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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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 PREPUBLICATION COPY—Uncorrected Proofs

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 Qual- ity, Alliance for Academic Internal Medicine, American Academy of Family Physi- cians, 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, conclu- sions, 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-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25983 Library of Congress Control Number: 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 Medi- cine. 2021. Implementing high-quality primary care: Rebuilding the founda- tion of health care. Washington, DC: The National Academies Press. https://doi. org/10.17226/25983. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

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. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

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 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 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 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 KOLLER, President, Milbank Memorial Fund ALEX 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 BENJAMIN OLMEDO, Physician Assistant, Family Medicine and Clinical Informatics, Dignity Health BRENDA REISS-BRENNAN, Director, Mental Health Integration, Intermountain Healthcare HECTOR RODRIGUEZ, Henry J. Kaiser Endowed Chair, Professor of Health Policy and Management, University of California, Berkeley v PREPUBLICATION COPY—Uncorrected Proofs

MARY ROTH McCLURG, Executive Vice Dean, Chief Academic Officer, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill ROBERT WEYANT, Associate Dean for Dental Public Health and Community Outreach, School of Dental Medicine, University of Pittsburgh Study Staff 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 QATO, University of Southern California School of Pharmacy Consultants 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 vi PREPUBLICATION COPY—Uncorrected Proofs

Reviewers 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 manu- script remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: RUTH BALLWEG, University of Washington L. EBONY BOULWARE, Duke University School of Medicine GWEN DARIEN, National Patient Advocate Foundation KAREN DeSALVO, Google Health, Google LLC ARVIN GARG, University of Massachusetts Medical School LAURIE G. JACOBS, Hackensack Meridian School of Medicine CARLOS ROBERTO JAÉN, UT Health San Antonio M. A. J. LEX MacNEIL, Midwestern University (retired) KEDAR S. MATE, Institute for Healthcare Improvement GLORIA J. McNEAL, National University EUGENE RICH, Mathematica MARTIN ROLAND, University of Cambridge SARA ROSENBAUM, The George Washington University PENELOPE ANN SHAW, University of Massachusetts vii PREPUBLICATION COPY—Uncorrected Proofs

viii REVIEWERS JEANNETTE E. SOUTH-PAUL, J. South-Paul Academic Consultants, LLC SUSAN E. STONE, Frontier Nursing University Although the reviewers listed above provided many constructive com- ments 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 inde- pendent 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. PREPUBLICATION COPY—Uncorrected Proofs

Contents PREFACE xi ACKNOWLEDGMENTS xv ACRONYMS AND ABBREVIATIONS xvii ABSTRACT 1 SUMMARY 3   1 A NEW VISION FOR PRIMARY CARE 19   2 DEFINING HIGH-QUALITY PRIMARY CARE TODAY 45   3 PRIMARY CARE IN THE UNITED STATES: A BRIEF HISTORY AND CURRENT TRENDS 71   4 PERSON-CENTERED, FAMILY-CENTERED, AND COMMUNITY-ORIENTED PRIMARY CARE 93   5 INTEGRATED PRIMARY CARE DELIVERY 141 ix PREPUBLICATION COPY—Uncorrected Proofs

x CONTENTS   6 DESIGNING INTERPROFESSIONAL TEAMS AND PREPARING THE FUTURE PRIMARY CARE WORKFORCE 181   7 DIGITAL HEALTH AND PRIMARY CARE 225   8 PRIMARY CARE MEASURES AND USE: POWERFUL, SIMPLE, ACCOUNTABLE 259   9 PAYMENT TO SUPPORT HIGH-QUALITY PRIMARY CARE 281 10 ENHANCING RESEARCH IN PRIMARY CARE 333 11 THE COMMITTEE’S APPROACH TO AN IMPLEMENTATION STRATEGY 357 12 A PLAN FOR IMPLEMENTING HIGH-QUALITY PRIMARY CARE 369 APPENDIXES A COMMITTEE MEMBER, FELLOW, AND STAFF BIOGRAPHIES 387 B RECOMMENDATIONS FROM PRIMARY CARE: AMERICA’S HEALTH IN A NEW ERA 403 C COMMITTEE’S CALCULATIONS TO DETERMINE THE IMPACT OF THE DECREASED DENSITY OF PRIMARY CARE PHYSICIANS BETWEEN 2005 AND 2015 409 D THREE SYSTEM-LEVEL TABLES OF ACTORS AND ACTIONS 413 E THE HEALTH OF PRIMARY CARE: A U.S. SCORECARD 417 PREPUBLICATION COPY—Uncorrected Proofs

