Oliver T. Fein, M.D.
Associate Clinical Professor of Medicine and Public Health
Columbia-Presbyterian Medical Center
Robert E. Isman, D.D.S., M.P.H.
Chief
Dental Health Section
California Department of Health Services
Morgan N. Jackson, M.D., M.P.H.
Division of Primary Care
Agency for Health Care Policy and Research
Sarah B. Keating, M.P.H., Ed.D., R.N.
Professor and Chair
Department of Nursing
San Francisco State University
Carolyn C. Lopez, M.D.
Vice President and Medical Director
Rush Access HMO, Inc., Chicago
Lucille C. Perez, M.D.
Associate Director for Medical and Clinical Affairs
Substance Abuse and Mental Health Services Administration
Roberto Ramirez, M.H.S.A., Ph.D.
Assistant Professor
Health Services Administration Program
University of Puerto Rico
Carl M. Toney, P.A.
State Department of Rural Health
Atlanta, Georgia
STRUCTURAL CHARACTERISTICS OF PRIMARY CARE
The Secretary should recommend to the President that an Inter-departmental Group, including representatives of the Environmental Protection Agency and the Departments of Labor, Housing, Education, Transportation, and Justice, be established to assist in the development of a national health policy which reflects the multifactorial determinants of health represented in the mission of each of these departments.
The Secretary of Health and Human Services should promote primary health care systems characterized by integrated networks of primary care providers, public health agencies, health centers and hospitals, in which providers are responsible for defined populations and health services are based on epidemiologically determined community needs assessments and disease surveillance.
The Secretary of Health and Human Services should advocate the elimination of all co-payments and deductibles for preventive and primary care services in any health plan. Strong consideration should be given to providing incentives to use preventive services and disincentives for using specialist services. For instance, financial incentives might be used to encourage the use of immunizations, mammography or smoking cessation counseling, and co-payments for specialist services might be reduced or eliminated when referral to the specialist is made by a primary care provider.
The Secretary of Health and Human Services should mandate the monitoring of health expenditures for public health, prevention, primary, secondary and tertiary care. The Secretary should also establish targets for shifting federal resources from secondary and tertiary care to public health, preventive and primary care, and should then regularly evaluate the effects of financial incentives on improving the health of the American public.
The Secretary of Health and Human Services should place a high priority on supporting clinical information systems technology directed at facilitating the development of community-oriented primary care. This means focusing the technology on primary care provider needs with specific attention to patient and provider confidentiality.
STRUCTURAL CHARACTERISTICS OF PRIMARY CARE
Good morning Secretary Shalala.
The task assigned to our Primary Care Policy Fellowship Work Group was to examine the structural characteristics of primary care. We would like to begin by stating that we believe that the ultimate success of any health care reform initiative requires that the issues be specifically framed around the following four concepts:
In terms of health status determinants, we suggest that while the purpose of a national health care program is to improve and maintain the health of the public, it is important to recognize that health care, including primary health care, is only one component of health. The determinants of health status in our society are multifactorial, and include full employment, adequate housing, better education, high wages, and an end to discrimination. To improve the individual and collective health of our communities, all of these factors must be improved as well.
Our model of primary care tries to integrate all of these resources at the local level. While we are aware that many of these environmental determinants of health status are not under the direct purview of the Secretary of Health and Human Services, this broad view of health leads us to our first recommendation.
RECOMMENDATION
The Secretary should recommend to the President that an Interdepartmental Group, including representatives of the Environmental Protection Agency, and the Departments of Labor, Housing, Education, Transportation, and Justice, be established to assist in the development of a national health policy which reflects the multifactorial determinants of health represented in the mission of each of these departments.
As an example, as part of our Fellowship training, we have had the opportunity to visit a number of sites providing primary health care services in the general Washington, D.C./ Virginia areas. One such site was a migrant health center, partially funded by the Public Health Service. In addition to the primary health care services provided the center, they have also expanded their role by getting directly involved in supporting the construction and maintenance of an apartment complex for migrant & seasonal farm workers and their families. The housing provided through the migrant health center is an alternative to the sub-standard accommodations in which migrant families are usually forced to exist.
