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Chapter 3 PRACTICE ARRANGEMENTS FOR PRIMARY HEALTH CARE Primary care, as defined in Chapter 2 of this report, is delivered by various categories of health professionals 1/ in a variety of practice arrangements or units ranging from solo to large medical group practices. 2/ The suitability of some prototypes of practice arrange- ments and their appropriateness for the delivery of primary care are examined in this chapter, following a brief description of the health conditions encountered in primary care practice units, and the physi- cians, physician assistants, and nurse practitioners providing primary care today. CONTENT OF PRIMARY CARE PRACTICE Currently, primary care is being delivered in physicians' offices, hospital emergency rooms, hospital outpatient departments, clinics, neighborhood health centers, and other provider units. 3/ Although hospital settings are one site for rendering primary care, 4/ most is still delivered in physicians' offices. 5/ Of the more than one billion visits made to physicians annually in the United States, approximately 60 percent are made to office-based physicians. 6/ With available data, visits to office-based physicians may be described either from the patient's perspective (presenting problems) or from the physician's perspective (diagnoses). Although patients visit office-based physicians for many reasons, few types of presenting problems account for a large proportion of the visits. The five most frequent problems presented by patients account for approximately 19 percent of the visits, and only 21 different pre- senting problems account for about 50 percent of the visits. 7/ However, a single complaint can be due to many different causes. Abdominal pain, for example, can be symptomatic of several different physical dysfunc- tions, psychological stress, or both. The description of primary care obtained from an analysis of physicians' diagnoses is similar to the patients' characterization. Although 158 diagnoses assigned by physicians account for 90 percent of the visits, only ten diagnoses account for almost 33 percent of the visits. These ten diagnoses, in order of their frequency, are medical and special examinations, medical and surgical after care, essential benign hypertension, prenatal care, acute upper respiratory infection -29-

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in an unspecified site, neuroses, chronic ischemic heart disease, otitis media (inflammation of the middle ear), diabetes mellitus, and eczema and dermatitis. 8/ Available data are not helpful in quantifying some important aspects of primary care such as prevention, health education, and counseling services. 9/ For example, some preventive services, such as well baby and child care, are contained in the category of medical and special examinations. Other preventive services such as inoculations, vaccinations, and prenatal care are recorded separately. They account for 4.8 percent of the visits to office-based physicians. 10/ Little direct reliable information is available about health education. Physicians report that in 16.6 percent of patients' visits, medical counseling and psychotherapy or therapeutic listening were provided as the major treatment. 11/ The data presented above may not, in the committee's opinion, pro- vide a complete picture of the nature of primary care. Certain complex characteristics of primary care, while difficult to quantify, are unique and integral to its practice. For example, primary care units contin- uously deal with an array of vaguely defined presenting problems which require identification and resolution. In addition, although the practice unit, according to the definition, can manage 90 percent of these problems, the practice unit must recognize its limitations and refer patients whose problems cannot be managed for secondary and tertiary consultations. PHYSICIANS PROVIDING PRIMARY CARE As defined in Chapter 2, primary care is based on the scope, charac- ter, and integration of the services provided. Although many types of health professionals provide primary care, it is generally agreed that the physician has a central role. Federal legislation identifies family medicine, general internal medicine, and general pediatrics as primary care specialties, 12/ whereas the American Medical Association also includes obstetrics and gynecology. Recent studies suggest that other medical specialists spend con- siderable time in delivering primary care. 13/ A study of cardiologists revealed that 21.3 percent of the average cardiologists' patient contact was for care outside his or her own field. 14/ Some 70 percent of the subspecialists trained at the Mayo Clinic in internal medicine spend almost half their time in primary care. 15/ Data indicate that 69 percent of all visits to office-based physicians are to general and family practitioners, internists, pediatricians, and obstetricians and gynecologists. General and family physicians receive the largest percentage (40 percent) of all patient office visits, 16/ although they represent only 16 percent of practicing physicians. 17/- -30-

