Rapid and profound changes are under way in the organization and financing of health care in the United States. Driven largely by concerns about the rising costs of health care, some of these changes are intended to control the growth of expensive, specialized services and to favor growth in the role of primary care. The desirability of greater emphasis on primary care has long been recognized by the Institute of Medicine (IOM) and other groups and reflected in public policies at the federal and state levels. Efforts to encourage primary care in the past have included federal and state support for training of primary care clinicians, direct support for the organization of primary care services to disadvantaged populations, and development of health maintenance organizations (HMOs) and other financing mechanisms that encourage primary care.
These policies and steps have not, however, been the major force in bringing about renewed emphasis on primary care. In fact, pronouncements, studies, and public policies intended to encourage primary care have seemed remarkably ineffective as the health care system continued its drift of the past 50 years toward ever greater dependency on services provided by medical specialists and the related growth of hospital-based care. Meanwhile, a growing body of evidence suggested that this trend toward expanded use of specialized services has contributed significantly to an unsustainable increase in health care costs, has aggravated problems of access to basic services for some of our population, and has failed to address effectively common health problems that cause disability and death in the population.
Many factors encourage specialization. Among them are growth of medical knowledge based on biomedical research; methods of reimbursement of physicians
and hospitals that support the expanded use of medical technologies; and a training system based in specialized care settings. Prior reports by the IOM (1978) and other organizations (e.g., the Physician Payment Review Commission [PPRC] in its annual reports of the 1980s and 1990s; the Council on Graduate Medical Education [COGME] in its periodic reports over the same time period) have documented these trends and demonstrated how, until fairly recently, they overwhelmed the factors that promote primary care.
Today, powerful economic forces in the health care market, especially the actions of large purchasers of group health benefits, are driving a shift away from specialized services and toward primary care. In the absence of comprehensive health care reform, these market forces are likely to remain dominant in reshaping health care. Because cost is the major concern behind these market forces, primary care is seen as desirable because it is less expensive. Although wholeheartedly endorsing the emphasis on primary care, the IOM study committee appointed to produce this report (see below) is concerned about spotlighting primary care as a means to control the use of expensive, specialized services rather than as a better way to meet the health care needs of people.
In the longer run, the American people will accept only a system that meets their needs for good health care, and they will resist changes that are perceived as aimed principally at controlling costs. The committee believes that primary care is the foundation of that health care system—one that is effective and responsive as well as efficient in the use of expensive resources. Medical science will continue to improve its ability to diagnose and treat diseases, but primary care can assure that advances in diagnosis and treatment are used in a way that emphasize personal values in our diverse society; that emphasize health promotion, disease prevention, and early intervention; that enhance the ability of the individual to maintain effective functioning in daily life; and that facilitate links among individuals, their families, and their communities.
In this report, the committee sets out its vision of primary care, taking full advantage of the forces that have brought primary care to the fore after decades in eclipse. Its focus is on ensuring that primary care is shaped by concern for meeting people's needs for health care in the best traditions of the health professions. This vision includes continuous innovation and improvement in the performance of the health system. The committee cannot answer all questions that might arise about primary care, but it can and does identify the directions in which to go and the means by which to get there. As laid out in this report, these objectives include:
- a clear definition of the function of primary care that can guide public and private actions to improve health care;
- organizational arrangements for health care that are built on a foundation of strong primary care and that facilitate the coordination of the full array of services essential for maintaining and improving individuals' health status;
- improved information systems and quality assurance programs for primary care;
- ways to make primary care available to all Americans, regardless of economic status, geographic location, language, or cultural background;
- financing mechanisms that encourage quality primary care rather than episodic interventions late in the disease process;
- a primary care workforce sufficient in numbers to meet the needs for primary care, equipped with appropriate skills and competencies, and prepared to work in teams that include primary care physicians, nurse practitioners, physician assistants, community health workers, and other health professionals;
- an enhanced knowledge base for primary care, drawn from clinical and health services research; and
- program evaluation, dissemination of innovations, and continued education of both clinician and patient as means continually to improve the primary care system in an era of rapid change.
