Rebuilding the Foundation of Health Care
Linda McCauley, Robert L. Phillips, Jr., Marc Meisnere,
and Sarah K. Robinson, Editors
Committee on Implementing High-Quality Primary Care
Board on Health Care Services
Health and Medicine Division
A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by contracts between the National Academy of Sciences and the Academic Pediatric Association, Agency for Healthcare Research and Quality, Alliance for Academic Internal Medicine, American Academy of Family Physicians, American Academy of Pediatrics, American Board of Pediatrics, American College of Physicians, American Geriatrics Society, Blue Shield of California, The Commonwealth Fund, Family Medicine for America’s Health, Health Resources and Services Administration, New York State Health Foundation, Patient-Centered Outcomes Research Institute, Samueli Foundation, Society of General Internal Medicine, and U.S. Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-68510-8
International Standard Book Number-10: 0-309-68510-9
Digital Object Identifier: https://doi.org/10.17226/25983
Library of Congress Control Number: 2021937669
Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
Copyright 2021 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Implementing high-quality primary care: Rebuilding the foundation of health care. Washington, DC: The National Academies Press. https://doi.org/10.17226/25983.
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Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.
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COMMITTEE ON IMPLEMENTING HIGH-QUALITY PRIMARY CARE
LINDA McCAULEY (Co-Chair), Dean and Professor, Neil Hodgson Woodruff School of Nursing, Emory University
ROBERT L. PHILLIPS, JR. (Co-Chair), Founding Executive Director, The Center for Professionalism & Value in Health Care, American Board of Family Medicine
ASAF BITTON, Executive Director, Ariadne Labs
TUMAINI RUCKER COKER, Associate Professor of Pediatrics, University of Washington School of Medicine
CARRIE COLLA, Professor, Geisel School of Medicine, Dartmouth College
MOLLY COOKE, Professor of Medicine, University of California, San Francisco
JENNIFER E. DeVOE, Sherrie & John W. Saultz MD Endowed Professor and Chair, Department of Family Medicine; Director, Center for Primary Care Research and Innovation, Oregon Health & Science University
REBECCA S. ETZ, Associate Professor, Family Medicine and Population Health, Virginia Commonwealth University
SUSAN FISHER-OWENS, Clinical Professor of Pediatrics, University of California, San Francisco, School of Medicine; Clinical Professor of Preventative and Restorative Dental Sciences, University of California, San Francisco, School of Dentistry
JACKSON GRIGGS, Chief Executive Officer, Heart of Texas Community Health Center, Inc.
SHAWNA HUDSON, Professor, Rutgers University
SHREYA KANGOVI, Associate Professor of Medicine, University of Pennsylvania
CHRISTOPHER F. KOLLER, President, Milbank Memorial Fund
ALEX H. KRIST, Professor, Family Medicine and Population Health, Virginia Commonwealth University
LUCI K. LEYKUM, Executive Associate Chair, Professor, Department of Internal Medicine, Dell Medical School, The University of Texas at Austin; Center Lead, The Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System
BENJAMIN OLMEDO, Physician Assistant, Family Medicine and Clinical Informatics, Dignity Health
BRENDA REISS-BRENNAN, Director, Mental Health Integration, Intermountain Healthcare
HECTOR P. RODRIGUEZ, Henry J. Kaiser Endowed Chair, Professor of Health Policy and Management, University of California, Berkeley
MARY ROTH McCLURG, Executive Vice Dean, Chief Academic Officer, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
ROBERT J. WEYANT, Associate Dean for Dental Public Health and Community Outreach, School of Dental Medicine, University of Pittsburgh
MARC MEISNERE, Program Officer, Study Director
TRACY A. LUSTIG, Senior Program Officer
SARAH K. ROBINSON, Research Associate
SAMIRA ABBAS, Senior Program Assistant
MICAH WINOGRAD, Senior Finance Business Partner
SHARYL NASS, Senior Director, Board on Health Care Services
JENNIFER PUTHOTA, Christine Mirzayan Science & Technology Policy Graduate Fellow (until April 2020)
National Academy of Medicine Fellows
KAMERON MATTHEWS, U.S. Department of Veterans Affairs
LARS PETERSON, American Board of Family Medicine
DIMA M. QATO, University of Southern California School of Pharmacy
JOE ALPER, Science Writer
ROBERT BERENSON, Institute Fellow, Urban Institute
RICHARD G. FRANK, Margaret T. Morris Professor of Health Economics, Department of Health Care Policy, Harvard Medical School
WILLIAM MILLER, Chair Emeritus, Department of Family Medicine, Lehigh Valley Health Network Professor of Family Medicine, Morsani College of Medicine, University of South Florida
KURT STANGE, Director, Center for Community Health Integration, School of Medicine, Case Western Reserve University
