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 companion 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 science. 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 developments of the last two decades as complete examples of community medicine and even of COPC. Still others, interested in COPC as an expansion and clarification of the scope of community medicine, would argue that most of the community medicine efforts of the 1960s illuminated the 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 practices 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 studiously 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 members. 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 experience different environments (or experience similar environments differently, 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 clinical 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 to the causes of disease, bored with prevention, excessively focused on patho-physiologic processes, and preoccupied with the details and refinements 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” confused 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 definitions 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.

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;
• 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 safeguarding the health of the community, and which follows through on this responsibility of taking action beyond the traditional mold of treating the complaints 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 community 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. ¹⁴

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 populations, 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 become almost commonplace in the United States. The classic Tecumseh ¹⁵ and Framingham ¹⁶ studies age only the most familiar of many examples. Some of these investigations have originated in health centers—the East Boston studies of chronic lung disease, ¹⁷ the Rochester studies of pediatric illness, ¹⁸ the Baltimore studies of streptococcal infection ¹⁹ —and 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 mining 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, environmental intervention, community organization, and health education be performed by 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 investigation, 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 practice 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 community 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 behavioral 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 accomplish changes in community knowledge, attitudes and behaviors, and medical care utilization.

The lack of this functional synthesis in practice has meant, over and over again, that the potential contribution of one or another of the components of a community oriented practice goes to waste because the feedback loop fails to close. Repeated and extensive epidemiologic studies described the changing nature of childhood illness in Rochester, but, as Pless and Pekeles ²⁰ discovered, that did not make any discernible difference in the actual performance or practice orientation of Rochester pediatricians. Epidemiologists at a health center may study the distribution of respiratory illness in a community in relation to environmental factors in the homes, but that in itself does not assure that there will be a systematic effort on the part of the health center's primary care teams to inquire about those risk factors, nor does it necessarily lead to organized feedback of information to the community itself in an effort to reduce or eliminate those at risk. A city health department may conduct an elegant study of the distribution of teenage pregnancies or low-birth-weight infants in a large poverty area; a hospital or health center in that area may use the data in organizing its outreach, family planning, prenatal care, and pediatric services. But that is not the same as a structured, reliable process of planned intervention by all of the area's primary care practitioners. It does not mean that protocols of definition, reporting, and treatment will be followed, that continuing surveillance will occur, or that evaluation and modification of existing programs will be possible.

In hypertension control, several studies of primary care practices have shown that only about 50 percent of men in their forties had their blood pressures recorded even once over a 10-year period. ²¹ An audit of the care of known diabetics in 38 primary care practices found that 52 percent were not getting supervision from any source, and 40 percent had had no retinal examinations during the previous 2 years, let alone the hours of teaching necessary for the education of patients in the nature of their disease. ²² Similar results were found in samples of patients with epilepsy and with lower respiratory tract disease. Until recently, community-based studies in the United States showed that half of those with blood pressures in the range mandatory for treatment were not known, half of those known were not treated, and half of those treated were not controlled. In hypertension, at least, we now know that when the care of identified patients is referred to individual practitioners in an uncoordinated system, there is a real and measurable cost in preventable mortality.

These gaps and failures are not caused solely by incompetence, or by willful refusal to care about community health. If we are to be more than merely hortatory, we must recognize that they are also the direct result of our definitions of medical professionalism—the roles and tasks that doctors define as their work—and of the organization, structure, and financing of the health care system in the United States.

COPC AND THE UNITED STATES SYSTEM: A PROBLEM LIST

There is a major difficulty, for us, with these definitions of COPC. They are inconsistent with the political economy of mainstream American medical care. They are written in other voices, describing other rooms in the house of medicine. We do not have regionalization of primary care, with registered patients and clearly defined populations eligible to use a specific practice, and there is no way for a single practice to “accept responsibility for the health of a community,” in most instances, even if it wanted to. We have multiple competing providers, selling personal health services to individuals or small groups, not communities. These diverse providers—private practitioners, hospital-based or free-standing medical groups, hospital-based outpatient units and emergency rooms, community health centers and the occasional health maintenance organization—are linked loosely, if at all, through referral mechanisms, but not for purposes of data-sharing, program development, surveillance, or risk-factor reduction. The reimbursement system offers almost no incentive for cooperation, but many for competition. Reimbursement is overwhelmingly for acute episodic curative care rather than for preventive or health-promotive services, let alone for epidemiologic and demographic studies, household surveys, outreach efforts, community organization, or health education.

