THE PRIMARY SOLUTION:The Case for Primary Health Care

1
THE PRIMARY SOLUTIONThe Case for Primary
(Health) Care

• Barbara Starfield, MD, MPH
• Presented at RNZCGP Annual Quality Symposium,
  Wellington NZ, February 13, 2009

2
Life Expectancy Compared with GDP per Capita for
Selected Countries
Country codes AGArgentina AUAustralia BZBrazil
CHChina CNCanada FRFrance GEGermany HUHungar
y INIndia ISIsrael ITItaly JAJapan MAMalaysia
MEMexico
NENetherlands POPoland RURussia SASouth
Africa SISingapore SKSouth Korea SPSpain SWSwe
den SZSwitzerland TKTurkey TWTaiwan UKUnited
Kingdom USUnited States
Source Economist Intelligence Unit. Healthcare
International. 4th quarter 1999. London, UK
Economist Intelligence Unit, 1999.
Starfield 11/06 IC 3493 n
3
Country Clusters Health Professional Supply and
Child Survival
186 countries
Starfield 07/07 HS 3754 n
Source Chen et al, Lancet 2004 3641984-90.
4
Primary health care is primary care applied on a
population level. As a population strategy, it
requires the commitment of governments to develop
a population-oriented set of primary care
services in the context of other levels and types
of services.
Starfield 07/07 PC 3755 n
5
Primary care is the provision of first contact,
person-focused, ongoing care over time that meets
the health-related needs of people, referring
only those too uncommon to maintain competence,
and coordinates care when people receive services
at other levels of care.
Starfield 07/07 PC 3756 n
6
Why Is Primary Care Important?
Better health outcomes Lower costs Greater equity
in health
Starfield 07/07 PC 3757 n
7
Evidence for the benefits of primary
care-oriented health systems is robust across a 
wide variety of types of studies

• International comparisons
• Population studies within countries
• across areas with different  primary care
  physician/population ratios
• studies of people going to different types of
  practitioners
• Clinical studies
• of people going to facilities/practitioners
  differing in adherence to primary care practices

Starfield 03/08 PC 3971 n
Source Starfield et al, Milbank Q 2005
83457-502.
8
Primary Care Orientation of Health Systems
Rating Criteria

• Health System Characteristics
• Type of system
• Financing
• Type of primary care practitioner
• Percent active physicians who are specialists
• Professional earnings of primary care physicians
• relative to specialists
• Cost sharing for primary care services
• Patient lists
• Requirements for 24-hour coverage
• Strength of academic departments of family
  medicine

Source Starfield. Primary Care Balancing Health
Needs, Services, and Technology. Oxford U. Press,
1998.
Starfield 11/02 02-405 sc
Starfield 11/02 PC 2366 n
9
Primary Care Orientation of Health Systems
Rating Criteria

• Practice Characteristics
• First-contact
• Longitudinality
• Comprehensiveness
• Coordination
• Family-centeredness
• Community orientation

Starfield 11/02 02-406 sc
Source Starfield. Primary Care Balancing Health
Needs, Services, and Technology. Oxford U. Press,
1998.
Starfield 11/02 PC 2367 n
10
Primary Care Scores, 1980s and 1990s
Scores available only for the 1990s
Starfield 07/07 ICTC 3758 n
11
System Features Important to Primary Health Care

0all regressive 1mixed 2all
progressive except Medicaid
Sources Starfield. Primary Care Balancing
Health Needs, Services, and Technology. Oxford U.
Press, 1998. van Doorslaer et al. Equity in the
Finance and Delivery of Health Care An
International Perspective. Oxford U. Press, 1993.
Starfield 11/06 EQ 3500 n
12
System (PHC) and Practice (PC) Characteristics
Facilitating Primary Care, Early-Mid 1990s
Best level of health indicator is ranked 1
worst is ranked 13 thus, lower average ranks
indicate better performance.
Starfield 03/05 ICTC 3099 n
Based on data in Starfield Shi, Health Policy
2002 60201-18.
13
Primary Care Score vs. Health Care Expenditures,
1997
UK
DK
NTH
FIN
SP
CAN
AUS
SWE
JAP
GER
US
BEL
FR
Starfield 11/06 ICTC 3495 n
14
Primary Care Strength and Premature Mortality in
18 OECD Countries
Predicted PYLL (both genders) estimated by fixed
effects, using pooled cross-sectional time series
design. Analysis controlled for GDP, percent
elderly, doctors/capita, average income (ppp),
alcohol and tobacco use. R2(within)0.77.
Starfield 11/06 IC 3496 n
Source Macinko et al, Health Serv Res 2003
38831-65.
15
Primary Care Oriented Countries Have

• Fewer low birth weight infants
• Lower infant mortality, especially postneonatal
• Fewer years of life lost due to suicide
• Fewer years of life lost due to all except
  external causes
• Higher life expectancy at all ages except at age
  80

