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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 -93-

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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 _94_

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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. -95-

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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 -96-

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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. -97-

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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 -98-

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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, _99_

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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 -100-

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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. -101-

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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 -102-

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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 1Q3-

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