Primary Care America's Health in a New Era (1996) / Chapter Skim
Currently Skimming:
The Delivery of Primary Care
The Delivery of Primary Care
Pages 104-147
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From page 104... ...
Although some of those forces are favorable to aspects of primary care, the committee is not convinced that the current health care market, by itself, will shape primary care to match all aspects of the definition. Further actions will need to be taken to provide the financial incentives and infrastructure that will help the health care system overcome barriers.
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From page 105... ...
Spread of Managed Care The term managed care has come to have many meanings. This committee uses managed care to refer to health plans that have a selective list of providers, both health professionals and hospitals, and that include mechanisms for influencing the nature, quantity, and site of services delivered.
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From page 106... ...
Current congressional deliberations on the future course of the Medicare program may result in further encouragement of enrollment of Medicare beneficiaries in capitated managed care plans. Of particular significance for this study is that one major objective of most managed care plans is to reduce the use of specialists and to increase the use of primary care clinicians.
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From page 107... ...
Development of Integrated Health Care Delivery Systems A related and overlapping trend is the development of vertically integrated delivery systems that combine physicians and other health professionals, hospitals, rehabilitation units, social services, chronic care capabilities, mental health and substance abuse programs, and health promotion and disease prevention programs into an organized whole that can provide and coordinate a comprehensive array of services. Some of the motivation behind the development of these systems is to increase and protect market share in areas where there is surplus capacity.
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From page 108... ...
Some patients are also disturbed if they believe that their relationship with a primary care clinician who is committed to their interests is being compromised by a large, impersonal, and perhaps distant organization. Growth in For-Profit Health Plans and Delivery Systems il Along with consolidation, health plans and integrated systems are increasngly under for-profit ownership.
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From page 109... ...
All in all, concern about the lack of involvement of primary care clinicians in the medical care of patients in longterm care settings remains high (IOM, 1986b; 1995~. Vision care and pharmacy services are collocated in some group model plans, and many plans include a dental care benefit.
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From page 110... ...
California has given the primary care label to obstetrics and gynecology through state law, and other specialist groups have staked out a claim to the domain of primary care. This desire to be designated as primary care clinicians is the result of managed care plans' requiring that enrollees choose a primary care clinician, usually a family practitioner, general internist, or pediatrician, who will control access to specialized services.
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From page 111... ...
Care of the Urban Poor Care for low-income or disadvantaged populations, concentrated in the inner cities, is complicated by the lack of universal insurance coverage, the health care needs of illegal immigrants, and the low payments for providers in many states. These problems have often been alleviated by internal cross-subsidies and federal program formulas that favor institutions and care settings that serve a disproportionate share of the poor.
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From page 112... ...
Because the benefits of primary care are important for meeting the health care goals of this society, the committee believes that a specific objective for the availability of primary care service should be established, focusing on the central relationship of the clinician and the patient. Recommendation 5.1 Availability of Primary Care for All Americans The committee recommends development of primary care delivery systems that will make the services of a primary care clinician available to all Americans.
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From page 113... ...
Financing of Primary Care Services The failure of comprehensive health care reform at the national level (which aimed at providing universal health insurance coverage) and the retreat from reforms at the state level (such as in Washington and Oregon)
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From page 114... ...
As a result there is an incentive to place primary care rather than acute inpatient services at the center of the health care system (Shortell et al., 1994~. By providing an overall cap on resources, however, capitation may also reward health care plans for not providing services, and services necessary for good care could be neglected.
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From page 115... ...
The committee did not have the opportunity to explore in detail the specific methods of paying primary care clinicians that would encourage good primary care. It did note during some site visits that innovations in the patterns of primary care and in the use of teams were associated with salary payment mechanisms.
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From page 116... ...
Although the methods for paying primary care clinicians are likely to continue to evolve and to include salary and capitation arrangements, fee-for-service reimbursement is likely to remain a method of payment for primary care for the foreseeable future. Such reimbursement may come as direct payment from a feefor-service health insurance plan, as with indemnity insurance plans and the regular Medicare Part B program, and it may be used as the method of payment for individual clinicians under a capitated health plan.