Starfield 07/07 IC 3762 n
Sources Starfield. Primary Care Balancing
Health Needs, Services, and Technology. Oxford U.
Press, 1998. Starfield Shi, Health Policy 2002
60201-18.
16
Is Primary Care as important within countries as
it is among countries?
Starfield 07/07 WC 3765 n
17
State Level AnalysisPrimary Care and Life
Expectancy
Starfield 07/07 WCUS 3766 n
Source Shi et al, J Fam Pract 1999 48275-84.
18
Primary Care and Infant Mortality Rates,
Indonesia, 1996-2000
constant Indonesian rupiah, in billions Source
Simms Rowson, Lancet 2003 3611382-5.
Starfield 07/07 WC 3796 n
19
Percentage Reduction in Under-5 Mortality
Thailand, 1990-2000
Starfield 07/07 WC 3797 n
Source Vapattanawong et al, Lancet 2007
369850-5.
20
Primary Care Score and Self-Rated Health,
Petrópolis, Brazil, 2004
1 excellent/ good health 0bad/fair/poor
health standard errors adjusted for clustering
by clinic
Starfield 07/07 WC 3768 n
Source Macinko, Almeida, de Sá, Health Policy
Plan 2007 22167-77.
21
Impact of PSF Coverage on Infant Mortality in
Brazilian States, 1990-2002 Marginal Effects
Based on 2-way fixed effects model of Brazilian
states, 1990-2002, n351 R20.90.
Non-significant (pgt0.05) control variables,
including physician and nurse supply and sewage
not shown.
Starfield 10/06 WC 3457 n
Source Macinko et al, J Epidemiol Community
Health 2006 6013-19.
22
Many other studies done WITHIN countries, both
industrialized and developing, show that areas
with better primary care have better health
outcomes, including total mortality rates, heart
disease mortality rates, and infant mortality,
and earlier detection of cancers such as
colorectal cancer, breast cancer,
uterine/cervical cancer, and melanoma. The
opposite is the case for higher specialist
supply, which is associated with worse outcomes.
Starfield 09/04 04-167
Starfield 09/04 WC 2957
Source Starfield B. www.pitt.edu/super1/lecture/
lec8841/index.htm
23
What We Already Know
A primary care oriented system is important for

• Improving health (improving effectiveness)
• Keeping costs manageable (improving efficiency)

Starfield 09/05 PC 3316
24
Does primary care reduce inequity in health?
Starfield 07/07 EQ 3769 n
25
In the United States, an increase of 1 primary
care doctor is associated with 1.44 fewer deaths
per 10,000 population.The association of
primary care with decreased mortality is greater
in the African-American population than in the
white population.
Starfield 07/07 WCUS 3770 n
Source Shi et al, Soc Sci Med 2005 61(1)65-75.
26
Primary health care oriented countries

• Have more equitable resource distributions
• Have health insurance or services that are
  provided by the government
• Have little or no private health insurance
• Have no or low co-payments for health services
• Are rated as better by their populations
• Have primary care that includes a wider range of
  services and is family oriented
• Have better health at lower costs

Sources Starfield and Shi, Health Policy 2002
60201-18. van Doorslaer et al, Health Econ 2004
13629-47. Schoen et al, Health Aff 2005 W5
509-25.
Starfield 11/05 IC 3326
27
Primary Care and Health Evidence-Based Summary

• Countries with strong primary care
• have lower overall costs
• generally have healthier populations
• Within countries
• areas with higher primary care physician
  availability (but NOT specialist availability)
  have healthier populations
• more primary care physician availability reduces
  the adverse effects of social inequality

Starfield 09/02 02-437 sc
Starfield 09/02 PC 2218 n
28
Conclusion
Although sociodemographic factors undoubtedly
influence health, a primary care oriented health
system is a highly relevant policy strategy
because its effect is clear and relatively rapid,
particularly concerning prevention of the
progression of illness and effects of injury,
especially at younger ages.
Starfield 11/05 HS 3329
29
Strategy for Change in Health Systems

• Achieving primary care
• Avoiding an excess supply of specialists
• Achieving equity in health
• Addressing co- and multi-morbidity
• Responding to patients problems
• Coordinating care
• Avoiding adverse effects
• Adapting payment mechanisms
• Developing information systems

Starfield 11/06 HS 3494 n
30
Health Workforce
Starfield 10/07 WF 3901
31
In 35 US analyses dealing with differences
between types of areas (7) and 5 rates of
mortality (total, heart, cancer, stroke, infant),
the greater the primary care physician supply,
the lower the mortality for 28. The higher the
specialist ratio, the higher the mortality in 25.
Above a certain level of specialist supply, the
more specialists per population, the worse the
outcomes.
Controlled only for income inequality Source Shi
et al, J Am Board Fam Pract 2003 16412-22.
Starfield 11/06 SP 3499 n
32
Percentage of People Seeing at Least One
Specialist in a Year
Sources Peterson S, AAFP (personal
communication, January 30, 2007). Jaakkimainen et
al. Primary Care in Ontario. ICES Atlas. Toronto,
CA Institute for Clinical Evaluative Sciences,
2006. Sicras-Mainar et al, Eur J Public Health
2007 17657-63. Starfield et al, submitted 2008.
Starfield 01/07 SP 3529 n
33
Resource Use, Controlling for Morbidity Burden

