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Being a Tulane Medical School alumni, I get a lot of information regarding my alma mater (mostly implying I should donate money). I was heartened to be spammed with a story about the growing clinical presence in community health centers. I have written in the past about the possibilities in such partnerships and have been following Tulane’s progress for several years. They are now involved in multiple sites (website found here) and have plans to expand even further.

I sent a copy of the article to my boss and he wanted to hear what I thought we could do if we chose to emulate Tulane. After some thought, I decided we might focus on these areas:

  • Tulane made a decision to partner with Community Health Centers in part because they were able to draw down resources for caring for the poor better than they could through the old Charity Hospital system . USA Family Medicine should consider partnering with a  Community Health Center and creating a Teaching Health Center under their umbrella. This would enable us to work with Medicaid/Medicare more effectively and use the additional resources to improve the program.
  • Here in Mobile, the community safety net needs to focus on health, not illness (as happened in New Orleans after Katrina). South Alabama needs to be the leaders in this. Someone needs to initiate and carry out a discussion regarding the health of our community, and who better than a medical school. We at South Alabama have focused our energy on taking care of sick people in the hospital and that is not where care will take place in the future.
  • Our medical school should add an emphasis on training learners to care for folks with chronic illness in a non-hospital setting and what better location to do it in than a well run Community Health Center. An article published last week in NEJM demonstrated excellent diabetic care could be accomplished in Community Health Center settings. Why shouldn’t students learn about this first hand?

In short, health care delivery is changing. New Orleans, as a result of a man made tragedy, has had to face some tough choices. Regarding health care delivery, the city seems to be better for it. I hope it doesn’t take a tragedy for the rest of us to take a hard look at our care delivery efforts.

As I have written before, the Teaching Health Center is seen as a way to move education into the community (using Community Health Centers as a training resource) and out of the Academic Health Center. Currently, 20 million Americans receive care in a CHC. They serve Americans who are unable to obtain access through more traditional means, either because of location (the community will not support traditional healthcare) or socioeconomic barriers. They provide primary medical care but also provide dental, mental health and substance abuse, pharmacy, health education, and other services that facilitate access to care, such as translation, transportation, and case management. In an expansion begun by President George W. Bush and continued by President Obama, they are receiving a huge increase in funding and are poised to work with academicians such as myself to help train the physician manpower necessary to succeed in this expansion.

This is good news, right? For those of you who have been following the health care debate, this is the worst nightmare of some. Americans like to be able to pay money for a perceived increase in value. If you don’t believe me, just look at the number of different cigarette brands that were used to sell a product that only does two things (deliver nicotine and shorten life expectancy). If we were to treat health care as a utility such as electricity then we would all get the same thing. After all, rich people seem happy with the same electricity and fire coverage as poor people so they ought to be satisfied with the same health care as well.

I don’t see all Americans queuing up (as the Brits do) for health care at the local community health center. My clinical practice is in a location that serves all types of patients and I can report that my patients are willing to come to my office and sit next to others who are there regardless of their ability to pay. I can also report that there are some who would prefer a less egalitarian environment.

Joe Sherger has described a tiered system that I believe is how primary care will break as well. He sees two distinct types of primary care practices:

Organized Team Model – Each PCP covers a large panel of patients (2000 or more) with one or more mid-level providers and others on site such a care manager, care coordinators, pharmacist and others.

Relationship Centered Model – Each PCP is a personalized care physician and has a smaller panel size (600-1200) with an activated medical assistant as care coordinator and a “neighborhood” of team members helping to coordinate care.

Our practice looks a lot like the first and I’m very comfortable with that. We are in an area of high need and using this model we can deliver services to the largest number of patients.  Joe has a different type of practice based on the second model that works as well.

As we design training expereinces for physicians, we will need to keep in mind that one size does not fit all. All people need a good primary care doctor and all doctors need to be paid what they are worth. It is likely that the practice experience may be different for different people.