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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."
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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.
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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
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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
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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.
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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.
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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.
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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-
Representative terms from entire chapter:
care manpower
