5: How Health Care Is Organized—I: Primary, Secondary, and Tertiary Care

People in the United States rightfully take pride in the technologic accomplishments of their health care system. Innovations in biomedical science have almost eradicated scourges such as polio and measles and have allowed such marvels as organ transplantation, “knifeless” gamma-ray surgery for brain tumors, and intensive care technology that saves the lives of children with asthma complicated by pneumonia. Yet for all its successes, the health care system also has its failures. For example, asthma is a leading cause of hospitalization in childhood. Proper health care can markedly reduce the frequency of severe asthma symptoms and of asthma hospital admissions. In cases such as Ruby’s, the failure to prevent severe asthma flare-up is not related to financial barriers, but rather reflects organizational problems, particularly in the delivery of primary care and preventive services.

The organizational task facing all health care systems is one of “assuring that the right patient receives the right service at the right time and in the right place” (Rodwin, 1984). An additional criterion could be “… and by the right caregiver.” The fragmented care Ruby received for her asthma is an example of this challenge. Who is responsible for planning and ensuring that every child receives the right service at the right time? Can an urgent care center or an in-store clinic at Wal-Mart designed for episodic needs be held accountable for providing comprehensive care to all patients passing through its doors? Should parents be expected to make appointments for routine visits at medical offices and clinics, or should public health nurses travel to homes and day care centers to provide preventive services out in the community? What is the proper balance between intensive care units that provide life-saving services to critically ill patients and primary care services geared toward less dramatic medical and preventive needs?

The previous chapters have emphasized financial transactions in the health care system. In this chapter and the following one, the organization of the health care system will be the main focus. While considerable debate has dwelled on how to improve financial access to care, less emphasis has been given to the question “access to what?” In this chapter, organizational systems will be viewed through a wide-angle lens, with emphasis on such broad concepts as the relationship between primary, secondary, and tertiary levels of care, and the influence of the biomedical paradigm and medical professionalism in shaping US health care delivery. In Chapter 6, a zoom lens will be used to focus on specific organizational models that have appeared (often only to disappear) in this country over the past century.

Primary, Secondary, and Tertiary Care

One concept is essential in understanding the topography of any health care system: the organization of care into primary, secondary, and tertiary levels. In the Lord Dawson Report, an influential British study written in 1920, the author (1975) proposed that each of the three levels of care should correspond with certain unique patient needs.

1. Primary care involves common health problems (e.g., sore throats, diabetes, arthritis, depression, or hypertension) and preventive measures (e.g., vaccinations or mammograms) that account for 80% to 90% of visits to a physician or other caregiver.

2. Secondary care involves problems that require more specialized clinical expertise such as hospital care for a patient with acute renal failure.

3. Tertiary care, which lies at the apex of the organizational pyramid, involves the management of rare disorders such as pituitary tumors and congenital malformations.

Two contrasting approaches can be used to organize a health care system around these levels of care: (1) the carefully structured Dawson model of regionalized health care and (2) a more free-flowing model.

1. One approach uses the Dawson model as a scaffold for a highly structured system. This model is based on the concept of regionalization: the organization and coordination of all health resources and services within a defined area (Bodenheimer, 1969). In a regionalized system, different types of personnel and facilities are assigned to distinct tiers in the primary, secondary, and tertiary levels, and the flow of patients across levels occurs in an orderly, regulated fashion. This model emphasizes the primary care base and a population-oriented framework for health planning.

2. An alternative model allows for more fluid roles for caregivers, and more free-flowing movement of patients, across all levels of care. This model tends to place a higher value on services at the tertiary care apex than at the primary care base.

Although most health care systems embody elements of both models, some gravitate closer to one polarity or the other. The traditional British National Health Service (NHS) and some large integrated delivery systems in the United States resemble the regionalized approach, while US health care as a whole traditionally followed the more dispersed format.