As can be seen from these objectives, primary care is not just a label for a set of clinicians. Rather, the committee views primary care as a system of services guided by a common vision. Realizing this vision poses a complex agenda—one that requires a coordinated strategy for implementation, many actors, and both short- and long-term steps. Primary care must include the appropriate organizational and financing arrangements, the necessary infrastructure, the knowledge base, a way of thinking and acting for the clinicians, and the understanding and support of patients and consumers. The committee hopes that this report will serve as a road map for a journey that will continue for many years.
The Institute Of Medicine Study
The IOM initiated this study with major funding provided by the U.S. Public Health Service (the Health Resources and Services Administration [HRSA] and the Agency for Health Care Policy and Research [AHCPR]), the Department of Veterans Affairs, The Robert Wood Johnson Foundation, The Pew Charitable Trusts, and The Josiah Macy, Jr. Foundation. All these foundations and government agencies as well as the IOM have had a long-standing interest in issues relating to primary care such as workforce, financing, organization and delivery, education and training, and research. As the study proceeded, the committee identified additional activities that would contribute to its deliberations, and additional support for these activities was received from a number of professional organizations and foundations (see list of sponsors in acknowledgments).
The Study Committee and Its Charge
In early 1994, the IOM appointed a study committee that conducted the major part of its work between March 1994 and October 1995. The committee, chaired by Neal A. Vanselow, M.D., consisted of 19 individuals (see roster on pp. iii–iv) with diverse expertise in the administration and governance of hospitals, HMOs, medical centers, and academic health centers; the practice of medicine (including the fields of family practice, general internal medicine, general pediatrics, cardiology, obstetrics-gynecology, and osteopathy); public health; nursing; physician assistant training; dentistry; health economics; long-term care; health services research; epidemiology; and consumer wellness. During its nine meetings and other study activities, the committee addressed the following charge:
[P]rovide guidance for augmenting and improving primary care as an essential component of an effective and efficient health care system. The study will focus on the health needs of the population and the functions of primary care in meeting those needs, not just on the numbers and roles of health care professionals choosing primary care careers. Attention will be given to the issues of the overall financing and organization of services as well as to the training and deployment of the primary care work force. An interim report providing the initial conclusions of the committee concerning the definition of the primary care function will be issued in September, 1994. The study will draw on the related work of federal agencies, foundations, and other organizations carrying out related studies and program initiatives.
To avail itself of expert and detailed analysis of several issues beyond the time resources of its members, the committee commissioned three major background papers. The first, by Inge Hofmans-Okkes, M.A., Ph.D. and Henk Lamberts, M.D., Ph.D., provides data on the majority of personal health service needs and is summarized as an appendix to Chapter 4. The second, by Frank deGruy III, M.D., examines the relationship between primary care and mental health and appears as Appendix D. The third, by William E. Welton, M.H.A., Theodore A. Kantner, M.D., and Sheila M. Katz, M.D., M.B.A., explores issues of primary care and public health and appears as Appendix F. In addition, a paper commissioned by HRSA and written by committee member Richard M. Scheffler, Ph.D., provides an economic analysis of workforce issues and appears as Appendix E.
In September 1994 the committee released Defining Primary Care: An Interim
Report (IOM, 1994). The definitions of primary care and the terms used in the definition acted as a reference point for the committee during its deliberations. The definition has been disseminated widely, and the committee has received considerable feedback from a variety of individuals, professional groups, and organizations. That work is incorporated in Chapter 2.
When IOM studies with national significance involve activities initiated at the state and community level, the IOM often makes a concerted effort to reach out to those engaged in such activities in those locales. The aims are (a) to learn about the activities and to understand the views of interested parties about issues pertinent to the local efforts and then (b) to apply those lessons, as appropriate, to broad national, professional, and policy-related issues. The IOM takes care, in these circumstances, not to evaluate or draw public judgments about organizational efforts.