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From page 117... ...
During the committee site visits, committee members heard from primary care clinicians and from patients that frequent changes in health plans offered by employers had forced patients to change physicians and that they
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From page 118... ...
The committee would like to encourage this trend. Three- or even five-year contracts would reduce the possibility that shifts in health plans would force patients to change primary care clinicians.
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From page 119... ...
Discussions of professional roles in primary care are influenced by many past tensions: the sometimes strained relationships between nurses and physicians, the struggle of primary care physicians for appropriate status in a medical environment dominated by specialists and subspecialists, and the arguments between such first-contact health professionals as optometrists and some of the medical profession. The tensions have been exacerbated in recent years by the growth of managed care arrangements that make primary care clinicians the path by which patients gain access to specialized medical services.
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From page 120... ...
There is little argument that among physicians (both allopathic and osteopathic) , family physicians, general internists, and general pediatricians are primary care clinicians.
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From page 121... ...
, do not make these other professionals part of the primary care team, although they are providing essential health services. In the committee's view, and in the many examples of teams observed on the site visits, the team nearly always will include a primary care physician.
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From page 122... ...
First is the continued increase in the number of specialists in the past two decades, both in absolute numbers and relative to the number of primary care physicians. The second trend is the growth of managed care plans, which emphasize primary care and control the use of care provided by specialists.
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From page 123... ...
Today most managed care plans control access to specialty care through a designated primary care clinician, so this pattern of specialist practice is likely to be less common for patients in managed care arrangements. For the committee, the issue is whether these patterns of specialist provision of primary care mixed practice and the principal physician role provide primary care as the committee has defined it.
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From page 124... ...
To enable the primary care clinician to carry out the primary care function at a level of excellence that best meets patients' needs requires appropriate training, experience, and support systems. The function of primary care is complex and demanding (see Chapter 4~; it involves many activities that extend beyond a reductionist focus on the diagnosis and treatment of a specific disease.
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From page 125... ...
that these professions be included in any classification of primary care clinicians or that these professions be considered part of the primary care team. The roles of these professions in primary care were also discussed at the committee's workshop on professional .
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From page 126... ...
Another set of health professionals, including physical therapists and podiatrists, may also provide first-contact services. Access to these services is often through regular referral mechanisms, and managed care plans frequently require referral by the primary care clinician.
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From page 127... ...
These include lack of health insurance coverage; low reimbursement under many state Medicaid programs; geographic isolation of the population to be served; lack of transportation; problems of recruiting and retaining health care personnel, especially physicians; language and cultural differences that often complicate communication; and special challenges in coordinating primary care with other health and social services. For many years, federal and state programs and private foundations have directed specific resources toward providing primary care for these populations.
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From page 128... ...
The trend toward managed care in the Medicaid program does not solve the problems of health insurance coverage for those who are ineligible for Medicaid or who lack private health insurance coverage. State contracts with managed care plans do offer some opportunity to assure the provision of primary care for underserved populations that qualify for Medicaid.
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From page 129... ...
For primary care programs supported in part by federal grants, the grant covers costs that are above and beyond reimbursement received through Medicaid, Medicare, private health insurance, and self-pay. One fear of these community clinics urban or rural, public or private expressed to the committee during its site visits was that as managed care plans spread to these communities, they would fail to recognize the higher costs associated with meeting the health needs of these populations or that such plans would seek to serve only those patients for whom adequate payment was available.
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From page 130... ...
Specific attention to the means of effective coordination across the array of services needs to be part of the explicit mission of the primary care clinicians and the organizational arrangements within which the primary care function is carried out. The complexities of the coordinating function are another argument for the development of integrated health care systems that can provide appropriate resources for effective coordination.
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From page 131... ...
The decision to refer should be accompanied by an exchange of information. In this exchange, ideally, the primary care clinician's knowledge of the patient's history, other health problems, and family and community circumstances is provided to the specialist; the specialist reciprocates with information that is relevant to the comprehensive care of the patient over time, including prevention of disease, maintenance of function, and appropriate treatment of the patient' s other health problems.
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From page 132... ...
