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Chapter 1 INTRODUCTION AND SUMMARY The complexity of the health services industry in the United States has, in recent years, heightened public and professional interest in primary health care. Access to the entire range of health services has its focus on the primary care practitioner, who also is expected to coordinate the services and to assure continuity of care. The importance of an adequate supply of primary care practitioners in the U.S. began to receive increased public attention during the 1960s. By 1976 the Congress declared, in the statutory preamble to the Health Professions Educational Assistance Act, that the availability of health care in general depends largely on the availability of primary care practitioners. Because appropriate manpower resources are essential to an effective primary care strategy, the Institute of Medicine undertook the study reported here to propose recommendations that would coordinate many important aspects of primary care manpower policy and to help assure that the development of that policy is based on appropriate information. An interest in contributing to the development of a national health manpower policy was initially expressed by Institute of Medicine members consider- ing the Institute's own program in the spring of 1972. A work group on health manpower proposed a study to examine the place of primary care in the U.S. health care system, and particularly the roles of different categories of primary care professionals. This report presents the conclusions of that study, begun in 1975. POLICY ISSUES IN PRIMARY CARE Primary health care is defined in this report as accessible, comprehensive, coordinated, and continual care provided by accountable providers of health services. It is generally recognized as the first level of personal health services (as distinguished from public, environmental, and occupational health services), where initial pro- fessional attention is paid to current or potential health problems. Frequently, primary care is associated with care of the "whole person" rather than care for an illness. The term 'primary care' has gained wide usage in the present decade, although the concept is not new. In the United States, national atten- tion began to be focused on primary care in the mid-1960s. At that time 1

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a series of commission reports by health leaders in the private sector proposed the development of training programs to prepare physicians to deliver comprehensive and continual care. 1/ These reports reflected a conviction that more socially oriented care, responding to a wide range of patients' problems, was needed to complement the growing medical use of highly specialized services and technological procedures. An increase in programs to train physicians for primary care has been accompanied by increased interest in having coordinated care delivered by an interdisciplinary team of physicians, nurses, and other therapists who can provide diverse services to the patient. 2/ To supplement physician services and make primary care available to medically underserved populations, programs have been established with federal support to train nurse practitioners and physician assistants. 3/* A growing body of literature 4/ indicates that a small number of issues have been paramount in discussions of primary care policy: 1. What is the scope of primary care? How should primary care be defined? What categories of health profes- signals are primary care practitioners? 2. What would be an adequate supply of primary care practitioners? What are the dimensions of any current or projected national shortage of primary care practitioners? 3. How can an appropriate distribution of manpower be attained in order to meet nationwide primary care needs? What public financial incentives and education policies are appropriate to help assure the availability of primary care in rural areas and inner cities? What financial incentives and education policies should be used to help assure the commitment of sufficient professional manpower to primary care vis-a-vis "secondary" or "tertiary" care? *In this report, the term 'nurse practitioner' refers to a graduate of an approved continuing or graduate education program to train regis- tered nurses to become nurse practitioners. 'Physician assistants,' including MEDEX, are either graduates of approved physician assistant programs or other persons certified as physician assistants. Nurse practitioners and physician assistants are referred to collectively as "new health practitioners." 2