Most American communities are not anyone's defined population for medical care. Most American consumers of medical care—the term itself reflects the structure of the system—do not regard themselves as part of anyone's defined population. For most people, a sense of belonging to a community does not extend to the process of seeking medical care; there is no perception of shared risks, problems, or goals, except in the face of major environmental hazards or a widespread lack of access to care for geographic or financial reasons, or because of health manpower shortages.

A single family may regularly consult a pediatrician, an internist, and one or two subspecialists, unconnected with each other and located outside the immediate community. In urban areas, a single city block may house a thousand such families, using several thousand physicians and a dozen hospitals among them. Outreach efforts and household surveys may be seen by such families as an aggressive intrusion and an invasion of privacy; they have not decided to be part of any practice's community program.

And the clientele of any one practice may be drawn from a dozen areas, different neighborhoods and communities, and be as diverse as any clientele of marketplace shoppers. Information on the diagnoses, risk-factor distributions, or medical care utilization of such a clientele, even if a practice cared to calculate and analyze them, would refer to no recognizable community denominator and yield no community-based rates. By provider and consumer alike, medical care is seen in the main as a commodity, not as an intervention in the health status of a community. This is as true of groups and organized primary care providers as it it is of solo practitioners. In implicit recognition of the political economy of health care, the approach by such groups to the “community” tends not to consider states of health or needed interventions, but is couched instead in terms of targeted marketing, market potential, and market penetration.

A further barrier to the development of COPC is the extraordinary mobility of American populations. U.S. census studies show that between 1975 and 1976, 40 percent of the population moved at least once: 72 percent of those 25 to 29 years of age, 63 percent of those 20 to 24, 60 percent of children 1 to 4 years old, 51 percent of children aged 5 to 9, 21 percent of noninstitutionalized adults aged 55 to 64, and 18 percent of those aged 65 to 74. ²³ These data, if anything, understate mobility, since they count the number of people who have moved, not the number of moves. The epidemiologic studies necessary for effective COPC are much more difficult when the denominators are in constant flux.

Something more is involved here, however, than the organization and financing of care. For three decades, the British have had a system more rational than ours: a national health service, capitation payment of physicians rather than reward for redundant and expensive procedures, a crude kind of regionalization, relatively stable practitioner lists with small turnover rates, and the removal of financial barriers to access. As in the United States, there has been an increase in utilization of physician services by the poor, to approximate or even exceed utilization by the more affluent (though not when controlled for state of health; the sicker poor are now only seeing physicians at the same rate as the healthier wealthier). Yet the problems of health manpower shortages in the inner cities of Great Britain, and the difficulties of relating primary care practices to the needs of low-income areas, are strikingly similar to those in the United States.

What is more, a recent study of inequalities in health status in the United Kingdom showed a pattern of persistent and sometimes widening differences in mortality between the social classes. ²⁴ The study notes that “despite the creation and the influence of the National Health Service, the health of those in the lower social classes has improved much more slowly than the health of the more affluent.” The “lack of improvement and in some respects deterioration” of working class health has been striking over the last 20 years, particularly with regard to the long-term effects of inadequately treated childhood disease; the greatest social class differences are in preventive services and child health. If the mortality rates of the wealthy had obtained among the poor, 74,000 lives of people under 75 would not have been lost during 1970-1972. This estimate includes nearly 10,000 children and 32,000 men aged 15 to 64.

