Community Oriented Primary Care New Directions for Health Services Delivery (1983) / Chapter Skim
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Opportunities and Constraints for Community Oriented Primary Care
Opportunities and Constraints for Community Oriented Primary Care
Pages 119-137
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From page 119... ...
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 procedureoriented, fee schedule consciousness of the physician entrepreneur.
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From page 120... ...
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 practice—assuming conditions are such that the practice can have a heavy fee-generating side—or from outside the practice.
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From page 121... ...
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.
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From page 122... ...
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 possible 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.
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From page 123... ...
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 leadership, 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.
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From page 124... ...
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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From page 125... ...
Yet neighborhood health centers were also part of a declared "War on Poverty," with its central themes of economic opportunity and "maximum 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 succeeded.
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From page 126... ...
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.
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From page 127... ...
It appears to me that greater opportunities for community oriented primary 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.
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From page 128... ...
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 community 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 concentrations of poverty so that each center would serve 25,000 people.
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From page 129... ...
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 community 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.
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From page 130... ...
(1977) Physician Staff Stability in Large Practice Organizations: Preliminary Summary of Organizational Data From Site Interviews.
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From page 131... ...
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 forerunners 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 remaining Public Health Service hospitals.
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From page 132... ...
Throughout this decade of development, the organizations fostered effective leadership in their own communities. I believe very strongly that effective community leadership is as important as the development of leadership in the medical community for community oriented primary care.
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From page 133... ...
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.
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From page 134... ...
Community organizations might then provide an attractive 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 individual level.
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From page 135... ...
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.
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From page 136... ...
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.
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From page 137... ...
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 implementatlon. Finally, there is work that can be done in terms of exploiting existing data bases for community oriented type of primary care analyses.
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