The Regionalized Model: The Traditional British National Health Service

The British NHS has traditionally typified a relatively regimented primary—secondary—tertiary care structure (Fig. 5-1).

1. For physician services, the primary care level is virtually the exclusive domain of general practitioners (commonly referred to as GPs), who practice in small- to medium-sized groups and whose main responsibility is ambulatory care. About half of all physicians in the United Kingdom are GPs.

2. The secondary tier of care is occupied by physicians in such specialties as internal medicine, pediatrics, neurology, psychiatry, obstetrics and gynecology, and general surgery. These physicians are located at hospital-based clinics and serve as consultants for outpatient referrals from GPs, in turn routing most patients back to GPs for ongoing care needs. Secondary-level physicians also provide care to hospitalized patients.

3. Tertiary care subspecialists such as cardiac surgeons, immunologists, and pediatric hematologists are located at a few tertiary care medical centers.

Hospital planning followed the same regionalized logic as physician services. District hospitals were local facilities equipped for basic inpatient services. Regional tertiary care medical centers handled highly specialized inpatient care needs.

Planning of physician and hospital resources within the traditional NHS occurred with a population focus. GP groups provided care to a base population of 5,000 to 50,000 persons, depending on the number of GPs in the practice. District hospitals had a catchment area population of 50,000 to 500,000, while tertiary care hospitals served as referral centers for a population of 500,000 to 5 million (Fry, 1980).

While this regionalized structure has recently become more fluid (Chapter 14), patient flow still moves in a stepwise fashion across the different tiers. Except in emergency situations, all patients are first seen by a GP, who may then steer patients toward more specialized levels of care through a formal process of referral. Patients may not directly refer themselves to a specialist.

While nonphysician health professionals, such as nurses, play an integral role in staffing hospitals at the secondary and tertiary care levels, especially noteworthy is the NHS’ multidisciplinary approach to primary care. GPs work in close collaboration with practice nurses (similar to nurse practitioners in the United States), home health visitors, public health nurses, and midwives (who attend most deliveries in the United Kingdom). Such teamwork, along with accountability for a defined population of enrolled patients and universal health care coverage, helps to avert such problems as missed childhood vaccinations. Public health nurses visit all homes in the first weeks after a birth to provide education and assist with scheduling of initial GP appointments. A national vaccination tracking system notifies parents about each scheduled vaccination and alerts GPs and public health nurses if a child has not appeared at the appointed time. As a result, more than 85% of British preschool children receive a full series of immunizations.

A number of other nations, ranging from industrialized countries in Scandinavia to developing nations in Latin America, have adopted a similar approach to organizing health services. In low-income nations, the primary care tier relies more on community health educators and other types of public health personnel than on physicians.

The Dispersed Model: Traditional United States Health Care Organization

The US health care system has had a far less structured approach to levels of care than the British NHS. In contrast to the stepwise flow of patient referrals in the United Kingdom, insured patients in the United States, such as Polly Seymour, have traditionally been able to refer themselves and enter the system directly at any level. While many patients in the United Kingdom have a primary care physician (PCP) to initially evaluate all their problems, many people in the United States have become accustomed to taking their symptoms directly to the specialist of their choice.

One unique aspect of the US approach to primary care has been to broaden the role of internists and pediatricians. While general internists and general pediatricians in the United Kingdom and most European nations serve principally as referral physicians in the secondary tier, their US counterparts share in providing primary care. Moreover, the overlapping roles among “generalists” in the United States (family physicians, general internists, and general pediatricians) are not limited to the outpatient sector. PCPs in the United States have assumed a number of secondary care functions by providing substantial amounts of inpatient care. Only recently has the United States moved toward the European model that removes inpatient care from the domain of PCPs and assigns this work to “hospitalists”—physicians who exclusively practice within the hospital (Wachter & Goldman, 1996; Goroll & Hunt, 2015).

