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The Meaning of Community Oriented Primary Care in the American Context H. Jack Geiger Any attempt to examine the concept of community oriented primary care (COPC) and consider itS implications for health care in the United States is, for me, a retrospective as well as a prospective exercise, one that recalls powerfully imprinting past experiences and invokes strongly held hopes for the future. At the outset, therefore, I believe I should identify those ex- periences and, tO the extent that I can, the biases they produced. During my senior year in medical school, in what proved to be the central experience of my undergraduate medical education, I worked and studied for 6 months with Professors Kark, Abramson, and their colleagues in South Africa at the Polela Health Center, serving a rural Zulu tribal reserve, and the Lamontville Health Center, serving an extraordinarily diverse peri- urban, African and Asian population near Durban.i That experience led definitively, if circuitously, to my own attempts at an approximation of community oriented primary care in rural Mound Bayou, Mississippi, and urban Columbia Point, Boston efforts in which Dr. Kark, Dr. John Casel, and other veterans of the South African endeavors served as occasional consultants. More recently, Dr. Kark spent 18 months as a visiting professor at the School of Biomedical Education at City College, assisting in attempts tO initiate practices of community oriented primary care as he now defines them in Harlem, the North Bronx, and Chinatown. Although almost 25 years have passed, my memories of Polela and La- montville are vivid. The health center's task was the provision of community oriented primary care, though it did not yet have that name, and a student's work consisted of the elements of COPC, continuing a tradition that ex- tended back to the community orientation of the Peckham Health Center2 60

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COPC in the American Context 61 and the descriptive epidemiology of William Pickles3 in England, and to the development of rural and urban health centers of the Peking Union Medical College by John Grant in China.4 The walls of the examining, consulting, and conference rooms at Polela and Lamontville were lined with charts and graphs of community demography, infant mortality rates, other mortality and morbidity rates, and their changes over time. It was almost impossible not to be aware of denominators when seeing an individual patient. The influence of culture, social structure, and environment on health status and health services was all the more apparent because all three were, to non-African eyes, exotic. Finally, and most fortunately, I did not learn about community organization and health education as didactic subjects. Instead, I had the opportunity tO acquire my sense of community structure and function by seeing patients in the community in their homes, in schools, in clusters of huts on rural hilltops, at the practices of traditional healers- and by working with indigenous community organizers and ed- ucators. Obviously, this experience made me an enthusiast, though I hope not an uncritical advocate. The later work at Mound Bayou and Columbia Point tempered that enthusiasm with an awareness of the difficulty of swimming upstream against the main current of medical care in the United States. And the recent experiences in New York working with health centers that have a constantly shifting constituency, in ill-defined communities, in a wildly irrational "marketplace" of personal health services have con- vinced me that community oriented primary care projects in the United States should be attempted, in the near term, primarily in rigorously defined settings that might permit rational growth and evaluation. As I will indicate, I believe there are more than enough such opportunities. DEFINITIONS: THE IDEOLOGY OF COMMUNITY MEDICINE In all this, I have not yet defined community oriented primary care or examined the definition offered by Drs. Kark and Abramson in their com- panion paper. To do that, I think we must first examine some of the problems in our definitions of community medicine itself. All of us in the field claim to be practicing community medicine, yet some of us assert it is a clinical discipline, while others tend to limit it to administrative and management sciences, policy studies, or epidemiology and behavioral sci- ence.5 Some see it as consultative to primary care; others insist it must be immersed in primary care and point to the community health center de- velopments of the last two decades as complete examples of community medicine and even of COPC. Still others, interested in COPC as an ex- pansion and clarification of the scope of community medicine, would argue that most of the community medicine efforts of the 1960s illuminated the

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62 PART I: THEORETICAL ISSUES concept of COPC but did not truly become full-scale community oriented primary care practices. In this view, interest in COPC is not simply nostalgia for the community medicine efforts of the 1960s, and bringing such prac- tices fully into being with the 1980s and 1990s will require us to do a great deal more (and some things differently) than we did then. I believe this ongoing argument over definitions is important, because it reflects something deeper: a long-standing and profound gap between the theoretical discussions and the working practices of community medicine. At its most general level, it is a separation between ideology, methodology, and clinical practice. By "ideology" in this context I mean simply the coherent set of principles or beliefs with which we approach a field of work principles or beliefs that determine the questions we ask, the data we collect, the analyses we make, and the interventions we attempt. The "ideology" of community medicine includes beliefs that are widely acknowledged but then stu- diously ignored in traditional "scientific" medicine. We believe that the biological, social, and physical environments are among the most powerful determinants of health and illness for populations and their individual mem- bers. We insist that in practice every individual patient must be seen and understood also as a member of multiple groups and populations; families, age cohorts, occupational groups, social classes, racial and ethnic groups, geographic clusters, and the like. We know that different populations ex- perience different environments (or experience similar environments dif- ferently, or manifest different behaviors) and are therefore differently at risk of disease. We believe these distributions of risks (or, conversely, of health, or strengths, or resources) call for multiple strategies of intervention. We care about the management of the individual patient, but we also assess patients as numerators, drawn from that local universe of denominators, the community, which requires us to combine curative with preventive or anticipatory medicine and individual with environmental (or even social and political) change. Of course, these are the traditional beliefs of "public health"that is, of concern for the health status of whole groups, communities, or populations, and not just the patients among them. It is the merger of these public health concerns with the clinical practice of medicine, and their application to the defined and socially coherent groupings we call communities, that creates the discipline of community medicine. By "methodology" I mean in particular the application to organized clin- ical practice of the methods of epidemiology and the behavioral sciences, particularly sociology, social psychology, and anthropology. By "clinical practice" I refer particularly to primary care, provided in organized health care delivery settings the kind of medicine least likely to be indifferent

