying, and unable to pay the types of fees that we would have to charge to remain viable.

A large percentage was on Medicaid and other entitlement programs.  But what we have done is:  1) looked at planning; 2) made sure that we had the type of training in utilization, management, and quality assurance to make the most of our resources.  We were quite fortunate that the seven faculty members (which by the way are now nine total faculty members) all had training in one way or another in managed care and in understanding cost-effectiveness and quality assurance.  That has helped us in developing successful practices.  We’re trying to impart that knowledge to the young physicians who are a part of our residency.

The residency is slated to reach a level of 18 residents total, six per year.  Right now we’re at five per year.  We have been able to attract the type of resident  who has a commitment to those communities.  They are primarily Hispanic but not all of them are, because we’ve always recognized that the people who have  been our role models by and large were not Hispanic.  It doesn’t mean that simply because someone is not Hispanic they cannot provide sensitive care to these individuals.  By the same token, somebody being Hispanic doesn’t automatically make them good candidates for providing services to those areas.

So the bottom line is, first, that we need to develop strategies in health manpower development that really focus on the types of things we’ve seen successfully done, such as bringing the types of students like minority students who return to their communities.  We need to focus our health manpower development on those individuals and give them the type of support, economic as well as academic, in order to succeed.

Secondly, we need to look at programs such as the White Memorial program.  I am sure there will be others that will rise in the wake of of this program because I am sure it will be successful in providing the health manpower needs for the particular region in which it exists.  We need to support those types of programs.  Whenever someone talks about creating one, we need to be there to give them the type of expertise they need to develop such a program.
Thirdly, we need to start thinking seriously about a medical school that is oriented to the Hispanic student, because that is tone way – as we have seen in the good models in the Black medical schools – of beginning to meet those needs.

I want to talk a little bit about what our philosophy is in the Chicano-Latino Medial Association.  A lot of people ask me why we don’t use the term Hispanic when that seems to be the rubric everyone likes.  The reason we chose Chicano-Latino is because it has a historical perspective to it.  Our roots are in history.  Our roots re in the civil rights movement and landmark issues such as the Brown vs. Board of Education, Plessy vs. Ferguson.

All of those decisions that occurred before us gave us the opportunities to become physicians in this country.  What unites us all is that we all come from similar socio-economic backgrounds.  That’s why we chose the term “Latino.”  We are of Mexican-American descent;  we’re Central American;  we’re South American, but what binds us together is culture, language, and socio-economic backgrounds.

It’s very important to remember when we begin  to work with health policy makers, that just because someone is Hispanic doesn’t necessarily mean they have the same priorities that our underserved communities have.  They may be in this country because they were escaping very rigid economic sanctions from dictatorial governments and not necessarily because they came here looking for a better life.  I think that’s a very important matter to remember.

What we do in CMAC is to look not only at health care issues such as access but also to look at increasing the educational opportunities for our communities. We really believe in community-oriented primary care.  We need to get involved in the schools.  We have an “adopt a school” program so that in a small measure we can address that, but on a policy level many of us are getting involved in the unfilled school districts and other areas of education.  Secondly, we believe in the economic development of our communities.

I talked about poverty levels in our communities.  But as physicians we can mobilize upwards of $1 million worth of resources simply by practicing medicine.  We’ve begun to understand that and we’ve begun to understand the impact that we can have on a particular community by making sure those resources stay within that community.

Thirdly, we need to look at empowering ourselves politically as politically as physicians while also empowering our communities.  That’s an important role that physicians can have – making sure that people fill out their census cards and that they get out there and get their colleagues, friends, and family members to vote and to become politically aware.  One of the hottest health issues in California is the reapportionment issue [at the level of county supervisorial districts].  That movement impacts directly on issues of self-determination and making sure that the expenditure of public funds benefits the right people.

We also need to look at developing our own leadership.  That’s what CMAC is all about.  Many of us are members of established medical organizations, yet we knew we had to develop an organization that addressed specifically the needs that were important to us and to able to have an organization that can mobilize people at a moment’s notice to support an issue that we feel is important.

It’s very important also to realize that we need to work within the established systems because the only way things are going to change is if we get into the mainstream.  Lastly, we need to recognize the need to build coalitions.  No one group can do it alone.  We cannot afford to be cultural nationalists and say only Hispanics can answer Hispanic needs.  We need to work together with our African-American colleagues, Native Americans, Asians, and the Anglo population because we are, indeed, a multicultural society that needs to work together.

I think one of the things that has always inspired me in my own medical education has been a mentor whom I had in medical school who happened to be an internist but who always supported my own goal of being a family practice physician.  That was Dr. Ernest Gold who has since passed away.  He always taught me that it was good to be important, but it was far more important to be good.  And that’s exactly what we try to do in the CMAC.  Thank you very much.

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”. The first of the three conference days will concentrate on the health care reform legislation that was enacted in 2010, but whose implementation remains unsettled and controversial. The second and third days will be devoted to the primary care physician “pipeline” – both in medical school and in postgraduate residency programs – particularly strategies to counter the geographic and specialty maldistribution of physicians in the United States.