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4. How and where should primary care practitioners be educated and trained? What attention should be paid to primary care in the education of physicians and other health professionals? What efforts are needed, if any, to devote sufficient educational resources to primary care? How should primary care practitioners and training programs be credentialed? As a whole, these issues require the development of a comprehensive health manpower policy for primary care. Manpower considerations have been prominent in the evolution of primary care policy, partly because of the importance of education and other health manpower considerations to the reduction of primary care shortages. Also, manpower considerations are basic to primary care policy because primary care is highly labor- intensive, relying more on personal communication and perhaps less on sophisticated equipment than do "secondary" or "tertiary" levels of care. Unfortunately primary care manpower issues must still be considered without the benefit of knowing where health care stops and social services begin. Preventive and promotional health education, counseling of patients, and continuity of care are all features of primary care with important social as well as medical implications. Therefore, manpower policies developed in this and earlier reports on primary care may have to be reconsidered when the bounds of health care are more clearly defined and the effects of primary care services on health outcomes are better understood. In this report, health manpower policy concerns are linked with a range of services that includes diagnostic and therapeutic procedures and health education. SCOPE AND METHODOLOGY OF THE STUDY The conduct of this study has been based on the belief that a reasoned choice among objectives is necessary for the development of primary care manpower policy. Alternative goals and strategy options have been considered by the study steering committee and are presented in this report along with the committee's recommendations. The study mandate was to develop an ''integrated" primary care man- power policy. In the committee's view, an integrated policy embraces all major categories of primary care practitioners and serves to coordinate all important policy actions affecting their use. This report therefore addresses not only such traditional manpower concerns as public funding of education, credentialing of practitioners, and qualitative and quan- titative aspects of training programs, but also the scope of primary care services, their reimbursement, and health services research. These latter issues so deeply affect the use and supply of primary care manpower that they must be included, in the committee's judgment, in any comprehensive and integrated, primary care manpower policy. 3-

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Functions and Roles The output of the study was originally intended to be a determi- nation of both the functions of primary care and the roles of different types of professionals in primary care. Functions and roles were thought to be the appropriate bases of an integrated primary care manpower policy. Consequently, the co~uittee's first product, a definition of primary care, is an attempt to delineate primary care functions as fully as can now be done for purposes of public policy. That definition has been published as an interim report 5/ and is reproduced as Chapter 2 of this volume. The committee, however, came to believe that an explication of the roles of different professional groups was not now a practical, policy- - oriented undertaking. In primary care, such roles overlap greatly and vary among practice settings and geographic locations. Roles often are not commensurate with training and experience. Occupational roles only now are being developed for the relatively new professional categories of family physicians, nurse practitioners, and physician assistants. Moreover, the activities of different professions may be merged in a team approach to health care. 6/ Activity of the Committee The committee began its two-year inquiry with a general goal of recommending policy toward an appropriate supply of trained practitioners providing high quality primary care to all populations in the country. In order to refine that goal, the committee developed a definition of primary care and a checklist with which to determine whether a provider is delivering primary care as defined. 7/ Because of the importance of the topic and wide interest in the study, the committee early in its deliberations formally solicited ideas and opinions from nearly one hundred concerned organizations and individuals. Statements by 18 organizations and individuals were presented at a one-day open meeting of the committee at the National Academy of Sciences in Washington, D.C., in January 1976. 8/ The committee met regularly to formulate a definition of primary care and to develop recommendations about the credentialing of primary care practitioners and their legal liability, the use and acceptance of nurse practitioners and physician assistants, and the financing of primary care services. Recommendations also were developed on the supply and distribution of primary care practitioners, the day-to-day content of primary care practice, and the contribution to primary care made by professional groups other than physicians in primary care disciplines, nurse practitioners, and physician assistants. Policy options and research needs were considered in each of these areas. The committee made its conclusions on the basis of the best available data and research findings; in some areas, however, it was compelled to exercise judgment in the absence of numerical data. Information used by the committee in arriving at recommendations included 4