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COPC in the American Context 63 to the causes of disease, bored with prevention, excessively focused on pa/ho-physiologic processes, and preoccupied with the details and refine- ments of technological intervention. Community oriented primary care (COPC) is an attempt, not merely in the abstract but in the performance of a practice of medicine, to end that separation between the ideology of community medicine, the methods of epidemiology and social science, and the provision of primary care clinical . . . services to communities. But this is precisely the claim that has been made repeatedly during the last two decades by one practice or another of community medicine. More often that not, these practices approached, rather than fully realized, a definition of community medicine. Though they had one or more of its essential characteristics, calling them "community medicine practices" con- fused the part with the whole. SIX FALLACIES IN SEARCH OF A DEFINITION This confusion has been so widespread and persistent that it is possible, by now, to identify a whole series of fallacies or errors in the working defi- nitions of community medicine practice. Each one has interfered with the development of a shared understanding of the nature of the field. It is important to review them before examining the operational meaning of something even more specific: community oriented primary care. THE GEOGRAPHIC FALLACY This confuses the practice of medicine in a community with a practice of community medicine. It fails to distinguish between passive community facilities that serve an area simply by virtue of their location (a subway stop, for example, or an emergency room) and active community programs that are based on a partnership with a defined community, a mutual definition of needs and programs, and shared goals. One of itS variants might be called the "underserved area fallacy." This assumes that projects serving low- income or urban minority populations must, by virtue of that characteristic alone, be practicing community medicine, and it has resulted in such pe- culiarly meaningless terms as "ghetto medicine." THE DEMOGRAPHIC FALLACY This assumes that the collection or recitation of denominators and popu- lation descriptorscensus data, vital statistics, morbidity and mortality f~g- ures, geographic mapping of patient origins means that this information

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64 PART I: THEORETICAL ISSUES is actually being used in a practice and that the practice is therefore targeted effectively at the population or area so described. But in fact, compiling data of this sort is often simply a requirement of grant applications, certif- icate of need clearances, or local health planning agency approval, and neither the grantor nor the grantees ever look at them again. The same is often true of data on other medical care resources in a target area, of information on utilization, of economic and environmental descriptions, and of other elements of community diagnosis. A more explicit and troublesome variant of this fallacy, in my view, is the contention that "the community tO which COPC is oriented need not be a true community in the sociological sense; it may be the people who live in a defined neighborhood, the list of patients registered with a provider of care, the children in a school, or the workers in a factory," or "all members of a local union or a mere collectivity of the practice's clients." These are useful and important aggregates. They are denominators of a special kind, and looking at them immediately carries a practice beyond the one-by-one examination of patients to an epidemiologic framework and an approach to rates. They may be important for such areas as occupational medicine, maternal and child health, health program planning, or quality- of-care audits. They make more sense when a provider has access to a whole community and wants to look at a part, with that larger denominator always in mind. But, with the possible exception of"defined neighborhood," these ag- gregates are not communities, as either health workers or the members of communities themselves understand that term. A practice that carries out such analyses may increase its effectiveness and efficiency, identify unsus- pected problems, and review what it is doing about them, but that does not, per se, make it a practice of community medicine or community ori- ented primary care. It is this willingness tO use the word "community" as a catch-all that has made it the battered child of the literature in social and community medicine, more often abused than respected. THE ORGANIZATIONAL FALLACY This assumes that organized settings of primary care delivery especially the existence of multidisciplinary health teams, outreach workers, and com- munity health workers drawn from the local population- indicate that COPC is happening. The assumption is more likely to be made if the provider's resources also include a management information system for the analysis of utilization, diagnostic and reimbursement data, or a mechanism for bud-

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COPC in the American Context 65 geting or health program planning. These are necessary but not sufficient elements in the achievement of COPC. They are present in many programs that do not, or cannot, assume responsibility for the health of a total com- munity or neighborhood. THE COMMUNITY ORIENTATION/AWARENESS FALLACY This is the most difficult to discuss, for I do not mean to suggest that orientation to the community as well as tO the individual, or awareness of a community's characteristics, are fallacious. They are among the most important elements in a practice of community medicine; everything else is built around them. They are the central attributes of the new kinds of physicians (and other health workers), defining their professionalism in new ways, that will be needed, together with profound changes in the structure of the health care delivery system, if community oriented primary care is tO be achieved as the dominant mode of health service delivery. Community orientation and awareness require systematic knowledge of the cultural, subcultural, and socioeconomic characteristics of communities and their members but almost everyone knows, in a general way, whether the community is urban or suburban or rural, middle-class or working-class, transitional or stable, ethnically distinct or polyglot. What is important is systematic use of that information in exploring the health status of popu- lations or delivering health services to individuals: information on family structures, community customs and mores, health belief systems, social networks, definitions of deviance, and systems of help. And also information on aspects of the micro- and macroenvironments: housing, water, sanitation, food, air quality, toxic hazards, and other risk factors. It is community orientation, the process of continually "looking at" or "keeping in mind" the community, that leads to the formulation of health status goals and plans of action for a community as well as for individuals. A community oriented practice almost by definition must know what's going on in its community, epidemiologically as well as socially and in terms of strengths and resources as well as pathology. The fallacy lies in the belief that community orientation and awareness are all or most of what is needed to achieve good community medicine. Community oriented primary care is not just an attitude one holds; it is something one does, a set of actions taken regularly and systematically as part of a strategy for changing the health status of a whole population. If for any reason these actions cannot be taken consistently, orientation and awareness themselves will not suffice to accomplish change.

