The Primary Care Extension Service

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The heath reform bill that will come out of the Senate HELP Committee http://help.senate.gov/BAI09A84_xml.pdf looks to be seriously flawed, although it will include a public option. The New York Times reports that after “The health committee’s blueprint builds on an incomplete version that was much criticized two weeks ago when the Congressional Budget Office reported that it would cost more than $1 trillion over 10 years and still leave up to 37 million Americans uninsured….Senator Edward M. Kennedy of Massachusetts, the health committee chairman, and Senator Christopher J. Dodd of Connecticut subsequently filled in details of the plan and scaled back subsidies that would help low-income people buy insurance.” http://www.nytimes.com/2009/07/03/health/policy/03health.html?_r=1&ref=health

Super. So in response to an inadequate bill that cost too much, they will cut the subsidies to the poorest Americans, likely leading to “coverage” that will be grossly inadequate, rather than cut the subsidies to the insurance industry by creating a single-payer plan that, as I have repeatedly pointed out, would cover everyone and cost much less. The savings would be in part in insurance company profit, but much more in the elimination of the enormous bureaucratic infrastructure that providers must have in place to bill and collect from insurance companies whose corporate goal is to pay as little as possible while avoiding covering those who really need it – the seriously ill. There could be little more inimical to the public’s health than a system run by insurance companies whose goal is not to spend more in the most efficient way possible to get maximal health for the population, but rather to game the system in such a way as to collect maximal premiums while paying out as little as they can get away with, even if that means “rescissions” of coverage – cutting people off when they get sick, as pointed out in the testimony of former CIGNA executive Wendell Potter before the Senate Commerce, Science, and Transportation Committee June 24 http://commerce.senate.gov/public/_files/PotterTestimonyConsumerHealthInsurance.pdf.
While the HELP Committee proposal will include a public plan, it will not significantly save money because the billing and collecting infrastructure will have to remain. In addition, it is likely that the insurance companies will continue to be happy to allow the public sector to cover the highest risk, sickest people – which will make it look less “efficient” and increase the cost.

However, there is at least one VERY good part to the HELP Bill. This is Section 455, http://help.senate.gov/BAI09A84_xml.pdf p 572, which calls for the establishment of Primary Care Health Extension Services. Obviously based on the enormously successful Cooperative Agricultural Extension Services, run by states usually through their land-grant university, such services would work to enhance the primary care infrastructure in rural areas by consultation and assistance in development of efficient operation, electronic health records, collaborative practice, and other areas which small rural practices usually lack the size to implement. “The Primary Care Extension Program shall provide support and assistance to primary care providers to educate providers about preventive medicine, health promotion, chronic disease management, mental health services, and evidence-based and evidence-informed therapies and techniques, in order to enable providers to incorporate such matters into their practice and to improve community health by working with community-based health connectors…” (referred to in this section as Health Extension Agents’).” The Health Extension Agent “…means any local, community-based health worker who facilitates and provides assistance to primary care practices by implementing quality improvement or system redesign, incorporating the principles of the patient-centered medical home to provide high-quality, effective, efficient, and safe primary care and to provide guidance to patients in culturally and linguistically appropriate ways, and linking practices to diverse health system resources.” This is definitely an idea whose time has come; using the Agricultural Extension model for support of primary care makes perfect sense.

Some such programs have already been piloted in a variety of states, including New Mexico, Oklahoma, and North Carolina, or regions, such as northern California. These programs are discussed in a recent JAMA article by Grumbach and Mold[1], which also contains much of the justification for their use http://jama.ama-assn.org/cgi/content/full/301/24/2589 . One model, New Mexico’s Health Extension Rural Offices (HEROs) were explicitly “…developed to improve community health and have close ties with the existing US Department of Agriculture extension service. HEROs are a partnership among the University of New Mexico’s Office for Community Health, New Mexico State University extension offices, County Health Councils, the state’s AHECs, community health centers, the Indian Health Service, community hospitals, rural family medicine residency programs, and a primary care practice– based research network. HEROs are strategically located in underserved rural counties and use county health report cards to guide interventions to address the primary determinants of health and illness.” These county health report cards, available at http://hsc.unm.edu/community/CountyReportCards/documents/CountyReports09.pdf, provide an excellent model for understanding community health status and the programs that might be developed to address them.

In addition, the HEROs programs emphasize the use of these health extensions to develop primary care workforce education pipeline programs.The 4-H program, a large part of most cooperative agricultural extension programs, is a great model for health careers pipeline programs. To physicians and other health care providers in underserved rural (as well as urban) areas, we are going to need to both create and maintain interest among young people in these areas, convince them that they can become health professionals, and develop strong programs for academic and social support that they will need to be successful. Along with the support for rural practices, the “county” (or multi-county) Health Extension agents can harness the enthusiasm of rural youth, their knowledge of genetics based on livestock breeding, and their interest in serving their communities. The communities themselves will certainly be enthusiastic supporters of such efforts.

Whatever the other limitations of the HELP committee bill may be, its recognition of an support for the patient-centered primary care medical home, and the development of primary care extension services to facilitate them, along with enhanced educational pipeline programs for health careers, are extremely important and creative advances in enhancing the health of the public.

[1] Grumbach K, Mold JW, “A health care cooperative extension service: transforming primary care and community health”, JAMA 2009;301(24):2589-91.
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