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Opportunities and Constraints for Comn:~unity Oriented Primary Care DorzaId L. Madison Over the years promoters of community oriented primary care (COPC) have recognized that for COPC to be effective there must be thoughtful consideration given to the opportunities and constraints that influence the success or failure of individual COPC practices as well as the movement as a whole. The environment that creates the opportunities and imposes the constraints must be continually examined, and a careful balance between these factors must be worked Out. The paper is an effort to describe some of the opportunities and con- straints that must be considered by today's practitioners of COPC. Let me first consider the forces that are presently working to inhibit the flourishing of COPC. In today's political and economic climate, there are many such forces; my list will necessarily be selective. Probably the most pressing problem is finding the money needed to get started and to remain solvent. The very nature of COPC makes this basic constraint more significant than it is for more traditional medical practice settings. Professing a community orientation means rejecting the procedure- oriented, fee schedule consciousness of the physician entrepreneur. How- ever, it goes further than that, and so do the financial consequences. In- variably, the community diagnosis will suggest that some of the most im- portant needs are for what the British call the "Cinderella services,") i.e., those items of service and organized programs that show little technological glitter and lack the glamour of more rapid health-restoring interventions but that often turn out to be more beneficial for more people in the long run. The Cinderella services of primary care include educational services, 119

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120 PART I: THEORETICAL ISSUES services directed to people in their home, special programs for identified groups of socially and medically dependent people, and, of course, organized measures for prevention at all of its levels. By definition, a community oriented practice includes in its program as many of these kind of services as it sees are needed by its community and that it can afford to provide or arrange. Since these services tend to be directed disproportionately to those least able to support them through payment of fees, and since they cost as much as most traditional items of primary medical care but are seldom recognized by insurance carriers or government financing schemes as a legitimate part of medical indemnification, there is little chance that their full costs can be met from the earnings they themselves might generate. Some subsidy is required, either from the heavy fee-generating side of the practiceassum- ing conditions are such that the practice can have a heavy fee-generating sideor from outside the practice. Subsidizing unprofitable services from within an organization is frowned upon as a questionable business practice by those who think in such terms, unless the unprofitable services can be made tO serve a legitimate business purpose. So, in the language of the accountants, the Cinderella services are given a new name: "overhead." The marketing people use another term: "loss leaders." Either term implies an "in the service of" relationship to what is considered the "real business" of the practice. Obviously, in such a relationship the value of these community oriented services will be mea- sured against criteria that are not those of community health. The usual source of an external subsidy is the government. For government to sub- sidize the Cinderella services, there must first be a social policy that gives priority to restoration and maintenance of people's health, and there must also be some commitment to equity in health services. When these are given attention, COPC tends to grow and prosper. At all other times it struggles. A second constraint that operates regardless of whether governmental subsidy is available is the fee-for-service method of providing medical care. Under fee-for-service, those items of service that can generate the highest dollar return tend to be favored over those that are priced lower. Moreover, the hours spent by physicians and other fee-generating workers in activities such as planning, teaching, evaluating, supervising, or jUSt meeting as a teamactivities of leadership that every community oriented practice re- quires are naturally considered to be "nonproductive" time. A private fee-for-service group might lessen this productivity emphasis by reducing the relationship between an individual's compensation and the volume of fee-generation credited to that individual. But the trend has been in the opposite direction.2 The emphasis on individual economic incentive

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Opportunities and Constraints __, 1_ 121 within a cooperative practice setting may very well enhance the production ~~ ~~..~ ;~_~~~ L.. : ~1 MU 111~111=, QUt 1t 15 ~ c-ons[~mnt Halest incorporating many of the program elements that form the basis for a community orientation. For example, one national study of large, primary care oriented multispecialty medical groups showed a negative relationship between group compensa- tion methods that were based mostly on an individual physician's fee-gen- erating activity and the emphasis given by these groups to continuing profes- sional education, quality assurance, patient care innovations, nonmedical primary care services, satellite locations, and after-hours serviced There is a further constraint that is related to fee-for-service, but is even more basic. A style of medical practice that values technological modalities of illness care as essential and that considers teaching, social and emotional support of the ill, and identification of those at risk as desirable but non- essential modalities has brought about a general preoccupation with cost that leaves little room (and no money) for any services beyond those deemed essential. Departments of medicine in many medical schools ride along on the earnings of two of their subspecialties: cardiology and gastroenterology. Why? Is it because these two have demonstrated the best record of restoring health? Who can say which medical specialty produces more health? The reason is that these two subspecialties of internal medicine offer the most technology for sale. It is now possible with fiber optics to gaze directly upon every nook and cranny along the entire length of the gastrointestinal tract at $5 dollars per centimeter. Such response to a stomach ache leaves few dollars available for alternative or additional responses. He who writes the ticket determines the destination. So long as a tech- nology-addicted profession retains control of a nation's health care, the services for salethe ones the people are told are essential- will be those that feed the addiction. Never mind how much healing results per dollar spent. The Cinderella services that are indicated as part of community oriented primary care will inevitably be caught in the budget squeeze, not because they themselves are especially expensive, although they do cost; not because they are less effective, although they will never be credited with as many dramatic results; but simply because other more expensive destinations are the most interesting to those who write the tickets, and getting there is budget-busting. Clearly, in the United States a major constraint for COPC is the pluralism of the American health care system. Rarely does any single source of primary care service a clientele that corresponds to the majority of people residing within a given area. Most American communities are served by many phy- sicians from a variety of practice organizations that may or may not be located within the area of the community. Even most rural localities, in- cluding many that formerly existed in a medical vacuum, now have access

