Health care reform proposals at the federal and state levels call for a higher proportion of primary care clinicians than now exists. Efforts to overcome nonfinancial barriers to health care for rural and disadvantaged populations have also frequently focused on the need for primary care services. In the private sector, managed care plans that emphasize the role of the primary care clinician as the pathway to care are growing quite rapidly, encouraged by employers and state governments, which view them as a means of moderating cost increases.

These changes come at a time of conflicting notions of how health care is and should be provided. In the first half of this century, personal health care was viewed as care provided by a physician to a patient who had long been known to the physician and with whom a trusting relationship had developed. The patient's concerns were understood in the context of family and community. This perspective derives from a time when technology and medicine had less to offer; medical knowledge was less organized by specialties; the general population was less mobile; costs of care were not of paramount importance; and corporate interests were little involved in the practice and financing of health care.

Since that time, health care has changed substantially. Most people in the United States are now accustomed to a high-technology, episode-based approach to health care, often provided by an array of specialists whose focus is more on an organ or a disease than on the whole person. Changes in insurance and employment may require frequent changes in health care providers. Corporations with stockholder interests are now involved in every facet of health care. Many uninsured and inner city residents have no regular source of care, or they may depend on a local emergency room or public clinic. Such approaches to care can easily result in conflicting advice, redundant or excessive use of technology, missing and fragmented information that can affect clinical decisionmaking, and disruption of personal relationships between patients and clinicians. In short, the notion of health care that prevailed in the early part of this century seems to have little counterpart in today's world, and the challenge is to transfer to today's society the trusting relationships we still value.

The nation is now grappling with how to create systems of care that are and will continue to be consistent with what it values—including personal relationships—in health care delivery. It does so within the changing realities of growth of specialized knowledge and techniques, concern about costs of health care, and the growth of large health care plans and integrated delivery systems. Sustaining the kind of health care that people want and that we, as a society, can afford will require uniquely American solutions that recognize this country 's particular methods of financing and organizing services, its admiration for technology, and its preferences for freedom to choose providers of care.

Across the country, medical practices and health plans are devising ways to achieve these goals, and the resulting systems will undoubtedly vary greatly.



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