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--> 9 Implementation Strategy Guiding Perspectives The committee believes that the recommendations presented in this report are essential steps toward strengthening primary care as the firm foundation for health care in this country. Chapter 1 presented underlying principles to guide these steps, but only through effective implementation will the benefits of these steps be achieved. Successful implementation will demand understanding of the importance of primary care as a foundation for effective, responsive, and efficient health care. That understanding must be shared by the public, in its capacity both as patients and as those who will ultimately determine the directions for health care in this free society. It will also require a commitment to action by public and private health policymakers and funders, the health professions, health care organizations, and those responsible for health professions education. To provide focus for the implementation effort, this chapter presents specific means for implementing the committee's recommendations and identifies the many parties whose commitment will be necessary. This plan for implementation is guided by several perspectives that, in the view of the committee, are essential for success. Mounting a Coordinated Strategy If primary care is to be strengthened in the directions indicated by this report, simultaneous actions will be required of many parties. The breadth of these actions reflects the breadth of primary care itself, for primary care is multidimensional
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--> and inclusive. A comprehensive strategy that deals with these many interrelated dimensions seems more likely to succeed. Focusing on needed changes one at a time is unlikely to be as successful, as indicated by the failure of many prior efforts to advance primary care to have the hoped-for impact. Actions must be focused toward a common objective, and they must be mutually reinforcing. For example, changes in education for primary care are unlikely to bring about desired changes in the practice of primary care unless the changes are reinforced by the organization and financing of services. The common objective is provided by the committee's definition. The many elements that together can advance primary care toward that objective can be viewed as a system—that is, ''a set or arrangement of things so related or connected as to form a unity or organic whole" (Webster's New World Dictionary, Second College Edition). Taking a Long-Range Perspective In addition to this systems view of the challenges of implementation, the committee believes that the strategy for implementation must have a long-range perspective, with action steps that can be taken in the shorter term to advance the strategy. Making intended changes in an enterprise as complex and fluid as health care is neither simple nor quick; continued learning from experience and from the development of new knowledge will be mandatory. The research and data recommendations outlined in Chapter 8 should help provide the means for this continuous learning process over the long term, but in the meantime we believe that we know the direction to take and enough about the needed action steps so that progress can begin immediately. Taking Advantage of Factors Favoring Primary Care Many of the actions recommended in this report are intended to shape changes already under way, rather than to mark the start of new efforts. The forces for change at work today can be important potential allies of the implementation strategy. Those forces were described in some detail in Chapter 5. For example, the growth of managed care and integrated health care systems that emphasize the role of primary care has raised the demand for primary care clinicians thus reducing the differential between the incomes of primary care clinicians and the incomes of medical specialists. Federal and state policymakers have also shown growing interest in the availability of primary care, particularly in rural areas, in the training of adequate numbers of primary care clinicians, and in the removal of legal barriers to the wider involvement of nurses and other types of health professionals in primary care. The rapid development of Medicaid managed care programs, and the likely continued growth of the enrollment of Medicare beneficiaries in managed care arrangements, will continue to merge the
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--> interests of government health care programs with the trend toward managed care in the private sector. Primary care seems to be on the rise in the career choices of physicians and nurses, as those entering the health professions read market signals. Educational programs for the health professions are focusing more attention on the preparation of clinicians for primary care. Although these forces for change can be allies in implementing the recommendations of this report, they tend still to be focused on achieving cost containment and, to a lesser extent, on improving access to basic services for hard-to-serve populations. Demonstrating the value of primary care to patients and to the broader society, over and above its cost savings alone, will require concerted efforts and time to implement the changes described in this report. Involving Interested Parties in the Implementation Effort The intended audiences for this report are very broad, and all must play some role in the implementation of the recommendations. They include: the health professions whose principal activity is the provision of comprehensive primary care and the organizations that represent them. These include physicians in family practice, general internal medicine, general pediatrics, and some obstetrician-gynecologists; nurse practitioners; and physician assistants; the many health professions that have a role in primary care as first-contact professionals for specific functions, such as dentists, optometrists, pharmacists, and others; medical specialists who have some primary care responsibilities or whose referral specialty functions require a relationship to and understanding of the appropriate scope of primary care clinicians; managed care plans, other health care insurers, integrated health care systems, community and rural health centers, and other organizations providing or arranging for the provision of primary care; academic health centers (AHCs) and other educational institutions providing education and training for primary care; federal, state, and local governments, which finance care, provide care, support training programs, license health professionals, regulate health care quality and cost, and carry out public health functions; employers and employer groups with health care interests; specialty boards and other professional organizations that set standards for training and that help define competencies and scope of practice for the professions; health services researchers and organizers of health data systems; foundations with interests in health care and education, including primary care; consumer health advocates (e.g., the American Association of Retired