Including general internists and general pediatricians, the total supply of generalists amounts to approximately one-third of all physicians in the United States, a number well below the 50% or more found in the UK (Agency for Healthcare Research and Quality, 2014). To fill in the primary care gap, some physicians at the secondary and tertiary care levels in the United States have also acted as PCPs for some of their patients. In contrast to physicians, nurse practitioners, and physician assistants are more likely to work in primary care settings and are a key component of the nation’s clinical workforce.

US hospitals are not constrained by rigid secondary and tertiary care boundaries. Instead of a pyramidal system featuring a large number of general community hospitals at the base and a limited number of tertiary care referral centers at the apex, hospitals in the United States each aspire to offer the latest in specialized care. In most urban areas, for example, several hospitals compete with each other to perform open heart surgery, organ transplants, radiation therapy, and high-risk obstetric procedures. The resulting structure resembles a diamond more than a pyramid, with a small number of hospitals (mostly rural) that lack specialized units at the base, a small number of elite university medical centers providing highly super-specialized referral services at the apex, and the bulk of hospitals providing a wide range of secondary and tertiary services in the middle.

Which Model Is Right?

Critics of the US health care system find fault with its “top-heavy” specialist and tertiary care orientation and lack of organizational coherence. Analyses of health care in the United States over the past half century abound with such descriptions as “a nonsystem with millions of independent, uncoordinated, separately motivated moving parts,” “fragmentation, chaos, and disarray,” and “uncontrolled growth and pluralism verging on anarchy” (Somers, 1972; Halvorson & Isham, 2003). The high cost of health care has been attributed in part to this organizational disarray. Quality of care may also suffer. For example, when many hospitals each perform small numbers of surgical procedures such as coronary artery bypass grafts, mortality rates are higher than when such procedures are regionalized in a few higher-volume centers (Gonzalez et al., 2014).

Defenders of the dispersed model reply that pluralism is a virtue, promoting flexibility and convenience in the availability of facilities and personnel. In this view, the emphasis on specialization and technology is compatible with values and expectations in the United States, with patients placing a high premium on direct access to specialists and tertiary care services, and on autonomy in selecting caregivers of their choice for a particular health care need. Similarly, the desire for the latest in hospital technology available at a convenient distance from home competes with plans to regionalize tertiary care services at a limited number of hospitals.

Balancing the Different Levels of Care

Advocates of a stronger role for primary care in the United States believe that it is too important to be considered an afterthought in health planning. In this view, overemphasis on the tertiary care apex of the pyramid creates a system in which health care resources are not well matched to the prevalence and incidence of health problems in a community. In an article entitled “The Ecology of Medical Care” published more than 4 decades ago, Kerr White recorded the monthly prevalence of illness for a general population of 1,000 adults (White et al., 1961). In this group, 750 experienced one or more illnesses or injuries during the month. Of these patients, 250 visited a physician at least once during the month, nine were admitted to a hospital, and only one was referred to a university medical center. Dr. White voiced concern that the training of health care professionals at tertiary care–oriented academic medical centers gave trainees like Dr. Billie Ruben an unrepresentative view of the health care needs of the community.

Updating Kerr White’s findings, Larry Green found precisely the same patterns 4 decades later (Fig. 5-2) (Green et al., 2001).

The ecological framework uses a population-based approach: For a defined population in the community, what is the incidence and prevalence of disease and health care needs and patterns of care seeking? This framework confirms the adage that “common disorders commonly occur and rare ones rarely happen (Fry, 1980).” The dominant pathology in an unselected population consists of minor ailments, chronic conditions such as hypertension and arthritis, and an array of behavioral conditions ranging from children with attention deficit and hyperactivity disorder to adults with depression and addictions to elders with cognitive decline. The incidence of new cancers is relatively rare, and only a handful of patients manifest complex syndromes such as multiple sclerosis. This is very different from the pattern of disease viewed from the reference point of an emergency department or intensive care unit, where distinct subsets of patients are encountered.

