Managed Care - June 2008 - (Page 36)

their mission statements. But as the medical home concept is being implemented, some things are getting lost in favor of bells and whistles that are not evidence-based. MC: Bells and whistles? STARFIELD: Electronic health records are an example of something that would be helpful if they contribute to the four functions of primary care, but no one is making an effort to provide evidence that they will. I am also concerned that the instruments being developed to certify physician practices as being a PCMH are completely missing the comprehensiveness function. They address access issues that are related to first contact, they have elements of patient-centeredness — although they sometimes define that as patient-focus in a disease context — and they have elements of integration, but they are completely missing the comprehensiveness side. MC: This is the first cautionary discussion of the medical home concept that I’ve ever heard. STARFIELD: Others are worried, too, especially in the business community. They are strongly in favor of primary care as we have defined it. MC: Employers seem like a natural audience for your work, especially those that are self-insured. STARFIELD: Last March, I received an award from the National Business Group on Health for excellence and innovation in value purchasing for promoting primary care. Can you imagine? They gave an academic an award for innovative purchasing. I’m not even an economist. I’m a physician and I understand primary care from practice experience and from research. MC: That must be encouraging. Do you see other evidence that things will change? STARFIELD: Many physician groups talk about reform, and we have seen a very large physician and allied health movement toward a single-payer system, but we don’t see a unified movement that is directed at changing the way we train physicians and the way we organize services. Rural areas have always cared about the shortage of primary care physicians, but now the shortage is everywhere. Still, there’s no unified movement that says, “Do something about it!” We see many splinter groups talking about it, but as long as the vested interests can divide and conquer and prevent a unified movement, we are not going to get it. MC: Where do we chip away at this? STARFIELD: Congress is one of the places you have to chip away. We need national health policies. You have to chip away at it with the Centers for Medicare & Medicaid Services. You have to chip away at it with the foundations, who could mount another Flexner Report. It was a foundation that did the Flexner Report to start with. The academic medical establishment also has to be forced to defend its notion that we need more and more specialists. They don’t defend it on the fact that we need it. They defend it on the grounds that people are demanding it. If they are going to go with demand, we will never control our costs, and we will never get a healthier population. So we chip away at those several places. MC: The major presidential candidates use the word change quite a bit. STARFIELD: The candidates are not talking about the health care system in the United States. They are only talking about insurance. MC: But payment shapes everything, doesn’t it? STARFIELD: Payment shouldn’t shape things. You have to have ideas that shape things, and then find a way to pay for them. Obviously, everybody needs to have access to care, but it’s not only financial. It has to be appropriate care. Nobody’s talking about appropriate care. They are only talking about ways to pay for care. And that’s why our health care costs are so high, because we are focusing only on paying without asking what we are paying for. MC: You have written and talked about the health care systems in other countries. Can America learn from these other systems? STARFIELD: I started my work with international comparisons, and then moved to looking at differences across states. We have so much evidence now from the United States that we don’t need to argue that we should do things the way the Brits or the Dutch do. It’s useful, though, to understand that our health is poorer than theirs. It’s useful because it forces us to think about why. And the answer is not in bad behaviors. Our population actually behaves better than populations of most countries in terms of smoking less and drinking less alcohol, for example. It is also not because we have major ethnic populations or racial populations, because even if you take out 36 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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