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22 PART I: THEORETICAL ISSUES to physicians located in nearby larger towns, physicians in virtually every specialty who depend for their living on many of the people in the smaller outlying communities.4 This state of affairs makes the practice of COPC health care in its pure form, as described by Sidney Kark in his book of that title, difficult or impossible to achieve except at the margin.5 In the United States there is no sectorization of responsibility for medical care as there is in the rural area of many developing countries, in the polyclinics of Cuba, or in much of the United Kingdom, where the general practi- tioner's list tends to correspond approximately, if not exclusively, with a small geographical area. However, even within the mainstream of a pluralistic system it should be possible to adopt many of the principles of COPC care. This has been described elsewhere using another term, one that perhaps implies a bit more strongly the possibilities for a community orientation by the main- strearn. The term is "community responsive practice."6~7 It means essentially the same thing, and I use it interchangeably with COPC. The very basis of community-responsive practice is a consciousness of the idea of "community" on the part of clinicians. All community-responsive practice depends in the first instance on a realization that the clients them- selves constitute a "community" that the practice can reach in some way, then on designing services and programs through which those at risk can be better served. By this, I mean that although we usually think of a "community" as being politically or socially defined (e.g., a town, county, or neighborhood, the students at a school, the workers at a factory), it may also be seen by a medical practice as the collectivity of its clients, whether or not they would otherwise emerge as a natural social grouping. The notion is that better, more responsive service is possible from the practice that knows the problems affecting its own "community" of patients. By this modified and somewhat compromised meaning of COPC, it becomes pos- sible for virtually any practice to take on a community orientation; in other words, every practice has a "community" of its own to respond to as soon as it recognizes that it does. The problem comes in the recognizing. The main constraint is the tra- ditional medical view that medicine's concern is only for individuals as they seek care, not for groups of people. This is a view that physicians are taught and one that the profession has defended repeatedly. In 1932 the Committee on the Costs of Medical Care published its final report. The central recommendation was that medical care be delivered locally by multidisciplinary groups ("community medical centers") con- trolled by professionals with lay participation. These would be hospital- based and regionally organized. The community orientation was never ex- plicit, but the implication of what might be involved was not lost on the

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Opportunities and Constraints 123 members of the committee who wrote the minority report (which was then endorsed by the AMA): It is always the individual patient who requires medical care, not disease or economic classes or groups.... It seems almost impossible to those who are not engaged in the practice of medicine to understand that the profession of medicine is a personal service and cannot adopt mass production methods without changing its character.8 The legacy of this traditional view still acts as an important constraint. Indeed, one could parody the language of the minority report and say, with some chagrin: It seems almost impossible to those who are engaged in the practice of medicine to understand that many problems affecting individuals could be more effectively addressed if such individuals could be considered as belonging to a group or a community, thereby enabling interventions that focus on communities of individuals who may share the same health problem. Still another constraint is the shortage of the kind of medical leadership that programs of COPC require. I mentioned physicians, and not admin- istrators, nurses, or other health professionals, because I do not perceive as great a shortage of leaders among these others, and also because I believe that medical leadership is critical, the sine qua non. The inertia represented by the traditional practice mode can never be overcome without it. There may now already be sufficient physicians willing to practice in community oriented settings. If not now, there will be soon; in fact, there is every prospect of an employers' market in the United States for physicians' serv- ices by the end of this decade. That is a different matter. COPC will still require physician-leaders, people who possess the combination of biomed- ical knowledge, commitment, creativity, and the skills needed to plan and . . carry out community or1entec . programs. In my experience there are surprisingly few of these physicians available. Perhaps this is because those who might otherwise qualify choose to do other things than primary care; or maybe primary care training fails to emphasize the necessary qualities or doesn't provide the needed skills; or possibly the incentives are simply not the right ones for today's young physicians. Whatever the reason, qualified and committed medical lead- ership, which may be the most important of all elements necessary for successful community oriented primary care programs, seems to be one of the most difficult to find. And its scarcity must be considered another constraint. And if the necessary money, professional attitudes, and committed med- ical leadership were all in place, another question would arise: Who would

