A national panel of experts says in a new report that family physicians need more training and better support to perform their new role of superdoctor.
Primary care physicians are at the heart of managed health care, which is becoming the dominant way of providing care as part of a drive to curb exploding medical costs.But the report released Tuesday by the National Academy of Sciences Institute of Medicine contends that the primary care provider must be far more than a mere gatekeeper whose role is to discourage excessive treatment.
"It's clear that the health care market is going this way, but we feel strongly there are a number of things that need to be improved in the delivery and financing of primary care," said Dr. Neal Vanselow, chairman of the Committee on the Future of Primary Care and a professor of medicine at Tulane University.
"In the long run, the committee believes that the American people will accept only a system that meets their needs for good health care, and they will resist changes that are perceived as aimed principally at controlling costs," he said.
Although committee members said that during two years they visited a number of health plans that appeared exemplary, "there are not a lot of plans out there now that have all the elements we would like to see," said Ken Cameron, immediate past chairman of the Group Health Cooperative of Puget Sound in Olympia, Wash., and a committee member.
The new model for family doctoring should be a team approach that includes a core of generalist physicians, nurse practitioners and physician assistants expected to resolve most medical problems, with physician specialists, therapists and other providers brought in as needed, the panel said.
The 19-member committee, made up mostly of medical academics and health plan executives, sidestepped long-simmering controversy over what the proper mix of general practice and specialist physicians should be.
Market forces are already pushing up the pay and supply of doctors in family and internal medicine and pediatrics, while curbing the income and ranks of specialists, who by some measures account for up to 70 percent of doctors in the U.S.
Dr. Larry Green, professor of family medicine at the University of Colorado Health Sciences Center in Denver, said the committee didn't set a specific goal for primary care clinicians because "whether there is a shortage or not depends on how you define what they do. It might turn out we need more than we think to achieve the kind of quality we want from the system."
Aside from concerns that front-line health providers be paid in a manner consistent with their central role, the committee also recommended that a set of "core competencies" be established for all health professions involved in primary care.
These include expertise in giving health exams, disease screening for early detection, management of patients with short-term and chronic illness, coordination of care among specialists and providing mental health and long-term care to patients.
Medical schools need to teach new doctors these skills, and retraining of physicians already practicing must emphasize them as well, the group said.
The committee also urged the government and health plans to develop and use "uniform methods and measures to monitor the performance of health care systems and individual clinicians," addressing both cost, quality, access and patient and provider satisfaction, with the results made public.
In addition, the government must establish a research system to track the care and health status of patients being managed under a primary care system. The committee termed the current knowledge base "skeletal at best."