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SUPPLEMENT: THE FUTURE OF PRIMARY CARE

Primary Care in a New Era: Disillusion and Dissolution?

Lewis G. Sandy, MD, and Steven A. Schroeder, MD

4 February 2003 | Volume 138 Issue 3 | Pages 262-267

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.

Author and Article Information

From The Robert Wood Johnson Foundation, Princeton, New Jersey; and the University of California, San Francisco, San Francisco, California.

Acknowledgments: The authors thank Kelly A. Hunt, researcher, and Jessica K. Siehl, research assistant at The Robert Wood Johnson Foundation, Princeton, New Jersey, for their research assistance.

Requests for Single Reprints: Lewis G. Sandy, MD, The Robert Wood Johnson Foundation, Route One and College Road East, PO Box 2316, Princeton, NJ 08543-2316; e-mail, lsandy{at}rwjf.org.

Current Author Addresses: Dr. Sandy: The Robert Wood Johnson Foundation, Route One and College Road East, PO Box 2316, Princeton, NJ 08543-2316.

Dr. Schroeder: Department of Medicine, University of California, San Francisco, 3333 California Avenue, Suite 430, San Francisco, CA 94118.

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