During late 1994 and through the summer of 1995, the committee conducted site visits. Three major visits were made to the following areas: Minnesota, southern California, and Texas and New Mexico. Shorter visits were made to rural North Carolina and Boston. (See Appendix A.) The sites were chosen to provide a firsthand view of primary care in these very different settings. Information gathered there confirmed the swift and profound changes that are under way in the financing and organization of health care in this country. Discussions with people engaged in the organization and delivery of primary care and involved in educational programs, as well as patients, reinforced the committee's view that primary care is a very rapidly moving target.
In December 1994 the full committee held a public hearing to gather information about a broad set of issues, including (a) the scope of primary care; (b) who should deliver primary care; (c) the organization and financing of primary care; (d) education, training, and research in primary care; (e) the committee's definition of primary care; and (f) other issues before the committee. A range of organizations were invited to express their views, describe their experiences, and comment on these matters, as well as to submit articles, descriptive materials, and position statements on primary care. In all, 86 organizations submitted written testimony and 31 organizations presented oral testimony at the public hearing. (See Appendix B.)
An invitational workshop held in January 1995 (see Appendix C) provided
an opportunity for thoughtful discourse among a knowledgeable and diverse group of experts concerning the scope and directions for research that can best strengthen the base of scientific knowledge for primary care, and it yielded insights that the committee incorporated in its conclusions and recommendations concerning primary care research and the infrastructure necessary to the research enterprise (see Chapter 8). A special issue of the Journal of Family Practice (February 1996) comprises papers based on many of the workshop presentations.
A second invitational workshop held in June 1995 (see Appendix C) featured a structured discussion by a diverse group of health professionals about the roles of the various health professions in carrying out the function of primary care. Materials and views from this workshop are reflected throughout this report (and especially in Chapters 3 through 7).
To guide its development of this report, the committee adopted five assumptions. These are, in the committee's judgment, critical for the future of primary care in this nation's health care system, and they are consistent with the evidence and logic presented throughout the report. The principles are:
- Primary care is the logical foundation of an effective health care system because it can address the large majority of the health problems present in the population.
- Primary care is essential to achieving the objectives that together constitute value in health care: high quality of care, including achievement of desired health outcomes; patient satisfaction; and efficient use of resources.
- Personal interactions that include trust and partnership between patients and clinicians are central to primary care.
- Primary care is an important instrument for achieving stronger emphasis on both ends of the spectrum of care: (a) health promotion and disease prevention and (b) care of the chronically ill, especially among the elderly with multiple problems.
- The trend toward integrated health care systems in a managed care environment will continue and will provide both opportunities and challenges for primary care.
Historic Roots And The Contemporary Context For Primary Care
Before World War II
Before World War II, health care in the United States was based on what would now be described as primary care. The Committee on the Costs of Medical Care, a private group established with support from foundations, carried out the first comprehensive study of health care in this country and, in 1932, stated that ''each patient would be primarily under the charge of the family practitioner … [and] … would look to his physician for guidance and counsel on health matters and ordinarily would receive attention from specialists when referred…" (CCMC, 1932, p. 63). Through the 1930s and 1940s general care was increasingly provided by pediatricians and internists (whose specialty boards were established in 1933 and 1936, respectively) in addition to general practitioners. In many locales, the public health nurse also provided important aspects of what we now call primary care.
The term primary care began to appear in the literature in the early 1960s. Kerr White and his associates made important contributions to the concept and study of primary care. The important 1961 article "The Ecology of Medical Care," written at a time when the growth of specialized care was well under way, used epidemiological analysis to show that most health care problems were appropriately addressed in the primary care setting (White et al., 1961).
Concerned by the decline of general practitioners as key providers of primary care, several major commissions issued reports in the 1960s1 that encouraged the establishment of family practice as a new primary care specialty. Nevertheless, the decline in the numbers of general practitioners continued (from 71,366 in 1965 to 42,374 in 1975), and the numbers of physicians trained in the new specialty of family practice did not make up for this decline. Meanwhile, the total number of physicians grew rapidly as medical education expanded, encouraged by federal and state policies and financial support that resulted from a perceived general shortage of physicians; most of this growth went into specialty care (COGME, 1992).