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published and unpublished material, papers prepared by the staff at the committee's request, presentations at the 1976 open meeting, and knowl- edge based on the committee's own expertise. No original research was undertaken by the committee. SUMMARY OF RECOMMENDATIONS Chapters 2 through 5 of this report present background discussion, policy options, and recommendations in each major area that the committee considers important to the development of primary care manpower policy. The concluding section (Chapter 6) proposes a schedule for implementing the recommendations. Each recommendation is meant to be feasible, broad enough to guide activity for several years, and important for meeting the nation's primary care needs. In Chapters 2 through 5, the essential data and evidence about the major topics are presented. These are followed by a description and evaluation of each of the policy options considered by the committee. Committee judgments, opinions, and beliefs are noted, as are the intended effects of each recommendation. Chapter 2: Primary Health Care Defined Opinions of various interested groups and existing definitions were reviewed to reach a consensus on the definition of primary care. The committee agreed that primary care should be accessible, comprehensive, coordinated, continual care delivered by an accountable provider of health services. The chapter also includes a checklist for determining whether a given health care provider is delivering primary care as defined. Chapter 3: Practice Arrangements for Primary Health Care The health problems and diagnoses most frequently recognized by physicians in primary care disciplines indicate the range of primary care services. Twenty-four diagnoses accounted in 1975 for about half of all office visits to general practitioners, family physicians, internists, pediatricians, and obstetricians and gynecologists in the United States. Visits to these physicians account for two-thirds of all office-based physician visits. Primary care is also delivered by nurse practitioners and physician assistants, approximately three-fourths of whom are employed in primary care settings. Prototypes of primary care practice arrangements include single specialty units (including family physicians), multispecialty units, family practice teams, and multispecialty teams. Teams include physi- cians and new health practitioners. Currently, three-fourths of practicing U.S. physicians work in solo or two-physician practices. The committee recommends that (Recommendation #1) because no practice arrangement has been_fou . . ~ . . , care as defined In this report should continue to De ~ e.~verea By 5

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various combinations of health care providers in a variety of practice arrangements. Diversity in delivery methods is advocated so that a flexible primary care system can benefit from a pluralistic approach to the needs of different types of communities. Chapter 4: The Supply and Distribution of Primary Health Care Practi- . . tioners Primary care manpower supplies and needs now constitute a major health policy consideration. The manpower issues include the overall supply of physicians and new health practitioners, physician specialty and geographic distribution, and monitoring and research priorities. The co~ittee notes that the supply of physicians in the United States will increase more than 60 percent by 1990 if total medical and osteopathic school enrollments continue at their current level. Physician productivity, population needs, and financial considerations make the adequacy of physician supply difficult to measure and evaluate, but the committee finds no reason to continue to increase the number of medical students across the country. However, it believes that an increasing number of future physicians should be in primary care. Pend- ing progress in determining the adequacy of physician supply, it is urged that (Recommendation #2) for the present, the number of entrants to medical school should remain at the current annual level. . . The supply of new health practitioners - nurse practitioners and physician assistants - is expected to exceed 40,000 in 1990, although only 9,500 new health practitioners had graduated from DREW formal training programs by 1976. The committee is impressed by the quality of care delivered by new health practitioners. Their productivity, potential use to medically underserved populations, ability to deliver health education and counseling, and cost-containment potential justify financial support of their training. Because of the projected rise in physician supply, however, an increase in the training rate of nurse practitioners and physician assistants now appears undesirable. In the committee's judgment (Recommendation #3), for the present, the number of nurse practitioners and physician assistants trained should remain at _ the current annual level. Reimbursement strategies were considered as a method for making primary care practice more attractive to physicians. The proportion of physicians in primary care disciplines has fallen from 94 percent in 1931 to 42 percent in 1963 and 38 percent in 1975. The committee rejects the option of increasing the number of physicians in primary care disciplines by increasing total physician supply. The committee instead proposes the following changes in reimbursement policies: (Recommendation #4) Third-party payors (federal, state, and private) should reimburse all physicians at the same payment level for the same s

