The nation's reliance on subspecialty care has put Americans at an increased risk of death and disease, leading to poorer health care outcomes and driving up health care expenditures, said a prominent primary care researcher during a presentation here on June 11.
Researcher Warns of Dependence on Subspecialty Care
By James Arvantes
• Washington
6/27/2007
"It is at our own peril that the United States is falling further and further behind in its primary care orientation," warned Barbara Starfield, M.D., M.P.H., a university distinguished professor in the health policy and management and pediatrics departments at Johns Hopkins University and Medical Institutions, in a videoconference presentation at a roundtable sponsored by the Patient Centered Primary Care Collaborative. "The peril is already evident in our declining position in the world in regard to the health of our population," said Starfield.
Co-author of the oft-cited "Contribution of Primary Care to Health Systems and Health" in the September 2005 Milbank Quarterly, Starfield presented data showing that countries with health care systems based on primary care have better health outcomes, lower costs and greater equity in health care than the United States, which has a health care system based more on subspecialty care.
In the United States, 60 percent to 80 percent of the population under the age of 65 sees a subspecialist in a year, a rate that is increasing, according to Starfield. In Ontario, Canada, by comparison, 31 percent of the population under 65 sees a subspecialist in a given year. In England, the rate is even lower at 16 percent. About one-third of the population that uses Spain's health care system sees a subspecialist annually, according to Starfield.
"All three of these countries have better health outcomes than the United States," she said.
Starfield shared data demonstrating the inherent advantages of primary care in providing better health outcomes at a lower cost, especially when compared to subspecialty care. An analysis of 35 separate studies that deal with differences between seven different subspecialty areas and five rates of mortality, found that in 28 of the studies, the greater the primary care physician supply, the lower the mortality rate.
In addition, "Primary care orientation is equity producing," said Starfield. "The association of primary care resources with decreased mortality is greater in the most deprived population, and that is the African-American population."
That same analysis shows that the higher the subspecialist ratio, the higher the mortality rate in 25 of the 35 studies. "Above a certain level of (sub)specialist supply, the more (sub)specialists per population, the worse the outcomes," said Starfield.
She also cited another U.S. study showing that for adults 25 and older who see a primary care physician as their personal physician rather than a subspecialist, health care expenditures are one-third lower. Moreover, adults relying on primary care physicians as their main source of care are nearly 20 percent less likely to die than their counterparts who used subspecialists, after controlling for age, gender, income, insurance, smoking status, perceived health and 11 major health conditions.
"Individuals with primary care physicians have lower costs and better outcomes even after controlling for a whole lot of other influences," said Starfield.
In the United States, an increase of one primary care physician is associated with 1.44 fewer deaths per 10,000 population and a 5 percent to 10 percent reduction in deaths per 10,000 people, depending on the cause of death, according to Starfield.
Other studies conducted within industrial and developing countries have reached similar conclusions, repeatedly demonstrating that "areas with better primary care have better health outcomes, including total morality rates, heart disease mortality rates and infant mortality," said Starfield. A primary care-based system also is more successful at earlier detection of certain cancers, such as colorectal cancer, breast cancer, uterine and cervical cancer, and melanoma, Starfield noted.
"The opposite is the case for higher (sub)specialist supply, which is associated with worse outcomes," she said.
Co-author of the oft-cited "Contribution of Primary Care to Health Systems and Health" in the September 2005 Milbank Quarterly, Starfield presented data showing that countries with health care systems based on primary care have better health outcomes, lower costs and greater equity in health care than the United States, which has a health care system based more on subspecialty care.
In the United States, 60 percent to 80 percent of the population under the age of 65 sees a subspecialist in a year, a rate that is increasing, according to Starfield. In Ontario, Canada, by comparison, 31 percent of the population under 65 sees a subspecialist in a given year. In England, the rate is even lower at 16 percent. About one-third of the population that uses Spain's health care system sees a subspecialist annually, according to Starfield.
"All three of these countries have better health outcomes than the United States," she said.
Starfield shared data demonstrating the inherent advantages of primary care in providing better health outcomes at a lower cost, especially when compared to subspecialty care. An analysis of 35 separate studies that deal with differences between seven different subspecialty areas and five rates of mortality, found that in 28 of the studies, the greater the primary care physician supply, the lower the mortality rate.
In addition, "Primary care orientation is equity producing," said Starfield. "The association of primary care resources with decreased mortality is greater in the most deprived population, and that is the African-American population."
That same analysis shows that the higher the subspecialist ratio, the higher the mortality rate in 25 of the 35 studies. "Above a certain level of (sub)specialist supply, the more (sub)specialists per population, the worse the outcomes," said Starfield.
She also cited another U.S. study showing that for adults 25 and older who see a primary care physician as their personal physician rather than a subspecialist, health care expenditures are one-third lower. Moreover, adults relying on primary care physicians as their main source of care are nearly 20 percent less likely to die than their counterparts who used subspecialists, after controlling for age, gender, income, insurance, smoking status, perceived health and 11 major health conditions.
"Individuals with primary care physicians have lower costs and better outcomes even after controlling for a whole lot of other influences," said Starfield.
In the United States, an increase of one primary care physician is associated with 1.44 fewer deaths per 10,000 population and a 5 percent to 10 percent reduction in deaths per 10,000 people, depending on the cause of death, according to Starfield.
Other studies conducted within industrial and developing countries have reached similar conclusions, repeatedly demonstrating that "areas with better primary care have better health outcomes, including total morality rates, heart disease mortality rates and infant mortality," said Starfield. A primary care-based system also is more successful at earlier detection of certain cancers, such as colorectal cancer, breast cancer, uterine and cervical cancer, and melanoma, Starfield noted.
"The opposite is the case for higher (sub)specialist supply, which is associated with worse outcomes," she said.