The training of physician assistants and nurse practitioners also began in this period, with the objective of filling part of the perceived gap in the shortage of physicians. Federal support, such as that authorized in Titles VII and VIII of the Public Health Act, encouraged these training programs.
Public sector financing of health services also emerged in the 1960s. To target the problem of access to health services for the poor, federal programs were launched to assist in the development of community-based comprehensive primary care centers for both the urban and rural poor. More well-known efforts to expand access to care were the Medicare and Medicaid programs for, respectively, the elderly and selected parts of the poor population.
By 1976, a growing belief that primary care physicians were in short supply led to federal support for the training of general internists and general pediatricians in addition to family practitioners. Several major private foundations, particularly the Robert Wood Johnson Foundation, devoted substantial funds to the encouragement of primary care and training for primary care.
The IOM report A Manpower Policy for Primary Care made a number of recommendations to shift the emphasis of medical care toward primary care (IOM, 1978). Drawing heavily on the earlier work of Alpert and Charney (1973), the report contained a definition of primary care that became widely used, but the report's policy recommendations were not implemented.
During this period, specialty care grew in most industrialized countries, but the proportion of physicians delivering primary care remained substantially higher in other nations than in the United States (Starfield, 1991, 1992). In 1978, the World Health Organization, in the so-called Alma-Ata declaration, put primary care at the center of its strategy of "health for all by the year 2000."
In the United States, the growth of HMOs was encouraged by the Health Maintenance Organization Act of 1973. Drawing on the experience of capitated group practice models, HMOs emphasized primary care services and lower hospital utilization. Their growth accelerated in the 1970s and 1980s (from 3 million members in 1973 to more than 29 million in 1987) largely through encouragement by business interests looking for a way to control their expenditures for employee health benefits. Much of this growth was in loose models based on networks of physicians and hospitals; the primary care physician filled a "gatekeeper" role as the required path to specialized services.
Despite these many independent efforts, primary care did not prosper in the midst of economic and professional incentives that continued to favor specialty care. Specialized services continued to increase as a proportion of all medical care.
Health Care Reform
When this study began, comprehensive reform of the U.S. health system seemed a likely prospect. A number of the proposals for comprehensive reform, including that of the Clinton administration, contained specific provisions intended to increase the emphasis on primary care. Whatever the specific arrangements, such extensive reform would have addressed the issue of health coverage for the growing numbers of uninsured. It would also have provided a specific framework for changes in health care and clearer patterns of accountability for the results of those changes.
Comprehensive reform initiated by the government did not come to pass, however, and it now seems unlikely for some years. Although some states have moved to develop and implement their own reform plans, the future of these plans is also uncertain in light of both the failure of national comprehensive reform and efforts to constrain spending at all levels of government. Incremental changes in the rules for the health insurance market may still occur at the national and state levels, but how these changes will affect the arrangements for primary care is unclear.
Despite the failure of comprehensive reform efforts, rapid changes in the organization and financing of health care continue, driven primarily by powerful forces in the health care marketplace. These forces are likely to continue and constitute the context in which the future of primary care will be determined. The major forces for change, as seen by the committee, involve the following eight sets of factors:
Continuing concerns of payers of group health benefits about the costs and effectiveness of medical care. Group payers include both private sector employers and federal, state, and local governments. All are concerned about what they perceive as unsustainable rates of increases in medical care expenditures. Derivative from cost concerns are questions about the effectiveness and necessity of specific health services.
These considerations have led to various approaches to managing care and capping expenditures, which often emphasize reducing the use of specialized services and hospital care and shifting more clinical responsibility to the primary care clinician. Health care plans and governments have also used their economic power to reduce levels of payment to providers. These actions have the aggregate effect of creating excess capacity in hospitals, reducing the demand for many specialized services, and creating economic pressures to reduce these capacities.
