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Chapter 6
CONCLUSION: To SCHEDULE OF IMPLEMENTATION
The changes in the health education and delivery systems advocated
in this report will not occur all at once. Due to the significant magni-
tude of the recommendations, a transition period of some duration is
needed for their accomplishment. And because different forces and
barriers affect in different ways the achievement of different proposals,
the implementation periods will vary.
Although there are differences in implementation, the recommendations
of this report are linked with a common policy goal: an approrpiate
supply of trained practitioners providing high-quality primary care to
all populations in the country In the committees opinion, this goal
is most likely to be attained if health policymakers adopt the entire
strategy proposed in this report, rather than selecting only a few
recommendations to implement. Primary care practitioners should be
encouraged to serve underserved populations, and they should be paid
fairly no matter where they practice. An adequate percentage of physi-
cians should be trained in primary care specialties, and they should be
taught a full range of primary care practice skills, including communi-
cation with patients and other professionals. The recommendations of
the report are general in form to allow for diversity and fine-tuning
in implementation, but each recommendation is considered important to
the success of an adequate and integrated primary care manpower policy.
The following schedule of prerequisites, time periods, and
responsible groups is a suggested guide for implementation of the
recommendations. The guide is not meant to be absolute or exhaustive.
Its purpose is to draw attention to key requirements for implementation,
to suggest an appropriate time frame, and to focus the interest of the
parties most responsible. This schedule is only one set of initiatives
that could be taken by these and other groups.
Prerequisites include policy actions, research results, and changes
in social attitudes. A prerequisite for implementation of a recommen-
dation is an advancement which would make the recommendation more
feasible, more widely acceptable, and more cogent.
Time periods represent a balance between the urgency of the
recommendations and the need to overcome or satisfy perceived
obstacles, such as academic inertia or delays in the operation of
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political bodies. It seems impossible to choose scientifically the number
of years needed to implement a broad policy recommendation, but the com-
mittee is emboldened by a desire to see these recommendations achieved
without the necessity of convening another study group to survey a
basically unchanged landscape ten years from now. A one-to-three year
period is prescribed for manpower legislation, a one-to-five year period
is suggested for legislative change in health care financing, and a four-
year maximum is used for academic policy changes not requiring major
research progress.
The term responsible groups is partly a misnomer, for responsibility
extends to individuals as well as groups. The recommendations can be
enacted only if health policymakers, academicians, providers, third-party
payers, and other publicly accountable persons are responsive. Ordinari-
ly, however, a particular government agency or a collection of private
interests has major responsibility for an area of recommendation.
Federal agencies have been designated on the basis of apparent
spheres of activity following the 1977 reorganization of DREW. No
attempt has been made to designate particular state agencies, because
state governments use various organizational arrangements to regulate
health.
Groups have been noted as responsible not only when they are in a
position to implement the recommendation itself, but also when they can
help attain a prerequisite or can provide guidance or pressure for imple-
mentation. The Association of American Medical Colleges (AAMC) and the
federal Bureau of Health Manpower are examples of the last type of
responsible group. In addition, the public - as consumers, citizens, and
taxpayers - has an interest in the entire area covered by the recommen-
dations. Public attention to the development of primary care manpower
policy will help assure the linkage of that policy to improvements in
the health care system.
Recommendation #1
Because no practice arrangement has been found superior to
any other, primary care as defined in this report should
continue to be delivered by various combinations of health
care providers in a variety of practice arrangements.
Prerequisites: Education of different categories of practi-
tioners to provide primary care; freedom for providers to use
diverse primary care settings.
Time required: None
Responsible groups: Association of American Medical Colleges
(AAMCt~ ~~f------d health professions schools 3 federal and
state legislatures (to assure sufficient funding of education
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programs and to show restraint in regulating providers), third-
party payers, providers of care.
Recommendation #2
For the present, the number of entrants to medical school
should remain at the current annual level.
Prerequisites: Acknowledgement that this is only a pause
pending more information and monitoring of the following:
the level of public demand for medical care; substitution
of physicians by new health practitioners; and the produc-
tivity and flexibility of different physician configurations
and types of practitioners in serving different populations
and meeting different needs.
Time required: Ten to fifteen years.
. . .
Responsible groups: Medical schools, the Congress, Health
Resources Administration of DREW, the states.
Recommendation #3
For the present, the numbers of physician assistants and nurse
practitioners trained should remain at the current annual level.