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Table 1 shows the ten diagnoses made most often by physicians in general and in family practice, internal medicine, pediatrics, and obstetrics and gynecology. 18/ The general and the family physician and the internist provide care 7~r a broad range of problems. However, the internist places a greater emphasis on diseases of an adult or aging population. In contrast, the practices of both pediatricians and obste- tricians and gynecologists include a more limited range of diagnoses. More than 31 percent of obstetricians and gynecologists' diagnoses are for prenatal care and almost 30 percent of pediatricians' diagnoses are for medical or special examinations that include well baby and child care. Other dimensions of primary care are the seriousness of the condition, the acute or chronic nature of the condition, and the physi- cian's disposition of the visit. 19/ A small percentage of the visits to primary care physicians are for serious conditions. The largest percentage of visits is made to the internists. 20/ Of all conditions seen by physicians the following percentages are chronic: internists, 57 percent; general and family physicians, 35 percent; obstetricians and gynecologists, 15 percent; pediatricians, 10 percent. 21/ Among the physicians discussed in the preceding paragraph, obstetricians and gynecologists most often request return visits while pediatricians make the greatest use of telephone follow-ups. Internists are most likely to refer patients to other physicians and facilities, and obstetricians and gynecologists hospitalize patients most often. 22/ PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS PROVIDING PRIMLY CAM In the last decade, members of two new professional categories, physician assistants and nurse practitioners, grouped together under the name of new health practitioners, have become providers of primary care. By 1976, there were an estimated 5,800 graduates of DREW funded nurse practitioner programs, and 4,600 graduates of DHEW funded physician assistant programs. 23/ There are differences in programs, but students in these training programs are being trained to provide many of the services delivered by physicians. , ~7 Most nurse practitioners and physician assistants are employed in primary care practice units. Of the nurse practitioners employed, 69 percent are providing primary care. Fifty-five percent of all nurse practitioners work in solo, group, and clinic practice. 24/ Of the 71 percent of physician assistants working with primary care physicians, more than half are practicing with general and family physicians. More than half are employed in solo, group, and clinic practice. 25/ (See Chapter 4 for a discussion of the supply and distribution of physician assistants and nurse practitioners and Chapter 5 for infor- mation about their education and credentialing.) -31-

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PRACTICE ARRANGEMENTS Although the traditional practice unit or arrangement for the delivery of primary care has been the solo practitioner with a small office staff, an important trend has been the growth of group practices, defined as ''three or more physicians formally organized to provide medical care." 26/ Approximately 30 percent of the internists, pedia- tricians, and obstetricians and gynecologists in patient care in 1975 were in group practice, as compared to only 18 percent of general and family physicians. 2~/ Moreover, three-quarters of internists and two- thirds of the pediatricians in groups were in multispecialty groups. In contrast, obstetricians and gynecologists were almost evenly distributed between single specialty and multispecialty groups. A slightly higher percentage of general and family physician group practice physicians were in multispecialty groups than were in single specialty groups. _/ Evidence on the relationship of the type of practice arrangement and the nature and utilization of primary care services is limited. Although there is documented evidence of decreased hospital use by members of prepaid groups, evidence on the effects of prepayment on the use of outpatient services and preventive services is inconclusive. 29/ Options and Recommendations In the committeels judgment 3 many different practice units are capable of providing good primary care. Such units can be identified through the dissemination and application of the checklist provided in Chapter 2. The committee evaluated four such practice arrangements as prototypes for the future provision of primary care based on the data and information presented in this chapter and on the attributes essen- tial for the provision of exemplary primary care as defined in Chapter 2. The committee compared the strengths and weaknesses of each to see if one should be employed in preference to others. The prototypes are: o the family practice unit - composed of one or more family physicians, 0 the multispecialty unit - composed of internists, pediatricians, and ~ ialists, 0 the family practice team - composed of one or more family physicians, and one or more new health practitioners, and o the multispecialty team - a unit composed of internists, pediatricians, and perhaps other specialists and new health practitioners. Family practice unit. The data on the practice of primary care by general and family physicians indicate they currently are the principal providers of primary care in an office setting. 30/ They receive the largest percentage of patient visits for primary care problems and care for a broad range of conditions without the need for referral. 31/ -33-

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Moreover, the committee believes that many patients favor a physician who serves all the family members. In providing services for an entire family, a family physician may become more aware of the genetic and environmental factors affecting each family member and use this knowledge in the patient's care. There are, nevertheless, other patients who prefer less personal involvement on the part of their physician. In the committee's opinion, the family physician provides quality primary care that is less dependent on technology and hospital facili- ties than care rendered by other physicians. The family practice unit has the potential for providing comprehensive, continuous, and integrated care. However, the unit may need to refer the more serious medical problems that could be managed better by practitioners in multispecialty units. Multispecialty unit. The multispecialty unit that includes internists, pediatricians, and perhaps other medical specialists such as obstetricians and gynecologists can achieve continuity and comprehensive- ness of care. The specialty mix and hospital training of the units' members may enable them to care for a large percentage of the patients' More serious problems without referral. In the experience of committee members, however, some multispecialty groups tend to refer the less serious problems such as simple fractures. These latter conditions occur more frequently than serious problems. Thus, these referrals are more disruptive of the comprehensiveness and continuity of care than services provided for serious illnesses. In the committee's view, many people perceive internists, pedia- tricians, and other specialists as having had the highest level of medical training. They therefore favor receiving primary care from such physicians. This type of primary care may be costly without being of higher quality than care delivered by other prototypes. Family practice team and the multispecialty team. In the committee's opinion, the employment and full~utilization of new health practitioners in practice units augments the ability of these units to provide primary care. The physician assistant and nurse practitioner have been shown to increase the productivity of practice units. They can perform many of the technical procedures in the practice and can manage follow-up for patients with chronic illnesses according to a regimen designed by the primary care physician. With their employment the physician can concentrate on the patient problems which require his or her unique skills. Nurse practitioners and physician assistants deliver quality care which is accepted by patients and physicians. In addition, some new health practitioners provide preventive services, health education, and patient counseling, thereby extending the range of primary care services usually delivered. Their employment may add to the accessibility of primary care services by increasing the number of hours a practice unit can be contacted by patients 32/ and by decreasing the patients' -34-