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--> Persons, unions, rural health groups, and advocates for the poor and populations with special health care needs); and the news media. Reaching such a broad array of audiences with the contents of this report will require more than the publication and distribution of the report. To involve these groups in implementation of the report's recommendations will call for continuing discussions and dialogue about the issues raised by the report and the development of common agendas of action for at least a critical core of interested parties. A Primary Care Consortium Mission of a Public-Private Consortium Coordinated implementation by many participants over time is unlikely to take place unless there is in place an entity whose purpose is to monitor and facilitate implementation, including building appropriate coalitions of the parties necessary for action. The committee regarded the creation of such an organization as central to the accomplishment of much of the primary care agenda laid out in the earlier chapter of this report. Recommendation 9.1 Establishment of a Primary Care Consortium The committee recommends the formation of a public-private, nonprofit primary care consortium consisting of professional societies, private foundations, government agencies, health care organizations, and representatives of the public. The mission of a primary care consortium would be to facilitate implementation of the recommendations in this report and to coordinate efforts to promote and enhance primary care. The consortium would also conduct research and development, provide technical assistance, and disseminate information on issues such as primary care infrastructure, innovative models of primary care, and methods to monitor primary care performance. These tasks are briefly discussed below. In addition, later in this chapter the committee comments on implementation of all the other recommendations it has made, noting in some instances where the consortium might be a critical factor in success. Organization of a Primary Care Consortium The consortium would take the form of a nonprofit corporation, with a board of directors, a full-time executive director, and other staff sufficient to carry out
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--> the functions described below. Because both the public and private sectors need to be involved in implementation, the board should include representatives of both public agencies and the principal nongovernmental organizations with interests in primary care. In addition, the consortium would clearly have an organizational structure, corporate or legal existence, and physical location. It would also be expected to conduct business, articulate a mission statement, promulgate policies, implement procedures, and carry out data analyses. The organization would seek grant support from government as well as foundations, health care organizations, professional societies, and business and consumer organizations with a stake in health care. Financing from a wide array of sources is desirable to symbolize the consortium nature of the entity. Some of this support should have a relatively long duration, such as five years, to provide needed stability for the long-term tasks. Functions of a Primary Care Consortium In addition to its functions of coalition building and of monitoring progress in implementing steps for the enhancement of primary care, the consortium should also have the capacity to conduct research and development. These activities could be supported by targeted grant funding. Among the activities to foster the primary care agenda that might be supported are (a) development of data systems and other infrastructure needs for primary care, (b) development and validation of primary care competencies, and (c) the evaluation of innovative approaches to primary care. Other functions, as described throughout this report, that would benefit from large-scale coordination could also be pursued or sponsored by the consortium. The full range of functions by this consortium could develop over time as needs are identified by the consortium membership and as funding is made available. The organization would also provide technical assistance to organizations and professional groups to enhance their primary care activities. This technical assistance could help assure that patients in all types of settings and locations would benefit from advances in primary care, not just those being served by large organizations with the internal infrastructure and capacities to take advantage of improved methods. This technical assistance function would include wide dissemination of information about improved methods and approaches for primary care, including but not limited to the improvements developed through the consortium's own activities. This information dissemination function could be a source of information about "best practices" in primary care, an action that might help to overcome the tendency of health care organizations to limit dissemination of improved methods that are providing the organization with advantages in a highly competitive market. The consortium could organize national meetings on primary care on a regular