It would be easy to interpret these data simply as supporting that radical critique of scientific medicine that argues that medical care itself can have little or no effect on the incidence and prevelance of disease in populations and that the power of the social, physical, and biological environments is all-determining. But as Hart has argued, ⁶ the likelier explanation is that scientific medicine—in its fullest sense of anticipatory care and planned efforts at risk reduction—has not been applied to whole populations, because the current organization of medical care does not support such efforts and physicians are uninterested. So long as the practitioner remains in the shopkeeper role, focused on episodic curative activities, the outcomes are not very different: Increased curative medical activity in the United States generates profits and in Britain generates taxes, but in neither case does health status improve. A measureable contribution of clinical practice to improvement in the health status of populations can hardly be expected until there is real regionalization, reward for preventive services, a merger of “public health” and clinical medicine concerns, more community medicine training of physicians and other health workers, and the provision of outreach and epidemiologic resources to practitioners.

Thus, for the long run, the widespread implementation of COPC in the American house of medicine will require transformations both in the structure of the system and the orientation of its work. Some would suggest then that rigorously defined COPC must await the evolution of a fully regionalized, totally accessible, preventively oriented noncommodity health care system. Instead I wish to focus our attention on something less than that millennium. What do we do until the evolution comes?

STARTING WHERE WE ARE, WITH THE PEOPLE AND PROGRAMS WE HAVE

If we list the existing models of COPC that meet most of the Kark and Abramson criteria, attempt to close the loop between community-based epidemiologic investigation and the interventions of providers, and include all the components of clinical community medicine practice, we discover that they share a number of characteristics. Most of them are overseas. Almost all of them exist in systems of medical care that provide wide access to care and remove fiscal barriers, rather than in entrepreneurial marketplace systems. Even where this is not so, whether in Western industrialized nations or developing countries, they serve clearly defined communities in the true social sense of that term, and they are usually the major (if not the only) source of primary care for those communities. Both the populations and the providers—the staffs—are relatively stable, with low turnover. Most of these COPC practice models are linked to an outside source of expertise and have additional special funding for epidemiologic and behavioral science study of their communities: an academic department of a medical or public health school, a health department, an epidemiology research unit, a medical research council.

It follows that these are the settings and characteristics we should look for first, even if we cannot duplicate all of them, in selecting opportunities for the further development of our own versions of COPC in the United States. I say “further development” even though I have argued that we have few if any existing American community practices that meet the definitional criteria for COPC (unless we are to revert to fallacious or partial definitions). Rigor need not induce nihilism; we already have many practices that presently have some or many of the elements of COPC—practices that, despite the difficulties and limitations imposed by our medical care system, are already partway there. A substantial number of them are in the kinds of settings that might permit the rational further development and evaluation of COPC. We have reason to believe that they are already effective in terms both of cost control and of impact on health status in their communities. As I hope to show subsequently, we now have evidence that even a partial shift toward organized, community-based care and a preventive/ anticipatory orientation—a change of structure and a change of heart—can have highly significant effects on health outcomes. The reports of the National Health Service Corps and the Rural Practice Project—to name just two—are alive with evidence that there are many health workers, in many programs, struggling to develop community oriented practices. It makes sense, then, to start where we are, with the people and programs we have, in furthering the development of COPC.

Some of these practices with the best potential for COPC are publicly funded; others are in the private sector. A disproportionate number are in underserved areas that have proved unprofitable for medical entrepreneurs. Where they are urban, those with the best potential serve well-defined communities that are relatively homogenous and tend to be socially or geographically isolated. In rural or small-town settings, some are the only providers of care. They include community health centers, singly or in networks; urban and rural health initiative projects; migrant health centers; rural and small-city group practices; and community hospital-based primary care practices.

Since community health centers are the most numerous and the best-studied of these (indeed, they are by now a distinct, if small, part of the total U.S. health care system), we should look briefly at their history and development, their achievements and failures, with a special focus on three questions. To what extent did they achieve COPC? What accounts for their success or failure in this respect? What would be necessary to change or add now to further the process?