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waiting time. In the committee's opinion, the family practice team has a unique role in the delivery of primary care in underserved areas, especially rural ones. A possible disadvantage of both units is the potential for a dim- inution in the continuity of primary care when the patient sees more than one provider. However, the committee's evaluation of the evidence suggests that continuity is increased by the presence of nurse practitioners and physician assistants. 33/ In the committee's judgment, there is no conclusive evidence to indicate the superiority of one of these prototypes or any other practice arrangement. For the present, therefore, the committee recommends that (Recommendation #1) because no practice arrangement has been found consistently superior to any other, primary care as . defined in this report should continue to be derive ~ ombi- nations of health care providers in a variety of practice arrangements. _ Pluralism is a useful feature of and, to the extent possible, should be preserved in the selection of practice units for primary care. The competition engendered by choices of primary care practice units may prove stimulating to innovation in the delivery of primary care and to perfecting current modes of delivery. In the committee's view, the requirements and preferences of the patient, the community, and the practitioner probably determine the best type of primary care practice unit for that community. The population base and economic status of the community and the preferences of the primary care practitioners are particularly important. Models of practice units for the future delivery of primary care are not necessarily limited to those discussed. All practice units that satisfy attributes of good primary care should be encouraged. The committee believes that it is in the public interest to develop diverse approaches and not to foster any one model at the expense of another. -35-

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REFERENCES Chapter 3 This chapter concentrates on the care provided by physicians, physician assistants and nurse practitioners. The contribution to primary care by other professionals is surveyed in the staff paper, "The Roles of Other Professions in Primary Care." 2. The terms 'practice unit' and 'practice arrangement' are used as synonyms. They refer to one or more providers of primary care. (See also Chapter 2.) The term 'setting' refers to the place where the care is delivered. Alberta W. Parker, "The Dimensions of Primary Care: Blueprints for Change," in Primary Care: Where Medicine Fails, ed.,~Spyros - Andreopoulos New York: John Wiley and Sons,-1974), pp. 15-77. Nora Piore, Deborah Lewis, and Jennie Seeliger, A Statistical Profile of Hospital and Outpatient Services in the United States: - Present Scope and Potenttal Role (New York: As~6r~ ~-~- Aid of Crippled Children, 1971). 5. Several hundred studies on the content of medical practice have appeared since 1930. Of the 65 reviewed for this report only three provide information on the content of practice of medical disciplines from a national sampling. The committee found the National Ambula- tory Care Survey, which collects information on ambulatory care provided by office-based physicians, contains the most comprehensive, reliable, and recent information and bases a large part of the chapter on this source. In doing so, the committee recognizes that ambulatory visits and primary care visits are not equivalent, but thinks the errors and misinterpretations introduced by such an assumption are not large enough to prejudice policy decisions. (For a further discussion, see staff papers, "A Compilation of Data on the Content of Primary Care Practice" and "An Evaluation of Data Sources on the Content of Medical Practice.") 6. U.S. Department of Health, Education, and Welfare, unpublished tabulations from the Health Interview Survey, 1976; U.S. Department of Health, Education, and Welfare, The National Ambulatory Medical Care Survey: 1973 Summary, United States, May 197 ~ Vital and Health Statistics, Series 13, No. 21 (October 1975~. DREW Publication No. (HRA) 76-1772, October 1975. -36-