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in primary care disciplines receive the same fees as other physicians for equivalent services. Higher fees would be justified only for specialty services provided on physician referral. Fee levels would be statewide under Recommendation #8. (Recommendation #5) private) should reduce the ~ primary care procedures and non-primary care procedures. The committee is not satisfied that current reimbursement practices provide adequate compensation for primary care services compared with surgery and other non-primary care services. (Recommendation #6) Third-party payors (federal, state, and private) should institute payments to practice units for those neces- sary services delivered by primary care providers and currently not reimbursed, such as commonly accepted health education and preventive - services. The delivery of comprehensive care stressing health mainte- nance is inhibited by a failure to reimburse for the full range of primary care services. Tests for efficacy and demonstration or special projects are suggested in initiating reimbursement of primary care providers for work in the prevention of illness and health education. The geographic distribution of primary care physicians is another subject addressed in Chapter 4. In the committee's judgment (Recommen- dation #7), training programs for family physicians, nurse practitioners, and physician assistants should continue to receive direct federal, _ ~ state, and private support, because these practitioners are the most feasible providers of Primary care to underserved populations. Also, some changes in reimbursement policies are advocated to encourage primary care practitioners to serve in shortage areas, although tile committee recognizes a dearth of available evidence linking reimbursement levels to physician location. The suggested changes are the following: (Recommendation #8) Third-party payors (federal, state, and private) should discontinue all geographic differentials in payment levels for physician services within a state. This recommendation would eliminate arty payment practice affording greater reimbursement to physicians in adequately served areas than to physicians in rural, underserved areas. (Recommendation #9) private) sho services at the same payment level regardless of whether the services are provided by physicians, nurse practitioners, or physician assistants. Lower reimbursement for new health practitioners suggests a two-t~ered system of care, overlooks the hign quality of services provided by nurse practitioners and physician assistants, and could hinder their employment. Practice units eligible for reimbursement could be owned by physicians, other health professionals, and private or public organizations.

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The committee also examines the importance of monitoring and researching the success of an integrated primary care manpower policy. The committee believes (Recommendation #10) that there should be an active, continuous program for monitoring a number of factors, including the numbers and specialty and geographic distribution of physicians, nurse practitioners, and physician assistants, and also for monitoring . the perceptions of the patient population regarding the adequacy and availability of primary care services. To expand and improve the knowledge base used in making decisions in primary care manpower policy, the committee finds (Recommendation #11) that an increased emphasis should be given to health services research in primary care manpower. Such research could be especially helpful in determining primary care manpower needs. It could also reveal why physicians choose to seek training and continue to practice in primary care or other specialties. Chapter 5: Education for Primary Health Care Practice Primary care education policy should assure both an adequate supply of primary care practitioners and levels of competency suitable for the task to be performed. At this time, major educational issues include percentage goals for primary care residencies, public support of primary care residency programs, the nature of primary care medical education and team training, and credentialing. Although the committee did not find an adequate data base for establishing a percentage goal for residency programs in primary care disciplines, it is inclined to believe that most physicians should be primary care practitioners, because primary care includes the management of the great majority of problems presented by patients. Therefore (Recommendation #12), the committee recommends a substantial increase in the national goal for the percent of first-year residents in primary care fields. Most committee members believe that perhaps the goal should be In the range of 60 to 70 percent while the current shortage exists. To develop graduate medical education in primary care disciplines, training facilities must be designed and faculties compensated. In the committee's view, government financial incentives are preferable to public action requiring that medical schools contribute prescribed portions of their resources to primary care training programs. The committee recommends (Recommendation #13) that federal and state govern- ments should continue to promote primary care partly by using financial incentives for the creation and support of primary care residency programs. The nature of medical education in general inhibits the development of primary care. A broad, simultaneous set of actions is recommended to assure an atmosphere better suited to primary care development. These actions include the following: (Recommendation #14) It is desirable that all medical schools direct