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66 PART I: THEORETICAL ISSUES Nowhere is this more evident than in the experience of many highly motivated physicians who worked in community health centers, Indian Health Service projects, migrant health centers, or the National Health Service Corps. They wanted to do more than respond to the complaints of individual patients suffering from disease; they sought to conserve health in populations as well as restore it in sick individuals. In Julian Tudor Hart's striking phrase, they wanted to move decisively away from the entrepre- neurial physician's role as a"medical shopkeeper," passively responding to customers, treating the sick and discarding the apparently healthy.6 They hoped, instead, to exploit the possibilities latent in everyday practice for the development of community health strategies not just patient care plans longer in time and broader in scope. They came to their work committed to community involvement, to "public health" interventions, and even to social and political activism in relation to health. Further, in choosing community-based care they had freed themselves of the medical establishment's pre-Copernican view of the health care sys- tem, which places the hospital at the center and regards the community (and its primary care providers) as the satellites. This is a view expressed powerfully in our professional language: When patients are in their com- munities, their jobs, and their families, we call them outpatients, and, when they are oat of all these settings, we call them inpatients. But what resulted, in all too many cases, was frustration and burn-out. Despite occasional forays beyond the confines of their offices, they were often overwhelmed by the continual burden of acute illness care, the re- volving door they had hoped to escape, and they could not get beyond the presenting symptom in the sick to the risk factor in the population at large. In recent years, furthermore, if teams existed they. were often cut back; if epidemiologic information was available at the outset, it was rarely main- tained, updated, or used in their work. They discovered, to quote Hart again, that: Anticipatory care is generally available in inverse proportion to the pressure of symptom-demand, and since prevention is most needed where contingencies are most frequent, no serious preventive service is ever able to develop. In the absence of planned care, salvage inevitably takes priority over maintenance. Health services evolving spontaneously in directions determined by the conflict- ing demands of clinicians, each claiming a share of shrinking or stagnant resources, inevitably favor hospital-based salvage, mainly concentrated on acute or what eventually proves terminal illness, rather than on simpler, cheaper care of less advanced disease outside hospitals This process, in many programs, was reflected in inexorable pressure to increase "productivity" that is, to see ever-higher volumes of patients for reimbursable acute curative care in shorter periods of time and by cutbacks

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COPC in the American Context 67 in the nonreimbursed services that are essential to a community oriented program: outreach, epidemiologic study, risk factor surveillance, community organization, and health education. The basic problems faced by these physicians (and other health workers) in practicing community oriented primary care were not those described by Mullan,7 or reported earlier by Geiger,8 Gordon,9 and others in dis- cussion of community conflict. They were, rather, the absence or insuffi- ciency of the other elements of COPC, particularly the community-based epidemiology. THE COMMUNITY INVOLVEMENT FALLACY In the United States, the usual meaning of"community involvement" and "accountability" is a community board, either advisory or with real budgetary and programmatic control, and a staff drawn in part from local community residents. But these are very different than a full-fledged ongoing process of community organization and health education, and they do not in them- selves unleash the strengths latent in almost every community and create "the vigor possible when a community is mobilized for an agreed social objective."6 That vigor and intensity of effort were often expressed when new health facilities or programs were sought for a community, but it frequently proved difficult to maintain them once programs were in op- eration and access to acute care was established. In recent years, there has been growing recognition that the first locus of primary care decisions is not in health services at all, but in families, social networks, and basic community institutions such as the church. The task can be redefined: It is not simply to involve the community in the programs of a community oriented practice, but rather to involve the practice in basic processes and structures within a community. (Community medicine practices have been guilty of their own pre-Copernican views.) This is the real significance of the development of organized lay referral networks, the training of "health facilitators," and the systematic enlistment of churches and other commu- nity-based institutions in health education and case-f~nding.~ They have the potential to create "agreed social objectives" in relation to health in . i` . . specific commumtles. THE EPIDEMIOLOGIC FALLACY In a modest number of organized settings of primary care delivery, careful and solid epidemiologic studies have been conducted, usually with special research funding. The participant sites in the national Hypertension De- tection and Follow-up Program are good examples.ll A few health centers

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68 PART I: THEORETICAL ISSUES have managed to complete annual or biennial household-by-household cen- sus listings of their communities and to use them for specific disease or risk-factor studies. Others have used vital statistics from traditional sources to plan their programs. Some are located in geographic areas that were selected for epidemiologic investigation by health departments or academic centers, and a few have active affiliations with such centers. The mere existence of epidemiologic projects does not necessarily mean, however, that the primary care practices themselves the routines of office practice, the work of health care teams, or data from outreach workers are collected in standardized ways according to a common protocol and added in as contributions to epidemiologic investigation. Neither does it necessarily mean that the results of population-based studies are system- atically reflected either in the programs of practitioners or in the work of community organizers and health educators. Epidemiology does not always reflect community involvement. Even where the will exists, barriers may be created by the pressures of acute care, limitations of funding, academic versus practitioner conflicts, or problems of the confidentiality of medical records. I have described these fallacies or imprecisions of definition at such length not to denigrate the activities they represent, each of which, by itself, is a substantial component of clinical community medicine in practice. Neither do I intend to set so rigorous a standard that we will be forced to conclude that "true" community oriented primary care does not now exist anywhere and is impossible of achievement. My purpose is to emphasize that if we are serious about COPC we cannot settle for less than all its essential components, linked by specific techniques as described by Hark, Ben- nett,~3 and others. It would be as dangerous to the development of COPC as it has been, on occasion, to the general understanding of"community medicine" if we are overgenerous in defining it. CRITERIA FOR COMMUNITY ORIENTED PRIMARY CARE With these fallacies in mind, let us turn to the recent definitions of COPC. Kark has defined it as a clinical practice that brings together those aspects of personal health care and of community medicine that are suitable for application in primary care. Some basic features include: . complementary use of epidemiologic and clinical skills; a defined population; . programs designed to deal with the health problems of the community or its subgroups in the primary care framework;

