Public Health Service
Primary Care Policy Fellowship

"A Model for Primary Care"

Ruth M. Baliweg, PA-C
MEDEX Northwest

Sara E. Barger, R.N., D.P.A.
Professor and Chair
Northern Illinois University

Robert C. Bowman, M.D.
Rural Health Education and Research
University of Nebraska Department of Family Practice

C. Patrick Chaulk, M.D., M.P.H. *
Senior Associate for Health
Annie E. Casey Foundation

William E. P. McMiller, M.D., M.P.H.
Assistant Professor
University of Illinois at Chicago

Jacalyn Ryberg, M.A., R.N., C.P.N.P.

Barbara Sheer, D.N.S.C.
Nurse Practitioner Program

* Presenter

The current medical paradigm has resulted in significant problems and gaps in the provision of health care in the United States. Currently, the U.S. spends nearly $2,400 per person on health care, 40% more than the next highest spending country, Canada. Despite these expenditures, some 37 million Americans are without health insurance coverage, another 40 million are underinsured, and millions more are uninsurable because of pre-existing medical conditions. As a result, in terms of health status – infant mortality, low birth weight babies, mortality rates from cancer, cardiovascular disease and injuries – the U.S. lags behind other countries which spend considerably less.

The root cause of much of this problem can be attributed to the orientation of our health care system, which emphasized diagnostic and procedural-oriented care over primary care. Instead, we need to re-focus our health care system by expanding primary and preventive care for all our citizens. This will result in a reduction in the need for procedurally-oriented treatment, and an improvement in many of our health status measures.

To achieve this goal, the Public Health Service Primary Care Policy Fellows for 1992 strongly urge that the Secretary use all resources at his disposal to facilitate the development of a national model for primary health care. We believe that the central ingredients of this model are the following:

  1. Comprehensive Services focusing on primary and preventive care, for example: mental health and substance abuse, dental services, counseling services, prenatal care, family planning, and EPSDT services for children. Although many of these services are currently available to some degree, individuals seeking out these services in many communities find that they are not available from one source (“one-stop shopping”) and must travel to several sites to obtain all necessary services.
  2. Coordination of Services described above. This will ensure economic and efficient use of existing services within the current health care system, drawing upon school-based programs, community and migrant health centers, public hospitals and teaching institutions, public transportation and housing programs, church-based services and a variety of services provided through business and volunteer organizations.
  3. Continuous Care must be maintained. Individuals must be able to access the primary care system in order to obtain timely services and early intervention and treatment. Episodic care, a hallmark of the uninsured and poor, leads to lower quality health care, more emergent problems, costlier care both in economic and human terms, and care that is more likely to require greater resources and technically-oriented treatment.
  4. Multi-disciplinary Care involving a wide range of primary care providers including, nurse practitioners, physician assistants, nurse midwives, physicians, dentists, and psychologists. In terms of both quality and economy, services are enhanced through the delivery of primary care by a wide range of providers.
  5. Community-Based orientation for this model is the final, and possibly most important, feature to developing a successful primary care model. This involves community-level representation in the needs assessment, operational and evaluation phases of this model. This will ensure the success of the primary care model by firmly basing the system on the unique needs, characteristics, and resources of the community itself.


We believe that the development of this system can begin immediately. The Federal role should involve the release of demonstration funds to competitive bidders representing both urban and rural communities, to begin linking existing services, improving quality of care, recruiting providers, and developing the infrastructure which can lead to a sustainable primary care system. As we described in our presentation to you, such a system has been successfully developed in Dallas, Texas. The recent problems in Los Angeles offer the opportunity for targeting Federal support for a variety of community programs which should include opportunities to promote a primary health care model. Experiences gained from such support can be shared with other communities.

Failure to redirect our health care system with a sharp focus on primary and preventive care will only chart us further onto the current troubled course which mismatches high health care spending with poor health outcomes.

Return to the Fellows' Policy Papers