Primary Care

America's Health in a New Era

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

Committee on the Future of Primary Care

Division of Health Care Services

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1996



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--> Primary Care America's Health in a New Era Molla S. Donaldson, Karl D. Yordy, Kathleen N. Lohr, and Neal A. Vanselow, Editors Committee on the Future of Primary Care Division of Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1996

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--> NATIONAL ACADEMY PRESS 2101 Constitution Avenue, NW Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. See the Acknowledgments for a complete listing of the organizations that provided support for this study. The stand-alone Summary is available in limited quantities from the Institute of Medicine, Division of Health Care Services, 2101 Constitution Avenue, NW, Washington, DC 20418. It is available on-line at http://www.nap.edu/nap/online. The complete volume of Primary Care: America's Health in a New Era is available for sale from the National Academy Press, 2101 Constitution Avenue, NW, Lock Box 285, Washington, DC 20055. Call 1-800-624-6242 or 202-334-3313 (in the Washington metropolitan area). Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Division of Health Care Services Committee on the Future of Primary Care. Primary care: America's health in a new era/Molla S. Donaldson … [et al.], editors; Committee on the Future of Primary Care Services, Division of Health Care Services, Institute of Medicine. p. cm Includes bibliographical references and index. ISBN 0-309-05399-4 1. Primary health care—United States. I. Donaldson, Molla S. II. Title. [DNLM: 1. Primary Health Care—United States. W 84.6 I587p 1996] RA427.9.I56 1996 362.1'0973—dc20 DNLM/DLC 96-25823 for Library of Congress CIP Copyright 1996 by the National Academy of Sciences. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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--> COMMITTEE ON THE FUTURE OF PRIMARY CARE NEAL A. VANSELOW, Chair,* Professor of Medicine and Adjunct Professor, Department of Health Systems Management, School of Public Health and Tropical Medicine, Tulane University Medical Center, New Orleans, Louisiana JOEL J. ALPERT,* Professor of Pediatrics and Public Health (Health Law), Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts CHERYL Y. BOYKINS, Director, National Black Women's Health Project, Atlanta, Georgia CAROLYN V. BROWN, Private practice, Burlington, Vermont KEN CAMERON, Chairman of the Board, Group Health Cooperative of Puget Sound, Seattle, Washington PETE T. DUARTE, Chief Executive Officer, Thomason Hospital, El Paso, Texas PETER ELLSWORTH, President and CEO, Sharp HealthCare, San Diego, California RAYMOND S. GARRISON, JR., Associate Professor and Chairman, Department of Dentistry, Bowman Gray School of Medicine, Winston-Salem, North Carolina LARRY A. GREEN,* Professor and Woodward-Chisholm Chairman of Family Medicine, University of Colorado Health Sciences Center, Denver PAUL F. GRINER,* Vice President and Director, Center for the Assessment and Management of Change in Academic Medicine, Association of American Medical Colleges, Washington, D.C. JEAN JOHNSON, Associate Dean, Health Sciences Programs, The George Washington University Medical Center, Washington, D.C. P. EUGENE JONES, Associate Professor and Director, Physician Assistant Program, Department of Health Care Sciences, University of Texas Southwestern Medical Center at Dallas HENK LAMBERTS,* Professor of Family Medicine, Academic Medical Center, University of Amsterdam, The Netherlands PAUL W. NANNIS, Commissioner of Health, City of Milwaukee Health Department, Milwaukee, Wisconsin R. HEATHER PALMER, Director, Center for Quality of Care Research and Education, Harvard School of Public Health, Boston, Massachusetts BARBARA ROSS-LEE, Dean, College of Osteopathic Medicine, Ohio University, Athens *   Institute of Medicine member.

