Part 2

Earlier Definitions of Primary Care: A Review

Interest in Primary Care

In the mid-1960s, a series of reports focused concern on the rapid decline in the availability of general physicians (the “general practitioner, ” or “GP”), who before the 1950s had provided the majority of care in solo practices (Millis, 1966; Lee, 1992). An explosion of new medical knowledge and new technologies had resulted in an increasing number of specialties and specialists. The development of multispecialty group practices became widespread and was accompanied by a rapid decline in the number of physicians choosing general practice as a career. At least partly in response to concern about the decline of general practice, the specialty of family practice emerged. New types of health professionals—such as nurse practitioners and physician assistants—also arose and became integral to health care delivery. New public policies were aimed at increasing both the total number of physicians and other health care practitioners and the number of primary care physicians, the latter through support of residency programs in family practice, general internal medicine, and general pediatrics. Other programs supported the training of nurse practitioners and physician assistants.

Categories Used to Define Primary Care

Since its introduction in 1961, the term primary care has been defined in various ways, often using one or more of the following categories to describe what primary care is or who provides it (Lee, 1992; Spitz, 1994). These categories include:



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Defining Primary Care:: An Interim Report Part 2 Earlier Definitions of Primary Care: A Review Interest in Primary Care In the mid-1960s, a series of reports focused concern on the rapid decline in the availability of general physicians (the “general practitioner, ” or “GP”), who before the 1950s had provided the majority of care in solo practices (Millis, 1966; Lee, 1992). An explosion of new medical knowledge and new technologies had resulted in an increasing number of specialties and specialists. The development of multispecialty group practices became widespread and was accompanied by a rapid decline in the number of physicians choosing general practice as a career. At least partly in response to concern about the decline of general practice, the specialty of family practice emerged. New types of health professionals—such as nurse practitioners and physician assistants—also arose and became integral to health care delivery. New public policies were aimed at increasing both the total number of physicians and other health care practitioners and the number of primary care physicians, the latter through support of residency programs in family practice, general internal medicine, and general pediatrics. Other programs supported the training of nurse practitioners and physician assistants. Categories Used to Define Primary Care Since its introduction in 1961, the term primary care has been defined in various ways, often using one or more of the following categories to describe what primary care is or who provides it (Lee, 1992; Spitz, 1994). These categories include:

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Defining Primary Care:: An Interim Report The care provided by certain clinicians—the Clinton administration's Health Security Act, for example, named the medical specialties of primary health care as family medicine, general internal medicine, general pediatrics, and obstetrics and gynecology. Some experts and groups have included nurse practitioners and physician assistants (OTA, 1986; Pew Commission, 1994). A set of activities whose functions define the boundaries of primary care—such as curing or alleviating common illnesses and disabilities; A level of care or setting—an entry point to a system that includes secondary care (by community hospitals) and tertiary care (by medical centers and teaching hospitals) (Fry, 1980); ambulatory versus inpatient care; A set of attributes, as in the 1978 IOM definition—care that is accessible, comprehensive, coordinated, continuous, and accountable—or as defined by Starfield (1992)—care that is characterized by first contact, accessibility, longitudinality, and comprehensiveness; A strategy for organizing the health care system as a whole—such as community-oriented primary care, which gives priority to and allocates resources to community-based health care and places less emphasis on hospital-based, technology-intensive, acute-care medicine (IOM, 1984). No one category incorporates all the dimensions that people believe are denoted by the term, and this has resulted in a lack of clarity and consensus about the meaning of the term. A clue to the difficulty lies in an ambiguity of the word primary, as noted in a background paper prepared for this report by Safran (1994). If primary is understood in its sense of first in time or order, this leads to a relatively narrow concept of primary care as “first contact, ” the entry point, or ground floor of health care delivery. This meaning of primary can connote only a triage function in which patients are then passed on to a higher level of care. If, on the other hand, primary is understood in its sense of chief, principal, or main, then primary care is better understood as central and fundamental to health care. This idea of primary care supports the multidimensional view of primary care envisioned by this IOM committee. This IOM committee thus reaffirms the importance of continuing to define primary care as multidimensional; it cannot be defined on the basis of a single dimension, as attractive as this might be for policymakers who formulate workforce policy and must decide who does or does not provide primary care. This exigency, faced by policymakers, has led to reliance on criteria based on, for example, residency training, care setting, or level of care (e.g., first contact). While fully acknowledging the need for a clearer sense of primary care to guide policymaking at the national and state level, the committee believes a careful but multidimensional view of primary care will permit a far richer discussion of organizational opportunities, professional development and satisfaction, health curricula reform, and improved health care than any single-dimension definition.

