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REPORT OF A STUDY A Manpower Policy for Primary Health Care May 1978 NATIONAL ACADEMY of SCIENCES Washington, D.C.

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NOTICE This is the report of a project undertaken with the approval of the Governing Board of the National Research Council, whose members are drawn from the Councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee appointed to conduct the project and prepare the report were selected for recognized competence and with the due consideration for the balance of disciplines appropriate to the project. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Supported in part by grants from The Robert Wood Johnson Foundation and the W.K. Kellogg Foundation. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of medical and other profes- sions for the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 Congressional charter responsibility to be an advisor to the Federal Government, and its own initiative in identifying issues of medical care, research, and education. TOM Publication 78-02 Library of Congress Catalog Card Number 78-56907 International Standard Book Number 0-309-02764-0 Available from Printing and Publishing Office National Academy of Sciences 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Printed in the United States of America

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I NSTITUTE OF MEDICINE NATIONAL ACADEMY OF SCIENCES 2101 CONSTITUTION AVENUE WASHINGTON, D. C. 20418 DAVID A. HAMBURG, M.D. PRESIDENT David E. Rogers, M.D., Sc.D. President The Robert Wood Johnson Foundation The Forrestal Center P.O. Box 2316 Princeton, New Jersey 08540 Dear Dr. Rogers: May 7, 1978 I am pleased to present to The Robert Wood Johnson Foundation the final report of the Study to Develop an Integrated Manpower Policy for Primary Care, conducted by the Institute of Medicine of the National Academy of Sciences. The study was undertaken with the foundation's generous support to formulate a cohesive health manpower policy for assuring the accessibility and appropriateness of primary care delivery. The study was based on a determination of the functions served by the primary care system and judgments about the roles of different catego- ries of primary care manpower. Entitled A Manpower Policy For Primary Health Care, the report con- tains an introduction and summary, a definition of primary care indicating its functions and distinctive characteristics, and background information, policy alternatives, and proposed recommendations affecting the supply, distribution, practice arrangements, education, and credentialing of primary care practitioners. Appropriate time periods and responsible groups are suggested for the implementation of each of the 20 recommen- dations. Staff papers developed in the study are not contained in the report but are publicly available in limited supply. We shall be pleased to discuss this report in greater detail with you and your colleagues in The Robert Wood Johnson Foundation. Cordial ly, 3~ ~t ~ ~ Enclosure

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I NSTITUTE OF MEDICIN E NATIONAL ACADEMY OF SCIENCES 2101 CONSTITUTION AVENUE WASHINGTON, D. C. 20418 DAVID A. HAMBURG, M.D. PRESIDENT Enclosure May 7, 1978 Russell G. Mawby, Ph.D. President W. K. Kellogg Foundation 400 North Avenue Battle Creek, Michigan 49016 Dear Dr. Mawby: I am pleased to present to the W.K. Kellogg Foundation the final report of the Study to Develop an Integrated Manpower Policy for Primary Care, conducted by the Institute of Medicine of the National Academy of Sciences. The study was undertaken with the foundation's generous sup- port to formulate a cohesive health manpower policy for assuring the accessibility and appropriateness of primary care delivery. The study was based on a determination of the functions served by the primary care system and judgments about the roles of different categories of primary care manpower. Entitled A Manpower Policy For Primary Health Care, the report contains an introduction and summary, a definition of primary care indicating its functions and distinctive characteristics, and background information, policy alternatives, and proposed recommendations affecting the supply, distribution, practice arrangements, education, and creden- tialing of primary care practitioners. Appropriate time periods and responsible groups are suggested for the implementation of each of the 20 recommendations. Staff papers developed in the study are not con- tained in the report but are publicly available in limited supply. We shall be pleased to discuss this report in greater detail with you and your colleagues in the W.K. Kellogg Foundation. Cordially, An-- ~ ~

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INSTITUTE OF MEDICINE Division of Health Manpower and Resources Development STEERING COMMITTEE Chairman Ee Harvey ESTES, M.D., Professor and Chairman, Department of Community and Family Medicine, Duke University Medical Center, Durham Members H. David BANTA, M.D., M.P.H., United States Congress, Office of Tech- nology Assessment, Washington, D.C. Douglas A. FENDERSON, Ph.~., Director, Continuing Medical Education, University of Minnesota, Minneapolis A. Alan FISCHER, M.D., Professor and Chairman, Department of Family Medicine, Indiana University School of Medicine, Indianapolis Loretta C. FORD, R.N., Ed.D., Dean and Director of Nursing, University of Rochester Medical Center, Rochester Charles A. JANEWAY, M.D., Physician-in-Chief, Emeritus, Children's Hospital Medical Center, Boston Charles E. LEWIS, M.D., Sc.D., Professor of Medicine, Public Health and Nursing, Department of Medicine, UCLA School of Medicine, Los Angeles Patricia A. McATEE, Ph.D., University of Colorado School of Medicine, Department of Pediatrics, Denver J. Warren PERRY, Ph.D., Dean and Professor, School of Health Related Professions, State University of New York at Buffalo Charles H. RAMMELKAMP, Jr., M.D., D.Sc. (Hon.), Director, Department of Medicine, Cleveland Metropolitan General Hospital, Cleveland David J. SANCHEZ, Jr., Ph.D., Assistant Professor of Ambulatory and Community Medicine, San Francisco General Hospital, San Francisco Continued vii

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John B.TURNER, D.S.W., Kenan Professor of Social Work, University of North Carolina, Chapel Hill David G. WARREN, J.D., Professor of Health Administration, Department of Health Administration, Duke University, Durham Jerry L. WESTON, R.N., Sc.D., Nurse Director, Division of Extramural Research, National Center for Health Services Research, Hyattsville viii

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INSTITUTE OF MEDICINE DAVID A. HAMBURG. M.D., President Division of Health Manpower and Resources Development Project Staff Richard M. Scheffler, Ph.D., Division Director and Project Director Gloria Ruby, M.A., Research Associate Neil Weisfeld, J.D., M.S.Hyg., Research Associate Juliana Goldberg, M.A. , Editor

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ACKNOWLEDGEMENTS Many individuals and organizations assisted the committee and staff in preparing this report and in offering valuable comments in earlier drafts. Some of them whom I would like to acknowledge especially are listed below. A special thanks to Ouida Upchurch who was the study director until September 1, 1977. She was largely responsible for the interim report, A Definition of Primary Care (reproduced as part of Chapter 2 of this some of the staff papers. Sunny Yoder provided substantive and editorial comments on the final draft of the report. Thomas Delbanco, a Robert Wood Johnson Health Policy Fellow, Jack Hadley of the Urban Institute, and Lauren LeRoy of the University of California at San Francisco Health Policy Program provided useful com- ments on the initial draft of the report. Jon Gabel and William S. Sobaski of the Health Care Financing Administration of the Department of Health, Education, and Welfare (DHEW) consulted with the staff on reimbursement issues. The National Center for Health Statistics, DREW, provided special tabulations from The National Ambulatory Medical Care Survey. Dr. Howard Stambler, Chief of the Manpower Analysis Branch, Office of Program Development of the Bureau of Health Manpower, DREW, offered important data and information on health manpower. To Linda Depugh and Dawn Gustafson, I would like to express a deep appreciation for their patience and hard work in the preparation and typing of the report. Richard M. Scheffler Division Director and Project Director X1

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