Defining Primary Care:

An Interim Report

Molla Donaldson, Karl Yordy, and Neal Vanselow, Editors

Committee on the Future of Primary Care

Division of Health Care Services

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1994



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Defining Primary Care:: An Interim Report Defining Primary Care: An Interim Report Molla Donaldson, Karl Yordy, and Neal Vanselow, Editors Committee on the Future of Primary Care Division of Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1994

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Defining Primary Care:: An Interim Report National Academy Press 2101 Constitution Avenue, NW Washington, DC20418 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. Support for this project was provided by The Department of Veterans Affairs, The Health Resources and Services Administration (U.S. Department of Health and Human Services, Public Health Service), The Pew Charitable Trusts, The Robert Wood Johnson Foundation, and The Josiah Macy, Jr., Foundation. Additional copies of this report are available from: Committee on the Future of Primary Care Division of Health Care Services 2101 Constitution Avenue, NW Washington, DC 20418 Copyright 1994 by the National Academy of Sciences. Printed in the United States of America. 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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Defining Primary Care:: An Interim Report COMMITTEE ON THE FUTURE OF PRIMARY CARE NEAL A. VANSELOW, Chair, * Former Chancellor and Professor of Medicine, Tulane University Medical Center, New Orleans, Louisiana JOEL J. ALPERT, * Professor of Pediatrics and Public Health (Public Law), Department of Pediatrics, Boston University School of Medicine CHERYL BOYKINS, Director, National Black Women's Health Project, Atlanta, Georgia CAROLYN V. BROWN, Assistant Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Vermont College of Medicine, South Burlington 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, * Samuel E. Durand Professor of Medicine, General Director, Strong Memorial Hospital, Rochester, New York JEAN JOHNSON, Associate Professor and Director, Nurse Practitioner Program, Department of Health Care Sciences, 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 and Chair, Department of General Practice, 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 SHEILA A. RYAN, * Dean, School of Nursing, Director, Medical Center Nursing, University of Rochester, Rochester, New York *   IOM Member

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Defining Primary Care:: An Interim Report 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 Director MOLLA S. DONALDSON, Associate Study Director LISA M. CHIMENTO, Program Officer HELEN C. ROGERS, Project Assistant

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Defining Primary Care:: An Interim Report 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 the first part of its study. 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 conference convened in May 1994 by Dr. Safran and Dr. Alvin Tarlov of the Health Institute. The committee is particularly grateful for the insights provided by those who attended the consensus conference. The committee appreciates the information and assistance it has received from the contract officers whose organizations are sponsoring the IOM study of the future of primary care. These include Jessica Townsend of the U.S. Public

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Defining Primary Care:: An Interim Report Health Service, Health Resources and Services Administration (HRSA); Carolyn H. Asbury, The Pew Charitable Trusts; Lewis G. Sandy, M.D., The Robert Wood Johnson Foundation; Francis P. Goldstein, M.D., Department of Veterans Affairs; and Victoria del Corral, The Josiah Macy, Jr. Foundation. Several staff members of the Pew Commission on the Health Professions and the Administrator, Bureau Directors, and others at HRSA and COGME have graciously provided information and assistance to the committee as well. The committee is also grateful for the assistance of Kathleen N. Lohr, Director of the Division of Health Care Services, who, in addition to providing guidance and help for the study project, also contributed a critical and detailed review of the manuscript and enabled the committee to make numerous improvements to earlier drafts. Helpful suggestions were also provided by Leonore C. Sloane, an astute editor and longtime observer of this field. 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 for the assistance during the report review and preparation stage of Claudia Carl and Michael Edington of the IOM's Office of Communications; the steady help of Nina Spruill, Financial Associate for the Division of Health Care Services, is also greatly appreciated.