5
The Delivery of Primary Care

The definition of primary care (Chapter 2) is a normative definition; that is, it defines what the committee believes the function of primary care should be. Whether the elements of this definition can be achieved and whether primary care can assume its proper role in the delivery of health care will be determined in a world of health care that is being reshaped by the forces described in Chapter 1. Although some of those forces are favorable to aspects of primary care, the committee is not convinced that the current health care market, by itself, will shape primary care to match all aspects of the definition. Further actions will need to be taken to provide the financial incentives and infrastructure that will help the health care system overcome barriers. This chapter includes recommendations for such actions. In addition to barriers that are specific to primary care, the committee notes that the lack of universal entitlement to health care benefits will continue to raise special problems for the uninsured and underinsured in obtaining access to primary care.

The committee is under no illusion that it can, or should, prescribe a single path for delivering primary care in an environment that is so diverse and changing so rapidly. Nevertheless, the definition presents clear guideposts for actions by the many actors in health care: health professions, health plans and organizations, payers for group coverage who set many of the standards within which health care is organized, and government regulators. Diversity in the means of achieving the committee's primary care objectives may be desirable, but the key elements of the definition should be the criteria by which actions to advance primary care are judged.

This chapter is presented in two sections. The first section outlines the



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--> 5 The Delivery of Primary Care The definition of primary care (Chapter 2) is a normative definition; that is, it defines what the committee believes the function of primary care should be. Whether the elements of this definition can be achieved and whether primary care can assume its proper role in the delivery of health care will be determined in a world of health care that is being reshaped by the forces described in Chapter 1. Although some of those forces are favorable to aspects of primary care, the committee is not convinced that the current health care market, by itself, will shape primary care to match all aspects of the definition. Further actions will need to be taken to provide the financial incentives and infrastructure that will help the health care system overcome barriers. This chapter includes recommendations for such actions. In addition to barriers that are specific to primary care, the committee notes that the lack of universal entitlement to health care benefits will continue to raise special problems for the uninsured and underinsured in obtaining access to primary care. The committee is under no illusion that it can, or should, prescribe a single path for delivering primary care in an environment that is so diverse and changing so rapidly. Nevertheless, the definition presents clear guideposts for actions by the many actors in health care: health professions, health plans and organizations, payers for group coverage who set many of the standards within which health care is organized, and government regulators. Diversity in the means of achieving the committee's primary care objectives may be desirable, but the key elements of the definition should be the criteria by which actions to advance primary care are judged. This chapter is presented in two sections. The first section outlines the

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--> committee's observations about the current trends and characteristics of U.S. health care that form the current context for the delivery of primary care. The second section contains the committee's conclusions and recommendations about changes needed to improve the delivery of primary care in order to realize more fully the potential of primary care to improve the health and satisfaction of patients. Current Pathways For Primary Care The rapid pace of change and the diversity of local circumstances are striking characteristics of current health care. Descriptive evidence about current directions of health care, augmented by the committee's five site visits, confirms the magnitude and rapidity of those changes. Ours is a health care system going through a major transition. From an era of growth in expensive services supported by open-ended financing, wide choice of clinicians and hospitals, and almost complete freedom for clinical judgment, the U.S. health system is moving quickly into an era of limits on resources, cost-based competition among health plans and providers, financial risk-sharing by providers, and constraints on patient choice of clinician. No one can predict accurately where the health care system will be in 5 years, let alone 10 or 20 years. Simple generalizations informed by past studies, even studies only a few years old, are limited in their ability to describe or explain current directions in health care. Yet we believe that broad pathways for that change can be identified and need to be taken into consideration. Some studies have identified stages of the health care market that imply a progression toward "mature" markets (University Hospital Consortium, 1993)—essentially those dominated by a handful of large, fiercely competitive health plans. The committee is wary, however, of any interpretation that such a progression is an orderly one. In visiting several areas of the country that are usually considered more mature health care markets (e.g., Minnesota and southern California), committee members observed that the pace of change continues to be rapid. Wherever these markets are going, they are not there yet. With these cautions and caveats, we do see broad themes, both in what is happening and in what has not happened. Spread of Managed Care The term managed care has come to have many meanings. This committee uses managed care to refer to health plans that have a selective list of providers, both health professionals and hospitals, and that include mechanisms for influencing the nature, quantity, and site of services delivered. Many of these plans have focused initially on using their market power to obtain discounts from physicians, hospitals, and other providers in an oversupplied market. They are