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Program in which residents have responsibility under faculty supervision for the provision of accountable accessible. comprehensive cons; nice 1 ant Need care. A majority of the committee asserts that analifi~d mecca ~ scuoo' graduates ShOUld be able to receive graduate training in primary care in programs affiliated with their schools. (Recommendation #15) In selecting among applicants for admission, medical schools should give weight to likely indicators of primary care career selection. Although the data and evidence are incomplete oh ~na~cacors now being Investigated include an affinity for personal service, interpersonal skills, ability to function as part of a team, and performance in behavioral and social sciences. Continued special attention should be given to admission of minority students. (Recommendation #16) students with a knowledge of epidemiology and aspects of behavioral and Undergraduate medical education should nrov;~ social sciences relevant to patient care. Medical students should be presented with an array of course material helpful to understanding and communicating with patients. This may require new courses or the inte- gration of new material into existing courses and clinical training. (Recommendation #17) Medical schools should provide all students with some clinical experience in a primary care setting. This experience might be obtained in academic medical centers, in nearby clinics or offices under faculty supervision, or under preceptorships. Primary care is a vital feature of medical education because primary care, as defined by the committee, is the level of care at which the great majority of health problems is managed. Experience in primary care clinical settings can provide medical students with role models useful for leading the students into primary care careers. (Recommendation #18) Medical schools and crimarv care training programs should teach a team approach to the delivery of primary care. The committee believes that primary care is best taught in a setting that offers patients combined professional skills and access to such services as mental health care, eye care, social support, allied health services, and efficient communication among different types of profes- sionals. In proposing credentialing policies, the committee is interested in assuring opportunity for innovation as well as promoting quality of care. (Recommendation #19) Amendments to state licensing laws should authorize, through regulations, nurse practitioners and Physician asslscants to provide medical services, including making medical diagnoses and prescribing drugs when appropriate. Nurse practitioners and physi- cian assistants in general should be required to perform the range of services they provide as skillfully as physicians, but they should not provide medical services without physician supervision. There are various opinions about degree of physician supervision required. _9 _

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Also on credentialing, the committee would promote development by the nursing profession of more uniform standards for nurse practitioner programs. The committee believes (Recommendation #20) that the nursing profession should continue to have accreditation responsibility for _ for nurse practitioner education and training, in collaboration with physicians and other health professionals. Chapter 6: Conclusions: The Schedule of Implementation The final chapter of the report emphasizes the importance of coordinating all aspects of primary care manpower policy. Chapter 6 also presents a schedule of implementation, suggesting prerequisites, time frames, and responsible groups for each recommendation of the report. STAFF PAPERS The following papers were prepared by staff members as part of the study effort.* Resource papers: These papers are comprehensive . . . on various issues as they relate to primary care the state of the art on these issues. surveys of the literature manpower. They represent LICENSURE OF PRIMARY CARE PRACTITIONERS. A discussion of the issues . . and current practices in public credentialing of physicians, nurses, and physician assistants. Strengths and weaknesses are suggested for various credentialing proposals. CONSUMER ACCEPTANCE OF NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS. A report on studies of patients' attitudes and behavior in response to care provided by these two new professional groups. PHYSICIAN ACCEPTANCE OF NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS. An analysis of studies of physician attitudes and other employment consi- derations involving use of nurse practitioners and physician assistants. Physicians' attitudes before and after working with the new health professionals are contrasted. LEGAL LIABILITY OF PRIMARY CARE MANPOWER. A review of malpractice and other legal concerns affecting the use of nurse practitioners and physician assistants. The apparent magnitude of legal risks is depicted. , *A limited number of copies of each resource paper is available on request from the Institute of Medicine, Office of Communications, at the address appearing on the back of the title page. 1 O