SOME SPECIFIC PROPOSALS

What should be the general direction and content of steps to further the development of COPC in the United States? What follows are a few general proposals, very conventionally grouped into (1) education and training and (2) service delivery.

CONCLUSION: A NOTE ON DREAMS AND NECESSITIES

The suggestion that COPC may be a romantic dream has particular poignance now. We are in a period of such regression that we will have to fight continually simply to preserve what we already have, let alone move forward. In ordinary times, innovation like that of the 1960s is followed by periods of attrition; ideas from new programs on the margins diffuse into the mainstream, but at the same time, as the “new” programs become established, they begin to conform to mainstream ideologies and forms of medical care. This may be the natural history of innovation in community medicine.

But today we are confronted with something more: a radical restatement of the problems of health care, a definition of the marketplace as the solution rather than a part of the problem, and an emphasis on cost containment almost without reference to health needs or any impact on health status. Health care is even more vulnerable than other sectors to a Social Darwinism that encourages the survival of the fittest—particularly the tertiarycare institutions that now dominate the medical marketplace. The consequences of reduced access to care (whether it is called a procompetition strategy or simply openly presented as budget-cutting of the kind that threatened in 1981 to remove 1.2 million people from access to the services of community health centers) may be heightened by the reappearance of malnutrition and increased environmental hazards for some segments of the population.

In such times, we may have to limit our COPC research and demonstration projects while the current wasteful attempt to rely primarily on the sale of personal medical services for improvement in health status runs its course. The evidence suggests that this attempt will increase total costs for medical care, even if it reduces costs to government, and that it will have no positive impact on health status.

Yet, from what has been shown above, there is already powerful evidence of what could be saved—in both human and financial costs—by a different approach. To the extent that these findings are generalizable, then COPC will, sooner or later, be recognized as a practical necessity. In the interim, the value of furthering COPC in the United States, on an experimental or demonstration basis, seems to me to be clear. In doing so, we may even further the evolution of the health care system. As in biological evolution, it does not matter whether the gradualists are correct, and we are in for a long, slow process of the accretion of small changes, or whether the punctuationalists are right, and we are at the start of some discrete but discontinuous burst of change. COPC, is, for our purposes now, both a romantic dream and a practical necessity.

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Discussants

David A. Kindig

For our discussion definitional clarity is clearly in order. The two papers just presented challenge us to consider a concept that goes beyond community-based primary care. The additional aspect that the Kark/Abramson definition of community oriented primary care (COPC) requires is the practitioners' involvement in epidemiologic studies of their community in order to obtain data that feed back into the goals and activities of their practice. The significant element here is not only being aware of what is going on with one's patients as a group, but also of health issues and health risks in the community outside of one's practice. This addition means that the health status and concerns of those who do not come into your office are as important to you as those who do. This is what I took to be the essence of the original OEO philosophy, which this conference brings into focus again. Dr. Geiger points out that the epidemiologic studies per se are not new; they have been carried out in a variety of settings. He makes the critical point that it is the synthesis of primary care practice and community epidemiology that forms this unique concept of community oriented primary care.

I will not spend my time commenting on the exciting potentials that this concept anticipates, not the least of which is the opportunity for the rejuvenation of professional idealism at the grass roots level, which seems so scarce in these times. Rather, I would like to focus on some of the difficulties that may be encountered in a more widespread implementation of COPC into practice settings across the country or world.

One conceptual difficulty is that the COPC model described by Drs. Kark and Abramson appears to require defined nonoverlapping communities with organized practices responsible for an entire community or segment of a community. This may be the case in some small towns or a rare inner-city area devoid of services, but beyond these, the medical care system is comprised of various provider groups and patient allegiances that would seem to make it very difficult to define a practice “community.” This is true at least for the purposes of including in the epidemiologic studies that portion of the community that is not enrolled in the practice. This is a serious problem. Such a series of nonoverlapping areas or perhaps population groups exclusively assigned to one group of providers is not the usual situation in the large number of cities, towns, and rural areas of our country.