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--> evolving, however, toward more organized arrangements that include some form of involvement of the providers in the risk assumed by the plan. That risk derives from the plan's agreement to deliver a defined package of services for a fixed amount per capita for an enrolled population, such as with the various forms of health maintenance organizations (HMOs). The involvement of providers in the success of the plan is intended to offer incentives for containing costs while maintaining patient satisfaction with the care received. Bailit (1995) estimates that in 1994, of a total of 180 million insured by private plans, enrollment in managed care totaled about 115 million persons. This estimate uses a definition of managed care that includes HMOs; "point of service" plans that combine HMO enrollment with an option to use providers outside the plan for an additional cost; and PPOs (preferred provider organizations), which offer a less structured arrangement that presents the enrolled person with a financial incentive to choose providers from a preferred list. He estimates that the number of individuals enrolled in managed care in the private market increased about 10 percent from 1993 to 1994. Enrollment in managed care in the public programs in 1994 was much lower than in private plans, at about 8 percent of Medicare beneficiaries and about 25 percent of those eligible for Medicaid. The rate of increase is greater, however, especially in the Medicaid program. Forty-two states are implementing some form of managed care in their Medicaid programs. Arizona (100 percent), Tennessee (74.9 percent), and Oregon (21.9 percent) lead the way in the percentage of Medicaid dollars spent through managed care arrangements, but many other states are moving aggressively in this direction (Lewin-VHI, 1995). Current congressional deliberations on the future course of the Medicare program may result in further encouragement of enrollment of Medicare beneficiaries in capitated managed care plans. Of particular significance for this study is that one major objective of most managed care plans is to reduce the use of specialists and to increase the use of primary care clinicians. The path to specialized care in most plans is through the primary care physician or other primary care clinician. Managed care, therefore, enhances the power of the primary care clinician to determine the services provided and by whom. The increasing future opportunities for primary care clinicians and the contrasting decline in the need for specialists have been described by Weiner and others in projecting future physician requirements (Weiner, 1993; COGME, 1995; PPRC, 1995). The growth of managed care, although substantial, is taking place predominantly in large and medium-sized markets. Those providing services in rural areas are anticipating the move of managed care into their communities, but managed care was not yet evident in the rural areas visited by the committee. The development of managed care varies widely by region. The most significant market penetration has been in the West, the upper Middle West, and the Northeast. The Southeast and South Central regions have less managed care at

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--> this time (GHAA, 1995). In all areas, managed care on the basis of an enrolled, capitated population is not available to the uninsured and many of the underinsured, a growing proportion of the U.S. population (EBRI, 1995). The growth of managed care plans is blurring the traditional boundaries between the insuring or financing function, with its strong concern for managing risk, and the provision of services and clinical decisions regarding those services. Managing risk is still important; no plan, regardless how efficient, wants to have a disproportionate share of sicker patients unless that risk can be shared. Most managed care plans, however, are also interested in how to improve the efficiency of services and how to maintain or increase patient satisfaction. Sophisticated buyers, such as the business community in the Twin Cities area, are developing performance standards for health plans that include clinical measures (Institute for Clinical Systems Integration, no date). Older staff and group model HMOs, such as Kaiser Permanente and Group Health Cooperative of Puget Sound, have long combined the insurance and patient care functions under a single organizational umbrella. Development of Integrated Health Care Delivery Systems A related and overlapping trend is the development of vertically integrated delivery systems that combine physicians and other health professionals, hospitals, rehabilitation units, social services, chronic care capabilities, mental health and substance abuse programs, and health promotion and disease prevention programs into an organized whole that can provide and coordinate a comprehensive array of services. Some of the motivation behind the development of these systems is to increase and protect market share in areas where there is surplus capacity. It is difficult to quantify the extent of systems change because so much is happening so rapidly. Many examples exist, mostly in larger cities but some in more rural areas, often built on preexisting multispecialty groups such as those of the Mayo, Marshfield, and Geisinger clinics. Based on examples seen in the site visits, these systems at their best provide opportunities for innovations in arrangements for services, in part by breaking down institutional and professional barriers to delivering services more efficiently. They also provide the critical mass and capital needed for the development of infrastructure, such as information and clinical decision systems, telephone triage programs, and training. In the best of these organizations, the functions of primary care move well beyond the gatekeeper function toward a fuller application of the committee's definition. These systems are not a new phenomenon; some of the older staff and group model HMOs have had many of these characteristics for some time. What may be new is an environment that encourages change rather than one that regards innovations as a questionable deviation from the norm. The pressure for continuing improvement in the cost-effective provision of services is present in older

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--> integrated systems with long track records of success as well as in newer systems that have been built by combining previously independent providers. For our purposes, the important point is that all of these systems are built on, or are building on, foundations of primary care clinicians, often by purchasing existing primary care practices. This primary care base is seen as necessary for both building and protecting market share and for creating a mechanism to control access to specialized services. In a capitated system, specialized services are seen as cost centers, rather than as revenue centers, and the organization has strong incentives to control such costs. Consolidation of Health Plans and Systems Both health plans and integrated systems are consolidating into larger organizations. They are driven to do so by several factors, including the need for capital, advantages in marketing, and potential economies of scale in developing and using infrastructure such as clinical information systems. Site visits to urban markets (the Twin Cities, southern California, and Boston) provided multiple examples in each site of major consolidations of health plans and provider organizations. In communities where this consolidation is far along, characterization of health care as a very local and personalized service—a cottage industry as it has often been called—no longer holds. Becoming part of a larger organization is causing considerable stress for clinicians who value highly the autonomy of their practice and personal relationships with their patients. Some patients are also disturbed if they believe that their relationship with a primary care clinician who is committed to their interests is being compromised by a large, impersonal, and perhaps distant organization. Growth in For-Profit Health Plans and Delivery Systems Along with consolidation, health plans and integrated systems are increasingly under for-profit ownership. In addition to the growth of existing for-profit plans and their acquisition of not-for-profit plans, some not-for-profit plans are converting to for-profit forms of ownership. The need to raise capital for expansion is often given as the reason for the growth of for-profit ownership. The long range effects of this trend are not clear, but it raises the possibility of conflict between the desires of the stockholders to maximize profit and the objectives of primary care to ensure adequate care for patients. It also underlines the need to have measures of performance that include the interests of patients, not just the financial interests of group purchasers and stockholders, and that are available to guide patients' health care choices (for a fuller discussion of these issues, which is beyond the scope of this report, see IOM, 1986a, and Gray, 1991).

