National Academies Press: OpenBook

Primary Care: America's Health in a New Era (1996)

Chapter: Front Matter

Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

Primary Care

America's Health in a New Era

Molla S. Donaldson, Karl D. Yordy, Kathleen N. Lohr, and Neal A. Vanselow, Editors

Committee on the Future of Primary Care

Division of Health Care Services

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1996

Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

NATIONAL ACADEMY PRESS
2101 Constitution Avenue, NW Washington, DC 20418

NOTICE: The project that is the subject of this report was approved by 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 responsible for this report were chosen for their special competencies and with regard for appropriate balance.

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.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in 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 adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

See the Acknowledgments for a complete listing of the organizations that provided support for this study.

The stand-alone Summary is available in limited quantities from the Institute of Medicine, Division of Health Care Services, 2101 Constitution Avenue, NW, Washington, DC 20418. It is available on-line at http://www.nap.edu/nap/online.

The complete volume of Primary Care: America's Health in a New Era is available for sale from the
National Academy Press,
2101 Constitution Avenue, NW, Lock Box 285, Washington, DC 20055. Call 1-800-624-6242 or 202-334-3313 (in the Washington metropolitan area).

Library of Congress Cataloging-in-Publication Data

Institute of Medicine (U.S.). Division of Health Care Services Committee on the Future of Primary Care.

Primary care: America's health in a new era/Molla S. Donaldson … [et al.], editors; Committee on the Future of Primary Care Services, Division of Health Care Services, Institute of Medicine.

p. cm

Includes bibliographical references and index.

ISBN 0-309-05399-4

1. Primary health care—United States. I. Donaldson, Molla S. II. Title.

[DNLM: 1. Primary Health Care—United States. W 84.6 I587p 1996]

RA427.9.I56 1996

362.1'0973—dc20

DNLM/DLC 96-25823

for Library of Congress CIP

Copyright 1996 by the National Academy of Sciences.

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

COMMITTEE ON THE FUTURE OF PRIMARY CARE

NEAL A. VANSELOW, Chair,* Professor of Medicine and Adjunct Professor,

Department of Health Systems Management, School of Public Health and Tropical Medicine, Tulane University Medical Center, New Orleans, Louisiana

JOEL J. ALPERT,* Professor of Pediatrics and Public Health (Health Law),

Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts

CHERYL Y. BOYKINS, Director,

National Black Women's Health Project, Atlanta, Georgia

CAROLYN V. BROWN,

Private practice, Burlington, Vermont

KEN CAMERON, Chairman of the Board,

Group Health Cooperative of Puget Sound, Seattle, Washington

PETE T. DUARTE, Chief Executive Officer,

Thomason Hospital, El Paso, Texas

PETER ELLSWORTH, President and CEO,

Sharp HealthCare, San Diego, California

RAYMOND S. GARRISON, JR., Associate Professor and Chairman,

Department of Dentistry, Bowman Gray School of Medicine, Winston-Salem, North Carolina

LARRY A. GREEN,* Professor and Woodward-Chisholm Chairman of Family Medicine,

University of Colorado Health Sciences Center, Denver

PAUL F. GRINER,* Vice President and Director,

Center for the Assessment and Management of Change in Academic Medicine, Association of American Medical Colleges, Washington, D.C.

JEAN JOHNSON, Associate Dean,

Health Sciences Programs, The George Washington University Medical Center, Washington, D.C.

P. EUGENE JONES, Associate Professor and Director,

Physician Assistant Program, Department of Health Care Sciences, University of Texas Southwestern Medical Center at Dallas

HENK LAMBERTS,* Professor of Family Medicine,

Academic Medical Center, University of Amsterdam, The Netherlands

PAUL W. NANNIS, Commissioner of Health,

City of Milwaukee Health Department, Milwaukee, Wisconsin

R. HEATHER PALMER, Director,

Center for Quality of Care Research and Education, Harvard School of Public Health, Boston, Massachusetts

BARBARA ROSS-LEE, Dean,

College of Osteopathic Medicine, Ohio University, Athens

*  

Institute of Medicine member.

Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

SHEILA A. RYAN,* Dean,

School of Nursing,

Director,

Medical Center Nursing, University of Rochester, Rochester, New York

RICHARD M. SCHEFFLER, Professor,

Health Economics and Public Policy, School of Public Health, University of California at Berkeley

WILLIAM L. WINTERS, JR., Clinical Professor of Medicine,

Baylor College of Medicine, Houston, Texas

Study Staff

KATHLEEN N. LOHR, Director,

Division of Health Care Services

KARL D. YORDY, Study Co-Director

MOLLA S. DONALDSON, Study Co-Director

LISA M. CHIMENTO, Program Officer (until July 1994)

ROBIN L. RIVKIND, Research Associate (until September 1995)

DIANE PRESCOTT, Research Assistant (as of September 1995)

HELEN C. ROGERS, Project Assistant (until January 1995)

ANITA M. ZIMBRICK, Project Assistant (as of January 1995)

H. DONALD TILLER, Administrative Assistant

Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

Preface

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. Health care reform proposals developed by both the federal government and several state governments have included measures to strengthen the delivery of primary care. More important in view of current trends has been the emphasis that market forces have placed on a vigorous primary care system. A further indication of the current level of interest has been the number and variety of public and private sponsors of this Institute of Medicine (IOM) study of the future of primary care.

The current IOM study can be divided into two phases. During the first phase the study committee, which included members with diverse backgrounds and interests, agreed upon a number of underlying principles related to primary care and also reviewed and updated the definition of primary care that had been developed by the IOM in 1978. The underlying principles are listed in Chapter 1 of this report. Of particular importance is the committee's consensus that primary care represents the logical foundation for the U.S. health care system of the future.

The revised definition of primary care was published in a September 1994 preliminary report and is also contained in Chapter 2 of this final report. It takes into consideration the numerous changes in health care that have occurred in the nearly two decades since the original IOM definition was published. It would be

Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

impossible to overemphasize the importance the committee attached to the new definition. Committee members continually referred to it when formulating recommendations on issues such as who is a primary care clinician, what should be the content of education and training programs in primary care, and what items should be included in the research agenda for primary care.

The second phase, which occupied the final 18 months of the study, involved visits to urban and rural primary care delivery sites, a public hearing, the preparation and review of several commissioned papers, and two workshops. It included an examination of topics such as the nature and content of primary care and the value of primary care to both individual patients and to the health care system as a whole. Also considered were the delivery of primary care, the needs of the primary care workforce, education and training in primary care, and primary care research requirements. Finally, the committee recognized that additional steps will be needed to implement the 31 recommendations contained in this report and therefore developed the implementation strategy outlined in Chapter 9.

The committee wishes to acknowledge the superb support it received from the IOM staff. Study Co-directors Karl Yordy and Molla Donaldson, and Kathleen Lohr, Director of the IOM Division of Health Care Services, all played major roles in gathering data, helping to define the issues, and writing the report. The committee was impressed with both their knowledge and their professionalism. Other IOM personnel who provided valuable assistance were Lisa Chimento, Robin Rivkind, Diane Prescott, Helen Rogers, Anita Zimbrick, and Don Tiller.

Although it is impossible to predict what the U.S. health care system will look like when the current pace of rapid change ends and a period of relative stability is reached, the committee is confident that primary care will remain an essential component of efforts to improve the quality of care, increase access to health care, and control health care costs. It hopes that this report will both convey the value, complexity, and richness of primary care and catalyze concrete steps to strengthen this crucial part of the delivery system.

Neal A. Vanselow, M.D.

Chair

Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

Acknowledgments

The Committee on the Future of Primary Care is appreciative of the assistance it and the study staff received from many individuals and organizations during its site visits. All were gracious in offering their time and insights regarding the direction of primary care. The committee also made much use of the written statements and testimony given at a public hearing held by the committee in December 1994. These testimonies provided thoughtful reactions to the committee's interim report and information about current and planned primary care activities.