The ecological framework does not imply that most health care resources should be devoted to primary care. The minority of patients with severe conditions requiring secondary or tertiary care will command a much larger share of health care resources per capita than the majority of people with less dramatic health care needs. Treating a patient with liver failure costs a great deal more than treating a patient for hypertension. Even in the United Kingdom, where the 50% of physicians who are GPs provide the majority of ambulatory care, expenditures on their services account for about 10% of the overall NHS budget. In the United States, the percentage of the budget spent on primary care is even lower. Thus, the pyramidal shape shown in Figure 5-1 better represents the distribution of health care problems in a community than the apportionment of health care expenditures. While almost all industrialized nations devote a dominant share of health care resources to secondary and tertiary care, the ecologic view reminds us that most people have health care needs at the primary care level.

The Functions and Value of Primary Care

Barbara Starfield, the foremost scholar in the field of primary care, conceptualized the key tasks of primary care as (1) first contact care, (2) longitudinality, (3) comprehensiveness, and (4) coordination. Dr. Wells’ care of the Smith family illustrates these essential features of primary care. He is the first-contact physician performing the initial evaluation when Ginny or other family members develop symptoms of illness. Longitudinality (or continuity) refers to sustaining a patient–caregiver relationship over time. Dr. Wells’ familiarity with Ginny’s condition helps him to better discern an acute infection. Comprehensiveness consists of the ability to manage a wide range of health care needs, in contrast with specialty care, which focuses on a particular organ system or procedural service. Dr. Wells’ comprehensive, family-oriented care makes him aware that Mrs. Smith’s smoking cessation program is an important part of his treatment plan for Ginny. Coordination builds upon longitudinality. Through referral and follow-up, the primary care provider integrates services delivered by other caregivers. These tasks performed by Dr. Wells meet the standard definition of primary care: “Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnerships with patients, and practicing in the context of family and community” (Institute of Medicine, 1996).

A functional approach helps characterize which health care professionals truly fill the primary care niche. Among physicians in the United States, family physicians, general internists, and general pediatricians typically provide first contact, longitudinal, comprehensive, coordinated care. Emergency medicine physicians provide first contact care that may be relatively comprehensive for acute problems, but they do not provide continuity of care or coordinate care for patients on an ongoing basis. Some obstetrician-gynecologists provide first contact and longitudinal care, but usually only for reproductive health conditions; it is the rare obstetrician-gynecologist who is trained and inclined to comprehensively care for the majority of a woman’s health needs throughout the lifespan. Similarly, a patient with kidney failure or a patient with cancer may have a strong continuity of care relationship with a nephrologist or an oncologist, but these medical subspecialists rarely assume responsibility for comprehensive care of clinical problems outside of their specialty area or coordinate most ancillary and referral services.

In addition to physicians, many generalist nurse practitioners and physician assistants in the United States deliver the four key Starfield functions and serve as primary care providers for their patients. Research performed in a selected number of practices have demonstrated comparable quality of care for patients treated by primary care physicians and nurse practitioners (Cassidy, 2012; Horrocks et al., 2002).

Studies have found that the core elements of good primary care advance the “triple aim” of health system improvement: better patient experiences, better patient outcomes, and lower costs (Starfield, 1998; Bodenheimer & Grumbach, 2007). For example, continuity of care is associated with greater patient satisfaction, higher use of preventive services, reductions in hospitalizations, and lower costs (Saultz & Albedaiwi, 2004; Saultz & Lochner, 2005). Care that is comprehensive, provided by family physicians, is associated with a 10% to 15% reduction in Medicare expenditures per beneficiary (Grumbach, 2015). Persons whose care meets a primary care–oriented model have better perceived access to care, are more likely to receive recommended preventive services, are more likely to adhere to treatment, and are more satisfied with their care (Bindman et al., 1996; Stewart et al., 1997; Safran et al., 1998). International comparisons have indicated that nations with a greater primary care orientation tend to have more satisfied patients and better performance on health indicators such as infant mortality, life expectancy, and total health expenditures (Starfield et al., 2005). Similar observations have been made comparing regions in the United States (Starfield et al., 2005). In an analysis of quality and cost of care across states for Medicare beneficiaries, Baicker & Chandra (2004) found that states with more PCPs per capita had lower per capita Medicare costs and higher quality. States with more specialists per capita had lower quality and higher per capita Medicare expenditures.