Although the more aggressive actions have been taken by private payers, several states are moving their Medicaid programs into managed care arrangements. The Medicare program has lagged in this movement; overall, only about 9 percent of beneficiaries are enrolled in plans with Medicare risk contracts (HMOs), but the proportion is much higher in some markets where managed care penetration is high. By contrast, Medicare has taken the lead on changes in methods of reimbursement in the fee-for-service sector, including changes in physician reimbursement that were intended to increase the payment for primary care services relative to specialty procedures. Discussions of substantial reductions in Medicare and Medicaid funding are likely to accelerate the move of these public programs into managed care arrangements.
The result of these actions is a strong growth in enrollments in HMOs and other forms of managed care, but the rates of HMO enrollment vary considerably across different areas of the country and there is little penetration of rural markets. In markets in which managed care penetration is high, intense cost-based competition results.
Development of integrated delivery systems and consolidation of providers and health plans. To compete effectively for patients and to meet the concerns of health plans, employers, and governments to hold down costs, physicians and institutional providers are increasingly forming integrated delivery systems built on a foundation of primary care. As the committee observed in its site visits to areas where markets have advanced far into this competitive managed care environment, physicians and hospitals are finding it difficult to survive without joining some form of organized arrangement for health care. Plans and delivery systems are also consolidating into larger aggregates that can access capital, market and compete effectively in broader areas, and develop the infrastructure (including data systems and clinical decision systems) needed for improved efficiency and effectiveness of services.
Growing influence of the private capital markets. The creation of large plans and integrated systems requires access to substantial capital. The need for capital has the practical effect of introducing a new set of decision makers who focus chiefly on financial viability. For for-profit plans, which are a growing proportion of the health care industry, growth in profitability over time is another major goal and criterion of success to which the health plans must be attentive.
Legislative actions affecting primary care in an era of reductions of public budgets. The federal government has encouraged primary care in several ways: subsidies for the training of primary care clinicians, changes in Medicare reimbursements for physicians, and grant support for organized primary care services at the community level. Unprecedented efforts to balance the federal budget make future funding of these federal programs uncertain. Efforts to reduce the growth of Medicare and Medicaid may contribute to the inability of health care institutions and organizations to meet the primary care needs (let alone the full range of health care needs) of the growing numbers of uninsured
throughout the country, and these steps to curtail federal programs will complicate, if not undermine, the actions that states and localities might wish to take to support and expand primary care services.
Meanwhile, various states have considered or taken actions intended to increase the proportion of primary care physicians and other clinicians being trained. Laws have also been passed or are being considered that designate certain specialties as part of primary care. State legislative actions have also expanded the scope of practice of nurse practitioners and physician assistants in many states, which has implications for the role of these clinicians in the provision of primary care. These state actions are often linked to concerns about rural health care and access to care by the poor in the inner cities, but the process serves to raise the level of awareness of primary care issues in the legislature.
A surplus of specialist practitioners. As the health care system shifts toward primary care and the demand for specialized care diminishes, a surplus of physicians and nurses who have been providing specialty services seems likely to emerge. Certainly this is true for physicians (IOM, 1996a). The concerns of these groups, expressed in the political process, are already being heard, especially with respect to the effects of downsizing and restructuring on the nursing profession (IOM, 1996b). These concerns may be a limiting factor on the rate of the changes described above.
Role of the patient in determining the pace and nature of changes in the patterns of medical care. An increasingly well-informed patient is an important force in determining the future course of medical care, including primary care. Some changes in the patterns of medical care disrupt long-established physician-patient relationships and established patterns of care that patients perceive as desirable. For example, when employers change health plans offered to employees, or when clinicians lose their affiliations with health plans and are no longer included in the panel of clinicians available to patients, then clinician-patient relationships are likely to be interrupted. Some patients resent being cut off from direct access to their established clinicians or to specialists of their choice.