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COPC in the American Context 69 . community involvement in both governance and implementation of the practice; . geographic, fiscal, and cultural accessibility; and . integration of curative, rehabilitative, preventive, and promotive health care. Madison and Shenkin emphasize the orientation/awareness dimension in their definition of a "community-responsive" practice as: . . . one which assumes a larger than ordinary share of responsibility for safe- guarding the health of the community, and which follows through on this re- sponsibility of taking action beyond the traditional mold of treating the com- plaints and problems of patients as they approach the practice one-by-one. Such action must start from the consciousness of community the notion that there exists some denominator of people from which come those who present at the practice seeking care. The community with which the practice is concerned may be socially defined (e.g., a country, a town, a neighborhood, all members of a local union, all migrant agricultural workers and their families within a two- county area) or it may be a mere collectivity of the practice's clients whether or not they emerge as a social grouping. In either case this consciousness of com- munity together with the awareness of its general health status and some of the problems that affect it is what allows the practice to formally plan activities aimed at designated target populations (e.g., prenatal care, health education programs, nutrition counselling, the care of groups of people at specific risk or sharing a common affliction.~4 At first glance, these definitions seem strikingly familiar. There is little new about calls for epidemiologic investigation, for the incorporation of behavioral science knowledge into clinical practice, or about the idea of community-as-laboratory. The initial proposals for neighborhood health centers, among many examples, spoke explicitly of defined populations, epidemiologic surveillance, and the merger of"public health" concerns with those of patient-centered clinical practice. They cited demographic data as denominators, used indicators of health status to characterize entire pop- ulations, and clearly were based on a consciousness of community. They were comprehensive in their definitions of health care, proposed the use of multidisciplinary health teams, stressed involvement of the community, and emphasized the removal of geographic, financial, and other barriers to access. Similarly, epidemiologic investigations of discrete communities have be- come almost commonplace in the United States. The classic Tecumsehi5 and Framinghami6 studies are only the most familiar of many examples. Some of these investigations have originated in health centers the East Boston studies of chronic lung disease,~7 the Rochester studies of pediatric

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70 PARTI:THEORETICALISSUES illness,18 the Baltimore studies of streptococcal infection19and have been community-based rather than limited to populations of health center users alone. The recruitment and training of community members as outreach workers has characterized many epidemiologic and primary care projects for at least two decades in the United States, three decades in the United Kingdom (for example, Cochrane's studies of the pneumoconioses in the Welsh min- ing valleys in the early 1950s), and for still longer at some health centers in developing nations. Is COPC, then, merely a repetition of these projects, a return to the 1950s and 1960s after all? I think not. What, then, is new about these definitions of COPC? I suggest that it is the synthesis, the assembly of these familar components into an ongoing whole and the insistence that all these elements of community orientation, demographic study, epidemiologic investigation, personal medical services, en?>iror~mental intervention, community organization, and health education be performed loy the same practice or team, or at least by a small number of practices and health agencies working as a single system (not just "coordinated". It is not just having all the parts, but closing the loop that links them. It is this synthesis that would permit the conduct of a daily primary care practice to become part of an epidemiologic investi- gation, or permit epidemiologic data to be used as the basis for the addition of specific new routines to office practice, tO community outreach, or tO health education. Community oriented primary care, then, is an approach to medical prac- tice that undertakes responsibility for the health of a defined population, by combining epidemiologic study and social intervention with the clinical care of individual patients, so that the primary care practice itself becomes a community medicine program. Both the individual patient and the com- munity or population are the focus of diagnosis, treatment, and ongoing surveillance. In COPC as in conventional primary care, for example, the goal for an individual hypertensive patient is detection, reduction of elevated blood pressure, and ongoing control; but, in a community oriented primary care practice, there is a further goal of determining the distribution of blood pressures in the population served (or potentially served) and intervening to shift the curve of that entire distribution to the left. In addition to the stock of biomedical knowledge, which is the core of every clinical practice, this requires the incorporation of at least two additional bodies of knowledge and their pragmatic application in practice: epidemiologic science and be- havioral science. The former is necessary for community diagnosis, problem definition, and a strategy of intervention. The latter is necessary to foster community participation in diagnosis and problem definition and to accom- plish changes in community knowledge, attitudes and behaviors, and med- . ... . lca . care utlllzatlon.

