and hospitals that support the expanded use of medical technologies; and a training system based in specialized care settings. Prior reports by the IOM (1978) and other organizations (e.g., the Physician Payment Review Commission [PPRC] in its annual reports of the 1980s and 1990s; the Council on Graduate Medical Education [COGME] in its periodic reports over the same time period) have documented these trends and demonstrated how, until fairly recently, they overwhelmed the factors that promote primary care.

Today, powerful economic forces in the health care market, especially the actions of large purchasers of group health benefits, are driving a shift away from specialized services and toward primary care. In the absence of comprehensive health care reform, these market forces are likely to remain dominant in reshaping health care. Because cost is the major concern behind these market forces, primary care is seen as desirable because it is less expensive. Although wholeheartedly endorsing the emphasis on primary care, the IOM study committee appointed to produce this report (see below) is concerned about spotlighting primary care as a means to control the use of expensive, specialized services rather than as a better way to meet the health care needs of people.

In the longer run, the American people will accept only a system that meets their needs for good health care, and they will resist changes that are perceived as aimed principally at controlling costs. The committee believes that primary care is the foundation of that health care system—one that is effective and responsive as well as efficient in the use of expensive resources. Medical science will continue to improve its ability to diagnose and treat diseases, but primary care can assure that advances in diagnosis and treatment are used in a way that emphasize personal values in our diverse society; that emphasize health promotion, disease prevention, and early intervention; that enhance the ability of the individual to maintain effective functioning in daily life; and that facilitate links among individuals, their families, and their communities.

In this report, the committee sets out its vision of primary care, taking full advantage of the forces that have brought primary care to the fore after decades in eclipse. Its focus is on ensuring that primary care is shaped by concern for meeting people's needs for health care in the best traditions of the health professions. This vision includes continuous innovation and improvement in the performance of the health system. The committee cannot answer all questions that might arise about primary care, but it can and does identify the directions in which to go and the means by which to get there. As laid out in this report, these objectives include:

  • a clear definition of the function of primary care that can guide public and private actions to improve health care;
  • organizational arrangements for health care that are built on a foundation of strong primary care and that facilitate the coordination of the full array of services essential for maintaining and improving individuals' health status;

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