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--> basis, perhaps annually, that would provide an opportunity to report on progress in implementing the primary care agenda and to share information about new approaches to improved primary care. An example of this approach to developing a field and monitoring progress are regular meetings held to advance the agenda of prevention and to monitor progress toward the health objectives for the nation. Although such convening and information-sharing activities are sometimes carried out by the federal government, we believe that the mixed sponsorship and governance outlined here is more in keeping with the wide array of interests in primary care that need to be involved. Government is one of those interests, but many aspects of the agenda proposed in this report require action and commitment by many entities in the private sector and at the state and local levels. The federal government is likely to remain an important force through its funding and direct delivery of health care, its support for data and research, its backing for the development and evaluation of service innovations, and its support for education and training of health professionals. The consortium should be useful to the government in carrying out these functions, but its status as an independent, nonprofit entity, with broad participation of the array of interested parties, should help assure that the consortium is not caught up in the specific federal policy agendas of the moment. Implementation Of Specific Recommendations This section offers a brief commentary about implementation of the specific recommendations presented in Chapters 2 and 5 through 8. The comments identify some of the key parties that need to be involved in implementing each recommendation, make suggestions about next steps, and offer observations about the general time frame for implementation. More complete discussion of each recommendation can be found in the chapter in which it was first introduced. Recommendation 2.1To Adopt the Committee's Definition Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. The recommendation that health policymakers, professional groups, and AHCs adopt the committee's definition of primary care is crucial, because building coalitions for action on other recommendations will be facilitated if all parties have agreed on a uniform definition of the primary care function. Even disagreements should have more focus if the beginning point of the discussion is the
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--> definition as provided in this report. Uniformity in the particulars of implementation by various parties should not be necessary or desirable if all are moving toward a common set of objectives for primary care. This recommendation should be implemented immediately, although refinements in interpretation will emerge as the definition is used in real primary care situations. The definition should be revisited at some interval, such as five years, perhaps at one of the national conferences convened by the consortium proposed in this chapter. Recommendation 5.1 Availability of Primary Care for All Americans The responsible parties for the full implementation of Recommendation 5.1 are funders of health care, both public and private. Specifically, adequate federal and state support needs to continue for primary care delivery systems for those underserved populations that are not yet being served by managed care plans and integrated delivery systems, including rural populations. Implementation of the recommendation falls as well on managed care plans and integrated delivery systems that are serving fully insured populations. Finally, those institutions with training responsibilities need to assure a supply of primary care clinicians that is adequate to achieving the goal of this recommendation. Full implementation is not likely in the near term. However, progress toward this objective can be made for those populations that have some form of health care coverage or are served by a delivery system targeted to the underserved (such as community health centers and rural health centers), whether funded by the federal government or by community resources such as free clinics. Recommendation 5.2 Health Care Coverage for All Americans Recommendation 5.2 bears on most of the other recommendations in that implementation of the full agenda for the strengthening of primary care will be incomplete in its coverage of the population without progress in making some form of health care coverage available for all Americans. At this writing, health care coverage is shrinking rather than expanding, and proposed changes in the Medicaid program may further shrink coverage, particularly for the working poor. Reversal of this trend is unlikely to occur through purely voluntary activity in the private sector as employers, especially small employers, seek to limit their exposure to the costs of health care coverage for their employees. Therefore, as indicated in the wording of the recommendation (see Chapter 5), the federal and state governments bear the principal responsibility for implementing this recommendation. Some of the foundations have served a useful function in exploring approaches to the wider availability of health care coverage, but those experiences
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--> indicate that government support is a necessary element of any approach achieving full coverage. Unfortunately, the failure of comprehensive health care reform at the federal and state levels in recent years would suggest that any implementation of this recommendation will be in the long run. Recommendation 5.3 Payment Methods Favorable to Primary Care The principal implementers of Recommendation 5.3 are the managed care plans, integrated health delivery systems, health insurance companies, and federal, state, and local governments that pay for health care services. Most of these payers are already using or developing ways of paying for care that are more favorable to primary care than past payment methods. Many of these plans already use comprehensive capitation for at least part of the population covered by the plan. The continued spread of managed care in the private sector and in public financing programs will probably continue the trend toward the