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COPC in the American Context 93 But is this a desired outcome? Are concepts such as COPC suited for institutional sponsorhsip, or are they better suited to a more independent community-based location and governance? My current thinking and ex- perience would lead me to the view that intrinsic characteristics of most major health care institutions are not conducive to the growth and devel- opment of such new and different undertakings. Medical shcools and teach- ing hospitals are large and bureaucratic with enormous inertia and com- mitment to more traditional forms of patient care, teaching, and research. They rarely have a community focus or administrative competence in office- based care. The time, energy, and political skill required for such a significant reorientation are enormous. On the other hand, these institutions possess strengths. Much of the conceptual foundation of primary care delivery and epidemiology lies within our academic faculties, and the financial and or- ganizational support and stability that a strong institution can provide to a new concept or organization, once embraced, is not insignificant. If I were responsible for recommending institutional arrangements for maximum secure growth of community oriented primary care practices, I would first pick small delivery sites such as model family practice clinics, health maintenance organizations, and neighborhood health centers, who see such concepts as a clear part of the basic mission but who are also affiliated with academic centers for backup and consultation and support. The small-to-medium HMO is a most promising opportunity for such de- velopments at this time because of their focus on a defined population and because the epidemiology has the potential for increasing cost-effectiveness as well as quality. Any major health care institution considered for spon- sorship should clearly be able to demonstrate why such an activity is in itS enlightened self-interesta motive for which I have growing respect. I am impressed with institutions whose history and philosophy, often from a religious base, give some security and guarantee that the time, energy, resources, and clout will be available when the academic and bureaucratic pitfalls mentioned earlier appear. Finally, I would like to make a brief observation on education for COPC, which is discussed much more extensively in the paper by Jo Boufford. Both Drs. Abramson and Geiger refer to the failure of the educational system in preparing students for such practice and suggest a number of remedies to address this. There is no doubt that students need more training in basic epidemiology and that, even today, adequate primary care expe- rience is lacking in many schools. I do not believe, however, that academic centers can adequately provide experiences in this synthesis of primary care and epidemiology that COPC envisions. It is counterproductive to expose students to inadequately developed or esoteric practice models prior to

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94 PART I: THEORETICAL ISSUES their being established as effective patient care mechanisms. The educational demands may retard the growth and efficiency of the practice. The exposure of students to underdeveloped or inefficient practice can either turn them off totally or provide an image of practice that is not feasible in the real world. Proponents and advocates of COPC should set as their goal the devel- opment and implementation of 25-50 operating COPC practice models over the next several years. Perhaps foundations would fund the epide- miologic component that is the missing piece in many settings and that third-party reimbursement will not cover. When these are in place and seeing enough patients to be cost-effective and capable of assuming an additional education mission, I believe far-sighted academic centers will be ready and willing to organize and even pay for appropriate educational experiences. But to burden such innovative practice models at the outset with any significant educational responsibilities would threaten the practices in the short run and their future educational potential in the long run. I would urge that there be early linkages of academic centers with developing practices to provide managerial, professional, and research expertise that can later be expanded to an educational focus. Fred Diaz My purpose here will be to try to summarize some of the problems at the Florida Community Health Center (FCHC) and to identify, if any, the confusion over where we are going. I will start with the four main bases that were covered in Geiger's paper. One of them is that the COPC must have a local community tO provide itS services. I believe that here in the United States, probably contrary tO some other countries, "community" has been divided into two groups, those who can pay and those who cannot pay. Therefore, we have developed two systems of health services: one, which is based on a private practice model, and another one, which has evolved with some of the community oriented aspects in it and which has taken the form of community health centers and migrant health centers throughout the United States. In looking at this, there have been certain regulations that have been imposed on migrants and community health centers so that they can es- tablish their "community." Part of it comes from the criteria for medically underserved areas (MUM, which include a number of criteria that must apply if a facility is tO be started, and the other has to do with limited access to services by migrants or a mobile population with a particular need that no one else is addressing. Therefore, when community health centers and migrant health centers start out, there are overlaps. They usually represent

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COPC in the American Context 95 situations that have been neglected and that have been undeveloped because of the economic structure, and then it does become difficult to really initiate COPC. A second point that has been alluded to is combining the personal health services of individuals and families with services to the community as a whole or its subgroups. Basically, when you deal with subgroups and I will be talking about subgroups of indigents or migrants or minorities you begin to also deal with another problem, which is that health is not their number one priority. Sometimes when dealing with the population as a whole and particularly with the subgroups, there are inherent problems that are built into the system that make it very difficult to achieve that community oriented practice. As a subgroup, indigents and migrants must be plugged into the mainstream of health. The way that has been done at the FCHC is by coordinating and integrating the services of various centers with providers of special services, hospitals, and public agencies to create a continuity of care for the individual, his family, and his community. In this area I do feel that we are providing COPC. This becomes rather difficult, however, because the reason the community health center or the migrant health center was started was because of economic problems with a partic- ular population. As an administrator or director of one of these units, one has to try to solve the economic problems and fit this population into hospitals, specialists' practices, and other community agencies. The reim- bursement process becomes crucial in determining how successful one is at coordination, integration, and initiationa total community oriented effort. Community health centers and migrant health centers have probably been some of the forerunners in developing or working in the team concept. The economic structure has forced them to actually use a combination of physician, dentist, outreach workers, family health workers, and all supple- mental services that back them up. I think they are our models and I do believe that FCHC is one of those that has been able to very successfully put this team together in a cost-effective way. An average overall-per-visit cost of $22 to S24 is quite effective when one looks at private practice and considers all the services that we offer the patient. This aspect of migrant and community health centers has resulted in a well-integrated system. Now, because of the integration and this kind of teamwork, migrant and community health centers are not only forced to, but look eagerly towards, accepting National Health Service Corps phy- sicians, dentists, etc., in their settings. At one time they were given as a gratis contribution; they were repaying their medical school scholarships. This gave them a chance to really work in a community where the services were greatly needed. The picture is drastically changing. The services of