Care Coordination and “Gatekeeping”

A concept that incorporates many of the elements of primary care is that of the primary care provider as gatekeeper. Gatekeeping took on pejorative connotations in the heyday of managed care, when, as described in Chapter 4, some types of financial arrangements with PCPs provided incentives for them to “shut the gate” in order to limit specialist referrals, diagnostic tests, and other services (Grumbach et al., 1998). A more accurate designation of the role of the PCP in helping patients navigate the complexities of the health care system is that of coordinator of care (Bodenheimer et al., 1999). Stories such as Polly’s demonstrate the importance of having a generalist care coordinator who can advocate on behalf of his or her patients and work in partnership with patients to integrate an array of services involving multiple providers to avoid duplication of services, enhance patient safety, and care for the whole person.

The Patient-Centered Medical Home

By the turn of the 21st century, primary care in the United States had reached a critical juncture and alarms sounded about an “impending collapse of primary care medicine” (Bodenheimer, 2006; American College of Physicians, 2006). Primary care clinicians like Dr. Retro struggled to meet patient demands for accessible, comprehensive, well-coordinated care. Many gaps in quality existed, and care often fell short of being patient centered. PCPs were demoralized by outmoded practice models ill-equipped to meet the demands of modern-day primary care and an ever-widening gap between their take-home pay and the escalating earnings of specialists. In the face of these challenges, decreasing numbers of US medical school graduates selected careers in primary care and many policy analysts concluded that the nation faced a major shortage of PCPs (Bodenheimer & Pham, 2010; Petterson et al., 2015).

In response to this crisis, the four major professional organizations representing the nation’s primary care physicians—the American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, and American Osteopathic Association—came together in 2007 and issued a report on a shared vision for reform of primary care. The Joint Principles of a Patient-Centered Medical Home has served as a rallying point for building a broad movement to revitalize primary care in the United States (Grundy et al., 2010).

The term “medical home” dates back to 1967, when it was first used by the American Academy of Pediatrics to describe the notion of a primary care practice that would coordinate care for children with complex needs. Rittenhouse and Shortell (2009) have provided a straightforward conceptualization of the patient-centered medical home as consisting of four basic cornerstones: primary care, patient-centered care, new-model practice, and payment reform. This framework begins by reaffirming Starfield’s fundamental functions of primary care and builds on those principles by calling for greater attention to patient-centeredness, such as the type of same-day scheduling methods adopted by Dr. Avantgard; implementation of innovative practice models, such as Dr. Avantgard’s development of team-care models that reengineer workflows and tasks; and changes in physician payment, such as blending fee-for-service with partial capitation and quality incentives. Another perspective on the patient-centered medical home is shown in Table 5-1.

The primary care reform movement in the United States has gathered momentum, with many large employers and consumer groups joining the physician organizations authoring the Joint Principles and other health professional groups to form the Patient Centered Primary Care Collaborative (Grundy et al., 2010). The Affordable Care Act included several measures to support patient-centered medical home reforms. Organizations such as the National Committee on Quality Assurance (NCQA) established programs with a checklist of requirements for grading practices applying to be recognized as patient-centered medical homes. Groups facilitating comprehensive reengineering of primary care practices issued roadmaps to transformation, such as the Building Blocks of High-Performing Primary Care (Bodenheimer et al., 2014) and the Change Concepts of the Safety Net Medical Home Initiative (Wagner et al., 2012). Evaluation of the first wave of practices and systems implementing the types of practice innovations called for under patient-centered medical home reforms have demonstrated some improvements in patient satisfaction and quality of care and reductions in use of costly emergency department and hospital services (Nielsen et al., 2015).

