Managed Care - June 2008 - (Page 34)

Her work has been used by governments in more than a dozen countries to pass legislation and to gain support for primary care. Starfield recently spent several days in Geneva reviewing a new report being issued by the World Health Organization on primary health care. At home, employers and several groups of primary care practitioners are using the evidence she’s compiled to call for greater emphasis on primary care. Yet while she is encouraged by the attention primary care is receiving, she is concerned that the United States does not have a unified movement or the political support necessary to move to a system based on more appropriate and rational use of health care resources. MANAGED CARE Editor John Marcille spoke with Starfield about why that is and whether she is hopeful that it will change. MANAGED CARE: What does it mean for our country that two thirds of physicians are specialists? BARBARA STARFIELD: It not only raises the cost of health care enormously, but it does not contribute commensurately to the health of the population. And it does not contribute to the equity of health care services provided to different populations. When I started studying this with 1980s data, the United States was somewhere around tenth in the world in terms of health indicators. Now it’s between twentieth and thirtieth, with costs that are much higher than any other country and more than twice as high as most other developed countries. The United States has been falling progressively further behind in most health indicators for at least two decades. So we are doing something really, really wrong, and one of the things we are doing wrong is using specialists for services that should be provided by primary care. MC: As a consumer, I would think that going to the most highly educated doctor with the best imaging devices and other equipment would be the best thing to do. STARFIELD: The elderly in this country are much more likely to go to a specialist than a primary care doctor, but I once spoke to a group of about 100 senior citizens in Baltimore and everyone was able to understand that inappropriate care is not good care. They could see the point. And the point is this: Specialists are trained in hospi- tals. They don’t get a representative picture of the way illness presents in the community because the population they are trained on is unusual. The patients they see are people who are referred to academic medical centers because their conditions are complex and unusual. So when physicians are finished with their training and begin to evaluate symptoms on their own, they are much more likely to suspect something that is serious. However, someone trained in the community will know that most symptoms don’t mean a zebra is present. They generally mean horses are present. But the specialist, over suspecting the likelihood of a serious illness, will do a very expensive and unnecessary workup. And all the things that are done in an unnecessary and expensive workup have a finite chance of an adverse side effect, including death. So people who go unnecessarily to specialists will have very high costs, will have unnecessary things done, and are placed at risk. That’s why, if you don’t have something that requires a specialist, it’s dangerous to see one. It’s not difficult to convince people of this; it just has to be put in the right context. MC: Does your training as a physician give you a unique perspective on this issue? STARFIELD: Yes, it does. When I went through my training, something in me recognized the fact that the experience I was getting in the hospital was not going to be very useful for practicing in the community. So I arranged with my professor to do something different in my last year, and I trained with outpatients rather than inpatients. These ideas have been with me for a long time. MC: What are the root causes of the problem? STARFIELD: It goes back about a century. We have never in this country had a strong primary care education model in medical school. In about 1910, Abraham Flexner published an influential report on medical education. It was a good report, but it had side effects. It said that medical education needed a science base, and it resulted in the closing of all the proprietary medical schools. It set in motion a focus on the biomedical in medical education, and from that time on, medical schools were built on a specialty basis. It grew worse after World War II. Physicians in the service had learned a lot during the war 34 MANAGED CARE / JUNE 2008

Table of Contents Feed for the Digital Edition of Managed Care - June 2008

Managed Care - June 2008 Editor’s Memo Contents Viewpoint Letters News and Commentary Legislation & Regulation Medication Management Compensation Monitor Plans Chart Course in Rough Waters A Conversation With Barbara Starfield, MD Smoke Signals from Payers Slow Going for Clinical Decision Support Back Pain and Physical Therapy Formulary Files PlanWatch Outlook

Managed Care - June 2008

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