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