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--> Diversity Among and Within Markets As noted, markets vary widely in the extent to which services have moved along the pathways described above. Most rural areas have not yet joined these trends, and some urban areas have much lower rates of managed care penetration. Within markets observed on the site visits, some health plans are developing service innovations that improve the efficiency of care; others are focusing on utilization management, sales efforts to increase market share, and risk-sharing with providers as their means to compete successfully in their markets. Some groups of clinicians are tightly organized, and some are looser confederations of clinicians who remain essentially independent contractors with ownership and control of their own practices. The clinicians involved in primary care services vary from plan to plan and setting to setting. In some plans extensive use is made of nurse practitioners and physician assistants; in others, much less. Other practices continue to emphasize the traditional role of the physician. Diversity is also seen in the type of primary care physicians involved. For example, in rural areas family physicians are prevalent, whereas in urban areas pediatricians and internists play a more prominent role. Coordination of Primary Care with Other Services The focus of most of the large delivery systems remains on more traditional medical services—acute and chronic care and preventive services provided by clinicians. The extent to which plans with enrolled populations are dealing with population-based health issues is not clear, although many examples of health education and behavior change programs exist. Cooperation with the public health agencies also seems weak. Coordination regarding mental health and substance abuse services may be harder because of the trend toward "carve-outs" for these services into separate benefit packages that are independently managed. This new trend is in addition to the continuing patterns of delivery of many of these services by separate organizations and of limitations on these services in benefit packages. Financial barriers to long-term care remain a significant problem. Few private plans include long-term care benefits. In the public sector, the Department of Veterans Affairs (VA) is a notable exception. All in all, concern about the lack of involvement of primary care clinicians in the medical care of patients in long-term care settings remains high (IOM, 1986b; 1995). Vision care and pharmacy services are collocated in some group model plans, and many plans include a dental care benefit. Dental services as an integral part of the primary care delivery system, however, are seen mostly in programs organized for the poor and by the Indian Health Service. Judgments may differ as to the likely results of these fissures in services for

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--> common health problems. Nonetheless, the lack of explicit arrangements for coordinating primary care with other services that are needed on a routine and recurring basis by many patients is striking, especially as integration of other aspects of acute services moves ahead rapidly. Current and Evolving Professional Roles There is evidence of the increasing demand for primary care physicians as their incomes are rising relative to those of specialists in many areas (Mitka, 1994a,b; 1995). Further evidence of the rising status of primary care among physicians is the desire of many specialists to be designated as primary care physicians. California has given the primary care label to obstetrics and gynecology through state law, and other specialist groups have staked out a claim to the domain of primary care. This desire to be designated as primary care clinicians is the result of managed care plans' requiring that enrollees choose a primary care clinician, usually a family practitioner, general internist, or pediatrician, who will control access to specialized services. There is also evidence of increasing demand for the use of nurse practitioners and physician assistants in primary care. Training programs for these professionals are expanding rapidly (see Chapters 6 and 7). The committee saw many examples of the involvement of these professions in primary care during its site visits, nearly always as part of a team that included physicians in a key role. Within integrated systems, the use of teams and delegation of primary care functions is proceeding rapidly (see Appendix E). In some locales, supply constraints, in particular, shortages of nurse practitioners, are impeding their greater use. During site visits, committee members saw examples of further delegation of clinical functions to registered nurses, licensed practical nurses, and desk clerks. Such delegation was the result of a deliberate decision process that examined how specific clinical problems could be managed more efficiently. In some of these settings, primary care physicians were focusing on more complex clinical problems and taking on managerial roles, thus moving the clinical boundaries between primary care physicians and specialists toward more specialized care. How widespread these changes are is difficult to document because doing so requires knowledge of the details of how particular functions are carried out, and these are only partially reflected in aggregate data on the numbers and types of professionals. This effort on the part of some of the more advanced integrated systems to redefine professional roles within a team concept may prove very important, however, as a future pathway for improving the efficiency and effectiveness of primary care. It may in turn have significant implications for training programs and for workforce policy. The care delivered by other first contact professionals such as dentists, eye care clinicians, and pharmacists is generally less coordinated with the broader functions of primary care.

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--> Primary Care in Rural Settings Observations made during site visits to rural areas are consistent with the extensive literature on rural care in noting what one host called the ''fragility" of many programs providing primary care to rural populations. Rural care is often dependent on some form of subsidy, as well as on a distant infrastructure that can provide technical assistance and professional backup. The reasons are several: the higher proportion of the uninsured and underinsured in many rural areas; higher costs of transportation; and lower volume of services. Primary care in the rural setting also includes a stronger emphasis on emergency care and the stabilization and transportation of patients with medical emergencies and trauma. Managed care has not yet penetrated most rural settings. The committee observed successful models of rural care, but none that did not have some form of subsidy or assistance (or both). It also observed impressive examples of the importance of community commitment to the maintenance of a primary care capacity in isolated rural areas. Care of the Urban Poor Care for low-income or disadvantaged populations, concentrated in the inner cities, is complicated by the lack of universal insurance coverage, the health care needs of illegal immigrants, and the low payments for providers in many states. These problems have often been alleviated by internal cross-subsidies and federal program formulas that favor institutions and care settings that serve a disproportionate share of the poor. The combination of competitive cost pressures and limits on public financing is likely to become much more acute in the near future and to make existing arrangements unstable. In some areas and states, such as Arizona, evidence suggests that managed care may be able to take on an increased share of these populations, but it is not clear how much such an approach can succeed without some form of subsidy that recognizes the extra costs now being incurred to serve the primary care needs of these populations. Role of Academic Health Centers In site visits, the committee heard numerous complaints from community programs about the lack of appropriate involvement of academic health centers (AHCs) in primary care and about the resulting lack of fit between the products of their training programs and the needs of managed care and community-based programs. The problems that AHCs face in surviving in the current health care market have been well documented elsewhere (Blumenthal and Meyer, 1993; Fox and Wasserman, 1993; Epstein, 1995; Josiah Macy, Jr. Foundation, 1995). The extra costs of training, the dependence on patient care income from referrals for tertiary services, the higher proportion of the poor in their service area, and