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by MARSHALL H. CHIN, The University of Chicago, and ANTONIA M. VILLARRUEL, University of Pennsylvania. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
The National Academies of Sciences, Engineering, and Medicine (the National Academies) has a long history of issuing independent reports that provide evidence and recommendations from national experts that address the directions the country should take to meet challenges that confront us. The Institute of Medicine (IOM) Study of the Future of Primary Care was launched in early 1994 with the intent to influence what was a maelstrom of health care reform at that time. In 1991, the Bush administration started a conversation about health reform that became a plank of Bill Clinton’s presidential campaign and a main focus of the Clinton administration’s political efforts. In addition to President Clinton’s proposal, more than 70 proposals from both sides of the aisle and beyond were considered before health reform foundered in 1994. Beyond the political failure to achieve consensus, considerable experimentation was happening in the marketplace that emphasized primary care. The preface to the IOM’s 1996 report Primary Care: America’s Health in a New Era speaks to the optimism and opportunity that the committee operated to influence:
After decades of relative neglect in a health care system that placed most of its emphasis on specialization, high technology, and acute care medicine, the value of primary care is again being recognized as part of the wave of reform that is sweeping the U.S. health care industry. There are numerous indications of the increasingly important role being played by primary care.
By the time that report was released, political paths to health reform were closed and managed care was also in trouble. What had been fallow ground for primary care was politically salted, and the report’s recommendations remained largely unimplemented. It is hard to imagine how primary care, and health care generally, would be different had even some of the 1996 report’s recommendations taken root. More than a decade later, the Patient Protection and Affordable Care Act in 2010 aided primary care through expansion of federally qualified health centers, Medicaid expansion, and health information technology support, but most of the 1996 report’s recommendations were still not addressed. A 2012 IOM report on integrating primary care and public health also highlighted the lack of relationships between these important community-based agents of population health and opportunities to purposefully heal this schism. The recommendations of this report also went largely unheeded.
Thus, the charge to the current committee was not to relitigate the evidence underpinning these prior reports and recommendations, nor was it simply to produce new recommendations, as is common with most consensus studies of the National Academies. Instead, this consensus committee had the unusual and specific charge to develop an implementation plan for recommendations, using the 1996 report as a starting point.
This study launched in January 2020 and ran headlong into the novel coronavirus pandemic, which quickly highlighted a host of problems in primary care:
- the perils of fee-for-service funding for supporting the health care platform where most people turn for heath advice and care;
- the dangers of the long-standing schism between public health and primary care to communicating a consistent message to the public;
- the lack of inclusion of primary care in national epidemic planning;
- the lack of understanding or inclusion of primary care in congressional COVID-19 relief bills;
- the bizarreness of not supporting telehealth prior to the pandemic; and
- the profound effect that social determinants have on the probability that a person will live or die.
In addition to the lens that the coronavirus pandemic offered to the committee, it was obvious early in the deliberations that major societal factors were framing the importance of a robust system of primary care. Several themes emerged that were critically important in our discussions with clinicians, health system experts, community advocates, and patients themselves. One major difference today compared to 1996 is the emergence of health information technology. Another change is the increased
recognition that health care teams, which today are more inclusive of non-clinician team members, ought not to be bounded by clinical walls but should be able to reach into and partner with communities. Similarly, issues of unequal access, health equity, and social determinants of health were commonly used to describe the current challenges and opportunities before us. These themes all informed the committee’s recommendations on how we measure, value, and support primary care’s capacity to respond to these changes.