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124 PART I: THEORETICAL ISSUES have the know-how? How does one approach the process of community diagnosis, and what does one do with the results? How does one match community health needs, once made visible, with responsive service pro- grams, and then evaluate their effectiveness? Few physicians or adminis- trators really know how do do this well. If epidemiology is the science they can use, where are they to learn it? Most medical students know epide- miology as the observational science used by investigators of communicable disease outbreaks, or else they think of it as the stuff of large-scale studies conducted from academic centers. In its most recent incarnation, under the fable of "clinical epidemiology," it deals largely with the methodology of clinical trials.9 All of this is important and necessary, but the application to community oriented primary care is missing. Where does the primary care physician learn to apply the science of epidemiology to community diag- nosis? In residency training? In some new kind of community medicine fellowship that does not yet exist? If the science of epidemiology remains inaccessible to the practicing primary physician, the community oriented primary care will lack a science base. This is not to say that no research is going on at the primary care level. Within the family practice movement in recent years, for example, there has been a considerable amount of research into the content of primary care practice.~ Unfortunately, there is also a tendency among some prac- ticing primary care physicians interested in research to StOp at that point, to acquire what might be called a census-taking fixation. This starts with a careful counting of one's patients and their presenting problems, perhaps using a computer to assist with the counting, revising, and updating; then describing the practice content in terms of the frequency of the various conditions seen, and soon; but it never really goes to the next stepusing this intelligence to make the program of the practice more responsive to its community of clients. Baseline data are, of course, important to have, but they should never be an end in themselves. The proof of the pudding, the test for whether practice content research really contributed anything valuable, is found in looking at the practice's program. Given the knowledge that "x" percent of a practice's patients between the age of 40 and 64 have been found to be hypertensive and are under care for that condition, what else is the practice doing about it? Can anything more be done for those being treated. What is being done for other patients in the practice who may be at risk? In the community-at-large? A primary care practice's com- munity orientation begins logically with data, but it cannot stop there. A fixation at this point, affecting some of the best primary care physicians, is yet another constraint. A recurrent theme in the American experience with sponsored primary care programs is the theme of multiple goals in conflict. In the 1960s the introduction of neighborhood health centers represented an important in-

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Opportunities and Constraints 125 novation in American medical care. They were designed to be compre- hensive, family centered, and provided personalized attention and other amenities that are expected by most Americans but that the intended clients mostly the poor of the inner citiesdo not usually receive in the teaching hospital outpatient clinics that were their major source of primary medical care. Yet neighborhood health centers were also part of a declared "War on Poverty," with its central themes of economic opportunity and "maxi- mum feasible participation." Neighborhood health centers attempted to address both of these themes medical care reform and intervention in the poverty cycled the same time in a single program. Most of them suc- ceeded. But conflicts did arise over what was most important, what were the priorities. These conflicts were not only between health center staff and local spokesmen for the poor, but also with the sponsoring federal agency and the Congress, which was gradually changing policy objec- tives. ii,l2 This theme of shifting and sometimes conflicting goals carried on into the 1970s with the federally sponsored rural initiatives, including the Na- tional Health Service Corps (NHSC). Conflicts arose over whether these practice settings should attempt to become community-responsive pro- grams, as the leaders of the NHSC and many of the physicians assignees and other staff envisioned, or were they merely a manpower deployment strategy, as viewed by some in Congress, and, as such, to be seen as a temporary and inherently inferior alternative to the less rapid, laissez faire movement to private physicians into the rural areas? The question was of program quality versus the more quantitative presence of a resource. Such differences have led to changing criteria for funding and are another im- portant constraint for community oriented primary care. I can think of no major program in the United States, public or private, that has attempted to sponsor community oriented primary care and has been able to stay free of this ambiguity of goals. That concludes my highly selective list of constraints. Now, what of the opportunities? It isn't likely that next year will bring a new flurry of federally sponsored initiatives. Nor is there reason tO believe that the medical schools and residency programs are about to begin emphasizing a new community awareness and the skills that physicians need tO incorporate community- responsive programs into their practices. Still, in this day of cost-conscious- ness, when the medical care lexicon features "competition" as the favorite term and "marketplace" as the preferred concept, when a physician glut lies waiting around the corner, there may yet be a place for community . . Orlentec primary care. One scenario might go as follows: First, there will soon be too many specialists competing for too few referral sources, including self-referrals. At the same time, those practice organizations that wish to remain in the

