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

4. Access to Care of Uninsured Persons 7160-64 6855-59 6135-54 5425-34 5519-24 751-18 63All persons under age 65 Percent of uninsured with a usual source of care Starfield 10/02 Source: Cunningham, 1998.

5. Odds Ratios for Factors Associated with Not Using a Regular Source of Care, US Children, 1991 Gap in health insurance 1-6 months1.5  7 months1.7 Father not employed1.5 No father in home1.8 Family moved1.7 Perceived barrier to care2.4 Child with chronic condition1.9 Source: Kogan et al., 1995. not significant: parental education, ethnicity, marital status, maternal age, site of usual care, type of health insurance

6. Odds Ratios (Adjusted) for Access and Use for Uninsured as Compared with Insured Children, 1993-4 No regular source of care6.1 Unable to get needed medical care5.8 No after-hours medical care1.6 Not satisfied with care1.4 Not seen a doctor in a year2.1 Source: Newacheck et al., 1998. Adjusted for various sociodemographic and health characteristics Starfield 1998

7. Significant Predictors of Primary Care, 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. Starfield 09/02 Source: NSECH, 2002

12. Odds Ratios* for Subsequent Hospitalization among Medicaid Patients Having Continuity with Regular Doctor, Delaware, 1993-5 All conditions0.56 Ambulatory care sensitive conditions0.66 *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 UninsuredNS 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 doctor2.9 Lack of knowledge2.0 Number of children in family1.4 Not significant: Race, Time since appointment made Note: All children covered by insurance Source: Lieu et al., 1994. Starfield 1998

15. Factors Influencing the Likelihood of Seeing a Physician in the Presence of Symptoms, Ages 11-17 † Odds Ratio Race NS Ethnicity NS Income NS Insurance NS Usual source of care1.67 † 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 Odds ratios Receipt of preventive care Less for those without a regular source of care or with different sources for prevention and for illness care Receipt of emergency services Greater for those with different sources 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 clinician88 Yes, without specific clinician82 No, non-CHC sick care site80 No sick care site76 Source: O’Malley & Forrest, 1996. 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). 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 Starfield 11/02 Source: Starfield, 1998

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