Insurance, the Presence of a Medical Home, and the Benefits of Primary Care for Children Barbara...
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Transcript of Insurance, the Presence of a Medical Home, and the Benefits of Primary Care for Children Barbara...
Insurance, the Presence of a Medical Home, and the Benefits of
Primary Care for Children
Barbara Starfield, MD,
MPH
November 2002
What increases the likelihood of a
medical home?
Starfield 09/02
Predicted Probability of Having a Usual Source of Care among High-Income Insured, Low-Income Insured, and
Uninsured Adults, by State Safety-Net Vulnerability
Source: Holahan & Spillman, 2002.
*High income insured significantly different from low income insured at the 5% level.
Least vulnerable*
Somewhat vulnerable
Most vulnerable*
100908070605040302010
0
High-income insuredLow-income insuredLow-income uninsured
Access to Care of Uninsured Persons
7160-64
6855-59
6135-54
5425-34
5519-24
751-18
63All persons under age 65
Percent of uninsured with a usual source of care
Starfield 10/02Source: Cunningham, 1998.
Odds Ratios for Factors Associated with Not Usinga Regular Source of Care, US Children, 1991
Gap in health insurance1-6 months 1.57 months 1.7
Father not employed 1.5
No father in home 1.8
Family moved 1.7
Perceived barrier to care 2.4
Child with chronic condition 1.9
Source: Kogan et al., 1995.
not significant: parental education, ethnicity, marital status, maternal age, site of usual care, type of health insurance
Odds Ratios (Adjusted) for Accessand Use for Uninsured as Compared
with Insured Children, 1993-4
No regular source of care 6.1
Unable to get needed medical care 5.8
No after-hours medical care 1.6
Not satisfied with care 1.4
Not seen a doctor in a year 2.1
Source: Newacheck et al., 1998.
Adjusted for various sociodemographic and health characteristics
Starfield 1998
Significant Predictors of PrimaryCare, Inner City Latino Children
(Los Angeles), 1992Continuity of well and sick care
Continuous Medicaid*
1.5Uninsured*
0.4Source of well child care**
HMO20.7
Public clinic0.3
Child health status1.6
Starfield 09/02
Insurance and Hospitalizations
Increased eligibility for Medicaid significantly reduced rates of hospitalization for ambulatory care sensitive conditions (ACSC), especially for children under age 6, for whom the expansions were greater.
Source: Kaestner, et al., 2001. Starfield 09/02
Insurance Doesn’t Guarantee Good Primary Care
Increasing Medicaid eligibility leads to greater coverage and greater presence of a regular source of care. However, black children are more likely to use poor regular sources (not doctors’ offices). Thus, just providing insurance may increase disparities between population subgroups unless good sources of primary care are available.
Source: Currie & Gruber, 1996. Starfield 09/02
Why is a medical home important?
Starfield 09/02
Insurance Doesn’t Guarantee Good Primary Care
About 90% of children are insured.
About 90% have a regular source of care.
BUT less than 50% of young children have a regular doctor.
Starfield 09/02Source: NSECH, 2002
Odds Ratios* for Subsequent Hospitalization among Medicaid Patients Having Continuity with
Regular Doctor, Delaware, 1993-5
All conditions 0.56
Ambulatory care sensitive conditions 0.66
*after control for sociodemographic characteristics
Source: Gill & Mainous, 1998. Starfield 03/02
Factors Influencing the Likelihood of Seeing a Physician, US Children, Ages 11-17†
Odds Ratio
Race (African American) NS
Ethnicity (Hispanic) NS
Family Income
Middle* NS
Low** NS
Insurance
Uninsured NS
Usual source of care (yes) 1.95* 200-399 % of poverty** Less than 200 % of poverty† controlled for overall health status, disability, and mental health attributes Source: Bartman et al., 1997. Starfield 1998
Logistic Regression Analysis of Predictors of Delay of 90 Days or More for MMR Immunization:
Northern California Kaiser Permanente, 1992
Adjusted Odds Ratio
No regular doctor 2.9
Lack of knowledge 2.0
Number of children in family 1.4
Not significant: Race, Time since appointment madeNote: All children covered by insurance
Source: Lieu et al., 1994. Starfield 1998
Factors Influencing the Likelihoodof Seeing a Physician in the Presence
of Symptoms, Ages 11-17†
Odds Ratio
Race NS
Ethnicity NS
Income NS
Insurance NS
Usual source of care 1.67
† controlled for overall health status, disability, and mental health attributes
Source: Bartman et al., 1997. Starfield 1998
Factors Related to Untimely Initiation of Prenatal Care, Low Income California Women, 1994-5*
Inadequate knowledge of importance of primary care 5th birthEducation high school or lessTransportation problemsFeared disclosure of pregnancyNo regular source of care before pregnancyUnwanted/unplanned pregnancy
Not significant: income, Medicaid coverage, age, race, ethnicity, smoking, stress*in order of importance (odds ratios)
Source: Braveman et al., 2000. Starfield 03/02
Impact of Having One Regular Source of Care,
Rural Youth in Maryland, 1992
Odds ratios
Receipt of preventive care
Less for those without a regular source of care or with different sources for prevention and for illness care
Receipt of emergency services
Greater for those with different sources
Source: Ryan et al., 2001. Starfield 03/02
Receipt of Routine Care by Children Whose Regular Source of Care Is a Community Health
Center,US, 1988
% with age-appropriate interval since last routine care visit
Continuity
Yes, with specific clinician 88
Yes, without specific clinician 82
No, non-CHC sick care site 80
No sick care site 76
Source: O’Malley & Forrest, 1996.
When insurance is included in a multivariable regression analysis, the adjusted odds ratio for the effect of a specific clinician on age-appropriate routine care interval was unchanged (1.84).
Starfield 1998
Does provision of the elements of primary care
separately by multiple providers constitute a
“medical home”?
Starfield 04/02
Elements of Primary Care
First-contact
Ongoing person-focused care (“longitudinality”)
Comprehensiveness
Coordination
Family-centeredness
Community orientation
Cultural competenceStarfield 04/02
Benefits of Longitudinality,Based on Evidence from the Literature
Identification Identificationwith a Person with a Place
Better problem/needs recognition More accurate/earlier diagnosis Better concordance
Appointment keeping Treatment advice
Less ER use Fewer hospitalizations Lower costs Better prevention (some types) Better monitoring Fewer drug prescriptions Less unmet needs
Increased satisfaction
Evidence good Evidence moderate
Starfield 11/02Source: Starfield, 1998
Conclusion
Insurance is an important determinant, although not the only one, of having a medical home.
Having a medical home confers many benefits, especially if the regular source is a person.
Starfield 04/02