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126 PART I: THEORETICAL ISSUES business of delivering primary care beyond the episodic encounter (a service item now being claimed by a new medical version of the Seven-Eleven convenience store) will start to compete openly with each other for a permanent clientele. Second, in order to attract and retain the loyalties of patients, these primary care providers will naturally emphasize the advantage that can accrue to the patient from maintaining a long-term affiliation with a primary care practice. Not emphasizing such advantages would be to risk losing the client to one of many competing providers in a crowded field. Of course, in order to emphasize the value of a continuing affiliation, some of these advantages must become visible. And this, it seems to me, is where community-responsive practice might find a place. The primary care practice that views its clients as a communitycom- municating with them, looking to their needs, and responding with programs of care- should have a decided competitive advantage over practices that continue to view themselves and their patients exclusively in the traditional one-by-one, one-on-one manner. Already, the idea that some additional kind of response may be necessary is getting attention. For example, the AMA's trade newspaper, American Medical News, recently featured a report on the competitive importance of organized patient education programs in group practice.~3 Again from the American Medical News, in a front page story on practice promotion, the president of a New York advertising firm says, "We're all up against it nowadays. Competition is growing in every field. Physicians can't afford to sit back and wait for patients. They're going to have to develop a media strategy and market their services."~4 And this copy from a journal advertisement: "Build your practice by doing a public service. Boost your visibility among thousands of potential patients. Rev- olutionary new MD advertising program. Reply Box 12824, New England Journal of Medici~ze."~5 I did reply. The scheme is for the private physician to sponsor a series of health messages in the local newspaper, a sort of Mobil Oil series on the common cold, the best kind of exercise, fat me- tabolism explained, and several other topics, and, at the bottom, a promi- nently displayed credit line: "this message is brought to you as a public service by so and so, MD." Advertising is only a start. On the local level, in a crowded market, there must also be performance if the practice hopes to keep the loyalties of the few among those "thousands of potential pa- tients" who may have decided to sample the product. And other things being equal, it is in performance that a community-responsive practice should hold the competitive edge. Now this scenario assumes that the new marketplace will lease to better programs of care. Of course, it may not happen that way at all. Thinking of the less profitable health care activities in a practice as "loss leaders" or "overhead" instead of an ethical professional response to community needs

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Opportunities and Constraints 127 could instead prove more conducive to the medical equivalent of the white sale, the end-of-the-year, two-for-one special on physical checkup, etc., than to a new recognition that a practice's clients are a community with com- munity needs that ought to be addressed. Yet the possibility for competition to stimulate real community responsiveness does exist and may provide one of the true "opportunities" of this epoch. It appears to me that greater opportunities for community oriented pri- mary care exist outside the United States, especially in the less developed nations. This is not to say that Third World nations do not have a set of constraints all their own. But some of the more important of these may now be less constraining than they have been in the past. In 1959 Dr. John Grant prepared a report for the International Cooperation Administration (ICA), the predecessor agency of AID, in which he noted a number of problems confronting health care programs in the less developed countries. Dr. Grant was at the time of this report nearing the end of his 42 years with the Rockefeller Foundation, in whose service he had worked all over the world advocating community oriented primary care, although he didn't call it by name. One of the most important of the problems, Grant noted to the ICA, was a tendency by consultants from the United States, as well as nationals trained in the United States, to "propose a type of health care organization for the less developed nations which is unsuited for their needs." Grant wrote: The separation of preventive medicine from curative medicine is almost a fetish in the United States. One of the earliest offenders in exporting this attitude to underdeveloped areas to the detriment of future medical progress was The Rock- efeller Foundation. Curative and preventive medical care just cannot be separated in the organization of health services in the less developed countries.... Fur- thermore, the emphasis of the ICA missions in the health field have largely been directed towards (the technical aspects of health problems), with the result that the larger, more basic problems have most often not been resolved. The World Health Organization issued a remarkable document for its Con- ference on Primary Care in 1979 at Alma-Ata.~7 This report is rich both in strategy and specifics, and much of its main theme follows directly from John Grant's earlier observations. A brief quote: Health resources are allocated mainly to sophisticated medical institutions in urban areas. Quite apart from the dubious social premise on which this based, the concentration of complex and costly technology on limited segments of the population does not even have the advantage of improving health. Indeed, the improvement of health is being equated with the provision of medical care dispensed by growing numbers of specialists, using narrow medical technologies for the benefit of the privileged few.... At the same time, disadvantaged groups

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28 PART I: THEORETICAL ISSUES throughout the world have no access to any permanent form of health care. These groups probably total four-fifths of the world's population, living in rural areas and urban slums.... Thus, most conventional health care systems are becoming increasingly complex and costly and have doubtful social relevance. They have been distorted by the dictates of medical industry providing medical consumer goods to society. Even some of the most affluent countries have come to realize the disparity between the high care costs and low health benefits of these systems. Obviously it is out of the question for the developing countries to continue importing them. Other approaches have to be sought. In the Third World, where a country's total resources may be insufficient to afford access to the technology-intensive Western version of health care for more than a small fraction of the population, usually the elite in the capital city, there is now recognition that the acquisition of expensive tertiary facilities must be replaced by national policies of equal access to community oriented primary care. In countries where the political philosophy allows such a collectivist health policy, the opportunities for advancing community oriented primary care are greater now than they have ever been. The economic logic and the ethical soundness of this kind of distributive strategy, as well as some of the individual models that we can expect will be developed in these Third World countries, may well prove attractive and adaptable to other societies in the future. In the United States the picture looks less promising. Yet if we have learned anything from the late 1960s, it is that the present state of affairs ought not to be projected as the future state. In 1967 and 1968 many of us shared the feeling that if we worked hard enough, virtually all of the nation's disadvantaged citizens would soon have access to responsive com- munity oriented health care programs. A 1967 analysis by the Department of Health, Education, and Welfare projected a need for 620 comprehensive neighborhood health centers in communities with sufficiently high concen- trations of poverty so that each center would serve 25,000 people. i~ Fifteen years ago it didn't occur to some of us that the early momentum of the Great Society would not continue until such goals were within sight. The important lesson is recognizing that 1982 will soon be history, just as the 1960s are now. One school of alchemy holds that history will repeat itself. This theory of historical recapitulation does not, so far as I know, lend itself to proof in the scientific era. It does invite speculation. Earlier in this nation's history an era of progressive reform in conservation of natural resources, redis- tribution of wealth, restraints on free enterprise, and equal access to political participation was interrupted by a "foreign" war. After the war came a decade of prosperity and a time of great personal self-indulgence, the first