This criticism, however, may be applying the model too literally. It is probably not possible or even desirable to insist that every primary care practice be community oriented in this way. What would be desirable would be to have a modest number of such “pure” practices in place while others who provided quality primary care to whoever came through their doors attempted to do some epidemiology on this group of patients and in the community at large, either as extensions of their practice or in conjunction with other practices in the same area.

What kind of settings are best suited to this purpose, and what would be the role of major health care institutions such as medical schools, hospitals, and academic health centers in such practices? I have tackled these questions in a number of ways since the early 1960s, when I, along with others, began trying to get a major midwestern medical school to consider providing primary care services in its immediate community and later as a part of the growing student health movement. At that time, we found most major institutions extremely resistant to such ideas, primarily because the concept did not fit into the common understanding of the mission of a medical school or teaching hospital. In those rare institutions that were open to such concerns, there was precious little experience or expertise in primary medical practice or community outreach and sensitivity so that first moves, even though well intentioned, were often not successful.

The situation is different today, with departments of family medicine and community or social medicine established in most academic centers and certain institutions having distinguished themselves as leaders in the establishment of neighborhood health centers, area health education centers, and primary care medical and interdisciplinary education. However, it is not clear that this change over a 20-year period means that we now have in place established institutions that will be eager to pick up and implement the challenges of COPC? Why is this so? It is tempting to identify the lack of resources resulting from the current economic situation as a primary factor, and it certainly plays an important role. Most institutions, faced with significant cutbacks in all sources of revenue, are struggling to preserve the basic core academic and service programs. New oportunities in COPC or other areas of academic endeavor will not even get a serious review in many places. But what if resources were not limited—would the possibility of institutional sponsorship be increased? It would certainly be more likely, although many administrators have become increasingly skeptical of federal or private start-up funds that leave the institution holding the bag when the 3- or 4-year developmental period is over. Certainly, changes in patient care reimbursement so as to include the costs of such activities would encourage additional institutional involvement or sponsorship.

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 experience would lead me to the view that intrinsic characteristics of most major health care institutions are not conducive to the growth and development of such new and different undertakings. Medical shcools and teaching hospitals are large and bureaucratic with enormous inertia and commitment 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 organizational support and stability that a strong institution can provide to a new concept or organization, once embraced, is not insignifcant.

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 developments 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 sponsorship should clearly be able to demonstrate why such an activity is in its enlightened self-interest—a 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 experience 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 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 development and implementation of 25-50 operating COPC practice models over the next several years. Perhaps foundations would fund the epidemiologic 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 establish their “community.” Part of it comes from the criteria for medically underserved areas (MUA), 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 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 particular 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 reimbursement process becomes crucial in determining how successful one is at coordination, integration, and initiation—a 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 supplemental 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 $24 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 physicians, 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 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 manpower for some of these shortage areas. The third point involves the development of methods of community diagnosis and surveillance, the development 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 prevalance and incidence within the population served. Basically, FCHC has more than 62,000 persons 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 uncontrolled, 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 computer-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 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 us—which I doubt—what brings us together in this assembly is the experience shared in those days, the insights gained, 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 oriented 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, discrimination, and equal opportunity. The programs of the Great Society, as Henry Aaron has so well expressed it, were unparalleled by any peace time concensus 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 care—access 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 risk—pregnant 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 them—family planning, community mental health services, and neighborhood health centers.

“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 economic 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 residents—an 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, 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 1960s—exhilarating, frustrating, unique—there evolved, and has since matured, a systematic set of convictions 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 American 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 country, 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, Watergate, 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 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 federal, 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 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 longrange 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 maximize 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 redistributive framework was agreed upon. Thus decentralized resource allocation 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 decision making is obvious.

To turn for a moment to more immediate opportunities to make use of an expanded epidemiologic framework, consider developments that are 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 surveillance, 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 capitation-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 Massachusetts 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 identified 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 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 development 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 residents of the Bronx. Under this plan, a coalition of community health centers for primary care services would be linked with specialty and inpatient services 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 organizations, these experiments can be expected to bring about the involvement 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.