This is one example of how insightful assessment of the “global” health status of a given community, coupled with a creative intervention strategy, can successfully reach out and address those kinds of issues which go beyond a traditional medical care model.
Attributes of Primary Care
When considering the attributes of primary care itself, we believe that this model serves as the cornerstone of the health services system and is the means by which the goals of that system – optimization of health and equity in the distribution of resources – are balanced. As such, primary care can be defined as the integration of services that promote and preserve health; prevent disease, injury and dysfunction; and provide a regular source of care for acute and chronic illnesses and disabilities. Primary care serves as the usual entry point into the larger health services system and takes responsibility for assuring the coordination of health services with other human services. The primary care provider incorporates community needs, risks, strengths, resources, and cultures into clinical practice. The primary care provider shares with the family an ongoing responsibility for health care.
The essential attributes of primary care include the following: Primary care is first contact care; it is continuous, coordinated, and comprehensive in scope; it is community-oriented and family-centered; and it is care which is accessible, developmentally appropriate, and delivered in a culturally competent and accountable manner.
Attributes of Primary Health Care Systems
To assure that primary care is delivered in the most effective and efficient way possible, we believe there are also certain essential characteristics of a primary health care SYSTEM.
The first of these is INTEGRATED NETWORKS of primary care providers, that include private offices of health care providers, community health centers, local health departments, regional health centers, regional hospitals, and hospitals where highly specialized tertiary care is provided.
Implicit in our concept of integrated networks is that such networks represent ORGANIZED DELIVERY SYSTEMS in which providers are responsible for a DEFINED POPULATION, and that the health services that are provided are based on the ACTUAL HEALTH NEEDS of communities, as determined by scientifically sound community needs assessments and disease surveillance. Thus, our vision of primary health care systems is that they just integrate the personal health services delivered by health care providers with the essential functions of assessment, policy development and assurance provided by public health agencies. Together, these integrated systems of care are also known as “community-oriented primary care.”
RECOMMENDATION
The Secretary of Health and Human Services should promote primary health care systems characterized by integrated networks of primary care providers, public health agencies, health centers, and hospitals, in which providers are responsible for defined populations and health services are based on epidemiologically determined community needs assessments and disease surveillance.
One such example is an initiative which is about to be undertaken by the State of Maine on behalf of its citizens who are stricken with HIV/AIDS.
The Maine strategy will be to bring together representatives from the general community, HIV/AIDS community, state policy makers, and various elements of the public and private health service delivery system, for the single purpose of developing a plan to provide comprehensive, community-based, primary care services to a group of individuals who have significant, and often complex, health care problems.
Through this type of private-public partnership it is anticipated that a rational and compassionate program will be established; community driven in its orientation, systematically prudent in its utilization of finite health services resources.
Financial Incentives for Primary Care
As we move on to the issue of financial considerations, we are particularly concerned about the issue of financial barriers to primary care access in the form of “co-payment” requirements.
We believe that, in spite of all the attention directed at health care reform, there has been no clear message to the American people that primary care should be the organizing principle for a reformed health care system. This message is important because primary care, of all health care reform options, offers the best chance for improving the health status of all Americans at an affordable cost because of primary care’s close link to prevention and public health.
We believe that one way to help assure that primary care will be the centerpiece of health care reform is to eliminate co-payments and deductibles for preventive and primary care services in a reformed health care system. In recent years, co-payment has been expanding, not only in private health insurance, but also in health maintenance organizations. Co-payment erects a financial barrier to access to health services. Barriers to the use of specialty services may be appropriate, but there should be no barriers to preventive or primary care services. Co-payment affects the poor disproportionately. It fosters means testing and ingrains multiple tiers of health care delivery. Co-payment should be banned from all health insurance for primary care in America. This would send an unequivocal message to all Americans about the importance of primary care.