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--> governance processes that make difficult a quick response to market changes are all handicaps for these institutions in a highly competitive health care market. For many of these institutions these factors constitute barriers to greater focus on primary care. Despite these barriers, there are also examples of effective involvement of AHCs in strengthening primary care. In one state, an AHC's mission statement was explicit about its commitment to primary care, and this mission was reflected in the curriculum and in assistance to communities in providing primary care. Moving Toward Delivery Of Primary Care As Defined Some aspects of the current health care scene favor further emphasis on primary care as the foundation for the health care system. Despite these favorable forces, many obstacles remain to be overcome in reorienting a large and complex health care system. As a sector of the economy that consumes about one-seventh of this society's resources and that is still growing faster than the rest of the economy, many powerful interest groups have a financial and professional stake in the status quo. Market forces seem to have the strength to require significant alterations in that status quo, but as stated earlier the committee remains skeptical that the market, by itself, will achieve a primary care system that meets its definition and that is widely available to the American public. Because the benefits of primary care are important for meeting the health care goals of this society, the committee believes that a specific objective for the availability of primary care service should be established, focusing on the central relationship of the clinician and the patient. Recommendation 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. In order to achieve this goal, steps need to be taken to create conditions favorable to primary care. Some steps involve public policies and the commitment of public resources by federal and state governments (even in a time of stringency for public budgets). Other steps entail voluntary actions to shape existing forces for change so that they more nearly match the committee's definition of primary care. Many of the desired changes will not be achieved rapidly. The results may vary widely in their particulars and still constitute movement in the right directions. Specific actions in isolation from other needed actions are not likely to be successful. In this sense, bringing about the needed changes in primary care is a systems problem in which many elements interrelate. For example, shifts in the

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--> education of primary care clinicians to encourage the function of a primary care team, as described in Chapter 7, are unlikely to have the desired result if the practice environment does not also support those changes. The rest of this chapter identifies some of the specific areas where action is needed to shape the course of the delivery of primary care toward the objectives that were identified in the definition. Financing of Primary Care Services The failure of comprehensive health care reform at the national level (which aimed at providing universal health insurance coverage) and the retreat from reforms at the state level (such as in Washington and Oregon) mean that many Americans remain without health insurance coverage. Furthermore, cost-competitive market forces are likely to exacerbate some of the problems of providing care to the uninsured. The proportions of the population that are either underinsured or uninsured are rising (EBRI, 1995; Short and Banthin, 1995). As long as significant financial barriers to access continue to exist for many millions of people, the objectives and implementing reforms recommended in this report, even if instituted fully, will not make the benefits of primary care available to many of those without health insurance. Addressing specific ways that health care coverage could be extended to everyone is beyond the scope of this report, but we note in the strongest terms that the primary care agenda for the nation will remain incomplete until this extension takes place. Recommendation 5.2 Health Care 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 care coverage for all Americans. The importance of this recommendation is accentuated by the effects of market forces in reducing the internal cross-subsidies and other forms of implicit subsidies that have helped to cover the health care needs of the uninsured. Likely reductions in the growth of public financing of health care in coming years will make these subsidies even harder to sustain. Therefore, the current situation of financial barriers to primary care for some of the population is almost sure to worsen without some form of public action. The committee is aware of the controversies that may be engendered about who should be included under the rubric of "all Americans." It is beyond the scope of this committee to address these complicated issues in detail, especially the issues of coverage of undocumented aliens. If universal coverage is realized,

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--> however, the coverage should at least extend to all those who are legal residents, whether or not they are citizens. In addition to the lack of universal coverage for medical care, this nation seems nowhere near a policy that addresses the need to cover the costs of long-term care for the elderly and the chronically ill. This gap will continue to make more difficult the appropriate coordination of primary care services with long-term care services. Delivery systems for primary care services need to assure the actual availability of services to all. Universal coverage may by itself encourage availability for some individuals and populations for whom primary care is currently unavailable or very inconvenient. But removing financial barriers to primary care through universal coverage is unlikely by itself to achieve the goal of availability of primary care services set out in Recommendation 5.1, and specific efforts will be required for some populations. Later sections of this chapter address the need for special efforts to reach some populations with primary care services. Individuals in otherwise well-served areas may also face problems of availability, and these should also be addressed. Arrangements for the financing and monitoring of care would need to include achievement of this goal. For the large sector of the population that does have health insurance, some methods of paying for services seem more likely than others to encourage primary care. As implemented in the United States, fee-for-service payments have favored procedural services and specialized care. In contrast, financing methods involving a single payment that covers specified services for an enrolled population over a period of time have provided incentives for primary care. Such global capitation payments have been used for many years by HMOs as various forms of managed care have spread and capitation has become more frequent. One study of the development of integrated delivery systems demonstrated that capitated payment mechanisms covering the continuum of care are most likely to promote clinical integration, preventive care, and treatment of patients in the most appropriate setting. As a result there is an incentive to place primary care rather than acute inpatient services at the center of the health care system (Shortell et al., 1994). By providing an overall cap on resources, however, capitation may also reward health care plans for not providing services, and services necessary for good care could be neglected. Performance monitoring and public dissemination of quality-of-care information, as well as the opportunity for enrollees to change plans at regular intervals, are intended to motivate plans to provide quality services or risk losing their market share in the competitive environment in which most plans function. If these mechanisms to provide good information about plans work, health plans that provide good care efficiently should succeed. Such monitoring mechanisms, however, are still not fully developed in most markets. Methods for translating capitation into reimbursement for specific primary

