By James Arvantes
American Academy of Family Physicians, September 2, 2009
Barbara Starfield, M.D., M.P.H., is a renowned researcher, scholar and author. A distinguished professor with appointments in the departments of Health Policy and Management and Pediatrics at the Johns Hopkins University Bloomberg School of Public Health and School of Medicine in Baltimore, she is known throughout the world for her work in demonstrating the value of primary care.
Starfield, who also is the director of the Johns Hopkins University Primary Care Policy Center, has repeatedly presented evidence demonstrating how primary care can enhance health care access, improve quality and outcomes, and reduce costs. Her efforts have served to strengthen and solidify the argument for a primary care-based health care system in this country.
Q. What, in your view, is wrong with our current health care system?
A. The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality.
Q. Why is that the case?
A. It is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. Primary care everywhere in the world is most of the care, for most of the people, most of the time. We have done a reasonably good job at making (sub)specialty care available, but a lot of (sub)specialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily. If we followed what the evidence shows, we could do a whole lot better with a much better infrastructure of what we call primary health care.
Q. What must health care reform accomplish for it to be successful?
A. For health care reform to be successful, the system must focus on providing more primary care to more people. We know exactly what we mean when we say primary care. It is not just having a family physician or internist. It is providing services that achieve four functions. First of all, care has to be accessible, and we know that our care is not very accessible compared to countries that do much better than we do on health.
Second, care has to be person-focused over time. Now, instead of focusing care on meeting peoples’ needs, professionals define the needs — usually in terms of having a specific disease — and then forget about the people while dealing with the disease. We know from evidence that if you don’t deal with people’s problems, people are much less likely to get better. We are focusing on diseases that are professionally defined needs. We are not focusing on people-defined needs. Unless we address people-defined needs, we are not going to get good health outcomes.
The third characteristic is comprehensiveness. Instead of referring so much unnecessarily to (sub)specialists, we have to reserve (sub)specialist care for things that (sub)specialists are really needed for — the less common and complicated things — and take much better and more care of most health needs within a primary care setting.
The fourth characteristic is coordination. People have to go elsewhere for (sub)specialized services every now and then and that is good care, not bad care. When they do go, the care they receive elsewhere has to be coordinated with their ongoing care.
We know exactly what primary care is, we know exactly why systems organized around it do a better job. It is not a secret, it is not rocket science, but we don’t do it.
Q. If this obvious, why isn’t it done?
A. It is not done because there are enormous numbers of people and organizations who profit from the way health care is organized now. A lot of health policy is explicitly made by medical academia. Medical academia and teaching hospitals decide what to teach, and that is often not what the needs are in the community. Most graduates leave their training thinking that the biggest needs in the population are complicated diseases. They don’t appreciate the way problems present in the community, and they really don’t know how to deal with them because they have been trained in institutions that focus on relatively unusual problems. We are not doing a good job of training a cadre of professionals to provide the infrastructure for health services.
In addition, powerful, vested interests are keeping the system the way it is, and … they don’t want to change the system because they believe they have too much to lose. As health needs change in populations, providers should be changing to adapt their mission to the new realities of disease management and health promotion.
June 12, 2011
I have very sad news. Barbara Starfield, professor of Health Policy and Management, died Friday evening of an apparent heart attack while swimming — an activity that she dearly loved.
Our School has lost one of its great leaders. Barbara was a giant in the field of primary care and health policy who mentored many of us. Her work led to the development of important methodological tools for assessing diagnosed morbidity burden and had worldwide impact. She was steadfast in her belief that a quality primary care system is critical to the future of health care in this country and worldwide and received numerous accolades for her work in this important area…
Michael J. Klag, MD, MPH
Dean, Johns Hopkins Bloomberg School of Public Health
By Don McCanne, MD
Barbara Starfield made a difference. The momentum she created is so intense that it cannot be broken, but will carry us forward until we finally bring to reality our dream of a high-performance health care system based on a patient-oriented primary care infrastructure. We’ll all be better off for her efforts.