As co-chairs, we are indebted to the dedication and critical thinking of the committee members who shaped this report. The volunteer committee comprised of 20 members from a diversity of backgrounds but with a shared commitment to primary care as a common good. We are also indebted to the patients and patient advocacy groups that met with us and whose suggestions and experiences helped shape this report; we hope they see their voices in these pages.
The committee wishes to acknowledge the superb support it received from the National Academies staff. Study Director Marc Meisnere, Senior Program Officer Tracy Lustig, Research Associate Sarah Robinson, Senior Program Assistant Samira Abbas, and Sharyl Nass, Senior Director of the Board on Health Care Services, were essential to the work behind meeting our unusual charge and contributing to the management and writing of the report. The committee also appreciates the considerable help of three National Academy of Medicine fellows, Drs. Kameron Matthews, Lars Peterson, and Dima Qato.
We are sensitive to the fact that 1996 report recommendations and those of subsequent IOM reports dealing with primary care remain fallow. Primary care was reinvented in the United States in the late 1960s, embraced by the world at Alma Ata in 1978, reported on by the IOM in 1978, 1983, 1996, and 2012, and emphasized by most efforts at health reform in the United States. We believe that some of the challenges we address in this report are at the root of the major differences in population health in the United States compared to our global neighbors. The evidence is there, the public values are clear, and care teams want to change the way that they function today. All that is needed is meaningful action to begin the change. We hope that this report will provide clear guidance on the actions we need to take to provide to the public what is necessary to improve lives and promote health. If there is one key message that readers should take away from this report, it is that the committee firmly believes that primary care should be a common good, available to all and sufficiently valued and resourced to repair health equity in the United States.
Linda McCauley and Robert L. Phillips, Jr., Co-Chairs
Committee on Implementing High-Quality Primary Care
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This Consensus Study Report would not have been possible without the invaluable contributions from many experts and stakeholders dedicated to primary care. The committee would like to thank all of the speakers and participants who played a role in the public meetings conducted for this study, as well as the many others who provided valued insight and responded to rapid requests for information to accommodate our short and demanding timeline, including the individuals who shared their personal stories from the patient perspective with the committee.
Many of these contributors, with their affiliations at the time of their presentations to the committee, are listed below:
The committee appreciates the sponsors of this study for their generous financial support: Academic Pediatric Association, Agency for Healthcare Research and Quality, Alliance for Academic Internal Medicine, American Academy of Family Physicians, American Academy of Pediatrics, American Board of Pediatrics, American College of Physicians, American Geriatrics Society, Blue Shield of California, The Commonwealth Fund, Family Medicine for America’s Health, Health Resources and Services Administration, New York State Health Foundation, Patient-Centered Outcomes Research Institute, Samueli Foundation, Society of General Internal Medicine, and U.S. Department of Veterans Affairs. The committee thanks Richard Frank for his invaluable consultation and the following individuals who provided commissioned papers: Robert Berenson, Adele Shartzer, and Roslyn Murray from the Urban Institute for their paper on primary care payment models; William Miller for his account on the history of primary care; and Kurt Stange for his paper on the effects and consequences of the COVID-19 pandemic on primary care.1 The committee gives special thanks to Joe Alper for his writing and editing contributions and Casey Weeks for his graphic design expertise.