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Opportunities and Constraints 129 "me" decade, which merged into a period of economic "meism" with un- controlled entrepreneurship and speculation made possible by a govern- ment that believed its motto, "the business of America is business." Non- control soon led to out of control, which was followed by economic crisis and great human suffering. Out of the crisis came also a change in priorities, hope, fertile ground for new ideas, and ultimately a more humane national . . 1C .entlty. I do not make this historical reference as an exercise in nostalgia, nor am I hoping for a complete recapitulation of events that would necessitate another economic collapse before the next era of progress is possible. I sincerely hope that the pendulum, as it swings back, will somehow omit that portion of its arc. The pendulum will surely continue to swing, and there will again be opportunities for community oriented primary care to fulfill its promise as the best way for personal health care to improve health. There are still people in the United States who are disenfranchised from effective health protection, disenfranchised even if their "access" to medical care, as measured by frequency of physician visits, has increased. There is still a national responsibility to promote the general welfare. And there remain advocates of the notion that relief from the pain of ill health and its prevention can be best accomplished by a single team of health workers who will attend each individual's problems while looking for ways to address such problems on a community level. The present opportunity, it seems to me, is to further develop and share the methods of community oriented primary care so that they might be applied as widely as possible in a variety of organizational contexts in prepaid group practice plans and private suburban practices, in urban public hospitals and rural health centers, in training programs for physicians and other health workers, in the United States and around the world. This requires a group of people who have shared the experience of doing com- munity oriented primary care and who feel bound by an ethic of service to continue, regardless of the constraints, so that the goal of better health for all might continue to be pursued effectively by those whose principal task is to heal the pain of individuals. REFERENCES 1. Barristella, Roger, and Chester, Theodore (1973) Reorganization of the Na- tional Health Service: Background and Issues in England's Quest for a Com- prehensive-Integrated Planning and Delivery System. Milbank Mem. Fond Q. 5 1:489-530. 2. Freshnock, Larry, and Jensen, Lynn (1981) The Changing Structure of Medical Group Practice in the United States, 1969 to 1980. J. Am. Med. Assoc. 245:2173- 76.

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130 PART I: THEORETICAL ISSUES 3. Madison, D., Tilson, H., and Konrad, R. (1977) Physician Staff Stability in Large Practice Organizations: Preliminary Summary of Organizational Data From Site Interviews. Chapter in Donald L. Madison, Tilson, Hugh H., and Konrad, Thomas R. (1977) Physician Recruitment, Retention, arid Satisfaction in Medical Practice Organizations, Volume 11Studies and Publications. Chapel Hill, N.C.: Health Services Research Center, University of North Carolina. 4. Schwarts, W.B., Newhouse, T.P., Bennett, B.W., and Williams A.P. (1980) The Changing Geographic Distribution of Board-Certified Physicians. N. Engl. J. Med. 303:1032-38. 5. Kark, Sidney K. (1981) The Practice of Commz`nity-Orie~zted Primary Health Care. New York: Appleton-Century-Crofts. 6. Madison, Donald L., and Shenkin, Budd N. (1978) Leadership for Commanity- Responsive Practice. Chapel Hill, N.C.: The Rural Practice Project. 7. Madison, Donald L., and Shenkin, Budd N. (1980) Preparing to Serve NHSC Scholarships and Medical Education. Public Health Rep. 95:3-8. 8. Committee on the Costs of Medical Care (1932) Medical Care for the American People The Final Report, Chicago: The University of Chicago Press. 9. Feinstein, A.R. (1972) Why Clinical Epidemiology? Clin. Res. 20:821-25. 10. Profile of the Residency Trained Family Physician in the United States 1970- 1979 (1980) Special issue of]. Fam. Practice 11:~5~. 11. Davis, Karen, and Schoen, Cathy (1978) Health and the War on Poverty A Ten-Year Appraisal. Washington, D.C.: The Brookings Institute. 12. Schorr, Lisbeth Bamberger, and English, Joseph T. (1968) Background, Context and Significant Issues in Neighborhood Health Center Programs. Milbank Mem. Fund Qua. 46:289-96. 13. Golin, Carol B. ~ 1981) Group Practices See More Competition. Am. Med. News 24(44):3. 14. Stacy, Tames (1982) Competition, Capitalization Costs to Bind More MDs Into Corporate Groups. Am. Med. News 725~1):1. 15. Advertisement (1982) N. E,zgl. .~. Med. 306 16. Grant,.John B. (1963) The Health Program of the International Cooperation Administration. P.64 in Conrad Seipp, ea., Health Care for the Commz`,zity Selected Papers of Dr..Iohn B. Grant. Baltimore: The Johns Hopkins Press. 17. World Health Organization and United Nations Children's Fund (1978) Pri- mary Health Care: A Joint Report. Geneva: World Health Organization. 18. U.S. Department of Health, Education, and Welfare, Office of the Assistant Secretary (1967) Program Analysis Delivery of Health Servicesfor the Poor. Wash- ington, D.C.: U.S. Government Printing Office.