Prerequisites: Acknowledgement that this is only a pause
pending more information and monitoring of the following:
the level of public demand for the provision of medical and
other services by new health practitioners; the substitution
of physicians by new health practitioners; and the productivity
and flexibility of different interprofessional configurations
and types of practitioners in serving different populations -
and meeting different needs.
Time required: Ten to fifteen years.
Responsible groups: Training programs, the Congress, Health
Resources Administration of DREW, the states, private funders
of new health practitioner training programs.
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Recommendation #4
Third-party payors (federal, state, and privately should
reimburse all physicians at the same payment level for
the same primary care service.
Prerequisites: Knowledge or belief that the service is
.
performed adequately, or at the same general level of com-
petence, by physicians in different specialties or practice
arrangements.
Time required: One to five years.
Responsible croups: The Congress, Health Care Financing
Administration of DREW, Blue Shield and other insurance
c arriers .
Recommendation #5
Third-party payers (federal, state, and private) should reduce
the differentials in payment levels between primary care pro-
cedures and non-primary care procedures.
Prerequisites: Awareness that changes in physician fee
structures will be resisted; enhanced recognition of the
medical value of primary care vis-a-vis surgical and
tehnological services; more data on extent of differentials.
Time required: One to three years is required to institute
change, although a generation may be required to complete
the process by ending inappropriate financial discentives
to primary care practice.
Responsible groups: Health Care Financing Administration of
DREW, state Medicaid authorities, fiscal intermediaries and
insurance carriers in cooperation with hospitals, clinics,
and other providers of care.
Recommendation #6
Third-party payers (federal, state, and private) should institute
payments to practice units for those necessary services delivered
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by primary care providers and currently not reimbursed, such as
commonly accepted health education and preventive services.
Prerequisites: Knowledge that such services are medically
beneficial or desired by patients; more study of prepayment
capitation as an alternative to fee-for-service payment.
Time required: One to three years to institute payments,
with subsequent adjustments as appropriate.
Responsible groups: Health Care Financing Administration
of DHEW with congressional approval, state Medicaid authori-
ties, Blue Shield and other insurance carriers, unions,
business and other purchasers of health insurance, National
Center for Health Services Research of DHEW.
Recommendation #7
Training programs for family physicians, nurse practitioners,
and physician assistants should continue to receive direct
federal, state, and private support, because these practi-
tioners are the most feasible providers of primary care to
underserved populations.
Prerequisites. Well-designed and administered training programs.
Time required: None
Responsible groups. The Congress, Bureau of Health Manpower
of DHEW, the states, potential private funders of training
programs for family physicians and new health practitioners.
Recommendation #8
Third-party payers (federal, state, and private) should discontinue
all geographic differentials in payment levels for physician ser-
vices within a state.
Prerequisites: Knowledge or belief that such differentials
are unfair or discourage physicians from practicing primary
care in rural areas.
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Time required: One to five years.
Responsible groups: The Congress, Health Care Financing
77- ----DHEW, state Medicaid authorities, fiscal
intermediaries and insurance carriers.
Recommendation #9
Third-party payers (federal, state, and private) should reimburse
the practice unit for the same primary care services at the same
payment level regardless of whether the services are provided by
physicians, nurse practitioners, or physician assistants.
Prerequisites: Knowledge or belief that the services are
performed adequately or at the same general level of competence
by all three professional groups; knowledge or belief that pay-
ment differences among the three groups are unfair or comprise
a financial disincentive for nurse practitioner or physician
assistant practice.
Time required: One to five years.
Responsible groups: The Congress, Health Care Financing
]Ga~=-i-'------DHEW, state Medicaid authorities, Blue
Shield and other insurance carriers.
Recommendation #10
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.
Prerequisites: Better coordination of health services
~ .
research, including establishment of a long-term
monitoring program; a more adequate data base.
Time required: This should begin within a year.
.
Responsible groups: The Health Resources Administration 3
National Center for Health Statistics, and National Center
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for Health Services Research of DHEW, and other research
organizations, sponsors, and workers.
Recommendation #11
An increased emphasis should be given to health services
research in primary care manpower.
Prerequisites: Recognition of the limits of available
data; an adequate supply of researchers.
Time required: None
Responsible groups: The National Centers for Health Statistics
and Health Services Research of DHEW, the Health Care Financing
Administration of DHEW, and other research organizations, sponsors,
and workers. (Examples of research sponsors are foundations,
universities, and the Veterans Administration.)
