Costs and Benefits of a Medical Home

1
Starfield
2
Benefits of Primary CareEvidence from
International Comparisons of 13 Industrialized
Countries
Starfield 09/02
3
The Countries, Mid-1990s
Australia (AUS) Belgium (BEL) Canada
(CAN) Denmark (DK) Finland (FIN) France
(FR) Germany (GER) Japan (JAP) Netherlands
(NTH) Spain (SP) Sweden (SWE) United Kingdom
(UK) United States (US)
Starfield
4
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, 1998.
Starfield
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Primary Care Orientation of Health Systems
Rating Criteria

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

Source Starfield, 1998.
Starfield
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Primary Care Scores, 1980s and 1990s
1980s
1990s

• Belgium 0.8 0.4
• France - 0.3
• Germany 0.5 0.4
• United States 0.2 0.4
• Australia 1.1 1.1
• Canada 1.2 1.2
• Japan - 0.8
• Sweden 1.2 0.9
• Denmark 1.5 1.7
• Finland 1.5 1.5
• Netherlands 1.5 1.5
• Spain - 1.4
• United Kingdom 1.7 1.9

Starfield 2000
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System and Practice CharacteristicsFacilitating
Primary Care, Early-Mid 1990s
GER
FR
BEL
US
SWE
JAP
CAN
FIN
AUS
SP
NTH
DK
UK
Starfield 11/00
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Health Care Expenditures per Capita, 1996
Belgium France Germany United States ----- ----- ----- ----- 1693 1978 2222 3708
Australia Canada Japan Sweden ----- ----- ----- ----- 1776 2002 1581 1405
Denmark Finland Netherlands Spain United Kingdom ----- ----- ----- ----- ----- 1430 1389 1756 1131 1304
Starfield 2000
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Primary Care Score vs. Health Care Expenditures,
1997
UK
DK
NTH
FIN
SP
CAN
AUS
SWE
JAP
GER
US
BEL
FR
Starfield 10/00
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International ComparisonsBirth Outcomes and
Primary Care Score
Primary Care Score
Low
Med
High
14
11.5
12
9.5
10
Countries with weak primary care infrastructures
have poorer health performance.
7.3
8
Average Rankings
5.5
6
4.8
4.6
4
2
Low BEL, FR, GER, US Med AUS, CAN, JAP,
SWE High DEN, FIN, NTH, SP, UK
0
Low BirthWeight
Post Neonatal
Mortality
R -.74 plt.001
R -.38 NS
Source Starfield Shi, 2002.
Starfield 09/02
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Average Rankings for Health Indicators, YPLL
(Total and Suicide) in Countries Grouped by
Primary Care Orientation

• All Except Suicide Suicide
  All Except External
• Female Male Female Male
  Female Male
• Lowest 9.5 10.8 7.3 8.3
  8.8 10.8
• (Belgium,
• France,
• Germany,
• US)
• Middle 3.8 2.8 7.0 7.3 3.8
  3.5
• (Australia,
• Canada, Japan,
• Sweden)
• Highest 7.6 7.4 6.8 5.8
  8.2 7.0
• (Denmark,
• Finland,
• Netherlands,
• Spain, UK)

Source OECD, 1998.
Starfield 2000
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Average Rankings for World Health
Organization Health Indicators for Countries
Grouped by Primary Care Orientation
Overall Health
Child Survival Equity
DALEs
36.3
22.5
16.3
Lowest (Belgium, France, Germany, US)
26.0
16.5
4.8
Middle (Australia, Canada, Sweden,
Japan)
29.1
11.0
15.8
31.6
15.2
16.0
Highest (Denmark, Finland,
Netherlands, Spain, UK)
Source Calculated from WHO, 2000.
Starfield 10/02
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Primary Care Features Consistently Associated
with Good/Excellent Primary Care

• System features
• Regulated resource distribution
• Government-provided health insurance
• No/low cost-sharing for primary care
• Practice features
• Comprehensiveness
• Family orientation

Starfield 10/01
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Benefits of Primary CareWithin-Country Studies

• Ecological analyses Effect of primary care
  doctor to population ratios (US, UK)
• Case control studies (US)
• Hospitalizations for avoidable conditions or
  complications (US, Spain)
• Survey data on impact of affiliation with a
  primary care doctor (US, Spain)
• Path analyses at state and local levels (US)

Starfield 09/02
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Rates of Avoidable Pediatric Hospitalization for
Diabetes Mellitus and Pneumonia and Family
Physicians per 10,000 Population
Source Parchman Culler, 1994.
Starfield 10/02
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State Level AnalysisPrimary Care and Life
Expectancy
PC physicians/population positively associated
with longer life expectancy.
Source Shi et al., 1999.
Starfield 03/02
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Path Coefficients for the Effects of Income
Inequality and Primary Care on Health Outcome
50 US States, 1990
Total Mortality
Infant Mortality
.42
.35
-.36
-.29
Income Inequality (Robin Hood Index)
-.33
Primary Care Physicians
.58
-.37
Life Expectancy
Low Birthweight
.41
-.17
plt.05 plt.01.
Source Shi et al., 1999.
Starfield
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Path Coefficients for the Effects of Income
Inequality and Primary Care on Health Outcome
50 US States, 1990
Life Expectancy
Total Mortality
Neonatal Mortality
.39
.40
-.35
-.38
-.18
Income Inequality (GINI COEFFICIENT)
-.33
Primary Care Physicians
.18
.16
.42
Stroke Mortality
Postneonatal Mortality
-.38
-.33
Life Expectancy
plt.05 plt.01.
Source Shi et al., 1999.
Starfield
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Reductions in Inequality in Health by Primary
Care Self-Reported Health,60 US Communities,
1996

• Percent reporting fair or poor health
• Areas with low income inequality
• No effect of primary care resources
• Areas with moderate income inequality
• 16 increase in areas with low primary care
  resources
• Areas with high income inequality
• 33 increase in areas with low primary care
  resources
• compared with median of primary care
  physicians to population ratios

Based on data in Shi Starfield, 2000.
Starfield 2000
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Reductions in Inequality in Health by Primary
Care Postneonatal Mortality,50 US States, 1990
Areas with low income inequality High primary
care resources 0.8 decrease in mortality Low
primary care resources 1.9 increase in
mortality Areas with high income
inequality High primary care resources 17.1
decrease in mortality Low primary care resources
6.9 increase in mortality
compared with population mean
Based on data in Shi Starfield, 2000.
Starfield 2000
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Low Birthweight among US Rural, Urban, and Health
Center Infants
US urban infants
8.8
7.5
Urban health center infants infants
Geographic area
US rural infants
6.8
Rural health center infants
6.0
African American urban infants
13.6
African American urban health center infants
10.4
Racial composition
African American rural infants
13.0
African American rural health center infants
7.4
0.0
2.0
4.0
6.0
14.0
12.0
10.0
8.0
Source Politzer et al., 2001.
Starfield 09/02
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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
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Primary Care and Equity Evidence-Based Summary
In areas with low social inequity, the additional
effect of primary care is small. In areas of high
social inequity, the additional effect of primary
care is larger.
Starfield 09/02