development of a variety of ways of paying for primary care under an overall framework of capitation. While some of the aims of this recommendation are already achieved, full implementation is still in the future. Recommendation 5.4 Payment for Primary Care Services The action on Recommendation 5.4, which calls for fee-for-service payments to reflect better the value of primary care, falls to the private and public third-party payers. The work in developing the Resource-Based Relative Value Scale (RBRVS), appropriately modified to address its current deficiencies, provides the basis for a payment methodology that reflects more closely the value of primary care services. The Physician Payment Review Commission and the Health Care Financing Administration are likely to remain key participants in the further refinement and application of the RBRVS, but payment innovations in the private sector can also advance this recommendation. Building on work already done, implementation can proceed without delay. Recommendation 5.5 Practice by Interdisciplinary Teams Recommendation 5.5 will be realized chiefly through the actions of clinicians and health care plans, health centers, and integrated delivery systems. Payers can use their influence to encourage the use of teams. The role of foundations and the federal government in supporting and evaluating team delivery models has already been important and should continue. The role of the training programs in encouraging team delivery is covered by Recommendation 7.7. Research
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--> on primary care teams is included in the research agenda set out in Chapter 8. Implementation is already under way in many settings. Full implementation will require some time and simultaneous changes in the care and the training environments. Recommendation 5.6 The Underserved and Those With Special Needs The implementers of Recommendation 5.6 include public and private payers and care programs directed at these populations. Development of methodologies for monitoring access to appropriate care requires actions by the research community and the supporters of research, both the federal government and the foundations. The consortium described above may be able to play a useful role in stimulating the development and testing of methodologies for tracking access. Implementation can begin immediately. Full implementation, however, would require that tracking methodologies be developed and applied, an accomplishment that could take several years. Recommendation 5.7 Primary Care and Public Health The main implementers of Recommendation 5.7 are the public health agencies and the managed care plans. Foundations and government could support models of cooperation. The proposed consortium could play a role in encouraging an ongoing dialogue between the public health and the primary care communities so that issues of population-based health can be adequately addressed. Implementation can begin now. Because of the many organizational and attitudinal barriers to be overcome, and because of the resource constraints that face parties in both primary care and public health, full implementation in many communities probably lies 5 to 10 years in the future. Recommendation 5.8 Primary Care and Mental Health Services Primary care clinicians and mental health professionals are the main implementers of Recommendation 5.8, but payment policies and managed care arrangements must be changed. Mental health "carve-outs" are bringing this issue to the fore. The teaching and research communities involved with both primary care and mental health care need also to emphasize the importance of this interface and develop the needed knowledge base. While approaches to building this important linkage are under way in some environments, historic patterns of practice push full implementation into future years. The work on bringing these systems together requires effort and tenacity
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--> that begins in the near term and deals with the major changes in the way that health care is organized and financed. Recommendation 5.9 Primary Care and Long-Term Care Recommendation 5.9 identifies the principal parties at interest as third-party payers, health care organizations, and the health professions. Nurse practitioners and geriatricians are a key resource for accomplishing the goals set forth in this arena. Experimentation with funding methods that are a better match for the needs of long-term care patients should continue, as should the development and evaluation of care models. The foundations and the federal government need to continue their support of innovation and analysis for this issue. Given their heavy role in long-term care, the states should become more uniformly active in supporting this innovation and analysis. A barrier to full implementation is the lack of a coherent national policy about payment for long-term-care services, which leaves serious gaps in coverage and pushes much of the cost burden onto the Medicaid program. The time for full implementation is probably off in the distance. However, further analysis of this issue can begin now, taking the probable revamping of the Medicaid program into account. The substantial role of private foundations in these issues needs to continue, especially because the public sector is frightened by the future expenditure levels and the possibility of movement toward a new entitlement program. Recommendation 5.10 Quality of Primary Care The research community, the existing programs for monitoring quality for public and private programs, primary care clinicians in practice, and representatives of the public all need to be involved in developing improved means for monitoring and improving quality (Recommendation 5.10). Support from private foundations, federal and state governments, and health care plans will continue to be necessary. The proposed consortium may be able to play a role in bringing these parties together around a common agenda, backed by the capacity to evaluate current approaches. Full implementation will be long term. Useful steps by both private organizations and the federal government have already taken place and provide a basis for further progress.