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--> This will enable patients in either setting to benefit from coordinated treatment plans dealing with the full range of their health problems, and it will improve diagnosis and treatment of mental health problems, including those requiring specialized services. In many care settings, this means increased consultation and involvement of primary care clinicians and mental health professionals with each other's service domains. Integrated health care systems would seem to be the logical home for such collaborative approaches. Finally, the primary care research program discussed in Chapter 8 should include a significant focus on the primary care role in mental health, including study and evaluation of care models and natural experiments. Recommendation 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. Long-Term Care and Primary Care The importance of long-term care is growing as the number of the elderly, especially the very old, increases. These services raise difficult issues for coordinating care. Long-term care extends well beyond the provision of personal health services to encompass issues of housing, nutrition, assistance in the activities of daily living, social services, transportation, and the roles of voluntary caregivers. Looming large over the breadth and content of these services is the lack of a coherent set of social policies concerning funding for long-term care services. The roles of primary care in the provision of long-term care services are intertwined with these issues. Nearly all persons who receive long-term care services, either formally organized or provided by family and friends, are high users of medical services, including primary care. Because the elderly, or the seriously disabled of any age, typically have multiple medical problems, including a high incidence of mental health problems, the problems of coordination by primary care clinicians or teams are compounded. Furthermore, many of these patients are in declining health, and this calls for a different mind-set than does the provision of acute services with the intent of providing cure or significant alleviation of symptoms. Markers of effective performance by clinicians in terms of desired patient outcomes are different at least in degree if not in kind for this population. Maintenance of function and emotional support, rather than treatment of a physiological condition, become even more important objectives for the primary care clinician.

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--> The aspect of the definition that speaks to the context of family and community becomes especially important in these circumstances, and the need for coordination of services is great. Effective treatment of medical problems requires that primary care clinicians be aware of patients' living circumstances, personal capabilities, and other persons involved in their care. Coordination of treatment plans with others involved in provision of long-term care services is often essential. Simply involving primary clinicians often becomes a problem because of the inability of patients to go to a clinician's office; the resulting special demands on clinicians' time, for which there may be little financial or emotional compensation, pose yet further obstacles. Even today, there are complaints that primary care clinicians do not visit the home- or institution-bound patient and do not take an active role in their care or care plans (IOM, 1986b). Many aspects of improving long-term care have not been adequately addressed by society as a whole. Among these issues are the preoccupation with holding down acute care costs for the elderly served by Medicare; the reluctance to extend entitlement any further; the possibility of new and strong incentives for states to reduce their exposure to long-term care costs through caps on Medicaid expenditure; and the steady increase in the numbers of the very old. Taken together, these factors almost guarantee that coordination of long-term care and primary care will remain beset with problems and frustrations for both clinicians and patients. Some avenues for improvement and some care models show promise of better integration of services. Demonstration programs such as the Social Health Maintenance Organization (S/HMO) programs, the Program for the All-Inclusive Care of the Elderly (PACE program), and others pool Medicare, Medicaid, and private funding sources to provide a coordinated approach to care that includes medical services (IOM, 1995). Coordination seems more likely in integrated health care systems that are built on a base of primary care and that have an extended primary care team, because these approaches can include nurse practitioners and social workers who are well informed about the care of the dependent elderly and about community resources that can help. These members of the primary care team can also maintain personal contact with patients in the home or long-term care setting and monitor their medical condition and treatment plans. The primary care team members in turn should participate in the joint planning with those providing long-term care services to develop plans that include attention to the patients' needs for primary care and for the coordination of other medical services. A primary care team member can serve as case manager in coordinating an array of services for the individual with long-term care needs or can work with a case manager from outside the team. Finally, the primary care clinicians and team members can help provide emotional support and counseling for patients whose medical and living circumstances interact to accentuate fear and anxiety.