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Opportunities and Constraints Discussants 131 Leans Reyes In response to Dr. Madison's paper, I would like to share my experiences with you and discuss the opportunities for COPC more than constraints. The constraints on COPC have been covered rather adequately. They have been with us for a long time, are likely to be around for a bit longer, and, in my view, are constraints that need to be addressed and resolved by another community the medical community. In addition to my primary care work experiences with urban Indian health and now with tribal health on an Indian reservation, I have been involved, on a volunteer basis, with an institution that is very important to the rest of my work. I currently serve on the council for a new entity in the city of Seattle. It is the Seattle Public Health Hospital Preservation and De- velopment Authority, a public corporation that last November took over ownership and control of what used to be a U.S. Public Health Service (PHS) hospital. This organization is important because it abounds with many opportunities for the kinds of things that we are talking about in connection . . . . Wlt n community orlentec . primary care. The hospital began its community involvement with a number of com- munity organizations in the late sixties and in the early seventies. Among the earliest organizations involved with the then Seattle PHS Hospital were the Seattle Indian Health Board and an organization called the Public Health Care Coalition, whose members included community activists, the fore- runners of what eventually became community clinics, hospital employees, and patient group representatives. The Public Health Care Coalition really organized around the hospital in an effort to keep it open when, in the early 1970s, the Nixon Administration was trying to close the eight re- maining Public Health Service hospitals. The Seattle Indian Health Board, while involved and interested in keep- ing the hospital open, had another agenda. It was looking for a place to live and a hospital to back up the services that it was beginning to provide in a free clinic environment. However, it was the Public Health Care Coalition that introduced one of the essential elements of COPC (com- munity involvement) into their early relationship with the hospital. They advocated establishing a community governing council for the PHS hospital, even if it continued to operate as a federal institution. The community organizations believed that the institution had tO respond tO the community and that the community had tO define the way in which services were offered. The coalition member organizations and the Seattle Indian Health

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132 PART I: THEORETICAL ISSUES Board have continued to exist over the last decade, have survived a number of trials, have grown, and have learned. The sometimes painful, always exciting, evolution has proven beneficial to the Seattle community and the Seattle PHS Hospital. Two years ago, when the PHS hospital began to develop its master plan to improve services and facilities, the relationships it had established with community programs helped secure the valuable support of local, state, and national politicians and a number of the other agencies and groups. The support continued and grew as the hospital be- came the focus of Seattle's effort to transfer it from federal to community central. Throughout this decade of development, the organizations fostered ef- fective leadership in their own communities. I believe very strongly that effective community leadership is as important as the development of lead- ership in the medical community for community oriented primary care. Community leaders expect to be involved in discussions that define how a primary care program responds to community needs. And in my experience, community leaders have learned that such involvement is more likely to occur if there is also some community control. It is especially important when setting goals to avoid conflicting multiple goals that result from dif- fering views of the organization's purposes and priorities. During the last 10 years, the various community organizations continued and expanded their relationships with the hospital. The local and state governments, the congressional delegation, the University of Washington Medical School, other community hospitals, and the health planning agen- cies all became involved in efforts to keep the hospital open so that, when the federal government finally succeeded in calling for the closure of all PHS hospitals, a network of interested organizations, agencies, politicians, and others from the community was in place to help the hospital continue its work, a significant part of which is delivering or supporting the delivery of primary care. All of the various interests were well represented on the task force that identified alternatives for continuing hospital operations when the hospital became a nonfederal facility. When the public corporation charter was developed, there was strong insistence that the mission of the hospital continue its former commitment to provide care to traditional beneficiaries and patients from the community clinics, many of whom would have no source of payment, the so-called unsponsored patient. In a sense, this hospital has several already well-defined communities about whom it knows a great deal, having served them over a number of years. Some of the aspects of community oriented primary care are absent. For example, there has not yet been much opportunity to evaluate what is known about these patients, except as the individual community organi-