For the rest of the population enrolled in managed care plans, there are numerous examples of how these plans can play an important role in health promotion and disease prevention functions that involve services to and interaction with individuals. Plans with capitated funding typically include a wide range of preventive services in their benefit package, in contrast to the exclusion of many or most preventive services in traditional health indemnity plans.
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From page 133... ...
Commenting that "we must view both public health and primary care as two interacting and mutually supportive components of an increasingly complex integrated system having the single common goal of improving the health of a community and its diverse population," they outline a systems approach for bringing about this integration. This approach involves developing a means by which to identify the functions of the public health agencies for population-based health activities and those of integrated health systems for personal health services (including preventive and health promotion services for individuals)
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From page 134... ...
Moving primary care services toward a more population-based approach will also require changes in the education of primary care clinicians (see Chapter 7) that can build on many activities already under way, such as those supported by private foundations under the "Health of the Public" projects of The Robert Wood Johnson Foundation and The Pew Charitable Trusts and the communityoriented health education programs supported by the W.K.
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From page 135... ...
to reform the health care system offer an opportunity to find the most effective of these modifications and to discover fruitful collaborative structures both within the primary care setting and between primary care clinicians and mental health professionals. The issue of referrals is further complicated by the way that mental health services are financed.
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From page 136... ...
Second, models of assistance to primary care clinicians by mental health professionals need to be further developed, implemented, and evaluated. Third, financial and organizational disincentives for a strengthened primary care role need to be reduced so that the primary care clinician can and will provide needed and effective services for those mental health problems that will inevitably present in the primary care setting and that are often imbedded in other health problems.
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From page 137... ...
These models should involve both primary care clinicians and mental health professionals. Long-Term Care and Primary Care The importance of long-term care is growing as the number of the elderly, especially the very old, increases.
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From page 138... ...
Even today, there are complaints that primary care clinicians do not visit the home- or institution-bound patient and do not take an active role in their care or care plans (IOM, 1986b)
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From page 139... ...
, which provide fringe benefits for public employees in that state. A governmental equivalent is the competitive contracting process for state Medicaid programs that selects managed care plans to serve the Medicaid population, as in Arizona, Tennessee, and a number of other states.
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From page 140... ...
The technical problems of case mix, instability of enrollments, and the multiple factors affecting outcomes, among others, will complicate the measurement task. The unit of review health care organization or individual primary care clinician or practice is yet another issue.
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From page 141... ...
In recent years, the health professions have also become wary of the motivations of health plans competing in a market that is very sensitive to cost. A governmental model is illustrated by the classic state role in licensure of health professionals and institutions, by the quality assurance and improvement efforts for the Medicare program, and by the regulation of nursing homes under a federal-state relationship related mostly to the Medicaid program.
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From page 142... ...
Several basic approaches to infrastructure development and support might be considered: · Methods of payment for primary care services should recognize the costs
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From page 143... ...
The health care market in many locales is likely to remain a mix of small and large primary care organizations in the near and medium term, yet the large organizations, especially forprofit enterprises, will have significant advantages in raising capital. As long as the health care market is skewed by such factors, the third approach may be desirable, at least for underwriting those infrastructure needs that require extensive initial capital for technical development (such as clinical information and decision systems)
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From page 144... ...
health care scene that will influence the extent to which primary care evolves in this country. These include the spread of managed care, the expansion of integrated delivery systems, the consolidation of health plans and systems, growth in for-profit ownership of health plans and integrated delivery systems, the diversity between and within health care markets, the special challenges of primary care in rural areas and for the urban poor, the need for primary care to coordinate with other types of services, current and evolving roles for health care professionals, and the role of academic health centers in primary care delivery.
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From page 145... ...
First, the committee recommends establishing as a goal the availability of the services of a primary care clinician for all Americans. Second, the committee makes several recommendations to assure that mechanisms for financing primary care services provide appropriate incentives for sustaining a strong primary care function.
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From page 146... ...
. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1994 Current Population Survey.
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From page 147... ...
Competing in the Maturing Health Care Marketplace: Strategies for Academic Medical Centers. Prepared in consultation with APM Management Consultants.
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