Preface 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 market- place 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 medi- cine, 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. xi PREPUBLICATION COPY—Uncorrected Proofs

xii PREFACE 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 recommen- dations 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 expan- sion, 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 popula- tion health and opportunities to purposefully heal this schism. The recom- mendations 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 con- sensus 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 congres- sional 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 emer- gence of health information technology. Another change is the increased PREPUBLICATION COPY—Uncorrected Proofs

PREFACE xiii 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 commit- tee 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. Dima Qato, Kameron Mat- thews, and Lars Peterson. 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, em- braced 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 PREPUBLICATION COPY—Uncorrected Proofs

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Acknowledgments 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 re- sponded 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: Toyin Ajayi, Chief Health Officer and Co-Founder, CityBlock Christine Bechtel, Co-Founder, X4 Health Robert Berenson, Institute Fellow, Urban Institute Marc Boutin, Chief Executive Officer, National Health Council Doug Eby, Vice President of Medical Services, Southcentral Foundation Larry Green, Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care, University of Colorado School of Medicine Kelly Kelleher, Chlapaty/ADP Endowed Chair for Innovation in Pediatric Practice, Nationwide Children’s Hospital Barbara Leach, Family Support Specialist and Special Projects Coordinator, University of North Carolina Family Support Program xv PREPUBLICATION COPY—Uncorrected Proofs

xvi ACKNOWLEDGMENTS Amy Liebman, Director of Environmental and Occupational Health, Migrant Clinicians Network Thomas Mattras, Director of Primary Care Operations, U.S. Department of Veterans Affairs Kara Odom Walker, Secretary of Health and Social Services, Delaware Hoangmai (Mai) Pham, Vice President of Provider Alignment Solutions, Anthem Inc. Jennifer Purdy, Executive Director for Veterans Patient Experience, U.S. Department of Veterans Affairs Winifred Quinn, Director of Advocacy and Consumer Affairs, AAPR Allysa Ware, Project Director, Family Voices 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 Medi- cine for America’s Health, Health Resources and Services Administration, New York State Healthcare Foundation, Patient-Centered Outcomes Re- search 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 Lau-Scott, Rebecca Morgan, Maya Thomas, and Colleen Willis. 1  The commissioned papers can be found at https://www.nap.edu/catalog/25983. PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations AAMC American Association of Medical Colleges ACA Patient Protection and Affordable Care Act ACO accountable care organization AHRQ Agency for Healthcare Research and Quality AMA American Medical Association APRN advance practice registered nurse BLS U.S. Bureau of Labor Statistics 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 Community Health Improvement Plan CHIPRA Children’s Health Insurance 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 CNM certified nurse-midwife CPC Comprehensive Primary Care CPC+ Comprehensive Primary Care Plus CTSA Clinical and Translational Science Awards xvii PREPUBLICATION COPY—Uncorrected Proofs

xviii ACRONYMS AND ABBREVIATIONS EHR electronic health record FFS fee-for-service FQHC federally qualified health center GIS geographic information system GME graduate medical education GNE graduate nurse education 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 Act HPSA Health Professional Shortage Area HRSA Health Resources and Services Administration HSR health services research IHS Indian Health Service IMPaCT Individualized Management for Patient-Centered 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 MLP Medical–Legal Partnership MU Meaningful Use 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 PREPUBLICATION COPY—Uncorrected Proofs

ACRONYMS AND ABBREVIATIONS xix NIH National Institutes of Health NMHC nurse-managed health center NP nurse practitioner NQF National Quality Forum OECD Organisation for Economic Co-operation and Development ONC Office of the National Coordinator for Health Information Technology PA physician assistant 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 PRO patient-reported outcome RHC rural health clinic RN registered nurses ROI return on investment RUC Relative Value Scale Update Committee SCF Southcentral Foundation SDOH social determinants of health SES socioeconomic status 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 PREPUBLICATION COPY—Uncorrected Proofs

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Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care Get This Book
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High-quality primary care is the foundation of the health care system. It provides continuous, person-centered, relationship-based care that considers the needs and preferences of individuals, families, and communities. Without access to high-quality primary care, minor health problems can spiral into chronic disease, chronic disease management becomes difficult and uncoordinated, visits to emergency departments increase, preventive care lags, and health care spending soars to unsustainable levels.

Unequal access to primary care remains a concern, and the COVID-19 pandemic amplified pervasive economic, mental health, and social health disparities that ubiquitous, high-quality primary care might have reduced. Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes. For this reason, primary care is a common good, which makes the strength and quality of the country's primary care services a public concern.

Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care puts forth an evidence-based plan with actionable objectives and recommendations for implementing high-quality primary care in the United States. The implementation plan of this report balances national needs for scalable solutions while allowing for adaptations to meet local needs.

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