Barbara Starfield, M.D., Focuses on Primary Care and Health Care Reform

Barbara Starfield, M.D., M.P.H., is a renowned researcher, scholar and author. A distinguished professor with appointments in the departments of Health Policy and Management and Pediatrics at the Johns Hopkins University Bloomberg School of Public Health and School of Medicine in Baltimore, she is known throughout the world for her work in demonstrating the value of primary care.

Starfield, who also is the director of the Johns Hopkins University Primary Care Policy Center, has repeatedly presented evidence demonstrating how primary care can enhance health care access, improve quality and outcomes, and reduce costs. Her efforts have served to strengthen and solidify the argument for a primary care-based health care system in this country.

AAFP News Now recently sat down to talk with Starfield about the current health care system, health care reform and the role family physicians can play in the health care reform debate.

Q. What, in your view, is wrong with our current health care system?

A. The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality.

Q. Why is that the case?

A. It is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. Primary care everywhere in the world is most of the care, for most of the people, most of the time. We have done a reasonably good job at making (sub)specialty care available, but a lot of (sub)specialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily. If we followed what the evidence shows, we could do a whole lot better with a much better infrastructure of what we call primary health care.

Q. What must health care reform accomplish for it to be successful?

A. For health care reform to be successful, the system must focus on providing more primary care to more people. We know exactly what we mean when we say primary care. It is not just having a family physician or internist. It is providing services that achieve four functions. First of all, care has to be accessible, and we know that our care is not very accessible compared to countries that do much better than we do on health.

Second, care has to be person-focused over time. Now, instead of focusing care on meeting peoples' needs, professionals define the needs -- usually in terms of having a specific disease -- and then forget about the people while dealing with the disease. We know from evidence that if you don't deal with people's problems, people are much less likely to get better. We are focusing on diseases that are professionally defined needs. We are not focusing on people-defined needs. Unless we address people-defined needs, we are not going to get good health outcomes.

The third characteristic is comprehensiveness. Instead of referring so much unnecessarily to (sub)specialists, we have to reserve (sub)specialist care for things that (sub)specialists are really needed for -- the less common and complicated things -- and take much better and more care of most health needs within a primary care setting.

The fourth characteristic is coordination. People have to go elsewhere for (sub)specialized services every now and then and that is good care, not bad care. When they do go, the care they receive elsewhere has to be coordinated with their ongoing care.

We know exactly what primary care is, we know exactly why systems organized around it do a better job. It is not a secret, it is not rocket science, but we don't do it.

Q. If this obvious, why isn't it done?

A. It is not done because there are enormous numbers of people and organizations who profit from the way health care is organized now. A lot of health policy is explicitly made by medical academia. Medical academia and teaching hospitals decide what to teach, and that is often not what the needs are in the community. Most graduates leave their training thinking that the biggest needs in the population are complicated diseases. They don't appreciate the way problems present in the community, and they really don't know how to deal with them because they have been trained in institutions that focus on relatively unusual problems. We are not doing a good job of training a cadre of professionals to provide the infrastructure for health services.

In addition, powerful, vested interests are keeping the system the way it is, and ... they don't want to change the system because they believe they have too much to lose. As health needs change in populations, providers should be changing to adapt their mission to the new realities of disease management and health promotion.

Q. What role should family physicians play in the current health care reform debate?

A. Family physicians have to be in the forefront of health care reform. They have to marry the reform of financial access with the reform of services.

We lack a primary care infrastructure in this country. Building it has to be supported by more incentives to medical schools and to residency programs for primary care training, more incentives for training outside the hospital, and more appropriate reimbursement for primary care physicians. Primary care physicians work harder than (sub)specialists and should be appropriately compensated.

Q. What types of research do you plan to work on going forward?

A. I am planning to work -- as I have in the past -- on improving effectiveness and, particularly, equity in health services, so deprived groups get health care that is commensurate with what we think good health care should be. That doesn't mean following guidelines. What it means is following the health needs of patients. I think person-focused care over time still needs a lot more research. I think what should be covered in primary care rather than (sub)specialty care really needs a lot of research.

For example, there are three kinds of primary care physicians in this country, general internists, general pediatricians and family physicians. The evidence is clear that family physicians provide a broader range of services than the general internists or general pediatricians. The evidence we have so far is greater comprehensiveness is important. So I think we need more research on how we can get the general internists and the general pediatricians to be trained outside of the hospital so they too can provide the breadth of services that family physicians are already providing, such as minor surgery.

Q. What contributions has the AAFP's Robert Graham Center made in the area of research?

A. I think their contributions have been enormous during the past 15 years. They are asking the right questions. They are dealing with the issues of what primary care is, what it should be and what it accomplishes.

Q. You have studied a lot and published a lot on other countries and their use of primary care in improving outcomes and lowering costs. If you had to pick a country for the United States to learn from in terms of how their health care system functions, what country would that be?

A. That is a difficult question because no country has it perfect. But I think in terms of coming a long way in a rather short period of time in an industrialized -- rather than a developing -- country, Spain could provide some important lessons. Spain changed its health policies in the mid 1980s. It systematically moved from two-hour-a-day consultations to health centers -- a process that started in the most deprived areas of the country and spread over a period of 10 years to the whole country. They are basing their primary care health centers on the four principles of primary care. Spain probably now contributes relatively more primary care research than the United States does, given its smaller population size.

Q. How would you rate their outcomes?

A. Their outcomes are better than ours. They do less than we do, but they have better outcomes at much lower costs.

Q. The Veterans Administration adopted a primary care-based system. Is it a good model?

A. The VA understands primary care. It was visionary in adapting the definitions of primary care to the realities of providing services to its population in a way that facilitated self-evaluation. It devised health information systems that keep account of people and peoples' problems. The fact that they are introspective in what they do and constantly try to make improvements and adapt their electronic health records so that they are working to achieve the four functions of care puts the VA way ahead of most other health care systems. Of course, there are other good health care systems in the country as well. They are good models. We really don't have to look abroad to learn how to improve what we do.

Q. Is Medicare a good model?

A. No. Medicare is an excellent model for universal coverage. But it plays by the same rules as the rest of the system. And those rules are pretty much unrestricted use and disease orientation. It pays by diseases, not based on people's needs.

Q. How should Medicare be restructured to focus on patients? In an ideal setting, how should it work?

A. Currently, the criteria for quality are whether guidelines are followed. Guidelines assume that there is an average patient and everyone is like the average patient. But the reality is that variability is the norm, especially with regard to various types and degrees of comorbidity. We have guidelines for several diseases, such as diabetes and hypertension, but they all assume that there are no coexisting conditions that might make the guidelines inappropriate.

Q. What should physicians follow, then?

A. We should work toward a system -- and we already have prototypes -- to find out whether people improve. That is pretty simple. Just focus on the outcomes. That doesn’t mean at the same time you cannot try to devise processes that are proxies for the outcomes, but right now we do not have those. And we do not have any guidelines that assure that peoples' health problems are adequately recognized.