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Background information: This information was prepared to assist the committee in its deliberations. These papers are not intended to be comprehensive or for general use. DEFINITIONS OF PRIMARY CARE. An analysis of the content of 33 primary care 4~rit~r~; [= ji~~in the United States and five other definitions. The usage of such terms as 'accessibility,' 'comprehensive- ness,' and 'continuity' is described. PUBLIC PAYMENT FOR PRIMARY CARE SERVICES. A brief discussion at the issues in publicly reimbursing primary care physicians, nurse practitioners, and physician assistants. The issues focus on the effects of present and possible alternative reimbursement mechanisms on physician geographic distribution, physician specialty distribution, and utilization of nurse practitioners and physician assistants. EDUCATION OF PRIMARY CARE PRACTITIONERS. A discussion of the educa- tion and training of primary care physicians, nurse practitioners, and physician assistants. Topics covered include numbers and types of students, costs, curricula, and federal support. ROLES OF OTHER PROFESSIONS IN PRIORY CARE. A description of the contributions made to ~ delivery by selected professional groups, such as dietitians, social workers and physical therapists. The paper presents conclusions of the committee. Selected data sources: These papers contain a description of the data suurc~s considered and used by the committee. They were not prepared for general use. An EVALUATION OF DATA SOURCES ON THE CONTENT OF MEDICAL PRACTICE. . An assessment of the major studies of medical practice in the United States. The paper concludes that the National Ambulatory Medical Care Survey is now the most useful study for examining primary care physician practice. DATA ON THE SUPPLY AND DISTRIBUTION OF PRIMARY CARE PHYSICIANS. A report on available data describing physician specialty distribution and the geographic placement of physicians in primary care disciplines. Particular attention is paid to the geographic distribution of family physicians, general practitioners, internists, and pediatricians. The state of the art in the collection and analysis of physician distribu- tion data is briefly described. A COMPILATION OF DATA ON THE CONTENT OF PRIMARY CARE PRACTICE. A review of available information rac- teristics, and patient visits provided by family physicians, general practitioners, internists, pediatricians, and obstetricians and gyne- cologists. Information from the National Ambulatory Medical Care Survey, the National Diagnostic and Therapeutic Index, and other data sources are analyzed. 11

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DATA ON THE ROLES OF THE PHYSICIAN ASSISTANT AND NURSE PRACTI- TIONER. A review of research on roles of the new health professionals. Nurse practitioner and physician assistant productivity data also are examined . -12- -

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References . Chapter 1 1. Citizens' Commission on Graduate Medical Education, Report, The Graduate Education of Physicians, by John S. Millis, Chairman (Chicago: American Medical Association, 1966~; Ad Hoc Committee on Education for Family Practice of the Council on Medical Education of the American Medical Association, Report, Meeting the Challenge of Family Practice, by William R. Willard, Chairman (Chicago: American Medical Association, 1966~; Committee on Medical Schools and the Association of American Medical Colleges in Relation to Training for Family Practice, Report, 'planning for Comprehensive and Continuing Care of Patients Through Education," by Edmund D. Pellegrino, Chairman, Journal of Medical Education 43 (1968~: 751-9. 2. Lowell T. Coggeshall, Report, Planning for Medical Progress Through Education (Evanston, Illinois: Association of American Medical Colleges, 1965). 3. See Chapter 4. 4. Particularly significant works on primary care include Joel J. Alpert and Evan Charney, The Education of Physicians for Primary Care, DREW Publication No. (HRA) 74-3113 (19739; Spyros Andreopoulos, ea., Primary Care: Where Medicine Fails (New York: John Wiley and Sons, 1974~; Association of American Medical Colleges, "Proceedings of the Institute of Primary Care" (Washington, D.C.: 1974~; and Philip R. Lee, Lauren LeRoy, Janice Stalcup, and John Beck, Primary Care in a Specialized World (Cambridge, Mass.: Ballinger Publishing Co., 1976~. 5. Institute of Medicine, "Primary Care in Medicine: A Definition" (Washington, D.C.: National Academy of Sciences, 1977~. See Chapters 2-5 and staff papers, "Education of Primary Care Prac- titioners," '~Data on the Supply and Distribution of Primary Care Physicians," "A Compilation of Data on the Content of Primary Care Practice," "Data on the Roles of the Physician Assistant and Nurse Practitioner," and "Licensure of Primary Care Practitioners." 7. See Chapter 2. -13-

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8. Each organization or individual invited to the open meeting was asked to submit a paper suggesting references, areas of inquiry, and important policy considerations. Submitted papers were reviewed by the committee, which selected 18 of the papers for presentation at the meeting. In addition, all 73 of those who attended were afforded the opportunity to address the committee with brief statements or questions. -14-