Furthermore, this principle should be extended to specialty services. Co-payment for specialty services should be reduced or eliminated when referral to the specialist is made by a primary care provider. This approach promotes cost-effective primary care by discouraging direct access to the most expensive provider, namely the specialist.
We need to shift resources from secondary and tertiary care to public health, preventive and primary care. The elimination of co-payments and deductibles for preventive and primary care services is one step in that direction, but additional regulatory strategies may be necessary, such as setting federal expenditure targets for public health, prevention, primary care, secondary and tertiary care.
RECOMMENDATIONS
The Secretary of Health and Human Services should advocate the elimination of all co-payments and deductibles for preventive and primary care services in any health plan. Strong consideration should be given to providing incentives to use preventive services and disincentives for using specialist services. For instance, financial incentives might be used to encourage the use of immunizations, mammography or smoking cessation counseling, and co-payments for specialist services might be reduced or eliminated when referral to the specialist is made by a primary care provider.
The Secretary of Health and Human Services should mandate the monitoring of health expenditures for public health, prevention, primary, secondary and tertiary care. The Secretary should also establish targets for shifting federal resources from secondary and tertiary care to public health, preventive and primary care, and should then regularly evaluate the effects of financial incentives on improving the health of the American public.
A good example of this type of active intervention is the recently completed childhood immunization program conducted by the “Atlanta Project”, under the leadership of former President Jimmy Carter.
This project, which included elements of the public-private health care sectors, non-profit organizations, and local community leaders, successfully brought about the immunization of a segment of the Atlanta community which was at great risk; and which, here-to-fore, had essentially been ignored.
Through innovative strategies, including the active involvement of Michael Jackson, one of the world’s pop musical superstars, a mechanism for providing critical public health services was developed. Additionally, portals of entry into the community for other public health and primary health care services have been established.
Information Systems Support for Primary Care
The final point we would like to address concerns the design, collection, and utilization of health related information.
In the last decade, there has been an explosion of computer-based information systems technology. Although there have been many imaginative demonstrations in the health care system, most current information systems technology has been directed at billing for individual encounters or hospitalizations.
With the caveat that confidentiality of information is crucial, there is, nevertheless, an enormous untapped potential for information systems technology in primary care. For instance:
This community-oriented primary care approach can build linkages with local public health agencies and encourage the development of epidemiologically determined community health needs assessment.
Despite the array of technology available which provides us with access to various pieces of information regarding: 1) the need for services; 2) delivery of services; and, in some cases, 3) the strategies regarding how to develop these services; what we do not have is a comprehensive way to bring together all the public health/private sector/social services data in a single universal format. We therefore would like to make our final recommendation:
RECOMMENDATION
The Secretary of Health and Human Services should place a high priority on supporting clinical information systems technology directed at facilitating the development of community-oriented primary care. This means focusing the technology on primary care provider needs with specific attention to patient and provider confidentiality.
We believe that attention to the information system aspects of health care reform is crucial. Development of such a system would allow a single set of records to be maintained on each individual. Such a system, with appropriate monitoring of access, would assure that individuals not suffer from unnecessary duplication of services or, even more importantly, absence of needed services.
Summary
By way of summary our work group would like to share our collective vision on health care reform.
We believe that, as a nation, we are at a cross road; a defining moment for this society as it relates to our commitment to health care. We stand at a fork in the road, and before us lies one road, well traveled strewn with disappointment and failure.
However, there is another road – far less traveled and probably somewhat more tortuous in its ascent. There are those of us who believe that it is this second road which leads to a better system; to what might be described as a new kind of “field of dreams” and opportunity, upon which a new “health care house” can be built.
We believe that all of this can be brought into the light. We believe that if we have the courage to follow the less traveled road, we will construct a “house” which will truly be a health care home for us all.
Thank you.