The Biomedical Model

The growth of the dispersed mode of health care delivery in the United States was shaped by several forces. One factor was the preeminence of the biomedical model among medical educators. An influential national study, the Flexner report of 1906, led to consolidation of medical training in academically oriented medical schools (Starr, 1982). These academic centers embraced the biomedical paradigm that was the legacy of such renowned 19th-century European microbiologists as Pasteur and Koch. The antimicrobial model engendered the faith that every illness has a discrete, ultimately knowable cause and that “magic bullets” can be crafted to eradicate these sources of disease. Physicians were trained to master pathophysiologic changes within a particular organ system, leading to the development of specialization (Luce & Byyny, 1979).

Advocates of a larger role for generalism and primary care in US health care have not so much rejected the concepts of scientific medicine and professional specialism as they have attempted to broaden the interpretation of these terms. They have called for a more integrated scientific approach to understanding health and illness that incorporates information about the individual’s psychosocial experiences and family, cultural, and environmental context as well as physiologic and anatomic constitution (Engel, 1977). The attempt to more rigorously define the scientific and clinical basis of generalism contributed to the emergence of family medicine in the 1970s as a specialty discipline in its own right, and the 1-year general practice internship was replaced by a 3-year residency program and specialty board certification.

Financial Incentives

A second and related factor influencing the structure of health care was the financial incentive for physician specialization and hospital expansion, which played out in a number of ways.

1. Insurance benefits first offered by Blue Cross covered hospital costs but not physician visits and other outpatient services.

2. As physician services came to be covered later under Blue Shield and other plans, a growing differential in payment between generalist and specialist physicians developed. New technologic and other procedures often required considerable physician time when first introduced, and higher fees were justified for these procedures. But as the procedures became routine, fees remained high, while the time and effort required to perform them declined (Starr, 1982); this resulted in an increasing disparity in income between PCPs and specialists (Bodenheimer et al., 2007). In the mid-1980s, the average PCP’s income was 75% of the average specialist’s income; by 2006, PCP income had dropped to only 50% of specialists’ income (Council of Graduate Medical Education, 2010). As Figure 5-3 shows, the percentage of graduating medical students planning to enter careers in primary care tracks the PCP-specialist income gap closely, with the proportion of students entering primary care decreasing as the earnings of PCPs relative to specialists declines.

   Figure 5-3

   Proportion of US medical students entering primary care strongly tracks relative incomes of primary care physicians. The figure shows trends over time in the average income of primary care physicians relative to specialist physicians in the United States, and in the percentage of graduating medical students in the United States planning on entering careers in primary care. In 1990, when the average primary care physician income was about half that of specialists, fewer than 20% of graduating students planned to enter primary care fields. By 1997, when primary care physician incomes had risen to more than 60% that of specialists, the proportion of graduating students entering primary care had increased in a parallel direction with 40% of graduates planning to enter primary care fields in 1997. Both relative incomes and intentions to enter primary care decreased after 1997. (From the Council on Graduate Medical Education. Twentieth Report: Advancing Primary Care, December 2010.)

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3. Federal involvement in health care financing further fueled the expansion of hospital care and specialization. The Hill–Burton Hospital Construction Act of 1946 allocated billions of dollars between 1946 and 1971 for expansion of hospital capacity rather than development of ambulatory services (Starr, 1982). The enactment of Medicare and Medicaid in 1965 perpetuated the private insurance tradition of higher payment for procedurally oriented specialists than for generalists. Medicare further encouraged specialization through its policy of extra payments to hospitals to cover costs associated with residency training. Linking Medicare teaching payments to the hospital sector added yet another bias against community-based primary care training.