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96 PART I: THEORETICAL ISSUES these health professionals are no longer free. There is little or no economic incentive for the centers, because now pay-backs must be made to the government for these scholarships and assignments. It does, however, help in rural health care settings, such as FCHC, because it does provide man- power for some of these shortage areas. The third point involves the de- velopment of methods of community diagnosis and surveillance, the de- velopment and evaluation of programs to modify the community's health- in other words, applied epidemiology. Federally funded community health centers and migrant health centers have been forced into some of that epidemiology by reporting requirements. These centers must collect certain data, produce statistics on numbers of people immunized and those who are not, and report on follow-up. This reporting ranges from a chalk mark every time a patient comes in and leaves the center to highly sophisticated computerized management information systems, as we have at FCHC. But we still fall quite short. We can correlate most any data in terms of prevalence and incidence within the population served. Basically, FCHC has more than 62,000 per- sons registered, and, as of this past year, it had more than 36,000 active users. It does create an excitement knowing that community oriented health care has tremendous potential. One of our reporting requirements addresses productivity. We run profiles on all of our medical providers and our dentists, and we do it by diagnosis. How many of a certain of diagnosis are seen? How many of them are newcomers and how many of them are repeated visits? This helps us to determine the kind of productivity levels that are achieved within the hours worked. These profiles also indicate the kind of prevalences that are within our population. We can break it out by age-groups, sex, ethnicity, zip code areas, etc. It has been very exciting. There has been an inherited problem, though, that leads us basically to the fourth point, and that is the application of the epidemiological skills needed to be able to really function under a true COPC. To be able to run the management information system, your data must be standardized so that whatever data is collected is the same in all your sites. Medical records must also be maintained in a standardized way. There must be very rigid interpretations, and they must be communicated to the providers so that you can rely on the data. For example, when a diabetic or a hypertensive comes in and is uncon- trolled, the right kind of code must be put down to indicate that he is an uncontrolled diabetic and an appointment has been set up for him within 3 weeks. If he doesn't appear for his follow-up visit, there is another com- puter-generated form that says this person did not return and has not been put into the control column, thereby closing that loop. It has been very difficult to set up this system, because many of the graduates that are coming out find this kind of regimen very difficult to

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COPC in the American Context 97 adhere to. We currently have 11 National Health Service Corps assignees. By the end of this year, with the birthing center that we are putting in to one of the local hospitals, with certified nurse-midwives and obstetrician/ gynecologists, we will have more than 22 involved with our total network. That is an awful lot of training and an awful lot of people to orient to a specific type of practice. At FCHC we have found that it takes as much as 6 months to a year to orient the new graduate after he/she arrives. At that point he/she is in one or two dispositions. He is either really catching on to what this whole program is about in terms of the standards that must be adhered to, the kind of coding that must be done, the kind of practice models, his role as a physician in this kind of an institution or a community health center, putting his all behind it, getting very excited over it, and in the last year being very productive; or, he is totally disillusioned because this is not what he had in mind when he went through medical school. He finds it difficult to stay with the regimens of the kind of practice you need, and, therefore, during the last 6 months, his productivity level really drops off and the center becomes anxious for his rotation to be over and his obligation to the government fulfilled. Therefore, I do agree with the Kark/Abramson paper and the Geiger paper that there is a tremendous need to orient the medical students in epidemiologic aspects of medicine, particularly as they relate to migrant and community health centers as well as COPC practices in general. I feel also that there must be some kind of funding source that will actually bring in a team as described in Dr. Abramson's paper and that will give these centers the kind of support in the form of expertise that they need. The funding should also provide for involvement with medical schools both in terms of faculty and students, particularly students that have an obligation to satisfy and have chosen to go to one of the migrant or community health centers. This kind of involvement may pave the way to a more integral type of team. Nora Piore We cannot absolutely prove that those are in error who tell us that society has reached a turning point, that we have seen our best days. But so said all who came before us, and with jUSt as much apparent reason.... Macaulay, 1830 It is good to have the opportunity to join with you in this health care policy conference at a time when society indeed seems at a turning point. Whether or not our best days are behind uswhich I doubt what brings us together in this assembly is the experience shared in those days, the insights gained,

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98 PART I: THEORETICAL ISSUES and our common concern with making that experience relevant and useful in these difficult and confusing times. To help us distinguish what may be transient economic and political trends from more underlying and persistent changes in our mixed medical care economy, and to understand better the potential role that community ori- ented primary care (COPC) and the epidemiologic basis for its operation might play in contemporary society, it may be useful to go back to the roots of these concepts. In the early 1960s the nation embarked on a remarkable series of efforts to address the problems of poverty, discrimi- nation, and equal opportunity. The programs of the Great Society, as Henry Aaron has so well expressed it, were unparalleled by any peace time con- census about the nation's difficulties and the need to tackle them since the New Deal. Unlike the New Deal, which side-stepped the issue of health security, the agenda of the 1960s included a many-faceted approach to improving access to medical careaccess to knowledge gained with public support for medical research, to care in hospitals built with public funds, to treatment from physicians trained in government-supported programs. In a single session, the Eighty-ninth Congress enacted more than two dozen pieces of health legislation. In addition to Medicare and Medicaid, a program of federal grants to voluntary and government institutions was adopted to bring federal resources to populations at particular riskpreg- nant women, children and youth, alcohol and drug abusers, the mentally ill, migrant workers, and other neglected segments of the population; and to stimulate new areas of service and new ways of delivering themfamily planning, community mental health services, and neighborhood health cen- ters. 'the Congress declares that fulfillment of our national purpose depends on promoting and assuring the highest level of health obtainable for every person...." These words, in the preamble to the Public Health Service Amendments of 1966, laid the basis in that period of unprecedented eco- nomic growth for expectations that the nation is still struggling to fulfill, in the quite different climate of inflation, resource scarcity, and skepticism about government that prevails today. Efforts to reshape the health delivery system in accordance with these mandates took many forms. The neighborhood health center, close to and responsive to community residentsan idea that has emerged periodically in American history proved particularly attractive to those skeptical about the ability of traditional structures to respond to these new mandates. Less than 3 percent of total public spending went to these programs, while billions of Medicare and Medicaid dollars flowed through the traditional channels of hospital, outpatient clinics' and physicians' offices, and into a new type of provider soon to be named the "Medicaid Mill." Nevertheless,