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 [See Archives of the National Conferences – The First National Conference’s Opening Remarks – April 20, 1990.] 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 50 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 ResortReports 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 March 25, 2012)

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

Sally Bachofer, MD, University of New Mexico, Albuquerque

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

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

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

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

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, MD, Creighton University, Omaha, Nebraska

Kevin Haughton, MD, Providence Health Systems, Olympia, Washington

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

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

Asma Jafri, MD, San Joaquin General Hospital, Stockton, California

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

Anna Peck, Student Doctor Network, Iowa City, Iowa

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

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

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

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

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

Daniel Webster, MD, Michigan State University, Traverse City

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

Ramiro Zuniga, MD, San Joaquin General Hospital, Stockton, California

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Allan Wilke, MD, Ross University School of Medicine

I’m writing this the weekend after the conclusion of the United States Supreme Court’s 3-part miniseries, Obamacare – Threat or Menace. It comes 27 months after I was persuaded to write a commentary on health care reform for the coastalresearch.org website, and my omelet-making versus refrigerator-raiding-for-leftovers analogy was foisted upon an unsuspecting public: [See Forum on Health Care Reform: Doctor Allan Wilke’s Thoughts].

Now a follow-up commentary has been requested. Folks should be careful what they wish for. Against my better judgment, I foist this.

A lot has happened since December 2008: Ted Kennedy died, a Democratic-controlled legislature passed and President Barack Obama signed the Patient Protection and Affordable Care Act (ACA or PPACA), the Tea Party rose to prominence and put the Republicans back into control of the House of Representatives, the Arab Spring blossomed, Michael Jackson and Whitney Houston died, and Adele swept the Grammy’s. What does it all mean?

The late Senator Edward Kennedy (left) at the signing of a bill by President Barack Obama (right)

Even the fevered imagination of Aaron Sorkin could not have come up with a West Wing scenario like this one. In May 2008, a full 6 months before Obama’s electoral landslide, Kennedy, the larger-than-life champion of universal health care picked the wrong time to develop a brain tumor and left the Senate floor for extended periods of time, returning on a stretcher on occasion to cast key votes. Obama, exploiting social media, went on to victory in November, pledging hope and change, and got the gift of expanded majorities in the House and Senate.

We naively saw passage of health care reform as a slam dunk. A Democratic President (and point guard) and the Democratic congressional majorities were set to make our hoped-for health care change a reality. It was a shock, then, but maybe not all that surprising (these are Democrats, after all), when we witnessed the legislative process begin to unravel. Kennedy’s negotiating skills and his sincere friendships with his colleagues across the aisle were sorely missed, and an opportunity for a bill with limited bipartisan support slipped away.

Scott Brown (left), the newly elected junior senator from Massachusetts, shares the front seat of his pickup truck with Worcester radio personality Bob Oakes

Senator Kennedy picked the wrong time to die, too. Massachusetts elected Scott Brown (a Republican!) to replace him. Could the apocalypse be upon us?

The filibuster-proof Democratic majority in the Senate evaporated. In the end Obama, Speaker of the House Nancy Pelosi, and Senate Majority Leader Harry Reid raided the ‘fridge and cobbled together a collection of health care reform proposals, including the individual mandate, originally advocated by conservative Republicans and Bush I in 1989.

(Note: If I had been in charge, I would have thrown the Republicans a bone and included tort reform. Unfortunately, trial lawyers hold too great a sway over the Democratic establishment for that to happen, and nobody asked me.)

The Trinity snatched victory from the mouth of defeat in a ham-handed manner that involved an arcane legislative rule. This tactic, however, angered the populace. Exploiting social media, the Tea Party took off and was instrumental in returning Congress to Republican control and reducing the Democratic majority in the Senate to gridlock level.

Meanwhile, events in the rest of the world were not put on hold. The most dramatic were the emergence of grassroots democracy movements in the Arab world and the Japanese tsunami. Ordinary citizens, exploiting social media (and, eventually, military-grade hardware) managed to bring down the governments of Tunisia, Egypt, Yemen, and Libya. Syria is next. I hope.

A magnitude 9.0 earthquake off the Pacific coast of Tohoku triggered a giant tidal wave, which managed to take out a nuclear reactor at Fukushima that had been built to withstand an earthquake and maybe a giant tidal wave, but not both. Where is Godzilla (or God) when you really need Him? Ghost ships ride the waves, threatening to run ashore in Alaska. Sarah can wave to them from her back porch.

I can hear Jurassic Park’s Dr. Ian Malcolm lecturing about chaos theory. People died. Babies were born. Life finds a way.

In June 2009, Michael Jackson, the king of pop, died of a propofol overdose, ostensibly because he wanted a good night’s sleep. He was 50 years old. His personal physician, a cardiologist, was eventually convicted of involuntary manslaughter. I don’t know if Mr. Jackson had a heart problem, but his head was definitely not screwed on right. Neither was his cardiologist’s.

In February of this year Whitney Houston, another massively talented artist, died in her bathtub at the tender age of 48. The cause of death was drowning after ingestion of several psychoactive substances. And maybe heart disease.

