Primary Care

The Institute of Medicine (IOM) defines Primary care 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 family and community." 1) "Integrated" refers to care that is comprehensive and addresses health care needs at any given stage of a patient's life cycle, coordinated, and continuous over time.

To the IOM, the relationship between a single clinician and a patient over time is central to the notion of primary care. The IOM recognizes that primary care often takes place within multidisciplinary, group practices and supports this arrangement, but emphasizes the residual need for one clinician to take the lead for every patient.

The broad reach of primary care includes 1) episodic care for acute symptoms, 2) management of chronic disease, and 3) disease prevention. In addition, however, the IOM specifically includes mention of "mental, emotional, and social concerns that involve the functioning of the individual."

Primary care providers in the US include general internists, pediatricians, family physicians, and obstetrician/gynecologists.; Among these groups, general internists are experts in caring for adults 2. They must have the experience, knowledge, and skill to evaluate a very broad array of symptoms and signs to arrive at correct diagnoses. They must be able to manage chronic conditions for the vast majority of patients with chronic disease (e.g., diabetes, COPD, renal failure, heart disease) who do not require exclusive care from a subspecialist. They must be able to deliver individualized preventive services. Finally, the emerging notion of a primary care internist includes expertise in patient-centered care, application of best evidence to all decision making, coordination of care, and management of health care teams including nurses and other non-physician providers. Many family physicians confine their practices to adults and have similar competence in this area to general internists. General internists, however, outnumber other primary care physicians in the United States. The number of practicing primary care internists is approximately 90,000, compared with 70,000 family physicians and 59,000 general pediatricians 3, 4.

How is Primary Care Delivered in the US?

The most common health care delivery system for primary care in the United States is the solo practice, followed by group practices, hospital clinics, federally qualified community health care centers, and staff model health maintenance organizations (HMO) including the Veterans Administration (VA)and large private organizations including Kaiser Permanente, Partners, and others. The Yale Health Plan is a small staff-model HMO.

This huge array of systems is supported by an equally complex payment system that includes public assistance programs (e.g., Medicare, Medicaid), the VA, private insurers, and self-payment5 While most US Citizens have some form of health insurance, about 16% do not. Uninsured people tend to be poor, unemployed adults who are not old enough to become eligible for Medicare.

Growing Shortage of Primary Care Physicians

In recent years, physicians and policy makers have raised concern that this fragmented, under-funded system of primary care is not fulfilling the health care needs of Americans6. In particular, Americans are finding it difficult to access primary care services and, when they do, the systems often provide inadequate care for chronic illness, mental illness, and continuity of care.7 Physicians who practice in primary care settings are pressed to see large numbers of patients during short visits to maintain income in circumstances of reduced per-visit compensation. Escalating demands of insurers, pharmacy providers, and regulators have created a work environment in which primary care providers spend increasing amounts of time away from patients, responding to oversight and creating reports. Adding to this challenging environment is the rapid pace of scientific advancement in medicine. While this progress means physicians can help patients achieve better health outcomes, it also means physicians must work harder to learn and apply new standards of care. Doing primary medicine well is becoming increasingly difficult in the current US health care environment. As one result, fewer students are entering primary care internal medicine and practicing primary care physicians are seeking other work8.

Search for a New National Policy

Led by the Society of General Internal Medicine and the American College of Physicians, many internists believe that the future of primary care internal medicine depends on reform in our system of physician reimbursement and in the organization of primary care delivery systems9. It is broadly understood that primary care physicians are paid less than other specialists9. This "primary care-specialty income gap" is the result of failures in the implementation of the resource-based relative value scale, which is used by Medicare to set physician reimbursement rates10. Recently, Medicare has indicated that any change in physician reimbursement would have to be budget neutral, meaning that increased payment to primary care physicians would need to be offset by lower reimbursement to other specialists. Such a change in allocation would probably require political intervention by Congress. Physicians can lobby for payment reform through their professional organizations, but they otherwise have little influence over this area of health care policy.

To overcome shortcomings in the delivery of primary care and to help create a more satisfying work environment for all health care personnel, the American College of Physicians has joined other professional organizations is promoting the concept of the Patient-Centered Medical Home, sometimes referred to as the Advanced Medical Home or Personal Medical Home5, 7, 11-13. In these homes, a personal physician accepts overall responsibility for the care of a patient, but provides medical services within a team which he or she leads is comprised of other health care providers, such as nurses or nurse practitioners, and support staff. Teams are structured around clear goals, objective outcome measures, and a patient-centered approach to medical care. The concept of the medical home emphasizes access, continuity and coordination of care, information management, and quality assurance. Supported by public funds, several models for the medical home are being tested.

The medical home might improve delivery of medical care to insured individuals and facilitate implementation of national quality standards, but it would not address the fragmented, inefficient reimbursement system or the barriers to access created by lack of health insurance. The US political culture emphasizes individual responsibility over common responsibility. Until this emphasis shifts and primary care finds greater favor among health care administrators, efforts to reform the national health care system may be limited to incremental efforts within states, municipalities, or private organizations. In the mean time, the work force for ambulatory care internal medicine will continue to draw from trainees who value the intellectual challenge and personal rewards of this subspecialty (including research and educational opportunities) enough to tolerate the low relative reimbursement, hard work, and administrative complexity.

  1. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary Care: America's Health in a New Era. Washington, DC: National Academy of Science; 1996.
  2. Reuben DB. Saving Primary Care. Am J Med 2007;120:99-102.
  3. Lindenhauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med 2007;357:2589-600.
  4. Administration HRaS. Physician Supply and Demand: Projections to 2020. Washington, DC: Health Resources and Services Administration; 2006.
  5. Physicians ACo. Achieving a high-performance health care system with universal access: what the United States can learn from other countries. Ann Intern Med 2008;148:55-75.
  6. Igelhart JK. Medicare, graduate medical education, and new policy directions. N Engl J Med 2008;359:643-50.
  7. Grumbach K, Bodenheimer T. A Primary Care Home for Americans. JAMA 2002;288:889-93.
  8. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students' career choices regarding internal medicine. JAMA 2008;300:1154-64.
  9. Iglehart JK. Medicare, graduate medical education, and new policy directions. N Engl J Med 2008;359:643-50.
  10. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007;146:301-6.
  11. Barr MS. The need to test the patient-centered medical home. JAMA 2008;300:834-5.
  12. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA 2004;291:1246-51.
  13. Blue Ribbon Panel of the Society of General Internal Medicine. Redesigning the practice model for general internal medicine. A proposal for coordinated care. A policy monograph of the Society of General Internal Medicine. J Gen Intern Med 2007;22:400-9.