Primary care in a new era: disillusion and dissolution?.
ABSTRACT The current dilemmas in primary care stem from 1) the unintended consequences of forces thought to promote primary care and 2) the "disruptive technologies of care" that attack the very function and concept of primary care itself. This paper suggests that these forces, in combination with "tiering" in the health insurance market, could lead to the dissolution of primary care as a single concept, to be replaced by alignment of clinicians by economic niche. Evidence already exists in the marketplace for both tiering of health insurance benefits and corresponding practice changes within primary care. In the future, primary care for the top tier will cater to the affluent as "full-service brokers" and will be delivered by a wide variety of clinicians. The middle tier will continue to grapple with tensions created by patient demand and bureaucratic systems but will remain most closely aligned to primary care as a concept. The lower tier will become increasingly concerned with community health and social justice. Each primary care specialty will adapt in a unique way to a tiered world, with general internal medicine facing the most challenges. Given this forecast for the future, those concerned about primary care should focus less on workforce issues and more on macro health care financing and organization issues (such as Medicare reform); appropriate training models; and the development of a conception of primary care that emphasizes values and ethos, not just function.
[Show abstract] [Hide abstract]
ABSTRACT: In the USA, primary care is usually defined as comprehensive or coordinated care that is delivered by physicians practicing general internal medicine, family practice, or pediatrics. Obstetrics and gynecology is sometimes included under the auspices of primary care since many women, particularly during the childbearing years, rely on these physicians for preventive services. Over the last 50 years, the funding models for primary care in the USA have been inconsistent and fragmented, resulting in a complex and inadequate funding system. Although many countries have developed government-sponsored, universal health care plans, the USA did not choose this route. Rather, significant change in US medicine has been the intended or unintended result of legislation and market-forces.Clinical Governance An International Journal 11/2003; 8(4):346-349. DOI:10.1108/14777270310499432
Medicina Clínica 02/2007; 128(4):141-147. DOI:10.1157/13098020 · 1.25 Impact Factor