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--> SHEILA A. RYAN,* Dean, School of Nursing, Director, Medical Center Nursing, University of Rochester, Rochester, New York RICHARD M. SCHEFFLER, Professor, Health Economics and Public Policy, School of Public Health, University of California at Berkeley WILLIAM L. WINTERS, JR., Clinical Professor of Medicine, Baylor College of Medicine, Houston, Texas Study Staff KATHLEEN N. LOHR, Director, Division of Health Care Services KARL D. YORDY, Study Co-Director MOLLA S. DONALDSON, Study Co-Director LISA M. CHIMENTO, Program Officer (until July 1994) ROBIN L. RIVKIND, Research Associate (until September 1995) DIANE PRESCOTT, Research Assistant (as of September 1995) HELEN C. ROGERS, Project Assistant (until January 1995) ANITA M. ZIMBRICK, Project Assistant (as of January 1995) H. DONALD TILLER, Administrative Assistant

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--> Preface After decades of relative neglect in a health care system that placed most of its emphasis on specialization, high technology, and acute care medicine, the value of primary care is again being recognized as part of the wave of reform that is sweeping the U.S. health care industry. There are numerous indications of the increasingly important role being played by primary care. Health care reform proposals developed by both the federal government and several state governments have included measures to strengthen the delivery of primary care. More important in view of current trends has been the emphasis that market forces have placed on a vigorous primary care system. A further indication of the current level of interest has been the number and variety of public and private sponsors of this Institute of Medicine (IOM) study of the future of primary care. The current IOM study can be divided into two phases. During the first phase the study committee, which included members with diverse backgrounds and interests, agreed upon a number of underlying principles related to primary care and also reviewed and updated the definition of primary care that had been developed by the IOM in 1978. The underlying principles are listed in Chapter 1 of this report. Of particular importance is the committee's consensus that primary care represents the logical foundation for the U.S. health care system of the future. The revised definition of primary care was published in a September 1994 preliminary report and is also contained in Chapter 2 of this final report. It takes into consideration the numerous changes in health care that have occurred in the nearly two decades since the original IOM definition was published. It would be

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--> impossible to overemphasize the importance the committee attached to the new definition. Committee members continually referred to it when formulating recommendations on issues such as who is a primary care clinician, what should be the content of education and training programs in primary care, and what items should be included in the research agenda for primary care. The second phase, which occupied the final 18 months of the study, involved visits to urban and rural primary care delivery sites, a public hearing, the preparation and review of several commissioned papers, and two workshops. It included an examination of topics such as the nature and content of primary care and the value of primary care to both individual patients and to the health care system as a whole. Also considered were the delivery of primary care, the needs of the primary care workforce, education and training in primary care, and primary care research requirements. Finally, the committee recognized that additional steps will be needed to implement the 31 recommendations contained in this report and therefore developed the implementation strategy outlined in Chapter 9. The committee wishes to acknowledge the superb support it received from the IOM staff. Study Co-directors Karl Yordy and Molla Donaldson, and Kathleen Lohr, Director of the IOM Division of Health Care Services, all played major roles in gathering data, helping to define the issues, and writing the report. The committee was impressed with both their knowledge and their professionalism. Other IOM personnel who provided valuable assistance were Lisa Chimento, Robin Rivkind, Diane Prescott, Helen Rogers, Anita Zimbrick, and Don Tiller. Although it is impossible to predict what the U.S. health care system will look like when the current pace of rapid change ends and a period of relative stability is reached, the committee is confident that primary care will remain an essential component of efforts to improve the quality of care, increase access to health care, and control health care costs. It hopes that this report will both convey the value, complexity, and richness of primary care and catalyze concrete steps to strengthen this crucial part of the delivery system. Neal A. Vanselow, M.D. Chair