The growth of hospitals and medical specialization was intertwined. As medical practice became more specialized and dependent on technology, the site of care increasingly shifted from the patient’s home or physician’s office to the hospital. The emphasis on acute hospital care had an effect on the nursing profession comparable to that on physicians. World War I was a watershed period in the transition of nursing from a community-based to a hospital-based orientation. During the war, US military hospitals overseas were much heralded for their success in treating acute war injuries. At the war’s conclusion, the nation rallied behind a policy of boosting the civilian hospital sector. According to Rosemary Stevens (1989),

Professionalism

The final factor accounting for the organizational evolution of US health care delivery was the nature of control over health planning. The United States is unique in its relative laxity of public regulation of health care resources. In most industrialized nations, governments wield considerable control over health planning through measures such as regulation of hospital capacity and technology, allocation of the number of residency training positions in generalist and specialist fields, and coordination of public health with medical care. In the United States, the government has provided much of the financing for health care, but without an attendant degree of administrative control. The Hill–Burton program, for example, did not make grants for hospital construction contingent upon any rigorous community-wide plan for regionalized hospital services. Medicare funding for physician training did not stipulate any particular distribution of residency positions according to specialty.

With government controls kept largely at bay, the professional “sovereignty” of physicians emerged as the preeminent authority in health care (Starr, 1982). Societies grant certain occupations special status as “professions” because of the unique knowledge and skill required of members of the profession, and the expectation that this knowledge and skill will be applied beneficially (Friedson, 1970; Light & Levine, 1988). Professionalism thus involves a social contract; in return for the privilege of autonomy, physicians bear the responsibility for acting as the patient’s agent, and the profession must regulate itself to preserve the public trust.

Their professional status vested physicians with special authority to guide the development of the US health care system. As described in Chapter 2, third-party payment for physician services was established with physician control of the initial Blue Shield insurance plans. Physician judgment about the need for technology and greater inpatient capacity drove the expansion of hospital facilities.

What was the nature of the profession that so heavily influenced the development of the US health care organization? It was a profession that, because of the primacy of the biomedical paradigm and the nature of financial incentives, was weighted toward hospital and specialty care. Small wonder that US health care has emphasized its tertiary care apex over its primary care base. In Chapter 16, we discuss the shifting power relationships in health care that are challenging the professional dominance of physicians.

The professional model and the biomedical paradigm are responsible for many of the successes of the US health care system. The biomedical model has instilled respect for the scientific method and curtailed medical quackery. Professionalism has directed physicians to serve as agents acting in their patients’ best interests and has made the practice of medicine more than just another business. Expansion of hospital facilities has meant that people with health insurance have had convenient access to tertiary care services and new technology and the expertise and availability of a wide variety of specialists. In many circumstances, the system is well organized to deliver the “right care.” For a patient in cardiogenic shock, the right place to be is an intensive care unit; for a patient with a detached retina, an ophthalmologist’s office is the right place to be.

However, there is widespread concern that despite the benefits of biomedical science and medical professionalism, the US health care system is precariously off balance. A model of excellence focused on specialization, technology, and curative medicine has led to relative inattention to basic primary care services, including such needs as disease prevention and supportive care for patients with chronic and incurable ailments. The value placed on autonomy for health care professionals and institutions has contributed to fragmentation of care. A system that prizes specialists who focus on organ systems and researchers who concentrate on genomics has bred apprehension that health care has somehow lost sight of the whole person and the whole community. The net result is a system structured to perform miraculous feats for individuals who are ill, but at great expense and often without satisfactorily attending to the full spectrum of health care needs of the entire population. During the 2009 debate in Congress leading up to the passage of the Affordable Care Act, one of the harshest critiques of the status quo in US health care came not from a Congressional Democrat, but from Senator Orrin Hatch, the senior Republican Senator from Utah. At a hearing on health reform, Senator Hatch said, “The US is first in providing rescue care, but this care has little or no impact on the general population. We must put more focus on primary care and preventive medicine” (Grundy et al., 2010).