Primary care in the United States is in crisis and must be reconstructed, according to a UCSF-led re

By Maureen McInaney on February 03, 2003

Primary care is in crisis – especially as changes occur in the United States population and in the financing and organization of the health care system, according to a series of reports led by a UCSF research team.

In a special supplement in the February 4, 2003 issue of The Annals of Internal Medicine, leaders in primary care urge a concerted, national effort to reconstruct primary care in order to care for our increasingly older, chronically ill, and diverse population. The supplement was funded by The Robert Wood Johnson Foundation.

According to the researchers, primary care is a vital component of high quality health care—its strengths deriving from its continuous relationship with patients, its broad perspective, and its flexibility and adaptability. Yet, there are new and substantial threats to primary care.

“Primary care is a core component of nearly all modern health care systems in the world – except in the United States,” said Jonathan Showstack, PhD, MPH, UCSF professor of medicine and health policy and lead author of the report. “If we don’t reconstruct the way that primary care is provided, we will inevitably face a very costly medical, financial, and human crisis.”

While patients value primary care, a host of organizational and financial pressures now impinge on primary care’s viability, according to Steven A. Schroeder, MD, UCSF distinguished professor of health and health care and co-author of a report in the series.

As a result, patients are increasingly dissatisfied with their relationships with their primary care physicians, according to the researchers. Access to primary care services is becoming much more difficult, even for those with insurance. In addition, primary care providers are finding it more difficult to respond to patients’ needs for accessible, comprehensive care, they said.

“The role of ‘gatekeeper’ has tarnished the image of the primary care physician,” explained Showstack. “Primary care providers are viewed by many patients as barriers to specialized care, rather than trusted partners and advocates who guide patients through their care.

The researchers also explain that the field of primary care has failed to hold its own among medical specialties. Fewer young physicians are choosing training in primary care.

“Primary care must be able to justify its place in a system where specialist physicians, nurses and other providers are increasingly providing principal care and where patients often choose to go to non-traditional settings for their care,” said Showstack.

The report derives from a Robert Wood Johnson Foundation sponsored summit held in October 2001 and attended by leaders in primary care and other health sectors. The leaders discussed the current and future challenges to primary care and developed new and innovative ideas about how primary care might meet the needs of our current and future population.

The researchers identified seven principles that can be used for the reconstruction of primary care and the health care system:

1. Health care must be organized to serve the needs of patients. Much of the current organization of medical care is structured to accommodate incentives in the reimbursement system and the preferences of providers, often with patients’ needs included only as an afterthought.

2. The goal of primary care systems should be the delivery of the highest quality care as documented by measurable outcomes. The definition of quality should be based on definable outcomes. This will require research to establish appropriate indicators of primary care quality and the development of methods to identify, collect, and evaluate the most relevant information.

3. Information and information systems are the backbone of the primary care process. Today’s health care information systems were designed primarily in response to administrative needs, with reimbursement at the top of the list. These systems rarely collect information that allows management of a patient’s needs over time or an assessment of the effects of care on patient health. Specifically, medical records should remain with the patient and be interactive for patients and providers alike.

4. Current health care systems must be reconstructed. The American health care system is a complex and fragmented set of providers, facilities and services that have been created based on requirements for reimbursement and the needs of providers. The system should be participant controlled, outcomes oriented, structured to address the needs of the population and focused on the ongoing relationship between a patient and primary care provider.

5. The health care financing system must support excellent primary care practice. Such changes must, at a minimum, include adequate reimbursement for primary care services such as performing a history and physical, counseling patients about their health, and being an advocate to guide patients through the health system.

6. Primary care education must be revitalized, with an emphasis on new delivery models and training in sites that deliver excellent primary care. Clinical training should occur in settings that provide high quality, continuous, patient-centered, outcomes-oriented, team-based care.

7. The value of primary care practice must be continually improved, documented and communicated. There must be a concerted, national effort to redesign, implement and evaluate new forms of primary care delivery.

Included in The Annals of Internal Medicine supplement devoted to the crisis in primary care in the United States are five reports:

1) Primary Care Medicine Crisis: Reconstruction and Renewal: Gordon Moore, MD, MPH, professor of ambulatory care prevention at Harvard Medical School and Jonathan Showstack, PhD, MPH, UCSF professor of medicine and health policy.

2) Defining the Future of Primary Care: What Can We Learn From Patients? Dana Gelb Safran, Sc.D, The Health Institute, division of clinical care research, Tufts New England Medical Center and the department of medicine, Tufts University, Boston, MA

3) Chronic Illness Management: What is the Role of Primary Care? Arlyss Anderson Rothman, PhD, MHS, RN-CS, FNP, UCSF assistant professor of Nursing; and Edward H. Wagner, MD, MPH, MacColl Institute of Healthcare Innovation, Group Health Cooperative of Puget Sound.

4) Primary Care in a New Era: Disillusion and Dissolution? Lewis G. Sandy, MD, executive vice president, The Robert Wood Johnson Foundation; and Steven A. Schroeder, MD, formerly president and CEO of The Robert Wood Johnson Foundation and now distinguished professor of health and health care at UCSF.

5) Primary Care: The Next Renaissance: Jonathan Showstack, PhD, MPH, UCSF professor of medicine and health policy; Nicole Lurie, MD, MSPH, senior natural scientist and Paul O’Neill Alcoa, professor, The Rand Corporation; Eric B. Larson, MD, MPH, FACP, professor of medicine, University of Washington; Arlyss Anderson Rothman, PhD, MHS, FNP, UCSF assistant professor of Nursing; Susan Hassmiller, PhD, RN, FANN, senior program officer, The Robert Wood Johnson Foundation.

This research was funded by The Robert Wood Johnson Foundation. The Robert Wood Johnson Foundation seeks to improve the health and health care of all Americans. To accomplish these goals, the Foundation supports training, education, research (excluding biomedical research), and projects that demonstrate the effective delivery of health care services.

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