Patients also express resistance to patterns of care established by managed care plans in the interest of cost containment. A current example is the controversy over lengths of hospital stay for obstetric care; pressures for shorter stays are being resisted by both women and clinicians, and state legislative actions are being taken or proposed that would impose length-of-stay requirements on managed care plans. In many of these situations, patients' concerns are augmented by clinicians' concerns about limitations on their freedom to make clinical decisions in the interests of their patients (or to provide patients with all appropriate information necessary for adequate decisionmaking). In the United States, changes in arrangements for a service as basic as medical care are unlikely to endure without the support of patients. If such support is to be achieved, it will need to be based on better understanding of the potential benefits of the changes in terms of the values that patients and their families hold dear.
Effects of changes on academic health centers. Academic health centers are under pressure to place more emphasis on primary care in their educational and patient care programs. At the same time, the aggressive competition of managed care plans and current and potential declines in federal and state support for their educational missions are making response to change even more difficult for these institutions. Their complex governance patterns make rapid change difficult under any circumstances, but their increasing dependence on clinical income, most of which is derived from highly specialized services, to subsidize their educational and research missions puts these institutions at a competitive disadvantage relative to health care plans that do not have these missions. Furthermore, an emphasis on primary care is at variance with the traditional clinical base of specialized, tertiary care services found in many institutions.
Continued growth of knowledge and technologies for improved medical care. The results of the continued rapid growth in biomedical knowledge—new diagnostic and therapeutic modalities—will continue to influence the nature and costs of health care. The potential benefits of these advances continue to be exciting and popular, but in a cost-constrained medical environment new technologies are being subjected to more examination of their costs and effectiveness. New technologies have, over the years, prompted increased specialization, but the environment of managed care is leading to more explicit decisions about the introduction and appropriate use of technologies and the roles of primary care clinicians in determining their use.
Advances in information technologies also have considerable potential for shaping the future of health care and the role of primary care. Computer-based patient records and decision assists have the potential to change the roles and functions of primary care clinicians and improve the participation of patients and consumers in making informed decisions about their own care.
Growth in knowledge and techniques for outcomes-based accountability in health care is also shaping the future of primary care. Although cost has been a principal engine of change in health care arrangements, including the shift toward primary care, better techniques for measuring outcomes, including measures that reflect the perceptions of the patient about the outcomes of care, are changing the nature of accountability in health care. Clinicians and health care organizations and institutions will be under more pressure to justify their activities and their use of scarce resources in terms of results—both clinical outcomes and measures of patient functioning and satisfaction. Primary care will face difficult challenges in developing and using appropriate outcome measures that will convince patients, health care systems, and payers that a primary-care-based health system can benefit patients as well as constrain costs. Because of the breadth of primary care and its longitudinal nature, and because of the difficulties of measuring outcomes attributable to the care process over the long time periods often required in ambulatory care, the technical challenges in developing appropriate outcomes-based accountability will be substantial.
Organization Of The Report
All the forces outlined above—and indeed others not yet perceived—will shape primary care in ways that this committee cannot fully anticipate. They constitute, however, an important context for the information presented and the findings and recommendations offered in the remainder of this report.
Chapter 2 incorporates much of the committee's interim report defining primary care (IOM, 1994). Chapter 3 discusses the value of primary care as viewed from the perspective of the individual and the policymaker, and it makes extensive use of illustrative vignettes. The nature of primary care, using the committee's definition as an organizing framework and drawing from its workshop on the scientific basis of primary care, is explicated in Chapter 4. Chapter 5 addresses the organization and delivery of primary care from the perspective of several current trends: changes in organization and financing; rising use of teams; growing needs of underserved populations; increasing recognition of the need for strong relationships between primary care and public health, mental health, and long-term care; the increasingly complex and fragile role of academic medical centers; and the emerging emphasis on information about quality of care.
Chapter 6 describes the primary care workforce and calls attention to the need to address all components of that workforce in concert, and Chapter 7 focuses on education and training issues for primary care clinicians. Chapter 8 identifies high priority research topics and documents the need for developing the infrastructure to support research efforts in this field. Finally, Chapter 9 discusses critical steps in implementation of the committee's recommendations.
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