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COPC in the American Context 99 it was the more experimental margin of the public medical care enterprise that attracted more adventurous health professionals and planners. Among these were substantial numbers of the best and the brightest from the nation's universities and medical schools who enlisted to design and develop new health-providing institutions in rural areas and urban slums. Assembled at this conference are the veterans of this exceptional chapter of American medical care history, together with their younger colleagues and students. Out of the experience of the 1960sexhilarating, frustrating, unique there evolved, and has since matured, a systematic set of convic- tions about the medical care enterprise in our society, a new iteration of views about the interface between medical and social intervention, about primary care and high-technology medicine, about society's responsibility for assuring access to health and medical care. These views, which some have described as the counterculture of Amer- ican medicine, have had a substantial impact on medical education and concepts of medical practice, particularly primary care, family medicine, and the role of new types of health professionals, and, while the vision of a network of a thousand neighborhood health centers spanning the nation never materialized, few hospital outpatient departments, emergency rooms, and even physicians' offices remained untouched by the criticism of crowded waiting rooms, long queues, lack of privacy, and impersonal and sometimes indifferent care. But by the 1970s, with constantly rising medical expenditures, a stagnant economy, and mounting federal and state budget deficits, attention that had been concentrated on access and quality turned to efforts tO curb rising health care expenditures and the search for incentives that would reduce what we now see as excessive use of services and unproductive investment of resources. Now it is another season. The voice of the turtle is no longer heard in the land, stilled by hostile political winds and overwhelmed by the mounting economic recession. One need not take a cataclysmic view of the current outlook to acknowledge that the climate of opinion, the mood of the coun- try, is no longer fixed on issues of equity and opportunity, but rather is concerned with inflation, unemployment, and the burden of taxes to pay for services to meet someone else's needs. This change in the national mood did not occur suddenly, one day in November, with a presidential election. Rather that election reflected storm signals, public uncertainties that had long been gathering. The deeply disturbing experiences of Vietnam, Wa- tergate, and the Iranian hostage crisis contributed to the loss of confidence in our ability to deal with inflation, lagging economic growth, and rising unemployment. Equally disquieting is the realization that the United States, deeply involved in a highly competitive global economy, cannot, as perhaps

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100 PART I: THEORETICAL ISSUES it once could, rely on an economic recovery strategy geared solely to internal markets. In the face of these developments, we are unlikely soon to see a return to the search for a single, coherent national solution to these complex problems. That sums up the bad news. There is some good news, too. To begin with, we must not ignore the fact that despite the cutbacks that have occurred and the threat of further disruption in social welfare policies, 28 million Americans today are covered by Medicare and another 21 million by Medicaid. Despite retrenchment and possible further reshuffling of fed- eral, state, and local responsibilities, the important fact is that a floor of health care protection remains precariously in place. Further, there are some reasons to think that there are limits to how far back the clock can be turned. The amount of cost shifting that is occurring in the health economy indicates some limits to the extent to which denial and deprivaton of care can be tolerated, perhaps less because of public conscience and more because of the instinct for survival on the part of provider institutions. Whatever the motivation, the fact is that it is an accepted component of public policy in Maryland, in New Jersey, and now in New York that the bad debt and charity care losses of voluntary hospitals be at least in part absorbed by third-party payers and thence transferred to the cost of health insurance premiums. Whether this is a more equitable or efficient way of providing fiscal coverage for hospital care of low-income patients than the use of the public tax system can certainly be debated. But it promises that some inpatient and ambulatory care losses will be absorbed in this fashion. If or when this burden becomes untenable on the private insurance side, and inadequate as a way to pay for indigent care, the search for other fiscal mechanisms can be expected to resume. Another indicator of the ineradicable changes in the topology of medical care left from the 1960s is that by the end of the 1970s there had been a substantial increase and extensive geographical redistribution of health care capacity (equipment plant and manpower) in the country. Don Madison, in his paper for this conference, describes the difficulty experienced by a rural neighborhood health center today in maintaining a stable constituency in a community where there are now many competing providers and where those providers now advertise their wares. This presents a very different picture from our earlier view of the rural community health center as a rare and exotic plant, flowering in a landscape empty of health manpower and health care resources. Of course there remain areas where services are in short supply and people who cannot pay. But these observations suggest that the investments in health resources and manpower made in the last two decades have indeed changed the landscape. Perhaps the most important factor in the current climate is that concern with alternative strategies to deal with shrinking revenues for health services