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--> Acknowledgments The Committee on the Future of Primary Care is appreciative of the assistance it and the study staff received from many individuals and organizations during its site visits. All were gracious in offering their time and insights regarding the direction of primary care. The committee also made much use of the written statements and testimony given at a public hearing held by the committee in December 1994. These testimonies provided thoughtful reactions to the committee's interim report and information about current and planned primary care activities. The committee benefited from thoughtful presentations by several experts invited to its meetings. At its first meeting, in March 1994, the committee heard from John M. Eisenberg, M.D., Chairman and Physician-in-Chief of the Department of Medicine at Georgetown University and Chairman of the Physician Payment Review Commission. Guest speakers at its second meeting, in May 1994, were Susan Schooley, M.D., Chair, Department of Family Practice, Henry Ford Health System; Patricia Simmons, M.D., Associate Professor, Department of Pediatrics and Adolescent Medicine, and Member, Board of Governors, Mayo Clinic and Foundation; and Jack M. Colwill, M.D., Professor and Chairman, Department of Family and Community Medicine, University of Missouri–Columbia, and Member, Council on Graduate Medical Education (COGME). At its July 1994 meeting the committee heard a presentation by Dana Gelb Safran, Sc.D., Senior Policy Analyst, Division of Health Improvement, The Health Institute, New England Medical Center. She and the committee engaged in a lively discussion about a background paper she wrote for the committee on defining primary care. Material in that paper was derived in part from a consensus

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--> conference convened in May 1994 by Dr. Safran and Dr. Alvin Tarlov of The Health Institute. Fitzhugh Mullan, M.D., Director, Bureau of the Health Professions, Health Resources and Services Administration (U.S. Public Health Service) gave a presentation on the changing primary care workforce at its June 1995 workshop on roles in primary care. Drs. Kerr White and Barbara Starfield were extraordinarily helpful to the committee in responding to requests for information and generous with ideas about primary care based on their long experience in this field. Joyce Fitzpatrick, while the Distinguished Nurse-Scholar-in-Residence at the IOM, provided very helpful material to the committee on interdisciplinary education and practice. The committee would like particularly to acknowledge the help of several organizations and individuals who provided data and conducted analyses for the committee: Carolyn Clancy, M.D., Agency for Health Care Policy and Research (USPHS); Paul A. Nutting, M.D., Ambulatory Sentinel Practice Network; Robert Larsen, M.D., FHP International, Inc.; Pauline Nefcy and Sarmad Pirzada of the Group Health Cooperative of Puget Sound; William Rush, Ph.D., and Leif I. Solberg, M.D., the Group Health Foundation; David Nerenz, Ph.D., the Henry Ford Health System; Merwyn R. Greenlick, Ph.D., and Nancy Clarke, the Kaiser Permanente Center for Health Research; Les Zendle, M.D., the Southern California Permanente Medical Group; Kathy Martin of Sharp HealthCare; Marcia J. Wilson of Sharp Rees-Stealy Medical Center, Inc.; and Peter Franks, M.D., University of Rochester/Highland Park Hospital. Major funding for this study was received from the following: Department of Veterans Affairs, The Josiah Macy, Jr., Foundation, The Pew Charitable Trusts, The Robert Wood Johnson Foundation, and the U.S. Public Health Service, the Agency for Health Care Policy and Research and the Health Resources and Services Administration (HRSA). HRSA provided additional funding for a workshop on the scientific basis of primary care held in January 1995. The committee and staff are appreciative of the help provided by the contract officers whose organizations sponsored the study. Additional funding for special study activities was received from Blue Cross of California, the Irvine Health Foundation, and the Pew Health Professions Commission for support of a constructive and informative workshop on roles in primary care that was held in Irvine, California, in June 1995. Funding for the committee's very useful and illuminating site visits was provided by the W.K. Kellogg Foundation. Additional funding was received from a large set of organizations. Many of these organizations also provided helpful materials and data in response to our numerous questions. These sponsors are the Ambulatory Pediatric Association, American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Physician Assistants, American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American

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--> Association of Dental Schools, American College of Osteopathic Family Physicians, American College of Physicians, American Geriatrics Society, American Medical Informatics Association, American Nurses Association, American Optometric Association, American Osteopathic Association, American Physical Therapy Association, and the Society of General Internal Medicine. Finally, the committee would like to express its gratitude to the IOM staff who facilitated the work of the committee. We are grateful for the secretarial and logistical support provided by Helen Rogers and Anita Zimbrick, to H. Donald Tiller, Administrative Assistant to the Division, and for the assistance during the report review and preparation stage of Claudia Carl and Michael Edington of the IOM's Reports and Information Office; the steady help of Nina Spruill, Financial Associate for the Division of Health Care Services, is also greatly appreciated.