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Defining Primary Care:: An Interim Report Given this belief, the committee draws on an extensive literature that includes a number of key articles on primary care. Early Definitions The notion of the primary physician providing continuing and comprehensive care was introduced very early. According to what became known as the Millis Commission report (1966), the primary physician . . . will serve as the primary medical resource and counselor to an individual or a family. When a patient needs hospitalization, the services of other medical specialists, or other medical or paramedical assistance, the primary physician will see that the necessary arrangements are made, giving such responsibility to others as is appropriate, and retaining his own continuing and comprehensive responsibility (Millis, 1966, p. 37). It also emphasized the need to focus “not upon individual organs and systems but upon the whole man, who lives in a complex social setting. . . .” (Millis, 1966, p. 35). From 1966 to the late 1970s variations and refinements of this concept appeared. In a classic monograph, Alpert and Charney (1973) described the three fundamental characteristics of primary medicine (defined as the personal health system of individuals and families, as distinguished from public health): Its clinicians (1) provide first-contact care (as compared to that based on referral), (2) assume responsibility for the patient over time regardless of the presence or absence of disease, and (3) serve as the “integrationist” (serve a coordinating role). They also believed that it was preferable that all family members be cared for by the same physician. The First IOM Definition In 1978, the IOM published a report entitled A Manpower Policy for Primary Health Care: Report of a Study. The second chapter, which had been released a year earlier as an interim report, defined the essence of primary care as it should and could be practiced: “accessible, comprehensive, coordinated and continual care delivered by accountable providers of personal health services.” That definition has been widely quoted and used. It has also proved useful as a touchstone for guiding the assessment of primary care. The report elaborated on each component of the definition, as shown in the Appendix to the present report and as discussed further in Part 3 below.

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Defining Primary Care:: An Interim Report Distinguishing Public and Personal Health Services Meanwhile, work by McKeown (McKeown and Lowe, 1966) and others led to a better understanding of socioeconomic, environmental, and behavioral factors affecting the health of individuals and populations. In a 1974 report, Canadian Minister of Health Marc Lalonde emphasized the importance of health promotion and disease prevention (Lalonde, 1974). Subsequently, the notion of primary care was expanded to the point where the World Health Organization conference at Alma-Ata (World Health Organization [WHO], 1978) defined primary health care as essential health care . . . made universally accessible to individuals and families in the community . . . through their full participation and at a cost that the community and country can afford [WHO, 1978, p. 3]. This definition, while appropriate for countries more in need of basic public health, takes the notion of primary care beyond what this IOM committee intends. The committee therefore distinguishes between two terms: (1) primary health care as defined by WHO, which includes such public health measures as sanitation and ensuring clean water for populations; and (2) this committee's term primary care, which focuses on the delivery of personal health services. For this reason, this interim report addresses personal health services and not population-based, public health services. There are, however, vital and important linkages that must be developed between primary care and public health programs that will be addressed in the full IOM report. The committee also notes the increasing intersections and changing connections between public health and personal health care delivery that are occurring as the country renews attention to the kinds of services that should be provided in the two sectors. Services such as childhood immunization that are now provided in the public health sector to individuals and communities who have no other source of care, may, under new forms of health care, be better provided a within primary care practice. The full report will address the complex issues regarding the boundaries and overlaps between primary care and public health. The 1984 Report on Community-Oriented Primary Care Abramson and Kark (1983) pioneered an emphasis on communities and their connections with health practitioners. They viewed community-oriented primary care (COPC) as “a strategy whereby elements of primary health care and of community medicine are systematically developed and brought together in a coordinated practice” (p. 22) to facilitate community diagnosis, health

