Donald L. Madison

Over the years promoters of community oriented primary care (COPC) have recognized that for COPC to be effective there must be thoughtful consideration given to the opportunities and constraints that influence the success or failure of individual COPC practices as well as the movement as a whole. The environment that creates the opportunities and imposes the constraints must be continually examined, and a careful balance between these factors must be worked out.

The paper is an effort to describe some of the opportunities and constraints that must be considered by today's practitioners of COPC. Let me first consider the forces that are presently working to inhibit the flourishing of COPC. In today's political and economic climate, there are many such forces; my list will necessarily be selective.

Probably the most pressing problem is finding the money needed to get started and to remain solvent. The very nature of COPC makes this basic constraint more significant than it is for more traditional medical practice settings. Professing a community orientation means rejecting the procedure-oriented, fee schedule consciousness of the physician entrepreneur. However, it goes further than that, and so do the financial consequences. Invariably, the community diagnosis will suggest that some of the most important needs are for what the British call the “Cinderella services,” ¹ i.e., those items of service and organized programs that show little technological glitter and lack the glamour of more rapid health-restoring interventions but that often turn out to be more beneficial for more people in the long run. The Cinderella services of primary care include educational services, services directed to people in their home, special programs for identified groups of socially and medically dependent people, and, of course, organized measures for prevention at all of its levels. By definition, a community oriented practice includes in its program as many of these kind of services as it sees are needed by its community and that it can afford to provide or arrange.

Since these services tend to be directed disproportionately to those least able to support them through payment of fees, and since they cost as much as most traditional items of primary medical care but are seldom recognized by insurance carriers or government financing schemes as a legitimate part of medical indemnification, there is little chance that their full costs can be met from the earnings they themselves might generate. Some subsidy is required, either from the heavy fee-generating side of the practice—assuming conditions are such that the practice can have a heavy fee-generating side—or from outside the practice.

Subsidizing unprofitable services from within an organization is frowned upon as a questionable business practice by those who think in such terms, unless the unprofitable services can be made to serve a legitimate business purpose. So, in the language of the accountants, the Cinderella services are given a new name: “overhead.” The marketing people use another term: “loss leaders.” Either term implies an “in the service of” relationship to what is considered the “real business” of the practice. Obviously, in such a relationship the value of these community oriented services will be measured against criteria that are not those of community health. The usual source of an external subsidy is the government. For government to subsidize the Cinderella services, there must first be a social policy that gives priority to restoration and maintenance of people's health, and there must also be some commitment to equity in health services. When these are given attention, COPC tends to grow and prosper. At all other times it struggles.

A second constraint that operates regardless of whether governmental subsidy is available is the fee-for-service method of providing medical care. Under fee-for-service, those items of service that can generate the highest dollar return tend to be favored over those that are priced lower. Moreover, the hours spent by physicians and other fee-generating workers in activities such as planning, teaching, evaluating, supervising, or just meeting as a team—activities of leadership that every community oriented practice requires—are naturally considered to be “nonproductive” time.

A private fee-for-service group might lessen this productivity emphasis by reducing the relationship between an individual's compensation and the volume of fee-generation credited to that individual. But the trend has been in the opposite direction. ² The emphasis on individual economic incentive within a cooperative practice setting may very well enhance the production of group income, but it is a constraint against incorporating many of the program elements that form the basis for a community orientation. For example, one national study of large, primary care oriented multispecialty medical groups showed a negative relationship between group compensation methods that were based mostly on an individual physician's fee-generating activity and the emphasis given by these groups to continuing professional education, quality assurance, patient care innovations, nonmedical primary care services, satellite locations, and after-hours service. ³

There is a further constraint that is related to fee-for-service, but is even more basic. A style of medical practice that values technological modalities of illness care as essential and that considers teaching, social and emotional support of the ill, and identification of those at risk as desirable but nonessential modalities has brought about a general preoccupation with cost that leaves little room (and no money) for any services beyond those deemed essential. Departments of medicine in many medical schools ride along on the earnings of two of their subspecialties: cardiology and gastroenterology. Why? Is it because these two have demonstrated the best record of restoring health? Who can say which medical specialty produces more health? The reason is that these two subspecialties of internal medicine offer the most technology for sale. It is now possible with fiber optics to gaze directly upon every nook and cranny along the entire length of the gastrointestinal tract—at $5 dollars per centimeter. Such response to a stomach ache leaves few dollars available for alternative or additional responses.