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--> Recommendation 5.11 Primary Care in Academic Health Centers (AHCs) The major implementers of Recommendation 5.11 are the AHCs and their faculties. Funders of clinical services and training programs in these centers, including state and federal governments, also need to be supportive of these changes. Many AHCs are addressing these issues today. However, the magnitude of the changes required, the uncertainty of funding for new approaches, and the normal slowness of decisions in a highly decentralized environment (accentuated by a faculty the majority of whom are not interested in primary care) make a longer time frame for implementation more likely, even when commitment by the leadership is present. Recommendation 6.1 Programs Regarding the Primary Care Workforce The current funders of primary care training at the federal and state levels, and to a lesser extent the foundations, are the principal parties for maintaining the current level of support (Recommendation 6.1, first part). The training programs and the health care plans are the implementers of the second part of Recommendation 6.1, which concerns improved competencies and access (see Chapter 6), although some continued subsidy of the services to underserved populations is likely to be needed. The actions called for can be immediate, since maintenance of effort rather than new programs is needed. Recommendation 6.2 Monitoring the Primary Care Workforce State and federal agencies, and particularly the Bureau of Health Professions in the Public Health Service, are important implementers of Recommendation 6.2. This conclusion derives from their responsibilities as funders of much of the training of health professionals and their traditional role of providing information and analysis about the health workforce. The cooperation and involvement of the professional societies will also be important for this function. Action can be immediate. Recommendation 6.3 Addressing Issues of Geographic Maldistribution Federal and state governments and the foundations are the funding sources for Recommendation 6.3, with health care plans and community health centers being necessary collaborators. Action can be immediate.
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--> Recommendation 6.4 State Practice Acts for Nurse Practitioners and Physician Assistants State governments are the implementers of Recommendation 6.4. The support and assistance of professional groups will also be necessary. Action can be immediate. Recommendation 7.1 Training in Primary Care Sites The medical schools are the implementers of Recommendation 7.1. The controlling factor of the speed of implementation is the availability and adequate funding of primary care sites for training. Recommendation 7.2 and Recommendation 7.3 Common Core Competencies Emphasis on Common Core Competencies by Accrediting and Certifying Bodies Implementation of Recommendations 7.2 and 7.3 will involve primary care clinicians from all of the groups involved in comprehensive primary care, the relevant specialty boards and equivalent professional bodies, accrediting bodies, certifying organizations for primary care training programs, state licensure officials, and educators. The proposed consortium may play a useful role by serving as a neutral site and convener for this function. Support to facilitate this work could come from foundations. Implementation could begin immediately. The final product, however, is likely to take several years to develop and several more years to implement; therefore, the final result can be looked for only in the long term. Recommendation 7.4 Special Areas of Emphasis in Primary Care Training For addressing questions of communication skills and cultural sensitivity, (Recommendation 7.4), the committee believes that the principal implementers are the training programs. Implementation can begin immediately, especially since curriculum development has already taken place to meet these needs in some programs. Recommendation 7.5 All-Payer Support for Primary Care Training All-payer support (Recommendation 7.5) would require federal legislative
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--> action. Some of the necessary policy analysis has already been done in the context of developing health care reform proposals. Some states might initiate such action themselves through state legislation that provides some form of tax on health insurance premiums. The full implementation of such a sweeping change will require a supportive legislative environment, absent a major health care reform proposal. Some progress at the margin might be made by negotiation at the state or local level aimed at achieving voluntary cooperation by the major health care plans. Such a voluntary approach to implementation is unlikely to pick up the small insurers, but their share of the market is likely to decline. Recommendation 7.6 Support for Graduate Medical Education in Primary Care Sites Federal legislation will be needed to add a requirement for all-payer support of graduate medical education (Recommendation 7.6) to the Medicare legislation. If an all-payer system is devised, the requirement would need to be included in that proposal. Passage of such legislation could be made part of any changes in the Medicare program. Implementation would need to await legislative action, but it could move ahead soon after the legislation passes and necessary regulations are promulgated. This could take several years even if the legislative change is made in the near future. Recommendation 7.7 Interdisciplinary Training