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--> Recommendation 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. Performance Monitoring for Primary Care In an era when resource constraints for health care will be a continuing reality, monitoring the performance of the health care system in terms of quality and patient outcomes will become increasingly important. Costs are quantifiable and a source of intense concern to large payers for health care, so one can safely assume that comparative cost data will become more widely available. The debate over future expenditures for the Medicare and Medicaid programs and the close attention to health plan premiums by employers and, where they bear part of the premium cost, by individuals assure that costs will remain in the forefront as one marker of performance. Other measures of performance, including technical quality of care, health status, and patient satisfaction, are also increasingly available. Examples include HEDIS (Health Plan Employer Data and Information Set), a system to measure HMO performance pioneered by the National Committee for Quality Assurance, and the requirements set out by such private groups as the employers in the Twin Cities area and CALPERS (the California Public Employees Retirement System), which provide fringe benefits for public employees in that state. A governmental equivalent is the competitive contracting process for state Medicaid programs that selects managed care plans to serve the Medicaid population, as in Arizona, Tennessee, and a number of other states. Performance monitoring systems should also include measures of access, which would require population-based data on such indicators as those recommended by the IOM in 1993 (IOM, 1993a). Such data cannot be gathered entirely by the health plans themselves, at least as long as a growing number of Americans are excluded from any health plan. Regardless of the prevailing interest among elected officials or the public in questions of access, the committee believes that levels of access should be considered an important indicator of overall performance of the health system, including primary care. This view is consistent with the committee's recommendation that access to primary care for everyone should remain an objective for American society (Recommendation 5.1). Potential users of information about health care performance include employers,

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--> governments on behalf of their beneficiaries and employees, individuals choosing among competing health plans, and health plans themselves. The developing performance monitoring models are aimed at total health system performance, yet most managed care plans make the operating assumption that increasing primary care as a proportion of the total health care activity will make the totality of care less costly without compromising quality or patient satisfaction. (At a minimum plans may assume that outcomes will be sustained at a level that will not cause the plan to lose enrollees or contracts with employers or government agencies.) Therefore, information on how well the primary care component of the plan is performing is likely to be very important to plan managers, purchasers, regulators, and patients. Until very recent years most of the resources to develop programs to assess quality have focused on inpatient services. In the current health care environment, however, it is imperative that substantial effort be put into further development of approaches to monitor the performance of primary care, particularly on dimensions of health care outcomes, patient health status, and patient satisfaction. The market in health care, even in those locations that have proceeded quite far down the road of competition among managed care plans, seems too compromised by lack of informed choice for the ultimate consumer, the patient, to be the sole arbiter of health system performance. Whichever mix of regulation—choice by large payers on behalf of consumers or direct choice by patients—emerges as the means of shaping desired performance by the health care providers and plans, better information will be the key. In the area of primary care, where the tradition of measurement is less and where the technical challenges of developing and implementing are formidable, an increased level of effort in developing those systems should have a high priority. As discussed elsewhere, the objective of accountability in primary care requires performance measurement. Other aspects of the definition make this task more rather than less difficult, because they emphasize characteristics of primary care that extend well beyond the competence with which a specific medical encounter is performed. Both process and outcome data will need to relate to the objectives of integration (continuity, comprehensiveness, and coordination), accessibility of services, sustained partnership with patients, the scope of services and the pattern of referrals (already tracked by most managed care plans), and knowledge of relationships to family and community relevant to the provision of primary care. The technical problems of case mix, instability of enrollments, and the multiple factors affecting outcomes, among others, will complicate the measurement task. The unit of review—health care organization or individual primary care clinician or practice—is yet another issue. Fortunately, this effort can build on work already done; the need to balance information on utilization and cost with information about the other measures of care that are necessary to measure performance and value should provide the motivation to proceed. The issue is not new, however. According to Kerr White,

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--> an important early figure in identifying the need for more emphasis on primary care in the U.S. health care system, "Performance and results are the criteria that society is using with increasing sophistication to assess the medical profession and its efforts; activity and costs are no longer adequate measures" (White, 1967, p. 848). The issue of who should be responsible for developing the measures and how they should be implemented is also complex, given Americans' general skepticism of the role of government. In recent years, the health professions have also become wary of the motivations of health plans competing in a market that is very sensitive to cost. A governmental model is illustrated by the classic state role in licensure of health professionals and institutions, by the quality assurance and improvement efforts for the Medicare program, and by the regulation of nursing homes under a federal-state relationship related mostly to the Medicaid program. Nongovernmental models are illustrated by the decades-long accreditation programs of the Joint Commission on the Accreditation of Healthcare Organizations and NCQA's accreditation of HMOs and the HEDIS effort cited earlier. A public-private collaborative model might be appropriate for efforts to develop performance measures, especially if it could continue over time to advance the state of the art of performance monitoring. The users could be both governmental agencies and private sector plans, with the public-private entity assuming a data audit function to certify the quality of the data. The committee has no firm view about which model is best, but history would suggest that a public-private consortium would match the distributed nature of health care responsibility in the United States. Recommendation 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 delivering 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. Infrastructure Development for Primary Care Primary care practices in the future are likely to require an infrastructure that extends beyond the usual capital requirements of facilities, land, and equipment. This factor in turn will call for investments that are beyond the capabilities of the individual primary care unit (i.e., a small group or team). These infrastructure