He who writes the ticket determines the destination. So long as a technology-addicted profession retains control of a nation's health care, the services for sale—the ones the people are told are essential—will be those that feed the addiction. Never mind how much healing results per dollar spent. The Cinderella services that are indicated as part of community oriented primary care will inevitably be caught in the budget squeeze, not because they themselves are especially expensive, although they do cost; not because they are less effective, although they will never be credited with as many dramatic results; but simply because other more expensive destinations are the most interesting to those who write the tickets, and getting there is budget-busting.

Clearly, in the United States a major constraint for COPC is the pluralism of the American health care system. Rarely does any single source of primary care service a clientele that corresponds to the majority of people residing within a given area. Most American communities are served by many physicians from a variety of practice organizations that may or may not be located within the area of the community. Even most rural localities, including many that formerly existed in a medical vacuum, now have access to physicians located in nearby larger towns, physicians in virtually every specialty who depend for their living on many of the people in the smaller outlying communities. ⁴ This state of affairs makes the practice of COPC health care in its pure form, as described by Sidney Kark in his book of that title, difficult or impossible to achieve except at the margin. ⁵ In the United States there is no sectorization of responsibility for medical care as there is in the rural area of many developing countries, in the polyclinics of Cuba, or in much of the United Kingdom, where the general practitioner's list tends to correspond approximately, if not exclusively, with a small geographical area.

However, even within the mainstream of a pluralistic system it should be possible to adopt many of the principles of COPC care. This has been described elsewhere using another term, one that perhaps implies a bit more strongly the possibilities for a community orientation by the mainstream. The term is “community responsive practice.” ^{6 , 7} It means essentially the same thing, and I use it interchangeably with COPC.

The very basis of community-responsive practice is a consciousness of the idea of “community” on the part of clinicians. All community-responsive practice depends in the first instance on a realization that the clients themselves constitute a “community” that the practice can reach in some way, then on designing services and programs through which those at risk can be better served. By this, I mean that although we usually think of a “community” as being politically or socially defined (e.g., a town, county, or neighborhood, the students at a school, the workers at a factory), it may also be seen by a medical practice as the collectivity of its clients, whether or not they would otherwise emerge as a natural social grouping. The notion is that better, more responsive service is possible from the practice that knows the problems affecting its own “community” of patients. By this modified and somewhat compromised meaning of COPC, it becomes 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.

The problem comes in the recognizing. The main constraint is the traditional medical view that medicine's concern is only for individuals as they seek care, not for groups of people. This is a view that physicians are taught and one that the profession has defended repeatedly.

In 1932 the Committee on the Costs of Medical Care published its final report. The central recommendation was that medical care be delivered locally by multidisciplinary groups (“community medical centers”) controlled by professionals with lay participation. These would be hospitalbased and regionally organized. The community orientation was never explicit, but the implication of what might be involved was not lost on the members of the committee who wrote the minority report (which was then endorsed by the AMA):

It is always the individual patient who requires medical care, not disease or economic classes or groups. . . . It seems almost impossible to those who are not engaged in the practice of medicine to understand that the profession of medicine is a personal service and cannot adopt mass production methods without changing its character. ⁸

The legacy of this traditional view still acts as an important constraint. Indeed, one could parody the language of the minority report and say, with some chagrin: It seems almost impossible to those who are engaged in the practice of medicine to understand that many problems affecting individuals could be more effectively addressed if such individuals could be considered as belonging to a group or a community, thereby enabling interventions that focus on communities of individuals who may share the same health problem.

Still another constraint is the shortage of the kind of medical leadership that programs of COPC require. I mentioned physicians, and not administrators, nurses, or other health professionals, because I do not perceive as great a shortage of leaders among these others, and also because I believe that medical leadership is critical, the sine qua non. The inertia represented by the traditional practice mode can never be overcome without it. There may now already be sufficient physicians willing to practice in community oriented settings. If not now, there will be soon; in fact, there is every prospect of an employers' market in the United States for physicians' services by the end of this decade. That is a different matter. COPC will still require physician-leaders, people who possess the combination of biomedical knowledge, commitment, creativity, and the skills needed to plan and carry out community oriented programs.

