. "E Life in the Kaleidodscope: The Impact of Managed Care on the U.S. Health Care Workforce and a New Model for the Delivery of Primary Care." Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press, 1996.
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of nurse practitioners and physician assistants. Successful development of the team delivery concept will require development of economic incentive systems that reward team effort. To stimulate thought about the challenges that a team concept produces, this paper presents an innovative model of team health production. Finally, the workforce modification suggests the need for an ambitious research agenda: one that deals with micro- and macro-issues of team and workforce composition, organizational forms and incentives, practice context, and overall health care policy.
In response to the projected excess supply of physician specialists,1 the rapid growth of managed care,2 and continued pressure to limit increases in health care costs, the organization of the U.S. health care workforce is likely to undergo dramatic change over the next few decades. Virtually all of the major workforce components are subject to reconfiguration. In broad terms, what will this reconfiguration look like? What are the implications of this reconfiguration for the previously established ideas about how to assess health workforce needs? What should a research agenda for the next few decades look like at this stage of the reconfiguration?
This paper addresses these questions with a special emphasis on primary care as defined by the Institute of Medicine (Institute of Medicine, 1994). The IOM definition emphasizes the integration of services and supports the team delivery of primary care.3
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (Institute of Medicine, 1994, p. 1).
Although most recent forecasts of physician supply have predicted a surplus of physician specialists (Gamliel et al., 1995; Kohler, 1994), some researchers believe that advancements in medical technology and other factors will create shortages of physicians (Schwartz, Sloan, and Mendelson, 1988; Schwartz and Mendelson, 1990). As explained elsewhere in this paper, projections of the size and composition of the future health care workforce are sensitive to assumptions about patient utilization patterns, use of nonphysician clinicians, and other factors.
For the purposes of this paper, managed care is defined as health plans and products that involve the integration of health care financing and delivery systems.
Although this definition does not explicitly mention teams, Chapter 2 of the 1994 IOM report discusses the importance of team structures in primary care (Institute of Medicine, 1994). "Team" is a broad term that connotes a collaborative grouping of individuals whose clinical, managerial, and interpersonal skills can be brought to bear on individual or family health. The composition of the team will vary according to the type of individual or population served. Although teams are often organized in a hierarchical manner, IOM conceives of teams as more democratic, interdisciplinary structures in which clinicians rotate leadership and accountability depending on the patient situation.