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Opportunities and Constraints 133 cations have been able to do. Some limited evaluation has occurred in some community health centers, but progress has been delayed and interrupted by the funding cuts of the current Administration. There is great potential for developing a data system that will track patients served by the network of services around the hospital. Some baseline data are available now on the American Indian population in Seattle. The system needs additional work and refinement, but a good beginning exists. The COPC element of community involvement is provided for in the Seattle Public Health Hospital structure. The 15-person governing hospital council will ultimately have 5 members of the board drawn from the con- stituent groups who use the hospital. That will enable patient groups to influence policies that are established for the hospital. The challenges that remain are many, of course, not the least of which is operating a financially viable hospital while at the same time assuming responsibility for the care of a very large number of unsponsored patients. However, the opportunities that exist are exciting. The energy level is still very high. If we fail to further the concept of community oriented primary care in Seattle, it will not be because opportunities do not exist. It will be because we could not overcome the constraints described by Dr. Madison. Having come this far, that would be unacceptable. Karen Davis I would like to emphasize some of the opportunities and challenges facing community oriented primary care. This is a particularly critical time~ne that calls for a community orientation in primary care. I think there are four major reasons for that. First, I think the nature of the health problems that face us is very much community-based. This is true whether one thinks about environmental health hazards, toxic waste problems in 50,000 com- munities in this country, or about life-style that results in major health problems; whether one thinks about economic conditions, such as stress pertaining to local plant closings or high unemployment rates that affect the health of populations in a community. We are increasingly seeing the nature of health problems related to various kinds of factors that affect more than one individual at a time in a community. I would include in that category things like the aging of the population and the need for community responses to the needs of the elderly in the community. So, unlike the character of diseases that affected individuals at one time in the past, I think we are now dealing with a set of modern-day health problems that are common to communities, and, therefore, com- . . . . . munlty OrleIltatlOn IS appropriate.

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134 PART I: THEORETICAL ISSUES The second factor is one that Don Madison cited and I would also stress, although perhaps in a more positive light. With the expanding supply of physicians and other health professionals that is occurring and will continue to occur throughout this decade, I think there are increased opportunities for health professionals to assume roles and take on activities that weren't their concern in the past. This may take the form of counseling, community involvement, concern with life-styles, and/or concern with psychological or social adjustment problems of children in a community. As health profes- sionals increase in number and have smaller patient loads per health profes- sional, they may turn to some of these additional types of services that have been lacking in the past. I think expansion in the supply of health profes- sionals also poses an opportunity for community organizations to enter into different types of relationships with health professionals. Where there are more physicians and other types of health professionals being trained, there will be a bigger pool from which to hire or contract with health professionals for health services. Community organizations might then provide an at- tractive alternative to self-initiated solo practices. The third factor that I think makes this a particularly important time for community oriented primary care does pertain to the whole problem of rising costs in the health sector and scarce resources, whether that is at a federal budget level, a state or local government budget level, or an indi- vidual level. Anytime there is an explosion in health care costs and a tight- ening up of source of funding to pay for these health care costs, there is a premium on prevention and on fostering individual and community re- sponsibility for health care. I think that the combination of very rapid increases in cost in this sector and a need to impose some stringency from different sources of payers is itself an opportunity that will exert pressure for new approaches, new ways of providing services to communities. The final factor, and I know it is very hard to think about this one as a positive factor, is the cutbacks and the reduced role of government at the federal, state, and local levels. Because of this reduction in the public role, it does place a greater burden and a greater responsibility on the private sector to pick up many functions that in the past have been handled by government. Health professionals in communities are in an excellent po- sition to speak out and to assume some of these broader responsibilities. One sees some of this increased responsibility occurring. Recently, a physician in North Carolina pointed Out that the limitation on prescription drugs under Medicaid means that one of his diabetic patients will not be able to get insulin. Publicizing the impacts of cutbacks and what effects they have on individuals is important. Health professionals could also take responsibility for planning communitywide responses tO health hazards in a community. This will be increasingly important with the relaxation of

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Opportunities and Constraints 135 environmental regulations. I think that health professionals are well-in- formed and well-placed to take on many of these responsibilities, if they will view the responsibility as moving beyond just the care of the individual patients they ordinarily encounter in the practice setting. I would like to turn to the experience that we have had to date with community oriented primary care. I think this conference is giving all of us an exposure to a variety of community oriented primary care experiences. In work that I have done in the rural area, I have certainly become familiar with a lot of efforts, whether they are models such as the Robert Wood Johnson Rural Practice Project that Don Madison was instrumental in launching; the network of nurse practitioners in primary care health centers in North Carolina; activities of student groups, such as the Vanderbilt Student Health Coalition that helped organize a number of primary care centers in Tennessee and surrounding states; or the community health centers in neighborhood health centers that were originally funded under the Office of Economic Opportunity. We have had extensive experience with community oriented primary care in a sundry of publicly and privately supported primary care programs. I would like to talk more specifically about the experience of the com- munity health centers, which is one that I have looked at fairly carefully and for which there is some important new information and some new studies. Community health centers have many of the ingredients of community oriented primary care. They do for the most part provide primary care as opposed to specialized or tertiary care. They are community controlled; that is to say, they have community boards that basically run the health centers. They foresee a broad-based approach that includes an emphasis upon prevention, a concern with education, a concern with nutrition, a concern with environmental health, and, in general, a very comprehensive approach to dealing with health problems. They use many types of health professionals (nurse practitioners, nurse midwives, community health work- ersWa whole host of health professionals to pursue a number of different roles. Typically these centers have strong community involvement of health professionals in the affairs of the community such as the Sunset Park group getting involved in renovating housing in a community tO a whole host of activities outside of a narrow definition of health. This experience with the community health center program has been very effectively targeted on high-need groups. More than 80 percent of the patients served by those programs are members of minority groups. Eight percent have poverty or near-poverty income levels. Funds under that program have gone tO assist those most in need in getting services. The recent studies that have come out in the last 6 months to a year have