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--> Contents     SUMMARY   1     Definition of Primary Care   2     Value of Primary Care   3     The Nature of Primary Care   3     The Delivery of Primary Care   4     The Primary Care Workforce   4     Education and Training for Primary Care   5     Research and Evaluation in Primary Care   6     A Strategy for Implementation   6 1   INTRODUCTION   13     The Institute of Medicine Study   15     Underlying Assumptions   18     Historic Roots and the Contemporary Context for Primary Care   19     Organization of the Report   25     References   25 2   DEFINING PRIMARY CARE   27     Early Definitions   28     The First IOM Definition   29     Distinguishing Public and Personal Health Services   29     The 1984 Report on Community-Oriented Primary Care   30     Changes in Health Care Delivery Today   31     The New Definition and an Explanation of Terms   31     Achieving the Goals of Primary Care as Defined   50     References   50

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--> 3   THE VALUE OF PRIMARY CARE   52     The Value of Primary Care for Individuals   53     Primary Care and Costs, Access, and Quality   62     The Limits of Primary Care in Improving Population Health   71     Summary   72     References   72 4   THE NATURE OF PRIMARY CARE   76     Content of Primary Care   77     Characteristics of Primary Care   80     Summary   88     Appendix: Data on the Majority of Personal Health Care Needs   89     References   102 5   THE DELIVERY OF PRIMARY CARE   104     Current Pathways for Primary Care   105     Moving Toward Delivery of Primary Care as Defined   112     Summary   144     References   145 6   THE PRIMARY CARE WORKFORCE   148     Workforce Trends and Supply Projections: Physicians   149     Workforce Trends and Supply Projections: Nurse Practitioners   158     Workforce Trends and Supply Projections: Physician Assistants   162     Other First-Contact Providers   165     Comment on Workforce Estimation   165     Conclusions and Recommendations about the Supply of Primary Care Clinicians   167     Summary   175     References   175 7   EDUCATION AND TRAINING FOR PRIMARY CARE   179     Appropriate Training in Primary Care   180     The Education of Physicians   180     Other Content Issues in Training for Primary Care   187     Financial Support for Graduate Training in Primary Care   196     Interdisciplinary Education of Primary Care Clinicians   203     Integrated Delivery Systems and Primary Care Training   206     Continuing Medical Education   207     Physician Retraining   208     Summary   211     References   212

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--> 8   RESEARCH AND EVALUATION IN PRIMARY CARE   216     Support for the Infrastructure for Primary Care Research   218     Priority Areas for Primary Care Research   234     Summary   244     References   244 9   IMPLEMENTATION STRATEGY   247     Guiding Perspectives   247     A Primary Care Consortium   250     Implementation of Specific Recommendations   252     Final Comment on Implementation   261     APPENDIXES         A Site Visits   265     B Public Hearing   268     C Workshops   274     D Mental Health Care in the Primary Care Setting Frank deGruy III, M.D.   285     E Life in the Kaleidoscope: The Impact of Managed Care on the U.S. Health Care Workforce and a New Model for the Delivery of Primary Care Richard M. Scheffler, Ph.D.   312     F Integrating Our Primary Care and Public Health Systems: A Formula for Improving Community and Population Health William E. Welton, M.H.A., Theodore A. Kantner, M.D., and Sheila Moriber Katz, M.D., M.B.A.   341     G Committee Biographies   374     INDEX   387

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