In my experience there are surprisingly few of these physicians available. Perhaps this is because those who might otherwise qualify choose to do other things than primary care; or maybe primary care training fails to emphasize the necessary qualities or doesn't provide the needed skills; or possibly the incentives are simply not the right ones for today's young physicians. Whatever the reason, qualified and committed medical 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. And its scarcity must be considered another constraint.

And if the necessary money, professional attitudes, and committed medical leadership were all in place, another question would arise: Who would have the know-how? How does one approach the process of community diagnosis, and what does one do with the results? How does one match community health needs, once made visible, with responsive service programs, and then evaluate their effectiveness? Few physicians or administrators really know how do do this well. If epidemiology is the science they can use, where are they to learn it? Most medical students know epidemiology as the observational science used by investigators of communicable disease outbreaks, or else they think of it as the stuff of large-scale studies conducted from academic centers. In its most recent incarnation, under the lable of “clinical epidemiology,” it deals largely with the methodology of clinical trials. ⁹ All of this is important and necessary, but the application to community oriented primary care is missing. Where does the primary care physician learn to apply the science of epidemiology to community diagnosis? In residency training? In some new kind of community medicine fellowship that does not yet exist? If the science of epidemiology remains inaccessible to the practicing primary physician, the community oriented primary care will lack a science base.

This is not to say that no research is going on at the primary care level. Within the family practice movement in recent years, for example, there has been a considerable amount of research into the content of primary care practice. ¹⁰ Unfortunately, there is also a tendency among some practicing primary care physicians interested in research to stop at that point, to acquire what might be called a census-taking fixation. This starts with a careful counting of one's patients and their presenting problems, perhaps using a computer to assist with the counting, revising, and updating; then describing the practice content in terms of the frequency of the various conditions seen, and soon; but it never really goes to the next step—using this intelligence to make the program of the practice more responsive to its community of clients. Baseline data are, of course, important to have, but they should never be an end in themselves. The proof of the pudding, the test for whether practice content research really contributed anything valuable, is found in looking at the practice's program. Given the knowledge that “x” percent of a practice's patients between the age of 40 and 64 have been found to be hypertensive and are under care for that condition, what else is the practice doing about it? Can anything more be done for those being treated. What is being done for other patients in the practice who may be at risk? In the community-at-large? A primary care practice's community orientation begins logically with data, but it cannot stop there. A fixation at this point, affecting some of the best primary care physicians, is yet another constraint.

A recurrent theme in the American experience with sponsored primary care programs is the theme of multiple goals in conflict. In the 1960s the introduction of neighborhood health centers represented an important innovation in American medical care. They were designed to be comprehensive, family centered, and provided personalized attention and other amenities that are expected by most Americans but that the intended clients— mostly the poor of the inner cities—do not usually receive in the teaching hospital outpatient clinics that were their major source of primary medical care. Yet neighborhood health centers were also part of a declared “War on Poverty,” with its central themes of economic opportunity and “maximum feasible participation.” Neighborhood health centers attempted to address both of these themes—medical care reform and intervention in the poverty cycle—at the same time in a single program. Most of them succeeded. But conflicts did arise over what was most important, what were the priorities. These conflicts were not only between health center staff and local spokesmen for the poor, but also with the sponsoring federal agency and the Congress, which was gradually changing policy objectives. ^{11 , 12}

This theme of shifting and sometimes conflicting goals carried on into the 1970s with the federally sponsored rural initiatives, including the National Health Service Corps (NHSC). Conflicts arose over whether these practice settings should attempt to become community-responsive programs, as the leaders of the NHSC and many of the physicians assignees and other staff envisioned, or were they merely a manpower deployment strategy, as viewed by some in Congress, and, as such, to be seen as a temporary and inherently inferior alternative to the less rapid, laissez faire movement to private physicians into the rural areas? The question was of program quality versus the more quantitative presence of a resource. Such differences have led to changing criteria for funding and are another important constraint for community oriented primary care. I can think of no major program in the United States, public or private, that has attempted to sponsor community oriented primary care and has been able to stay free of this ambiguity of goals.