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136 PART I: THEORETICAL ISSUES found some very interesting things about community health centers. Throughout the experience with that program, there have been a number of isolated studies in this city or that city that had indicated that the programs have had a positive impact on health and reduced infant mortality. A new study by economists at the National Bureau of Economic Research is a comprehensive analysis of the impact community health centers had on infant mortality. It has found a very marked impact of that program on infant mortality rates, particularly for blacks. Another study coming out of UCLA by Howard Freeman has investigated the hospitalization rates of those who use community health centers as their major source of care and has found that for those who get into that care system, hospitalization rates are 30 to 50 percent lower than for those who use other types of providers in the community. This controls for health status and socioeconomic status. Similarly, Steve Long and some of his colleagues at Syracuse have found lower hospitalization experienced for community health center users, using a survey of community health center users conducted by the Bureau of Community Health Services at the Department of Health and Human Services. Finally, a major contract has compared the total cost of care for Medicaid beneficiaries using community health centers with those using other settings and has found that the total cost of the Medicaid program is about 30 percent lower for those who have community health centers as their major source of care. There is a lot of evidence coming out that the programs do improve health and that they can provide care in a cost-effective way and, in fact, at lower cost than other alternatives. They have greatly improved their cost performance with the experience of the program, including reduced ad- ministrative costs and improved productivity. However, centers cannot sur- vive without financial support, because two-thirds of the poor are not cov- ered under Medicaid, and, therefore, there are many uninsured low-income individuals using centers and making it difficult for centers to make a go of it without financial support. Efforts in this area will require political efforts tO maintain funding for the program. It endured a 25 percent cut last year, and continuing efforts to maintain funding will be required, but I think there are some oppor- tunities to seek additional sources of funding by developing relationships, for example, with state Medicaid programs to move toward capitation sys- tems of reimbursement and, in general, to make state governments, em- ployers, private insurance companies, and others more familiar with this record and performance of these organizations. I would like to move to suggest a number of things that, I think, can be done to move beyond the types of experiences we have had in the past toward a new type of community oriented primary care. The dimension that needs to be added is a greater emphasis upon an epidemiologic ap-

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Opportunities and Constraints 137 preach. That would require that efforts in education be taken to expose more health professionals to this type of epidemiologic approach so that health professionals will increasingly think about the incidence and prev- alence of health problems relative to norms for population groups as a whole. Rather than dealing with people solely as individuals, they need to begin to think about what would be a normal rate of incidence in this community and why does it seem to be Out of line with this particular health problem; what can be causing it and what can we do about it. I think this will require efforts to build closer relationships between schools of public health and medical schools and other health professional schools. The second thing that I think should be done is to take advantage of some of the new competition ideas and try to find avenues for capitation reimbursement. I think Don Madison has pointed out in his paper that a lot of the problems had to do with fee-for-service reimbursement. If we can move toward systems of payment, whether it is under Medicaid, Med- icare, private health insurance, or other types of arrangements, which will pay health organizations a fixed amount in exchange for responsibility for the health of that population group, there will be more opportunities and more incentives for COPC. Thirdly, I think there need to be some demonstrations, looking partic- ularly at the efficacy of building epidemiologic methods into the practice of primary care. To the extent that there can be some documented evidence that this approach does improve efficiency and lower costs and improve health of communities, there would be strong support for wider imple- mentatlon. Finally, there is work that can be done in terms of exploiting existing data bases for community oriented type of primary care analyses. One untapped resource is employer health insurance plans. Most employers do provide health insurance to their employees. Their health insurers pay those claims, but nobody really looks at that as a population base and looks at what is the incidence of certain kinds of health problems among this em- ployee group and what could be the basis for those problems. There are a lot of opportunities for linking health hazards in the work place by ex- amination of that data base. A second type of data base that has sprung up pertains to hospital admissions. Some of those arise out of statewide hospital costs or budget review commissions, where one can find for communities various patterns of health conditions that may be atypical or abnormal and reasons for these unusual patterns can be explored. And finally, there needs to be better use of the Medicare data base on the elderly population to identify variations across communities in kinds of illnesses that would perhaps serve as triggers to health problems that affect that population generally.