The implementers of Recommendation 7.7 are the training programs and the various health care organizations that need to provide the training sites in which service by interdisciplinary teams is ongoing. The limiting factor in implementation for some training programs may be the availability of appropriate training sites. The training programs may need to work with primary care providers to create and fund sites where they do not exist. This could delay implementation by several years. Recommendation 7.8 Experimentation and Evaluation As listed in Recommendation 7.8, the funding sources for implementation of this recommendation are foundations, health plans, and government agencies. The training programs and the training sites must also be principal collaborators in the implementation. Because interdisciplinary team models already exist in
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--> many locales, design and implementation of these experiments could begin immediately. Recommendation 7.9 Retraining The participants in implementation of Recommendation 7.9 would need to include the training programs and the certifying bodies for the primary care disciplines. Full implementation would depend on the development of the common core competencies called for in Recommendation 7.2. Recommendation 8.1 Federal Support for Primary Care Research The implementers of Recommendation 8.1 would be the Department of Health and Human Services (DHHS), the Office of Management and Budget, and the appropriations and budget committees in the U.S. Senate and House of Representatives. In the current budgetary climate, implementation in the near term will be difficult, but the case is strong for some action now that would not require large funds in the context of the federal budget. Recommendation 8.2 National Database and Primary Care Data Set The principal implementer of Recommendation 8.2 would be DHHS, but the committee believes consultation with the health services research community, potential users in the health care system, state governments, and the primary care professional groups will be crucial. Other important actors will be practice-based primary care research networks (mentioned below). Implementation of the consultation and planning phase could begin within the year. Full development and implementation of the survey is probably at least five years away, assuming that funding is found. This might be an area for collaboration between private foundations and the government. Recommendation 8.3 Research in Practice-Based Primary Care Research Networks The agency designated by the Secretary of DHHS as the lead agency for primary care research would be the principal implementer of Recommendation 8.3. Assuming available funding, support could be provided within the year.
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--> Recommendation 8.4 Data Standards The federal government would have the implementing responsibility for Recommendation 8.4, and the committee expects that a collaborative effort involving the agency designated for primary care research, the Health Care Financing Administration, and the National Center for Health Statistics will probably be needed. Extensive consultation with data experts, health care plans, professional groups, the states, and the primary care research community would be in order in developing these standards. Implementation of the planning and design phase could begin immediately. Recommendation 8.5 Study of Specialist Provision of Primary Care The federal agency supporting primary care research and the foundations would need to take responsibility for the design and implementation of the study proposed in Recommendation 8.5. Consultation with appropriate physician groups would be essential. Implementation of the study design and consultation phase could begin immediately. Final Comment On Implementation With the apparent demise of comprehensive health care reform, the climate for moving ahead on a reform agenda affecting primary care might seem to be unfavorable. Yet, as noted at the beginning of this report, the pace of change in the health care systems of communities around the country remains very rapid. In those changes and the restructuring being proposed for Medicare and Medicaid, opportunities exist to pursue a strategy that holds promise for making the American health care system more effective and efficient. Important parts of the primary care agenda and strategy for implementation proposed in this report do require federal actions. For many elements, however, the key decisionmakers are more diffusely located across the states and communities of the nation, health care plans, educational institutions, and professions. The great private foundations, are also well suited to undertake some parts of this agenda and to engage in collaborative efforts with the other interested parties. Many of these groups are already committed to a renewed emphasis on primary care. In this situation, opportunities for coalition building and for implementation are at hand and should be exploited. That fact alone is one important reason that the committee has recommended establishment of the primary care consortium.
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--> This is a time when creative effort and collaboration can influence the forces driving health care change to take the directions defined by this committee. It will not be a time for weak hearts or quick fixes—but the promise of improving health care for Americans should be motivation enough to stay the course set out in this report.
Representative terms from entire chapter: