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News from the National Academies
Date: March 12, 1996
Contacts: Barbara J. Rice, Deputy Director,
Office of News and Public Information
Justin Lin, Media Relations Assistant
(202) 334-2138; Internet <news@nas.edu>

EMBARGOED: NOT FOR PUBLIC RELEASE BEFORE 11 A.M. EST TUESDAY,
MARCH 12

WITH MAJOR CHANGES, PRIMARY CARE CAN FORM BASE
FOR REBUILDING NATION'S HEALTH CARE SYSTEM

WASHINGTON -- Fundamental changes are needed to improve and expand primary health care in the United States in order to address the many challenges facing the nation's health care system, says a new report* by an Institute of Medicine committee. It specifies a set of recommendations aimed at providing all Americans with primary care services that respond to patients' needs while constraining health care costs. The report also details a plan for creating a well-trained, primary care work force that will increase access to high-quality health care.

Rapid and profound alterations in the organization and financing of health care in the United States are forcing a shift away from costly care by specialists and toward primary care physicians who can diagnose and treat a wide range of health problems. In the absence of comprehensive health care reform legislation, efforts to contain costs are likely to remain dominant in reshaping health care, but alone they are not adequate to produce the strong primary care system that is required, the committee said.

"Action is needed on a comprehensive strategy that recognizes primary care as the logical foundation for America's health care system," said committee chair Neal A. Vanselow, professor of medicine, Tulane University, New Orleans. "By reshaping primary care, we can give Americans a health care system that is able to address many of their health problems without bouncing them from specialist to specialist -- a system that can build the trust and partnership between doctor and patient that we all value and one that can use resources efficiently to keep costs down for everyone."

The committee firmly concluded that a primary care system and universal coverage must go hand in hand if the nation is to close the gaps in health care coverage for rural areas, inner cities, the chronically ill, and the elderly. The committee also concluded that a moderate shortage of primary care clinicians -- physicians, nurse practitioners, and physician assistants -- should disappear soon thanks to training efforts already in place to increase their numbers.

To move the nation into a new era of health care, the major changes needed range from adopting a new definition of primary care -- as the basis for improving health care delivery -- to tailoring education and training for primary care practice. The committee's detailed strategy includes the following recommendations:

> Establishing a set of common proficiencies in primary care practice for all trainees regardless of the discipline. These "core competencies" should include: periodic health examinations for patients; screening for early disease detection; evaluation and management of acute illness; assessment of patients and referral as appropriate; ongoing management of patients who have chronic diseases; coordination of care among specialists; and the provision of short- and long-term care in hospital settings. These competencies would be identified by a coalition of educational, professional, and accrediting bodies, to guide the education and training of practitioners.

> Adopting uniform methods and measures to monitor the performance of health care systems and individual clinicians in delivering primary care. Measures should address cost, quality, access, as well as patient and clinician satisfaction -- and the results should be made public.

> Obtaining support from all public and private health care payers for education and training in health professions. The committee also recommended reallocating Medicare funds used for graduate medical education to provide explicit support for primary care training in such non-hospital settings as health maintenance organizations, community clinics, and extended-care facilities.

> Using payment methods that promote primary care, in order to reimburse physicians and other health care providers. These include a fixed payment per person for services provided to those enrolled in a health care plan -- a method known as capitation. The traditional fee-for-service approach involves payments for each procedure and tends to increase the use of more-costly, specialized diagnostic and treatment procedures. When fee-for-service reimbursement is used, primary care physicians should be paid more to better reflect the value of their services, the committee said.

> Stimulating action by state governments to eliminate or reduce restrictions that prevent collaborative practice with nurse practitioners and physician assistants in providing primary care services.

> Establishing a primary care research infrastructure that would include a lead federal agency, data collection standards and a national data base, and research networks of primary care practices for studying the health care and health status of patients in "real-world" settings. In comparison with the nation's investment in biomedical research, the committee called the science base for primary care "modest" and the infrastructure needed to shore up the knowledge base "skeletal at best."

Creation of a non-profit consortium of professional societies, private foundations, government agencies, health care organizations, and representatives of the public was called for by the committee to coordinate efforts for promoting and enhancing primary care. The consortium would conduct research and development, provide technical assistance, and disseminate information on subjects such as primary care infrastructure, innovative models of primary care, and performance monitoring methods.

The committee also redefined primary care to furnish a clearer understanding of its essential and desirable attributes and to guide health care providers as they build new systems with primary care as a base. Primary care is defined by the committee as "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 the family and the community." This new definition stresses the importance of the patient and family, the community, the relationship between patient and primary care clinician, and the integration of services.

Determining who is a "primary care clinician" within the parameters of today's health care system is difficult, the report says. As a reference, the committee looked at how clinicians are trained today and what they do in their practices. For the purposes of its study, the committee agreed that those trained in family medicine, general internal medicine, and general pediatrics -- including many nurse practitioners and physician assistants -- are most likely to practice primary care.

The Institute of Medicine is a private, non-profit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster is below.
The study was funded by the Health Resources and Services Administration, Agency for Health Care Policy and Research, U.S. Department of Veterans Affairs, Pew Charitable Trusts, Robert Wood Johnson Foundation, and Josiah Macy Jr. Foundation. Additional funding was provided by Blue Cross of California, Irvine Health Foundation, Pew Health Professions Commission, W.K. Kellogg Foundation, 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 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 Society of General Internal Medicine.

*Pre-publication copies of Primary Care: America's Health in a New Era are available in two volumes from the National Academy Press at the mailing address in the letterhead; tel. (202) 334-3313 or 1-800-624-6242. The cost is $49.00 (prepaid) plus shipping charges of $4.00 for the first copy and $.50 for each additional copy. Reporters may obtain copies from the Office of News and Public Information at the letterhead address (contacts listed above).




INSTITUTE OF MEDICINE
Division of Health Care Services

Committee on the Future of Primary Care


Neal A. Vanselow, M.D. (1) (chair)
Professor of Medicine, and
Adjunct Professor of Health Systems Management
School of Public Health and Tropical Medicine
Tulane University, New Orleans

Joel J. Alpert, M.D. (1)
Professor of Pediatrics and Public Health
Department of Pediatrics
Boston University School of Medicine

Cheryl Boykins
Director
National Black Women's Health Project, Atlanta

carolyn V. Brown, M.D., M.P.H.
South Burlington, Vt.

Ken Cameron
Chairman of the Board
Group Health Cooperative of Puget Sound, Seattle

Pete T. Duarte
Chief Executive Officer
Thomason Hospital
El Paso, Texas

Peter Ellsworth
President and Chief Executive Officer
Sharp HealthCare, San Diego

Raymond S. Garrison Jr., D.D.S., M.S.
Associate Professor and Chairman, Department of Dentistry
Bowman Gray School of Medicine
Winston-Salem, N.C.

Larry A. Green, M.D. (1)
Professor and Woodward-Chisholm Chairman of Family Medicine
University of Colorado Health Sciences Center, Denver

Paul F. Griner, M.D. (1), (2)
Vice President and Director, Center for the Assessment and Management of Academic Medicine
Association of American Medical Colleges
Washington, D.C.

Jean Johnson, R.N.-C., Ph.D.
Associate Dean for the Health Sciences Programs
George Washington University Medical Center
Washington, D.C.

P. Eugene Jones, Ph.D., P.A.-C.
Associate Professor and Director, Physician Assistant Program
Department of Health Care Sciences
University of Texas Southwestern Medical Center, Dallas

Henk Lamberts, M.D., Ph.D. (1)
Professor of Family Medicine
Academic Medical Center
University of Amsterdam
The Netherlands

Paul W. Nannis (3)
Commissioner of Health
City of Milwaukee Health Department

R. Heather Palmer, M.B., B.Ch., S.M.
Director, Center for Quality of Care Research and Education
Harvard School of Public Health, Boston

Barbara Ross-Lee, D.O.
Dean, College of Osteopathic Medicine
Ohio University, Athens

Sheila A. Ryan, Ph.D. (1)
Dean, School of Nursing, and
Director, Medical Center Nursing
University of Rochester
Rochester, N.Y.

Richard M. Scheffler, Ph.D.
Professor, Health Economics and Public Policy
School of Public Health
University of California, Berkeley

William L. Winters Jr., M.D., F.A.C.C.
Clinical Professor of Medicine
Baylor College of Medicine, Houston

Institute Of Medicine STAFF

Clyde Behney, Division Director
Karl D. Yordy, Study Director
Molla S. Donaldson, Study Co-Director

(1) Member, Institute of Medicine
(2) Beginning October 1995, vice president, American Association of Medical Colleges, Washington, D.C.
(3) Beginning November 1995, senior program officer, Robert Wood Johnson Foundation, Princeton, N.J.