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Defining Primary Care:: An Interim Report surveillance, monitoring, and evaluation. They pointed out that such an approach requires knowledge of the demographic, socioeconomic, and cultural characteristics of communities. A study completed by the IOM in 1984 addressed COPC. That report described community-oriented primary care operationally as 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 [IOM, 1984, p. 2]. According to that report, primary care practitioners strive to deliver to their active patients (the “numerator” in a COPC context) effective and appropriate health services. The word community as used by the COPC committee meant any group of people that the practice or program might reasonably expect to cover. It did not mean, however, the community defined solely in terms of the practice 's active patients. The study directed its attention toward communities that included both users and nonusers of primary care services—the “denominator” in epidemiologic terms. An operational COPC model must satisfy three criteria. There must be (1) a primary care practice, (2) an involved and definable community, and (3) a set of activities that systematically address the major health issues of the community. In its case studies at that time, the IOM COPC committee found no fully developed example of COPC. However, efforts to implement COPC continue in many countries, including the United States. A 1992 Assessment of U.S. Primary Care In her recent book, Primary Care: Concept, Evaluation, and Policy (1992), Starfield emphasizes four elements of primary care derived from the Millis Commission report and the 1978 IOM definition: (1) first-contact care and gatekeepers; (2) longitudinality and managed care; (3) comprehensiveness and benefit packages; and (4) coordination and the referral process. She uses those four elements to specify important aspects of primary care and to conduct cross-national comparisons of primary care in 10 countries. The degree to which systems achieved the four elements of primary care varied considerably. Her analysis of primary care in the United States revealed a health care system based predominantly on unregulated, fee-for-service practice, and her rating of the attainment of primary care in the United States was the lowest of the 10 countries in which primary care was measured.

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Defining Primary Care:: An Interim Report Changes in Health Care Delivery Today The health care system, health policy, and health professional curricula in the United States are undergoing a period of rapid change. These shifts, particularly those that involve integrated delivery systems, could not have been reflected in the Millis Commission report, Alpert and Charney's 1973 monograph, the earlier IOM reports, or Starfield 's analysis of primary care. The development of integrated delivery systems means that primary care cannot be defined or assessed in isolation from the overall system of which it is part. Such systems involve physicians and other clinicians and the facilities they use to deliver a full array of services, for a fixed price, to a defined population, in settings that are most appropriate to patients' needs. Integration in this sense may be thought of as “vertical” (linking all levels of care that may be needed by a defined population, e.g., home, doctor 's office, hospital); it may also be “horizontal” (linking similar levels of care across communities, regions, or states (e.g., multi-hospital entities). Such horizontal integration is also occurring among clinicians. Through contracting arrangements, practitioners are encouraged (or often required) to use a given set of facilities, referral arrangements, and financial accounting and information systems. Through employer-based or government health plans, individuals are often given strong financial incentives to seek care from those same facilities and clinicians. In such health systems, the attributes of primary care specified in the 1978 IOM definition—accessibility, comprehensiveness, coordination, continuity, and accountability (see appendix)—also become attributes of the entire system. The trend in many communities, especially in larger health care markets, seems to be toward more formal arrangements that go beyond financial incentives and utilization management toward the active management of care through integrated delivery systems. The catchall term managed care has been used to describe arrangements that include a variety of delivery systems that range from fully integrated systems of health care delivery, such as those just described, to relatively loose financial arrangements that do not constitute truly integrated delivery systems. In the latter, managed care often is used to refer to cost management by conventional insurance plans (sometimes called network plans) that use strategies such as preadmission review and case management as their chief utilization management strategies (IOM, 1993). Another example of a narrow interpretation is provided by some contracting arrangements for the care of Medicaid beneficiaries. These plans stipulate only that individuals sign up with (or be assigned to) clinicians who are designated as their primary care providers and who authorize access to other health services. Those clinicians may be put at risk financially for use of specialty services as an incentive against their use. Plans such as these, which organize only financial arrangements and incentives,

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Defining Primary Care:: An Interim Report are managing costs only. It is, however, the trend toward truly integrated delivery systems that forms the context for the committee's definition of primary care and for its further deliberation for the full report.