The committee benefited from thoughtful presentations by several experts invited to its meetings. At its first meeting, in March 1994, the committee heard from John M. Eisenberg, M.D., Chairman and Physician-in-Chief of the Department of Medicine at Georgetown University and Chairman of the Physician Payment Review Commission. Guest speakers at its second meeting, in May 1994, were Susan Schooley, M.D., Chair, Department of Family Practice, Henry Ford Health System; Patricia Simmons, M.D., Associate Professor, Department of Pediatrics and Adolescent Medicine, and Member, Board of Governors, Mayo Clinic and Foundation; and Jack M. Colwill, M.D., Professor and Chairman, Department of Family and Community Medicine, University of Missouri–Columbia, and Member, Council on Graduate Medical Education (COGME).

At its July 1994 meeting the committee heard a presentation by Dana Gelb Safran, Sc.D., Senior Policy Analyst, Division of Health Improvement, The Health Institute, New England Medical Center. She and the committee engaged in a lively discussion about a background paper she wrote for the committee on defining primary care. Material in that paper was derived in part from a consensus

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

conference convened in May 1994 by Dr. Safran and Dr. Alvin Tarlov of The Health Institute.

Fitzhugh Mullan, M.D., Director, Bureau of the Health Professions, Health Resources and Services Administration (U.S. Public Health Service) gave a presentation on the changing primary care workforce at its June 1995 workshop on roles in primary care. Drs. Kerr White and Barbara Starfield were extraordinarily helpful to the committee in responding to requests for information and generous with ideas about primary care based on their long experience in this field. Joyce Fitzpatrick, while the Distinguished Nurse-Scholar-in-Residence at the IOM, provided very helpful material to the committee on interdisciplinary education and practice.

The committee would like particularly to acknowledge the help of several organizations and individuals who provided data and conducted analyses for the committee: Carolyn Clancy, M.D., Agency for Health Care Policy and Research (USPHS); Paul A. Nutting, M.D., Ambulatory Sentinel Practice Network; Robert Larsen, M.D., FHP International, Inc.; Pauline Nefcy and Sarmad Pirzada of the Group Health Cooperative of Puget Sound; William Rush, Ph.D., and Leif I. Solberg, M.D., the Group Health Foundation; David Nerenz, Ph.D., the Henry Ford Health System; Merwyn R. Greenlick, Ph.D., and Nancy Clarke, the Kaiser Permanente Center for Health Research; Les Zendle, M.D., the Southern California Permanente Medical Group; Kathy Martin of Sharp HealthCare; Marcia J. Wilson of Sharp Rees-Stealy Medical Center, Inc.; and Peter Franks, M.D., University of Rochester/Highland Park Hospital.

Major funding for this study was received from the following: Department of Veterans Affairs, The Josiah Macy, Jr., Foundation, The Pew Charitable Trusts, The Robert Wood Johnson Foundation, and the U.S. Public Health Service, the Agency for Health Care Policy and Research and the Health Resources and Services Administration (HRSA). HRSA provided additional funding for a workshop on the scientific basis of primary care held in January 1995. The committee and staff are appreciative of the help provided by the contract officers whose organizations sponsored the study.

Additional funding for special study activities was received from Blue Cross of California, the Irvine Health Foundation, and the Pew Health Professions Commission for support of a constructive and informative workshop on roles in primary care that was held in Irvine, California, in June 1995. Funding for the committee's very useful and illuminating site visits was provided by the W.K. Kellogg Foundation.

Additional funding was received from a large set of organizations. Many of these organizations also provided helpful materials and data in response to our numerous questions. These sponsors are the Ambulatory Pediatric Association, American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Physician Assistants, American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American

Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

Association of Dental Schools, American College of Osteopathic Family Physicians, American College of Physicians, American Geriatrics Society, American Medical Informatics Association, American Nurses Association, American Optometric Association, American Osteopathic Association, American Physical Therapy Association, and the Society of General Internal Medicine.