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COPC in the American Context 101 perforce claims the attention of federal, state, and local governments, as well as those in the public and private sectors who provide or purchase medical care. This now stems from practical pressures to make ends meet and to bring rising costs under control rather than from a search for a long- range coherent health policy for the nation. But these immediate pressures guarantee that there will continue to be a search for ways to organize and deliver health care that will max~nize the return on resources and anticipate and plan to meet the new demands on these resources that must be expected from changes in the demography of the population and the pattern of health and illness. In these circumstances the concept of community oriented primary care and the additional dimension of its essential relation to an epidemiologic data base become an effective and essential tool for addressing health policy issues in both conceptual and very practical ways. In the broadest conceptual sense, the development through the use of epidemiology of a systematized rational basis for the identification and prioritization of health care needs is central to any approach to health care planning, whether from a market or a regulatory point of view. From any point of view, a coupling of the ills that are prevalent with a knowledge of the state of the art in their prevention or amelioration sets the agenda for allocation of finite resources. Thus the COPC concept has much to contribute to improving the nation's capacity to make decisions on the basis of knowledge about what's out there to be treated and what is available to treat it with. Thus, despite the fact that little attention currently focuses on global national health proposals, the need for new mechanisms to operate in the health care economy occupies a central and visible place in the nation's concern. Of the administration's inner council deliberations about the form that the new federalism will take, the glimpses that one catches suggest that, even were there to be a state-federal trade-off between welfare and health care responsibilities, the details of the disposition of whatever health resources are to be allocated to a region or a state or a locality will be left to some lower level of government. Interestingly enough, the most recent version of a Kennedy-type national health insurance proposal also envisaged a structural format for health resources allocation in the nation linked to decentralized allocation of decision making, within whatever national re- distributive framework was agreed upon. Thus decentralized resource al- location decision making by region, by state, by community, or by individual provider would appear to be a likely component of evolving public health policy. The relevance of an epidemiologic data base at each such level of . . . . . . . . deClSlOn maKlNg IS OOVlOUS. To turn for a moment to more immediate opportunities to make use of an expanded epidemiologic framework, consider developments that are

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102 PART I: THEORETICAL ISSUES likely to take place regarding the role of state and local health departments. Somewhat in eclipse since the 1960s, they have recently reemerged for two reasons: one, with the end of federal support of planning agencies, in many areas the health department remains the single available mechanism with the authority and the mandate to oversee the needs and resources of the community to take responsibility for marshalling professional and civic concern for the public health. In some places this role of the public health agency extends much further. In New York State it regulates resource allocation, determines reimbursement rates, and serves as the guardian of the public health. Much thought, obviously, will now be given to the role of health departments, and here again the concepts of epidemiologic sur- veillance, newly emphasized by the COPC movement, are the traditional way of work for public health. A second reason for the reemergence of health departments as important instrumentalities is the new emphasis on health behavior, prevention, and life-styles, again traditionally the health department's turf. Finally, we come to some specific new opportunities for the COPC movement to play a significant part in shaping immediate changes in the organization and delivery of medical care. As Medicaid funding is reduced, and states and localities have greater latitude to experiment with most cost- effective ways of providing care for the covered population, attention is increasingly turning to the development of capita/ion-based group practice arrangements for the care of low-income patients. In Massachusetts, under the leadership of Dr. Jerome Grossman and New England Medical Center, a coalition of eight community hospitals is working with the state of Mas- sachusetts to develop a system whereby these hospitals will contract with the state to provide total care for Medicaid beneficiaries who enroll on a capitation basis in the group practice plan offered by any one of the eight cooperating institutions. The theory behind this plan is that, given an iden- tif~ed enrolled population with known characteristics and needs, the group practice can plan to use the total sum available under the capitation contract in the optimum manner to provide needed services for the entire group. This in effect combines the principle of the Kaiser plan on the one hand and of the neighborhood health center system on the other. For the first time there will be the opportunity to test out on a large scale whether these ways of providing care can work for the Medicaid population. Moving from Massachusetts to the South, and from the initiative of a group of hospitals to the leadership of a state department of health, planning is under way in Tennessee to establish a primary care network of community health centers working in cooperation with public and private institutional providers. Explicit in the planning of this network is the development of a community data base that will include both the epidemiologic information

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COPC in the American Context 103 and the identification of social service needs and social support networks that can be incorporated in a unified approach to meeting the needs of this population within the framework of diminishing public funds, commingling Medicaid and other public funds with private grants, third-party payments, and self-pay. A third illustration of the opportunity afforded by COPC is the devel- opment of ties between mainstream medical providers and experimental community health models that have too often operated at the margin of mainstream medicine. Montefiore Medical Center in the Bronx is providing the leadership to develop a prepaid health care network designed to offer comprehensive health care services tO Medicaid and other low-income res- idents of the Bronx. Under this plan, a coalition of community health centers for primary care services would be linked with specialty and inpatient ser- vices furnished by participating hospitals, with enrolled Medicaid and low- income patients covered by a negotiated Medicaid capitation rate. These are but three examples of many that are beginning tO surface as fiscal pressures force providers and communities to search for cost-effective systematic ways to provide essential services within the limits of extremely constrained resources. Because of the involvement of public and voluntary mainstream providers, together with experimental community-based or- ganizations, these experiments can be expected to bring about the involve- ment of mainstream medical resources that have eluded past efforts to restructure medical care; adversity may prove tO be the foster parent, if not the mother of, invention. At a time when, unexpectedly, there are new opportunities to extend the benefits of community oriented primary care, one cautionary word may be in order. It has to do with the nature of the scientific revolution in medicine, which in the last generation has drastically reduced some costs while increasing others by providing new ways of healing larger numbers of people who previously could not be helped at all. Many attribute a large share of the increase in health expenditure to these scientific advances. It is not so clear that improved primary care can achieve the necessary savings to balance off such rising costs. However much health education, prevention, and prompt care can accomplish to prevent, delay, or achieve a net reduction in morbidity, there is bound to remain a substantial and irreducible volume of serious and expensive illness, the crux of the dilemma of rising health care costs. It behooves primary care advocates to be prudent in claims of the extent to which investment in primary care can reduce the need for more advance forms of treatment, with the present state of our knowledge, if they are not to jeopardize their credibility.