• More DIFFERENT specialists seen higher total
  costs, medical costs, diagnostic tests and
  interventions, and types of medication
• More DIFFERENT generalists seen higher total
  costs, medical costs, diagnostic tests and
  interventions
• More generalists seen (LESS CONTINUITY) more
  DIFFERENT specialists seen. The effect is
  independent of the number of generalist visits.

Using the Johns Hopkins Adjusted Clinical Groups
(ACGs) Source Starfield et al, Ambulatory
specialist use by patients in US health plans
correlates and consequences. Submitted 2008.
Starfield 09/07 CMOS 3854
34
Percent of Patients Reporting Any Error by Number
of Doctors Seen in Past Two Years
Starfield 09/07 IC 3870 n
Source Schoen et al, Health Affairs 2005 W5
509-525.
35
There are large variations in both costs of care
and in frequency of interventions. Areas with
high use of resources and greater supply of
specialists have NEITHER better quality of care
NOR better results from care.
Sources Fisher et al, Ann Intern Med 2003 Part
1 138273-87 Part 2 138288-98. Baicker
Chandra, Health Aff 2004 W4184-97. Wennberg et
al, Health Aff 2005 W5526-43.
Starfield 12/05 SP 3343
36
What is the right number of specialists?What do
specialists do?What do specialists contribute
to population health?
Starfield 01/06 SP 3354
37
Enhancements to Primary Care

• Health information systems primary
  care/system-wide
• Analysis of variations in care
• with variations in use of secondary care
• with variations in type of payment
• with focus on patients versus diseases (P4P)
• Subspecialization in primary care
• Patient-centered primary care (poorly
  conceptualized)
• Chronic care model self-management support
  delivery system design decision support
  clinical information systems

ALL REQUIRE EVALUATION.
Starfield 02/08 PC 3966
38
Any evaluation of enhancements to clinical
primary care must consider the extent to which
they better achieve the evidence-based primary
care functions

• First contact for new needs/problems
• Person (not disease) focused care (enhanced
  recognition of peoples health problems)
• Breadth of services
• Coordination (enhanced problems/needs recognition
  over time)

Starfield 06/08 EVAL 4044
39
The impact of a health services intervention
should not be evaluated on the basis of a
structural element of health systems alone. The
value of health system structures lies only in
the behaviors that they engender. In order to
understand why and how things have an impact, it
is necessary to evaluate the impact of structures
on processes of care. That is why evaluations of
structures such as type or number of
practitioners, electronic health records, and the
Chronic Care Model (CCM) have inconsistent
results.
Starfield 10/08 EVAL 4072
40
The Health Services System
Source Starfield. Primary Care Balancing Health
Needs, Services, and Technology. Oxford U. Press,
1998.
Starfield 02/09 HS 4133 n
41
PCAT(Primary Care Assessment Tool)

• First-contact (access and use)
• Person-focused care over time
• Comprehensiveness (services available and
  provided)
• Coordination
• Family centered
• Community oriented
• Culturally competent

Starfield 05/03 03-095
Starfield 05/03 PCM 2479
42
Primary Care Scores by Data Source, PSF Clinics
Source Almeida Macinko. Validation of a Rapid
Appraisal Methodology for Monitoring and
Evaluating the Organization and Performance of
Primary Health Care Systems at the Local Level.
Brasília Pan American Health Organization, 2006.
Starfield 05/06 WC 3421 n
43
(No Transcript)
44
There is no such thing as a primary care
service. There are only primary care functions
and specialty care functions. We know what the
primary care functions are they are
evidence-based. Payment should be based on their
achievement over a period of time. Any payment
system that rewards specific services will
distort the main purpose of medical care to deal
with health problems effectively, efficiently,
and equitably.
Starfield 06/08 PC 4046
45
Primary Care
Starfield 02/08 EVAL 3968 n
46
Structural and Process Elements of the Essential
Features of Primary Care
Essential Features
Performance
Capacity
First-contact
Utilization Person-focused relationship
Accessibility Eligible population Range of
services Continuity
Longitudinality
Comprehensiveness
Problem recognition
Coordination
Starfield 1997 97-194
Starfield 04/97 EVAL 1108 n
47
Structural and Process Elements of the Essential
Features of Primary Care
Essential Features
Performance
Capacity
First-contact
Utilization Person-focused relationship
Accessibility Eligible population Range of
services Continuity
Longitudinality
Comprehensiveness
Problem recognition
Coordination
Starfield 10/08 EVAL 4071 n