Finally, the committee would like to express its gratitude to the IOM staff who facilitated the work of the committee. We are grateful for the secretarial and logistical support provided by Helen Rogers and Anita Zimbrick, to H. Donald Tiller, Administrative Assistant to the Division, and for the assistance during the report review and preparation stage of Claudia Carl and Michael Edington of the IOM's Reports and Information Office; the steady help of Nina Spruill, Financial Associate for the Division of Health Care Services, is also greatly appreciated.

Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
This page in the original is blank.
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×

3

 

THE VALUE OF PRIMARY CARE

 

52

   

The Value of Primary Care for Individuals

 

53

   

Primary Care and Costs, Access, and Quality

 

62

   

The Limits of Primary Care in Improving Population Health

 

71

   

Summary

 

72

   

References

 

72

4

 

THE NATURE OF PRIMARY CARE

 

76

   

Content of Primary Care

 

77

   

Characteristics of Primary Care

 

80

   

Summary

 

88

   

Appendix: Data on the Majority of Personal Health Care Needs

 

89

   

References

 

102

5

 

THE DELIVERY OF PRIMARY CARE

 

104

   

Current Pathways for Primary Care

 

105

   

Moving Toward Delivery of Primary Care as Defined

 

112

   

Summary

 

144

   

References

 

145

6

 

THE PRIMARY CARE WORKFORCE

 

148

   

Workforce Trends and Supply Projections: Physicians

 

149

   

Workforce Trends and Supply Projections: Nurse Practitioners

 

158

   

Workforce Trends and Supply Projections: Physician Assistants

 

162

   

Other First-Contact Providers

 

165

   

Comment on Workforce Estimation

 

165

   

Conclusions and Recommendations about the Supply of Primary Care Clinicians

 

167

   

Summary

 

175

   

References

 

175

7

 

EDUCATION AND TRAINING FOR PRIMARY CARE

 

179

   

Appropriate Training in Primary Care

 

180

   

The Education of Physicians

 

180

   

Other Content Issues in Training for Primary Care

 

187

   

Financial Support for Graduate Training in Primary Care

 

196

   

Interdisciplinary Education of Primary Care Clinicians

 

203

   

Integrated Delivery Systems and Primary Care Training

 

206

   

Continuing Medical Education

 

207

   

Physician Retraining

 

208

   

Summary

 

211

   

References

 

212

Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
This page in the original is blank.
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
This page in the original is blank.
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
This page in the original is blank.
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R1
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R2
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R3
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R4
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R5
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R6
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R7
Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R8
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R9
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R10
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R11
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R12
Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R13
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R14
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R15
Suggested Citation:"Front Matter." Institute of Medicine. 1996. Primary Care: America's Health in a New Era. Washington, DC: The National Academies Press. doi: 10.17226/5152.
×
Page R16
Next: Summary »
Primary Care: America's Health in a New Era Get This Book
×
Buy Hardback | $64.95 Buy Ebook | $49.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Ask for a definition of primary care, and you are likely to hear as many answers as there are health care professionals in your survey. Primary Care fills this gap with a detailed definition already adopted by professional organizations and praised at recent conferences. This volume makes recommendations for improving primary care, building its organization, financing, infrastructure, and knowledge base--as well as developing a way of thinking and acting for primary care clinicians. Are there enough primary care doctors? Are they merely gatekeepers? Is the traditional relationship between patient and doctor outmoded? The committee draws conclusions about these and other controversies in a comprehensive and up-to-date discussion that covers

  • The scope of primary care.
  • Its philosophical underpinnings.
  • Its value to the patient and the community.
  • Its impact on cost, access, and quality.

This volume discusses the needs of special populations, the role of the capitation method of payment, and more. Recommendations are offered for achieving a more multidisciplinary education for primary care clinicians. Research priorities are identified. Primary Care provides a forward-thinking view of primary care as it should be practiced in the new integrated health care delivery systems--important to health care clinicians and those who train and employ them, policymakers at all levels, health care managers, payers, and interested individuals.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!