Recommendation #12
The committee recommends a substantial increase in the national
goal for the percent of first-year residents in primary care
fields.
Prerequisites: In the long run, more information about
population needs for primary and non-primary care services,
the productivity and geographic mobility of primary care
physicians, the volume of primary care services provided
by different physician specialties and different manpower
configurations, and the effects of primary care residency
training on physician decisions to limit their practice to
primary care; in the short run, belief that most physicians
should be primary care practitioners, that primary care
physicians should receive specialty training in primary
care, and that most physicians now in practice are not
· _ e ~ e
mainly primary care practitioners.
Time required: One to three years.
Responsible groups: AAMC and medical schools, the Congress,
807~~~7 Faith Manpower and National Centers for Health
Statistics and Health Services Research of DHEW, the states,
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health services researchers and research sponsors, medical
specialty societies, Coordinating Council of Medical Education.
Recommendation #13
Federal and state governments should continue to promote
primary care partly by using financial incentives for the
creation and support of primary care residency programs.
Prerequisites: Acknowledgement that primary care residency
programs need assistance until becoming more firmly established.
Time required: None
Responsible groups: The Congress, Bureau of Health Manpower
of DHEW, the states.
Recommendation #14
It is desirable that all medical schools direct or have a
major affiliation with at least one primary care residency
program in which residents have responsibility under faculty
supervision for the provision of accountable, accessible,
comprehensive, continual, and coordinated care.
Prerequisites: Sufficient supply of primary care residency
.
training settings.
Time required: One to three years.
Responsible Groups: Medical schools, AAMC, Liaison Committee
3~~~0 ~on, Bureau of Health Manpower of DREW (for
funding).
Recommendation #15
In selecting among applicants for admission, medical schools
should give weight to likely indicators of primary care
career selection.
Prerequisites: More information about factors affecting
primary care career selection; acknowledgement that such
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indicators are legally and academically valid admissions
· ~
cr;Lterla.
Time required:, Now to five years.
Responsible Groups:. AAMC and medical schools, Liaison Committee
on bed ical Educatton, Bureau of Health Manpower and National
Center for Health Services Research of DREW, social researchers
and.research sponsors.
Recommendation #1.6
Undergraduate medical. education should provide students with a
knowledge of epidemiology and aspects of behavioral. and social.
sciences relevant to patient care.
Prerequisites: Sufficient supply of capable instructors, other
· —
educational resources, and practice settings where the Importance
of such subjects can be,il].ustrated.
Time required: Begin now.
Responsible groups:. AAMC and medical. schools; Liaison Committee
on Medical Education; potential federal., state, and private
funders of medical. education. -
Recommendation #17
Medical schools should provide al]. students with some clinical
experience in a primary care setting.
Prerequisites: Sufficient supply of capable clinical faculty
and.preceptors and of primary care settings.
Time required: Two to four years.
Responsible croups: AAMC and medical schools; Liaison Committee
on Medical Education; Bureau of Health Manpower of DHEW; potential
federal., state, and private funder-s of programs in primary care
clinical medical. education, including AHECs.
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Recommendation #18
Medical schools and primary care training programs should teach
a team approach to the delivery of primary care.
Prerequisites: Interprofessional collaboration among faculty
and clinical instructors; faculty acknowledgement of the
advantages of team training and the difficulties of implement-
ing it; sufficient supply of faculty capable of teaching a team
approach.
Time required: Now to four years.
Responsible croups: AAMC and medical schools; other health
professions schools, graduate training institutions and
educational organizations; accrediting bodies; Bureau of
Health Manpower of DREW; potential federal, state and private
funders of programs in primary care education.
Recommendation #19
Amendments to state licensing laws should authorize, through
regulations, nurse practitioners and physician assistants to
provide medical services, including making medical diagnoses
and prescribing drugs when appropriate. Nurse practitioners
and physician 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 with-
out physician supervision.
Prerequisites: Revision of state practice and regulations
_
w here necessary.
Time required: Now to three years.
Responsible groups: State legislatures and health professions
_ . .
regulatory agencies.
Recommendation #20
The nursing profession should continue to have accreditation
responsibility for nurse practitioner education programs and
should establish requirements for nurse practitioner education
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and training, in collaboration with physicians and other health
professionals.
Prerequisites: Acceleration of present efforts to develop
more uniform standards for nurse practitioner education.
Time required: Two years
Responsible groups:
League for Nursing.
-
.
American Nurses' Association, National
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Representative terms from entire chapter:
care financing
