Insurance, the Presence of a Medical Home, and the Benefits of Primary Care for Children

1. Insurance, the Presence of a Medical Home, and the Benefits of Primary Care for Children Barbara Starfield, MD, MPH November 2002

2. What increases the likelihood of a medical home? Starfield 09/02

3. 100 90 80 70 60 50 40 30 20 10 0 Least vulnerable* Somewhat vulnerable Most vulnerable* Predicted Probability of Having a Usual Source of Care among High-Income Insured, Low-Income Insured, and Uninsured Adults, by State Safety-Net Vulnerability High-income insured *High income insured significantly different from low income insured at the 5% level. Low-income insured Low-income uninsured Source: Holahan & Spillman, 2002.

4. Access to Care of Uninsured Persons Percent of uninsured with a usual source of care All persons under age 65 63 1-18 75 19-24 55 25-34 54 35-54 61 55-59 68 60-64 71 Source: Cunningham, 1998. Starfield 10/02

5. Odds Ratios for Factors Associated with Not Usinga Regular Source of Care, US Children, 1991 Gap in health insurance 1-6 months 1.5 ³7 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 not significant: parental education, ethnicity, marital status, maternal age, site of usual care, type of health insurance Source: Kogan et al., 1995.

6. Odds Ratios (Adjusted) for Accessand Use for Uninsured as Comparedwith 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 Adjusted for various sociodemographic and health characteristics Source: Newacheck et al., 1998. Starfield 1998

7. Significant Predictors of PrimaryCare, Inner City Latino Children(Los Angeles), 1992 Continuity of well and sick care Continuous Medicaid* 1.5 Uninsured* 0.4 Source of well child care** HMO 20.7 Public clinic 0.3 Child health status 1.6 Starfield 09/02

8. 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

9. 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

10. Why is a medical home important? Starfield 09/02

11. 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. Source: NSECH, 2002 Starfield 09/02

12. 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

13. 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

14. 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 made Note: All children covered by insurance Source: Lieu et al., 1994. Starfield 1998

15. Factors Influencing the Likelihoodof Seeing a Physician in the Presenceof 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

16. Factors Related to Untimely Initiation of Prenatal Care, Low Income California Women, 1994-5* Inadequate knowledge of importance of primary care  5th birth Education high school or less Transportation problems Feared disclosure of pregnancy No regular source of care before pregnancy Unwanted/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

17. Impact of Having One Regular Source of Care,Rural Youth in Maryland, 1992 Source: Ryan et al., 2001. Starfield 03/02

18. 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 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). Source: O’Malley & Forrest, 1996. Starfield 1998

19. Does provision of the elements of primary care separately by multiple providers constitute a “medical home”? Starfield 04/02

20. Elements of Primary Care First-contact Ongoing person-focused care (“longitudinality”) Comprehensiveness Coordination Family-centeredness Community orientation Cultural competence Starfield 04/02

21. Benefits of Longitudinality, Based on Evidence from the Literature Identification Identification with 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 Source: Starfield, 1998 Starfield 11/02

22. 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