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U.S. Department of Health, Education, and Welfare, "Ambulatory Medical Care Rendered in Physicians Offices: United States, 1975," Advanced Data from Vital and Health Statistics of the National Center for Health Statistics, No. 12, October 12, 1977, p. 7. 8. Ibid., p. 8. 9. The National Ambulatory Medical Care Survey codes and classifies patient problems according to a system specifically developed for the survey. It codes and classifies diagnoses according to the Eighth Revision of the International Classification of Diseases 7 ~ ther diagnostic classification schemes do not usually have prevention, health education and counselling listed as separate categories. Thus, such care may be provided and coded and classified under other categories, such as prenatal care, or may be provided as part of a visit and, therefore, not coded nor classified, or may not be pro- vided at all. 10. U.S. Department of Health, Education, and Welfare, "Ambulatory Medical Care Rendered in Physicians' Offices: United States, 1975," p. 8. 11. Ibid., p. 4. 12. P.L. 94-484 (1976). 13. Charlotte L. Rosenberg, "How Much General Practice by Specialists," Medical Economics, (September 15, 1975), pp. 131-5. This survey summer of 1975 found that 60 percent of the physt- cians in the 10 specialities surveyed provide care outside their own field. Seventy-five percent of the specialists in rural areas were . . . providing some primary care. 14. U.S. Department of Health, Education, and Welfare, "Evaluation of Cardiology Training and Manpower Requirements," edited by E.H. Adams and R.C. Mendenhall, No. (NIH) 74-623 (Springfield, Virginia: National Technical Information Services, 1974~. R.J. Reitemeier, J.A. Spitell and R.E. Weeks, "Participation by Internists in Primary Care: Results of a Survey of Mayo Clinic Alumni," Archives of Internal Medicine 135, Issues #2 (Feb. 1975~: 255-9. U.S. Department of Health, Education, and Welfare, unpublished tabu- lations from the National Ambulatory Medical Care Survey, 1975. 17. See staff paper, "Data on the Supply and Distribution of Primary Care Physicians." 37

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18. U.S. Department of Health, Education, and Welfare, unpublished tabulations from the National Ambulatory Medical Care Survey, 1975. 19. For a further discussion of these and other dimensions of primary care, see staff paper "A Compilation of Data on the Content of Primary Care Practice." 20. In the National Ambulatory Medical Care Survey, patient visits are described as very serious, serious, slightly serious, or not serious, depending on the extent of the impairment that might result if no care is provided. Unpublished data from the 1974 National Ambulatory Medical Care Survey show that 17 percent of patient visits to general and family physicians are for very serious and serious problems, 28.5 percent of patient visits to internists are for very serious and serious problems, 7.7 percent of all visits to obstetricians and gynecologists are for very serious and serious problems, and 10 per- cent of all visits to pediatricians are for very serious and serious serious problems. 21. Unpublished data from 1975 National Ambulatory Medical Care Survey. In this survey, acute conditions are defined as illnesses whose length is very brief, and chronic conditions are defined as illnesses for which the physician provides care over an extended period of time for the same diagnosis. 22. U.S. Department of Health, Education, and Welfare, unpublished tabu- lations from the National Ambulatory Medical Care Survey, 1975. 23. U.S. Department of Health, Education, and Welfare, "Report of the Physician Extender Work Group," Prepared for the Health Resources Policy Board, June 1977, pp. 6, 8. 24. Harry A. Sultz, Marie Zielezny and Louis Kinyon, "Highlights: Phase 2 of a Longitudinal Study of Nurse Practitioners," State University of New York at Buffalo, New York (mimeographed, June 1977~. 25. Richard M. Scheffler, The Supply and Demand for New Health Profes- sionals: Physician's Assistants and Medex, Final Report, Submitted . _ to U.S. Department of Health, Education, and Welfare, Contract No. 1-44184, November 1977. 26. The complete definition from the American Medical Association, Group Medical Practice in the U.S., 1975, p. 2, is "Group medical practice is the application oj:~r]~ir-~7ices by three or more physicians formally organized to provide medical care, consultation, diagnosis, and/or treatment through the joint use of equipment and personnel, and with the income from medical practice distributed in accordance with methods previously determined by members of the group." 27. American Medical Association, Group Medical Practice in the U.S., 1975, (Chicago: American Medical Association, 1976), pp. 38-9. -38-

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28. Ibid., pp. 37-8. Single specialty groups provide services predominantly in only one field of practice or major specialty. Multispecialty groups provide services in at least two fields of practice or major specialties. 29. Milton J. Roemer and William Shonick, ''HMO Performance: The Recent Evidence," The Milbank Memorial Fund Quarterly 51 (Summer 1973~: 271-317; Clifton Gaus, Barbara S. Cooper and Constance G. Hirschman, "Contrasts in HMO and Fee-for-Service Performance" 1976, (mimeographed). 30. U.S. Department of Health, Education, and Welfare, "Ambulatory Medical Care Survey." See staff paper, "A Compilation of Data on the the Content of Primary Care." U.S. Department of Health, Education, and Welfare, unpublished tabu- lations from the National Ambulatory Medical Care Survey, 1975. See staff paper, "A Compilation of Data on the Content of Primary Care." 32. Ellen C. Perrin and Helen G. Goodman, "Telephone Management of Acute Pediatric Illnesses," New England Journal of Medicine 248 (January 19, 1978~: 130-5. David M. Levine, et. al., "The Role of New Health Practitioners in a Prepaid Group Practice: Provider Differences in Processes and Out- comes of Medical Care." Medical Care 15 (April 1976~: 326-47. -39-

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