Purpose of Study and of This Interim Report
An Institute of Medicine committee has begun a 2-year study of the future of primary care. The study addresses the opportunities for and challenges of reorienting health care in this country to place greater emphasis on the function of primary care. Changes already occurring in the private and public sectors, and the possibility that health care reforms will intensify this emphasis, make timely this study's intent to provide a comprehensive strategy for guiding the future of primary care.
As a first step in the development of that strategy, the committee has developed a definition of primary care that is intended to be useful to health care professionals, health plan developers, policy makers, educators of health professionals, and the public as they confront the rapid changes in health care that are now under way and are likely to continue for the next 5–10 years. This interim report sets out the committee's definition of primary care for consideration and use by these audiences. The definition will also serve as a guide during the rest of the committee's study.
The Contemporary Context for the Definition
The organization and financing of personal health services in the United States are undergoing rapid changes that are being driven by market forces and by policies at the federal and state levels. Several of these changes entail a renewed emphasis on what is described as primary care practice, with the intent that this emphasis help achieve improved health through better access to needed services, moderation of cost increases, and better quality of care and patient satisfaction.
Health care reform proposals at the federal and state levels call for a higher proportion of primary care clinicians than now exists. Efforts to overcome nonfinancial barriers to health care for rural and disadvantaged populations have also frequently focused on the need for primary care services. In the private sector, managed care plans that emphasize the role of the primary care clinician as the pathway to care are growing quite rapidly, encouraged by employers and state governments, which view them as a means of moderating cost increases.
These changes come at a time of conflicting notions of how health care is and should be provided. In the first half of this century, personal health care was viewed as care provided by a physician to a patient who had long been known to the physician and with whom a trusting relationship had developed. The patient's concerns were understood in the context of family and community. This perspective derives from a time when technology and medicine had less to offer; medical knowledge was less organized by specialties; the general population was less mobile; costs of care were not of paramount importance; and corporate interests were little involved in the practice and financing of health care.
Since that time, health care has changed substantially. Most people in the United States are now accustomed to a high-technology, episode-based approach to health care, often provided by an array of specialists whose focus is more on an organ or a disease than on the whole person. Changes in insurance and employment may require frequent changes in health care providers. Corporations with stockholder interests are now involved in every facet of health care. Many uninsured and inner city residents have no regular source of care, or they may depend on a local emergency room or public clinic. Such approaches to care can easily result in conflicting advice, redundant or excessive use of technology, missing and fragmented information that can affect clinical decisionmaking, and disruption of personal relationships between patients and clinicians. In short, the notion of health care that prevailed in the early part of this century seems to have little counterpart in today's world, and the challenge is to transfer to today's society the trusting relationships we still value.
The nation is now grappling with how to create systems of care that are and will continue to be consistent with what it values—including personal relationships—in health care delivery. It does so within the changing realities of growth of specialized knowledge and techniques, concern about costs of health care, and the growth of large health care plans and integrated delivery systems. Sustaining the kind of health care that people want and that we, as a society, can afford will require uniquely American solutions that recognize this country 's particular methods of financing and organizing services, its admiration for technology, and its preferences for freedom to choose providers of care.
Across the country, medical practices and health plans are devising ways to achieve these goals, and the resulting systems will undoubtedly vary greatly.
Many people are encountering the term primary care provider for the first time as they enroll in managed care plans. The definition presented should help to shape people's expectations about primary care and improve their understanding as they use information about access, cost, and quality to make choices about which health care arrangements they prefer. To fully develop in all settings all the elements of primary care as defined by this IOM committee will require time and capital to put the required organization and infrastructure in place. The trend toward integrated health care systems may provide the necessary capital and infrastructure. In this report, the committee presents its view of the elements required for achieving the goals of primary care, but it does not regard any particular arrangement of services as the only way to accomplish them. However services are organized and financed, they must be of high quality, acceptable to patients and clinicians, and accessible in a socially equitable manner.
By providing a clearer understanding of the essential and desirable attributes of primary care, the definition should also serve as a guide to provider organizations as they develop health care delivery systems with primary care as their base. In this regard, the definition will also guide the further work of this committee as it addresses the question and issues outlined at the end of this report.
Why a New Definition Is Needed
Definitions of primary care already exist, including those developed by the IOM in 1978 and further elaborated in the IOM report on community-oriented primary care in 1984 (see IOM, 1978, 1984). The committee decided early on that the 1978 IOM definition was an excellent starting point for its work. It is desirable, however, to formulate a newer version of the definition that recognizes two important trends: the greater complexity of health care delivery and the greater interdependence of health professionals. In particular, these trends may be seen in the rapid growth of integrated delivery systems with enrolled populations and the use of teams for the delivery of primary care services. Attention is also being focused increasingly on several dimensions of health care that were not included in the 1978 definition, including (a) the need for clearer relationships between primary care, community, and public health needs; (b) the needs of and the roles of families; (c) a focus on the measurement and improvement of effectiveness and health outcomes; (d) patient satisfaction and the participation of individuals in health care decisionmaking; and (e) the scientific base of primary care.
The term primary care has served a useful purpose since it was introduced by White and others (White et al., 1961). It helped to crystallize awareness of a need for generalist physicians in an era of increasing specialization. It also
provided a basis for shared goals and training among physicians, nurses, and physician assistants. Some experts now argue that the term has outlived its usefulness as a guide to actions and policies. The committee believes, however, that the term primary care describes a function that is so imbedded in policy debates and actions in both the public and private sectors that the introduction of new terms1 would further confuse an already complex set of debates about future directions for health care.
The committee hopes that the concepts embodied in its definition of primary care will give the term additional meaning in a contemporary context and will focus attention on issues that have real consequences for improved performance of the health care system.
Given today's health care environment and the rationale for revisiting the earlier IOM definition, the committee has been guided by several assumptions that in its view are critical for the future of primary care in our health care system:
Primary care will be the logical foundation of an effective health care system because primary care can address a large majority of the health problems present in the population.
Primary care will be essential to achieving the objectives that together constitute value in health care—quality of care (including achievement of desired health outcomes), patient satisfaction, and the efficient use of resources.
Personal interactions that include trust and partnership between patients and clinicians will remain central to primary care.
Primary care will be an important instrument for achieving stronger emphasis on (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 delivery systems will continue and will provide both opportunities and challenges for primary care.
The terms generalist and generalist physician are used frequently in discussions that deal with primary care issues as defined by the committee. The relationship of primary care to generalism and generalist clinicians will be addressed in the full report.
Organization of the Interim Report
Part 2 of this report offers a review of earlier definitions of primary care. Readers familiar with this history might wish to skip to Part 3. Part 3 gives the committee's new definition of primary care. The definition is provisional; the committee will revisit the definition in its final report based on reactions received and further committee deliberations. Terms used in the definition are briefly discussed in the box that appears on pages 16–17 and are explained in more detail in the ensuing text. This text also emphasizes the relevant perspectives of the individual and the family, the community, and the integrated delivery system.
Part 4 acknowledges that some health care systems will, at the outset, have already moved further than others toward realizing the goals outlined in this report. Full realization of these goals will take some time in most health care settings, yet the committee's intent is to present goals that are achievable. Finally, Part 5 lists some of the issues and questions that will occupy the committee for the remainder of its study.