guiding our developing thoughts on the appropriate roles and relationships of both public health and primary care, however.

Over the past two decades, our understanding of public health and primary health care has gone through a number of important transitions. It is important to acknowledge, at this juncture, that public health and primary health care have each developed as distinct and largely unrelated (somewhat competitive) cultures over the past 80 years. It may now be important to develop a more integrated view of the two, however, because these distinct cultures are increasingly being forced to operate together as a result of a series of broader market reforms. Increasingly, these market reforms emphasize the development of competitive managed care programs and strategies to organize and provide integrated health care and preventive services at controlled cost and quality to defined populations, including most of those formerly cared for directly by local and state health departments. This can be seen by the increasingly rapid transition of Medicaid populations to a broad range of managed care programs over the past decade. In this context it is also important to acknowledge the seeming preference of our political system to seek market-oriented solutions to complex health care problems.

As a result, the public health of the past will increasingly become the population health of the future and the primary care of the past will increasingly become the clinical and preventive primary care and community-based medicine of the future. The combination of the two—working more closely (if not always in absolute harmony) in partnership with each other, with integrated health delivery systems, and with market-oriented financing systems to improve the health of the same populations—is increasingly likely to evolve toward the integrated community health system of the future.

In 1994 the IOM began its most recent exploration of primary care by clarifying its use of the term as one that "focuses on the delivery of personal health services" (2). This focus builds on the IOM's earlier conceptualization of COPC:

[By 1984 the notion of] community oriented primary care … [had evolved as] … "a strategy whereby the elements of primary health care and of community medicine are systematically developed and brought together in a coordinated practice" [Abramson and Kark, 1983, p. 22]. [It was also] the provision of primary care services to a defined community , coupled with systematic efforts to identify and address the major health problems of that community through effective modifications in both the primary care services and other appropriate community health programs [italics added] (1, p. 2; 2, p. 12).

IOM's most recent formal definition of primary care combines concepts contained in both paragraphs, above:

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 (2, p. 15).



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