That concludes my highly selective list of constraints. Now, what of the opportunities ? It isn't likely that next year will bring a new flurry of federally sponsored initiatives. Nor is there reason to believe that the medical schools and residency programs are about to begin emphasizing a new community awareness and the skills that physicians need to incorporate community-responsive programs into their practices. Still, in this day of cost-consciousness, when the medical care lexicon features “competition” as the favorite term and “marketplace” as the preferred concept, when a physician glut lies waiting around the corner, there may yet be a place for community oriented primary care.

One scenario might go as follows: First, there will soon be too many specialists competing for too few referral sources, including self-referrals. At the same time, those practice organizations that wish to remain in the business of delivering primary care beyond the episodic encounter (a service item now being claimed by a new medical version of the Seven-Eleven convenience store) will start to compete openly with each other for a permanent clientele. Second, in order to attract and retain the loyalties of patients, these primary care providers will naturally emphasize the advantage that can accrue to the patient from maintaining a long-term affiliation with a primary care practice. Not emphasizing such advantages would be to risk losing the client to one of many competing providers in a crowded field. Of course, in order to emphasize the value of a continuing affiliation, some of these advantages must become visible. And this, it seems to me, is where community-responsive practice might find a place.

The primary care practice that views its clients as a community—communicating with them, looking to their needs, and responding with programs of care—should have a decided competitive advantage over practices that continue to view themselves and their patients exclusively in the traditional one-by-one, one-on-one manner. Already, the idea that some additional kind of response may be necessary is getting attention. For example, the AMA's trade newspaper, American Medical News, recently featured a report on the competitive importance of organized patient education programs in group practice. ¹³ Again from the American Medical News, in a front page story on practice promotion, the president of a New York advertising firm says, “We're all up against it nowadays. Competition is growing in every field. Physicians can't afford to sit back and wait for patients. They're going to have to develop a media strategy and market their services.” ¹⁴ And this copy from a journal advertisement: “Build your practice by doing a public service. Boost your visibility among thousands of potential patients. Revolutionary new MD advertising program. Reply Box 12824, New England Journal of Medicine.” ¹⁵ I did reply. The scheme is for the private physician to sponsor a series of health messages in the local newspaper, a sort of Mobil Oil series on the common cold, the best kind of exercise, fat metabolism explained, and several other topics, and, at the bottom, a prominently displayed credit line: “this message is brought to you as a public service by so and so, MD.” Advertising is only a start. On the local level, in a crowded market, there must also be performance if the practice hopes to keep the loyalties of the few among those “thousands of potential patients” who may have decided to sample the product. And other things being equal, it is in performance that a community-responsive practice should hold the competitive edge.

Now this scenario assumes that the new marketplace will lease to better programs of care. Of course, it may not happen that way at all. Thinking of the less profitable health care activities in a practice as “loss leaders” or “overhead” instead of an ethical professional response to community needs could instead prove more conducive to the medical equivalent of the white sale, the end-of-the-year, two-for-one special on physical checkup, etc., than to a new recognition that a practice's clients are a community with community needs that ought to be addressed. Yet the possibility for competition to stimulate real community responsiveness does exist and may provide one of the true “opportunities” of this epoch.

It appears to me that greater opportunities for community oriented 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. But some of the more important of these may now be less constraining than they have been in the past. In 1959 Dr. John Grant prepared a report for the International Cooperation Administration (ICA), the predecessor agency of AID, in which he noted a number of problems confronting health care programs in the less developed countries. Dr. Grant was at the time of this report nearing the end of his 42 years with the Rockefeller Foundation, in whose service he had worked all over the world advocating community oriented primary care, although he didn't call it by name. One of the most important of the problems, Grant noted to the ICA, was a tendency by consultants from the United States, as well as nationals trained in the United States, to “propose a type of health care organization for the less developed nations which is unsuited for their needs.” Grant wrote:

The separation of preventive medicine from curative medicine is almost a fetish in the United States. One of the earliest offenders in exporting this attitude to underdeveloped areas to the detriment of future medical progress was The Rockefeller Foundation. Curative and preventive medical care just cannot be separated in the organization of health services in the less developed countries. . . . Furthermore, the emphasis of the ICA missions in the health field have largely been directed towards (the technical aspects of health problems), with the result that the larger, more basic problems have most often not been resolved. ¹⁶