Finally, deep appreciation goes to staff at the National Academies of Sciences, Engineering, and Medicine for their efforts and support in the report process, especially to Joe Goodman, Andrew Grafton, Megan Kearney, Sarah Kwon, Stephanie Miceli, Maryjo Oster, Devona Overton, Tina Seliber, Lauren Shern, Leslie Sim, Cyndi Trang, Dorothy Zolandz, and the staff of the National Academies Research Center, including Christopher Lao-Scott, Rebecca Morgan, Maya Thomas, and Colleen Willis.
|AAFP||American Academy of Family Physicians|
|AAMC||Association of American Medical Colleges|
|AAP||American Academy of Pediatrics|
|ACA||Patient Protection and Affordable Care Act|
|ACO||accountable care organization|
|AHRQ||Agency for Healthcare Research and Quality|
|AIMS||Ambulatory Integration of the Medical and Social|
|AMA||American Medical Association|
|APRN||advanced practice registered nurse|
|BPHC||Bureau of Primary Health Care|
|CDC||Centers for Disease Control and Prevention|
|CDPHP||Capital District Physician Health Plan|
|CHGME||Children’s Hospitals Graduate Medical Education|
|CHIP||Children’s Health Insurance Program|
|CHIPRA||Children’s Health Insurance Program Reauthorization Act of 2009|
|CHT||community health team|
|CHW||community health worker|
|CMMI||Center for Medicare & Medicaid Innovation (CMS Innovation Center)|
|CMS||Centers for Medicare & Medicaid Services|
|CPC||Comprehensive Primary Care|
|CPC+||Comprehensive Primary Care Plus|
|CTSA||Clinical and Translational Science Awards|
|EHR||electronic health record|
|FQHC||federally qualified health center|
|GAO||U.S. Government Accountability Office|
|GIS||geographic information system|
|GME||graduate medical education|
|GNE||graduate nurse education|
|GRACE||Geriatric Resources for Assessment and Care of Elders|
|GRECC||Geriatric Research, Education and Clinical Center|
|HCC||hierarchical condition category|
|HHS||U.S. Department of Health and Human Services|
|HIE||health information exchange|
|HIPAA||Health Insurance Portability and Accountability Act|
|HIT||health information technology|
|HITECH||Health Information Technology for Economic and Clinical Health|
|HPSA||Health Professional Shortage Area|
|HRSA||Health Resources and Services Administration|
|HSR||health services research|
|IHS||Indian Health Service|
|IMPaCT||Individualized Management for Patient-Centereds Targets|
|InCK||Integrated Care for Kids|
|IOM||Institute of Medicine|
|IPEC||Inter-professional Education Collaboration|
|LCSW||licensed clinical social worker|
|LPN||licensed practical nurse|
|MACRA||Medicare Access and CHIP Reauthorization Act|
|MAPCP||Multi-Payer Advanced Primary Care Practice|
|MCO||managed care organization|
|MedPAC||Medicare Payment Advisory Commission|
|MUA||Medically Underserved Area|
|NAMCS||National Ambulatory Medical Care Survey|
|NCEPCR||National Center for Excellence in Primary Care Research|
|NCQA||National Committee for Quality Assurance|
|NHSC||National Health Services Corps|
|NIH||National Institutes of Health|
|NMHC||nurse-managed health center|
|NQF||National Quality Forum|
|OECD||Organisation for Economic Co-operation and Development|
|ONC||Office of the National Coordinator for Health Information Technology|
|PACE||Program of All-Inclusive Care for the Elderly|
|PACT||Patient-Aligned Care Team|
|PBRN||practice-based research network|
|PCIP||primary care incentive payment|
|PCMH||patient-centered medical home|
|PCORI||Patient-Centered Outcomes Research Institute|
|PCP||primary care physician|
|PCPCH||patient-centered primary care home|
|PCR||primary care research|
|PFS||physical fee schedule|
|PPS||prospective payments system|
|RHC||rural health clinic|
|ROI||return on investment|
|RUC||Relative Value Scale Update Committee|
|RVU||relative value unit|
|SBHC||school-based health center|
|SDOH||social determinants of health|
|SMART on FHR||Substitutable Medical Applications and Reusable Technologies on Fast Health Interoperability Resources|
|THCGME||Teaching Health Center Graduate Medical Education|
|VA||U.S. Department of Veterans Affairs|
|WHO||World Health Organization|