EVOLUTION OF EMPLOYER-BASED GROUP HEALTH INSURANCE: FROM INDEMNITY/SERVICE PLANS TO MANAGED HEALTH INSURANCE PLANS – THROUGH 2000

THE CENTRALITY OF PRIMARY CARE – EXCERPTS FROM THE WORK OF BARBARA STARFIELD, M.D.

A. WHAT IS PRIMARY CARE?

EXCERPT – “Is Primary Care Essential?” Barbara Starfield, MD; The Lancet, 22 October 1994, Vol 344(8930), pages 1129-1133.

The conference convened by the World Health Organization at Alma Ata in 19781 used 100 words to describe primary care; they included essential, practical, scientifically sound, socially acceptable, universally acceptable, affordable cost, central function and main focus of overall social and economic development, first-level contact, and first elements of a continuing health care process. Serious planning for primary care requires a conceptualization that is easily and uniformly understood, implemented, and amenable to measurement.

Primary care is first-contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system. The elements of first contact, continuity, comprehensiveness, and coordination are included in most definitions proposed by professional organizations, agencies, and commissions [2-5]. When viewed from the perspective of populations as well as individual patients, a health system that seeks to achieve these four elements will be achieving what was envisaged in the Alma Ata Declaration.

Primary care is only one level of a health system, albeit a central one.

Other essential levels of care include secondary care, tertiary care, and emergency care (especially for serious trauma).

· Secondary and tertiary care are distinguished by their duration as well as by the relative uncommonness of problems that justify them.

· Secondary care is consultative, usually short-term in nature, for the purpose of helping primary-care physicians with their diagnostic or therapeutic dilemmas. Secondary care may be provided by informal consultations of secondary-care physicians with primary-care physicians, by regular visits of secondary-care physicians to primary-care facilities for the purpose of advising on management of patients with particular disorders (e.g., diabetes), or by short-term referral of patients.

· Tertiary care, in contrast, is care for patients with disorders that are so unusual in the population that primary-care physicians could not be expected to see them frequently enough to maintain competence in dealing with them. When the disorder has a substantial impact on other aspects of a patient's health, the tertiary-care physician may have to assume long-term responsibility for most of the patient's care, consulting with the primary-care physician for problems and needs that primary-care physicians are better equipped to handle.

All of these other levels of care require integration with primary care for the patient to receive clear and consistent advice.

B. THE SPECIAL CHARACTERISTICS OF PRIMARY CARE.

EXCERPT: “PRIMARY CARE AS PART OF US HEALTH SERVICES REFORM,” Barbara Starfield, MD, MPH and Lisa Simpson, MB, BCh, MPH; JAMA, June 23/30, 1993 – Vol 269, No. 24, pp. 3136-3139.

The poor development of primary care within the US health care system has received relatively little attention despite evidence that it may underlie or at least exacerbate access, quality, and cost problems. Primary care facilities make it possible for individuals to obtain services for illnesses before they become severe.

Primary care services, when properly linked to specialty services for consultation and referral, achieve better outcomes. Primary care services are also less costly than specialty services, largely because they are less technology-intensive. Higher levels of primary care manpower are associated with lower mortality rates. Where it has been examined as a characteristic, Primary Care is twice as important as insurance in maintaining health.