The World Health Organization issued a remarkable document for its Conference on Primary Care in 1979 at Alma-Ata. ¹⁷ This report is rich both in strategy and specifics, and much of its main theme follows directly from John Grant's earlier observations. A brief quote:

Health resources are allocated mainly to sophisticated medical institutions in urban areas. Quite apart from the dubious social premise on which this based, the concentration of complex and costly technology on limited segments of the population does not even have the advantage of improving health. Indeed, the improvement of health is being equated with the provision of medical care dispensed by growing numbers of specialists, using narrow medical technologies for the benefit of the privileged few. . . . At the same time, disadvantaged groups throughout the world have no access to any permanent form of health care. These groups probably total four-fifths of the world's population, living in rural areas and urban slums. . . . Thus, most conventional health care systems are becoming increasingly complex and costly and have doubtful social relevance.

They have been distorted by the dictates of medical industry providing medical consumer goods to society. Even some of the most affluent countries have come to realize the disparity between the high care costs and low health benefits of these systems. Obviously it is out of the question for the developing countries to continue importing them. Other approaches have to be sought.

In the Third World, where a country's total resources may be insufficient to afford access to the technology-intensive Western version of health care for more than a small fraction of the population, usually the elite in the capital city, there is now recognition that the acquisition of expensive tertiary facilities must be replaced by national policies of equal access to community oriented primary care. In countries where the political philosophy allows such a collectivist health policy, the opportunities for advancing community oriented primary care are greater now than they have ever been. The economic logic and the ethical soundness of this kind of distributive strategy, as well as some of the individual models that we can expect will be developed in these Third World countries, may well prove attractive and adaptable to other societies in the future.

In the United States the picture looks less promising. Yet if we have learned anything from the late 1960s, it is that the present state of affairs ought not to be projected as the future state. In 1967 and 1968 many of us shared the feeling that if we worked hard enough, virtually all of the nation's disadvantaged citizens would soon have access to responsive 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. ¹⁸ Fifteen years ago it didn't occur to some of us that the early momentum of the Great Society would not continue until such goals were within sight. The important lesson is recognizing that 1982 will soon be history, just as the 1960s are now.

One school of alchemy holds that history will repeat itself. This theory of historical recapitulation does not, so far as I know, lend itself to proof in the scientific era. It does invite speculation. Earlier in this nation's history an era of progressive reform—in conservation of natural resources, redistribution of wealth, restraints on free enterprise, and equal access to political participation—was interrupted by a “foreign” war. After the war came a decade of prosperity and a time of great personal self-indulgence, the first “me” decade, which merged into a period of economic “meism” with uncontrolled entrepreneurship and speculation made possible by a government that believed its motto, “the business of America is business.” Noncontrol soon led to out of control, which was followed by economic crisis and great human suffering. Out of the crisis came also a change in priorities, hope, fertile ground for new ideas, and ultimately a more humane national identity.

I do not make this historical reference as an exercise in nostalgia, nor am I hoping for a complete recapitulation of events that would necessitate another economic collapse before the next era of progress is possible. I sincerely hope that the pendulum, as it swings back, will somehow omit that portion of its arc. The pendulum will surely continue to swing, and there will again be opportunities for community oriented primary care to fulfill its promise as the best way for personal health care to improve health.

There are still people in the United States who are disenfranchised from effective health protection, disenfranchised even if their “access” to medical care, as measured by frequency of physician visits, has increased. There is still a national responsibility to promote the general welfare. And there remain advocates of the notion that relief from the pain of ill health and its prevention can be best accomplished by a single team of health workers who will attend each individual's problems while looking for ways to address such problems on a community level.

The present opportunity, it seems to me, is to further develop and share the methods of community oriented primary care so that they might be applied as widely as possible in a variety of organizational contexts—in prepaid group practice plans and private suburban practices, in urban public hospitals and rural health centers, in training programs for physicians and other health workers, in the United States and around the world. This requires a group of people who have shared the experience of doing 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.