Appendix B
Primary Care: America’s Health in a New Era Report Recommendations
The Institute of Medicine’s (IOM’s) 1996 report Primary Care: America’s Health in a New Era1 was foundational and represented an ambitious plan to strengthen primary care in the United States. The Committee on Implementing High-Quality Primary Care’s deliberations and the resulting report were highly influenced by it. The complete text of the recommendations put forth in 1996 is below.
RECOMMENDATIONS
2.1 To Adopt the Committee’s Definition
This committee has defined primary care as the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. The committee recommends the adoption of this definition by all parties involved in the delivery and financing of primary care and by institutions responsible for the education and training of primary care clinicians.
5.1 Availability of Primary Care for All Americans
The committee recommends development of primary care delivery systems that will make the services of a primary care clinician available to all Americans.
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1IOM (Institute of Medicine). 1996. Primary care: America’s health in a new era. Washington, DC: National Academy Press.
5.2 Health Coverage for All Americans
To assure that the benefits of primary care are more uniformly available, the committee recommends that the federal government and the states develop strategies to provide health coverage for all Americans.
5.3 Payment Methods Favorable to Primary Care
The committee recommends that payment methods favorable to the support of primary care be more widely adopted.
5.4 Payment for Primary Care Services
The committee recommends that when fee-for-services is used to reimburse clinicians for patient care, payments for primary care be upgraded to reflect better the value of these services.
5.5 Practice by Interdisciplinary Teams
The committee believes that the quality, efficiency, and responsiveness of primary care are enhanced by the use of interdisciplinary teams and recommends the adoption of the team concept of primary care wherever feasible.
5.6 The Underserved and Those with Special Needs
The committee recommends that public or private programs designed to cover underserved populations and those with special needs include the provision of primary care services as defined in this report. It further recommends that the agencies or organizations funding these programs carefully monitor them to ensure that such primary care is provided.
5.7 Primary Care and Public Health
The committee recommends that health care plans and public health agencies develop specific written agreements regarding their respective roles and relationships in (a) maintaining and improving the health of the communities they serve and (b) ensuring coordination of preventive services and health promotion activities related to primary care.
5.8 Primary Care and Mental Health Services
The committee recommends the reduction of financial and organizational disincentives for the expanded role of primary care in the provision of mental health services. It further recommends the development and evaluation of collaborative care models that integrate primary care and mental health services more effectively. These models should involve both primary care clinicians and mental health professionals.
5.9 Primary Care and Long-Term Care
To improve the continuity and effectiveness of services for those requiring long-term care, the committee recommends that third-party payers (including Medicare and Medicaid), health care organizations, and health professionals promote the integration of primary care and long-term care by coordinating or pooling financing and removing regulatory or other barriers to such coordination.
5.10 Quality of Primary Care
The committee recommends the development and adoption of uniform methods and measures to monitor the performance of health care systems and individual clinicians in delivery primary care as defined in this report. Performance measures should include cost, quality, access, and patient and clinician satisfaction. The results should be made available to public and private purchasers of care, provider organizations, clinicians, and the general public.
5.11 Primary Care in Academic Health Centers
The committee recommends that academic health centers explicitly accept primary care as one of their core missions and provide leadership in the development of primary care teaching, research, and service delivery programs.
6.1 Programs Regarding the Primary Care Workforce
The committee recommends (a) that the current level of effort to increase the supply of primary care clinicians be continued and (b) that these primary care training programs and delivery systems focus their efforts on improving the competency of primary care clinicians and on increasing access for populations not now receiving adequate primary care.
6.2 Monitoring the Primary Care Workforce
The committee recommends that state and federal agencies carefully monitor the supply of and requirements for primary care clinicians.
6.3 Addressing Issues of Geographic Maldistribution
The committee recommends that federal and state governments and private foundations fund research projects to explore ways in which managed care and integrated health care systems can be used to alleviate the geographic maldistribution of primary care clinicians.
6.4 State Practice Acts for Nurse Practitioners and Physician Assistants
The committee recommends that state governments review current restrictions on the scope of practice of primary care nurse practitioners and
physician assistants and eliminate or modify those restrictions that impede collaborative practice and reduce access to quality primary care.
7.1 Training in Primary Care Sites
All medical schools should require their undergraduate medical students to experience training in settings that deliver primary care as defined by this committee.
7.2 Common Core Competencies
The committee recommends that common core competencies for primary care clinicians, regardless of their disciplinary base, be defined by a coalition of appropriate educational and professional organizations and accrediting bodies.
7.3 Emphasis on Common Core Competencies by Accrediting and Certifying Bodies
The committee recommends that organizations that accredit primary care training programs and certify individual trainees support curricular reforms that teach the common core competencies and essential elements of primary care.
7.4 Special Areas of Emphasis in Primary Care Training
The committee recommends that the curricula of all primary care education and training programs emphasize communication skills and cultural sensitivity.
7.5 All-Payer Support for Primary Care Training
The committee recommends the development of an all-payer system to support health professions education and training. A portion of this pool of funds should be reserved for education and training in primary care.
7.6 Support for Graduate Medical Education in Primary Care Sites The committee recommends that a portion of the funds for graduate medical education be reallocated to provide explicit support for the direct and overhead costs of primary care training in nonhospital sites, such as health maintenance organizations, community clinics, physician offices, and extended care facilities.
7.7 Interdisciplinary Training
The committee recommends that (a) the training of primary care clinicians include experience with the delivery of health care by interdisciplinary teams; and (b) academic health centers work with health maintenance
organizations, group practices, community health centers, and other health care delivery organizations using interdisciplinary teams to develop clinical rotations for students and residents.
7.8 Experimentation and Evaluation
The committee recommends that private foundations, health plans, and government agencies support ongoing experimentation and evaluation of interdisciplinary teaching of collaborative primary care to determine how such teaching might best be done.
7.9 Retraining
The committee recommends that (a) curricula of retraining programs in primary care include instruction in the core competencies proposed for development in Recommendations 7.2 and 7.3 and (b) certifying bodies in the primary care disciplines develop mechanisms for testing and certifying clinicians who have undergone retraining for primary care.
8.1 Federal Support for Primary Care Research
The committee recommends that (a) the Department of Health and Human Services identify a lead agency for primary care research and (b) the Congress of the United States appropriate funds for this agency in an amount adequate to build both the infrastructure required to conduct primary care research and fund high-priority research projects.
8.2 National Database and Primary Care Data Set
The committee recommends that the Department of Health and Human Services support the development of and provide ongoing support for a national database (based on a sample survey) that reflects the majority of health care needs in the United States and includes a uniform primary care data set based on episodes of care. This national survey should capture data on the entire U.S. population, regardless of insurance status.
8.3 Research in Practice-Based Primary Care Research Networks
The committee recommends that the Department of Health and Human Services provide adequate and stable financial support to practice-based primary care research networks.
8.4 Data Standards
The committee recommends that the federal government foster the development of standards for data collection that will ensure the consistency of data elements and definitions of terms, improve coding, permit analysis of episodes of care, and reflect the content of primary care.
8.5 Study of Specialist Provision of Primary Care
The committee recommends that the appropriate federal agencies and private foundations commission studies of (a) the extent to which primary care, as defined by the IOM, is delivered by physician specialists and subspecialists, (b) the impact of such care delivery on primary care workforce requirements, and (c) the effects of these patterns of health care delivery or such care on the costs and quality of and access to health care.
9.1 Establishment of a Primary Care Consortium
The committee recommends the formation of a public–private, nonprofit primary care consortium consisting of professional societies, private foundations, government agencies, health care organizations, and representatives of the public.
