committee's observations about the current trends and characteristics of U.S. health care that form the current context for the delivery of primary care. The second section contains the committee's conclusions and recommendations about changes needed to improve the delivery of primary care in order to realize more fully the potential of primary care to improve the health and satisfaction of patients.

Current Pathways For Primary Care

The rapid pace of change and the diversity of local circumstances are striking characteristics of current health care. Descriptive evidence about current directions of health care, augmented by the committee's five site visits, confirms the magnitude and rapidity of those changes. Ours is a health care system going through a major transition. From an era of growth in expensive services supported by open-ended financing, wide choice of clinicians and hospitals, and almost complete freedom for clinical judgment, the U.S. health system is moving quickly into an era of limits on resources, cost-based competition among health plans and providers, financial risk-sharing by providers, and constraints on patient choice of clinician. No one can predict accurately where the health care system will be in 5 years, let alone 10 or 20 years. Simple generalizations informed by past studies, even studies only a few years old, are limited in their ability to describe or explain current directions in health care. Yet we believe that broad pathways for that change can be identified and need to be taken into consideration.

Some studies have identified stages of the health care market that imply a progression toward "mature" markets (University Hospital Consortium, 1993)—essentially those dominated by a handful of large, fiercely competitive health plans. The committee is wary, however, of any interpretation that such a progression is an orderly one. In visiting several areas of the country that are usually considered more mature health care markets (e.g., Minnesota and southern California), committee members observed that the pace of change continues to be rapid. Wherever these markets are going, they are not there yet.

With these cautions and caveats, we do see broad themes, both in what is happening and in what has not happened.

Spread of Managed Care

The term managed care has come to have many meanings. This committee uses managed care to refer to health plans that have a selective list of providers, both health professionals and hospitals, and that include mechanisms for influencing the nature, quantity, and site of services delivered. Many of these plans have focused initially on using their market power to obtain discounts from physicians, hospitals, and other providers in an oversupplied market. They are

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