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--> needs constitute a lengthy and very complex list of systems and information sources, such as: systems for — recording and maintaining clinical data, — providing assists to clinical decisionmaking (e.g., clinical practice guidelines, clinical algorithms), — monitoring quality of care, and — overall practice management; patient education materials relating to healthy behaviors and as background information that patients can use in participating in clinical decisionmaking about their care; information on the community and the population being served, including disease and injury patterns, environmental and workplace hazards, social and economic characteristics of the locale; information about community services available in the community, including health and social services, transportation services for patients without transport options of their own, and for rural areas, emergency medical services capabilities and transport systems, telecommunication links, and locum tenens support; and continuing education support for primary care staff. Extensive as this inventory of infrastructure needs is, it is not all-inclusive. (For example, not mentioned here is support for professional education and research, which are discussed in Chapters 7 and 8.) Furthermore, although the needs have been recognized for many years, a decade ago an IOM committee identified the lack of appropriate infrastructure support as one factor that inhibited the development of COPC practices in the United States (IOM, 1984). Some of these activities, such as clinical information systems, are generic to all of medical care; The Computer-Based Patient Record: An Essential Technology for Health Care (IOM, 1991) highlights this point. Even generic infrastructure needs, however, have aspects that are particularly related to primary care. For example, the chair of the IOM committee on the computer-based patient record has argued that such systems, although often developed in institutional settings, are even more pertinent to primary care because of the need to deal with patient data covering many problems and to follow the patient over substantial time (Detmer and Finney, 1992). It is not the intent of this report to deal with infrastructure needs separately but rather to address the questions of how, collectively, they might be met. Several basic approaches to infrastructure development and support might be considered: Methods of payment for primary care services should recognize the costs

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--> of infrastructure, thereby creating a market for these infrastructure services that will then be purchased by the primary care practices. This market would encourage others to bear development and marketing costs, as, for example, vendors of clinical information systems. Aggregation of primary care practices into larger integrated systems results in economies of scale that allow use of internal capital to develop infrastructure. Direct subsidy of infrastructure development either by public subsidy or voluntary contributions from organizations. The first two approaches by themselves have drawbacks. For example, low reimbursement rates or inadequate plan incomes in cost-competitive markets may mean that individual plans cannot finance infrastructure purchases. In addition, concentration of market power in a few large entities may give them competitive advantages (in part through well-capitalized infrastructure) that in turn will inhibit market entry by smaller health organizations. The health care market in many locales is likely to remain a mix of small and large primary care organizations in the near and medium term, yet the large organizations, especially for-profit enterprises, will have significant advantages in raising capital. As long as the health care market is skewed by such factors, the third approach may be desirable, at least for underwriting those infrastructure needs that require extensive initial capital for technical development (such as clinical information and decision systems), especially if those technologies are to focus specifically on the requirements of primary care. The development of infrastructure for primary care and assuring its wide dissemination could be advanced by creation of a new organization devoted to this purpose as well as other related functions, including relevant applied research. These are long-term strategic issues, and the committee returns to some of them in its final chapter on implementation. Role of Academic Health Centers in Delivery Of Care The academic health center (AHC) has as its principal missions the education of health professionals, patient care, and the conduct of research to advance health. These institutions have been and remain major providers of health care, primarily through their affiliated teaching hospitals and clinics. The patient care function has historically been seen as supportive of the education and research roles. It has been predominantly hospital based and focused on advanced, tertiary care. While most of the AHCs have provided some primary care, the primary care activities have remained a small part of the institutions' service role. To carry out the education functions discussed in Chapter 7, however, the service role of AHCs must develop a much stronger base in primary care. This requires creative new strategies that may involve affiliation with other health care organizations and primary care practice sites. These sites for primary care will be

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--> the equivalent of the historic role of the teaching hospital; they will need to provide high-quality service while fulfilling the teaching and mentoring responsibilities for new professionals and helping to advance the state of the art of primary care through applied research. The need to strengthen the primary care role of AHCs comes at a time when the financing of these institutions is under great strain; competing health care organizations draw clinical activities and revenues away from the AHCs and opportunities for internal cross-subsidies are limited. Many of these institutions also care for a larger share of the uninsured than do their competitors. As noted in Chapter 7, therefore, these functions will require some direct subsidy, just as the teaching hospital function has been subsidized for decades. Part of the challenge will be to provide primary care experiences that will prepare students for practice in a health care environment that is concerned about efficient use of resources. Therefore, the subsidy for education should not be used to shield the primary care teaching setting from the need to focus on efficiency and value. This strengthened role in primary care will call for an explicit modification of the mission of these institutions. As noted throughout the committee's site visits, many other health care organizations are skeptical about the commitment of the AHCs to primary care. Actions will be needed on their part to back up statements about the importance of primary care. It is also reasonable, however, for these institutions to expect that the extra costs of the educational function and of research and demonstrations in primary care will be covered by funding sources. Recommendation 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. Summary This chapter has outlined several features of the U.S. health care scene that will influence the extent to which primary care evolves in this country. These include the spread of managed care, the expansion of integrated delivery systems, the consolidation of health plans and systems, growth in for-profit ownership of health plans and integrated delivery systems, the diversity between and within health care markets, the special challenges of primary care in rural areas and for the urban poor, the need for primary care to coordinate with other types of services, current and evolving roles for health care professionals, and the role of academic health centers in primary care delivery.