Three days later on the strength of her second album 21, Adele Laurie Blue Adkins, a British blue-eyed soul-singer, won six of six Grammy awards, steamrolling her competition, including Lady Gaga. (Note: I really don’t know what color Adele’s eyes are, but, if they aren’t blue, they should be.)

A portrait of the artist from Adele's website

Adele’s former boyfriend has sued her, claiming he inspired the heartache of her album and is entitled to a share of her success. He’s probably heartless; he certainly suffers from testiculomegaly.  At the same ceremony, Diana Ross (but not the Supremes) accepted a lifetime achievement award. Aside from anorexia, I am not familiar with her health history, but as Herbert observed, “Living well is the best revenge.”

The ACA was designed to reform US health care slowly, in bits and pieces. The most polarizing part, the individual mandate, which will require almost every US citizen not already receiving health care benefits to purchase insurance or pay a fine, won’t come into play until 2014. The more popular parts (allowing young adults to stay on their parents’ policies until age 26, preventing insurance companies from denying coverage to people with pre-existing conditions or terminating coverage for people who become sick) are already in force. Rumor has it the ACA was born this way to promote Obama’s re-election.

Late in March 2012, the United States Supreme Court heard six hours of oral arguments in challenges to the ACA. This represents the longest oral arguments on any case in the last 45 years. (Note: the case in 1967 that was longer concerned natural gas rates in western Texas and southeastern New Mexico. If hot air can be equated with natural gas, I think I see a pattern here.)

The first day the justices heard arguments about whether they should even be taking up the case. I heard a collective, “Hell, yes!” Day 2 was devoted to the constitutionality of forcing someone to buy health insurance or broccoli.

Supreme Court Justice Anthony Kennedy, whose thoughts on PPACA interest many people, speaks at his alma mater, Stanford University

The last day looked at whether the federal government could legally arm-twist the states to expand Medicaid and whether the US had to eat all the leftovers or could the individual mandate be tossed in the garbage separately. The results of these high-level deliberations won’t be revealed until June.

I don’t pretend to know how the Supremes will decide the case, but I’ll bet you a Romney-sized wager, it will be 5-4. I’m not sanguine. This group is not going to win a lifetime achievement award. The words that Randy Newman sang in his 2008 composition, A Few Words in Defense of Our Country, [cf. www.youtube.com/watch?v=OldToIF5ZGs] keep rattling through my brain. Well, (to quote Mr Newman), Pluto’s not a planet anymore either!

The fact that this is playing out in the foreground of Obama’s reelection campaign is extraordinary, but not unprecedented given the Court’s apparent interest in dabbling in election politics (i.e., Bush v. Gore). Obama’s presumed opponent will be Mitt Romney, former governor of Massachusetts, who in 2006 enacted similar health care reform legislation there (the Massachusetts Health Care Reform Plan).

Obama says he patterned the ACA after Romney’s law, but Romney is stridently disavowing ever having any relations with that law. Baby, baby, where did our love go?

As the provisions of the law have been phased in, cracks in Massachusetts’ primary care infrastructure have emerged: there are not enough family docs to take care of Massachusettsans. Who would have guessed? Even so, the law has polled favorably with patients and physicians alike.

In the meantime, other state governments and health care systems are moving full steam ahead, preparing for reform measures yet to be in force, especially the establishment of insurance exchanges and accountable care organizations. Vermont passed a universal health care law. I take that to mean that Vermonters can get health care anywhere in the universe. If the ACA is struck down, do you think these efforts will be reversed? Me neither.

British Prime Minister Winston Churchill

Winston Churchill once remarked, “The Americans will always do the right thing… after they’ve exhausted all the alternatives.” I think this is how we’ll finally get health care reform: some parts will be legislated, some will be entrepreneurial opportunities, some will be the children of necessity, and others will be the children of CYA (“cover your assets”).

So, how do I make sense of all of this? What lessons do I take?

1. When you are trying to promote a project or program, it doesn’t matter how powerful your position is. Get everyone involved: everyone has a stake, everyone benefits, everyone shares responsibility or blame.

2. You cannot ignore people-power or the power of social media. As much as we’re led to believe otherwise, people are not sheep. If you provoke or oppress them, eventually they will rise up. Be on the right side of history. Especially, if they possess military-grade hardware.

3. There are not enough primary care physicians, but, for God’s sake, don’t allow a cardiologist to become yours.

4. Talent is wonderful, but it doesn’t immunize you from life’s travails. If you can transform life’s travails into art and real money, more power to you.

5. Death, despite all our protestations to the contrary, is not optional. It can come early, it can come late, but it will come. And you can count on it to disrupt things.

6. Planning is wise, but hubris isn’t; you can’t plan for every contingency, because you don’t know them all. T. rex will escape the inescapable confinement. Pride goeth before the fall.

7. You can’t hurry love. Or health care reform. There will be disruptions. Deal with it. Health care reform will come to the US, because it has to. After we’ve exhausted all the alternatives. Unless the Mayans were right.