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--> Having reviewed these topics, the committee considered what conclusions and recommendations it would make to overcome the barriers, or exploit the advantages, that these factors pose, or offer, to full implementation of the committee's vision of primary care in the future. In all, the committee advances 11 separate recommendations in the several different arenas. First, the committee recommends establishing as a goal the availability of the services of a primary care clinician for all Americans. Second, the committee makes several recommendations to assure that mechanisms for financing primary care services provide appropriate incentives for sustaining a strong primary care function. In this context the committee makes a strong statement about the need to have universal health care coverage to make possible universal access to primary care. Another recommendation concerns the organization of primary care and emphasizes the importance of the primary care team. With respect to underserved populations, the committee returns to its earlier themes to underscore the importance of primary care for populations who have special health care needs or who are traditionally underserved. Another major thesis of this chapter is the need for primary care to develop strong relationships with three other types of health activities—public health, mental health, and long-term care—and the committee offers three specific recommendations intended to reinforce the coordination and collaboration efforts in these areas. A tenth recommendation calls for specific steps to develop tools and approaches for monitoring and improving the quality of primary care and to make performance information available to a wide audience. The final recommendation calls on AHCs to make primary care a core element of their mission and to provide leadership in education, research, and service delivery related to primary care. References ACOG (American College of Obstetricians and Gynecologists). Findings from a study conducted for ACOG by the Gallup Organization to examine women's attitudes and experiences with OB/GYNs as their primary care physicians. Washington, D.C.: ACOG, 1993. Aiken, L.H., Lewis, C.E., Craig, J., et al. The Contribution of Specialists to the Delivery of Primary Care: A New Perspective. New England Journal of Medicine 300:1363-1370, 1979. Alpha Center. MSAs: Issues for States. State Initiatives in Health Care Reform, 16(Jan./Feb.):7, 1996. American Academy of Actuaries. Public Policy Monograph. Medical Savings Accounts: An Analysis of the Family Medical Savings and Investment Act of 1995. Washington, D.C.: American Academy of Actuaries, 1995. ASIM (American Society of Internal Medicine). Results of a survey of IPA model HMOs. Conveyed in letter dated May 3, 1995, from J.P. DuMoulin, Director, Managed Care and Regulatory Affairs. ASIM Survey of HMOs. Washington, D.C.: ASIM, 1995. Bailit, H.L. Market Strategies and the Growth of Managed Care. Pp. 3–13 in Academic Health Centers in the Managed Care Environment. D. Korn, C.J. McLaughlin, and M. Osterweis, eds. Washington, D.C.: Association of Academic Health Centers, 1995.

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--> Blumenthal, D., and Meyer, G.S. The Future of the Academic Medical Center Under Health Reform. New England Journal of Medicine 329:1812–1814, 1993. COGME (Council on Graduate Medical Education). Recommendations to Improve Access to Health Care Through Physician Workforce Reform. Fourth Report to Congress and the Department of Health and Human Services Secretary. Rockville, Md.: Health Resources and Services Administration, Department of Health and Human Services, 1994. COGME. COGME 1995 Physician Workforce Funding Recommendations for Department of Health and Human Services' Programs. Seventh Report to Congress and the Department of Health and Human Services. Rockville, Md.: Health Resources and Services Administration, Department of Health and Human Services, 1995. Detmer, D.E., and Finney, M.D. The Catalyst of Technology: How Will Advances in Information Technology Change the Role of the Primary Care Practitioner? Pp. 167–182 in Proceedings of the National Primary Care Conference, Vol. 2. Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, 1992. EBRI (Employee Benefit Research Institute). Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1994 Current Population Survey. EBRI Special Report SR-28 and Issue Brief Number 158. Washington, D.C.: EBRI, 1995. Epstein, A.M. U.S. Teaching Hospitals in the Evolving Health Care System. Journal of the American Medical Association 273:1203-1207, 1995. Fox, P.D., and Wasserman, J. Academic Medical Centers and Managed Care: Uneasy Partners. Health Affairs 12(1):85-93, 1993. GHAA (Group Health Association of America). Patterns in HMO Enrollment . 4th ed. Washington, D.C.: GHAA, 1995. Gray, B.H. The Profit Motive in Patient Care. Cambridge, Mass.: Harvard University Press, 1991. Greene, J.C., and Greene, A.R. Chapter 15: Oral Health. Pp. 315–334 in Health Promotion and Disease Prevention in Clinical Practice. S.H. Woolf, S. Jonas, and R.S. Lawrence, eds. Baltimore: Williams and Wilkins, 1995. Horton, J.A., Murphy, P., and Hale, R.W. Obstetrician-Gynecologists as Primary Care Providers: A National Survey of Women. Primary Care Update for OB/GYNS 1:212-215, 1994. Institute for Clinical Systems Integration. 1993 Annual Report. Minneapolis, Minn. : Institute for Clinical Systems Integration, no date. IOM. (Institute of Medicine) Community-Oriented Primary Care: A Practical Assessment. Volume I. The Committee Report. Washington, D.C.: National Academy Press, 1984. IOM. For-Profit Enterprise in Health Care. B.H. Gray, ed. Washington, D.C.: National Academy Press, 1986a. IOM. Improving the Quality of Care in Nursing Homes. Washington, D.C.: National Academy Press, 1986b. IOM. The Future of Public Health. Washington, D.C.: National Academy Press, 1988. IOM. The Computer-Based Patient Record: An Essential Technology for Health Care. Richard S. Dick and Elaine B. Steen, eds. Washington, D.C.: National Academy Press, 1991. IOM. Access to Health Care in America. M. Millman, ed. Washington, D.C.: National Academy Press, 1993a. IOM. Employment and Health Benefits: A Connection at Risk. M.J. Field and H.T. Shapiro, eds. Washington, D.C.: National Academy Press, 1993b. IOM. Real People, Real Problems: An Evaluation of the Long-term Care Ombudsman Programs of the Older Americans Act. J. Harris-Wehling, J.C. Feasley, and C.L. Estes, eds. Washington, D.C.: National Academy Press, 1995. IOM. The Nation's Physician Workforce: Options for Balancing Supply and Requirements. K.N. Lohr, N.A. Vanselow, and D.E. Detmer, eds. Washington, D.C.: National Academy Press, 1996.

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