The Johns Hopkins Primary Care Policy Center

Summary of Achievements in Primary Care Research

In 1978, the World Health Organization proposed a strategy for achieving Health For All. Widely considered a seminal document for developing an ethical basis for health services worldwide, its philosophical tone and absence of specific strategies made it an easy target in a world in which health services were becoming increasingly market-oriented, technologic, and impersonal.

At the same time as it became evident that international lending agencies were failing to improve the availability of health services for populations that could not afford to pay for them, evidence of the importance of primary care was being developed. The work of the Primary Care Policy Center (PCPC) at the Johns Hopkins Bloomberg School of Public Health was critical in producing this evidence. Over a period of 15 years, the Center, originally supported by the Bureau of Primary Health Care in the U.S. government, has produced most of the worldwide evidence of the benefits of primary care-led health systems, both in the United States and internationally. Primary care is person- and population-focused care with provision of accessible, comprehensive, and coordinated services as its hallmarks. It is distinguished by its orientation to overall health and illness experiences of people, rather than only toward biomedical characteristics of diseases. The Center's landmark 2005 paper summarized all of the evidence to date that primary care-led health systems produce greater effectiveness of health services with reductions in disparities in health across population subgroups, and at lower costs than health systems oriented toward disease-focused, specialty-dominated health systems.

The principals of PCPC, Drs. Barbara Starfield, Leiyu Shi, and James Macinko, are world renowned and highly sought after as informal advisers to governments and professional groups, particularly those concerned with building stronger primary care infrastructures in their health systems. These countries include, but are not limited to, Australia (where the primary care legislation specifically mentions the work done by th Center), New Zealand, Sweden, Lithuania, the United Kingdom, Spain, Brazil, South Africa, Thailand, Malaysia, Bulgaria, Canada, Chile, Argentina, and, most recently, Oman and Italy.

The landmark Pan American Health Organization document, Primary Care in the Americas, was based largely on evidence produced and summarized by the PCPC; the committee that launched it was co-chaired (with the deputy director of PAHO) by Dr. Starfield and staffed by Dr. Macinko. The report served as one basis for the 2008 World Health Report of the World Health Organization, for which Dr. Starfield served as reviewer and adviser.

Invitations to present at major international forums on the subjects of primary health care, equity in health care and health, and chronic diseases in the context of social and societal influences on health have increased in both number and frequency; international presentations in the most recent two years are listed below.

Starfield presentations

Starfield B. Global trends in primary care development. Phitsanulok, Thailand. February 3, 2007.
Starfield B. Adjusted Clinical Groups (ACGs): concept and method. Bangkok, Thailand. February 2007.
Starfield B. Chronic illness, co-morbidity, and primary care quality. Bangkok, Thailand. February 5, 2007.
Starfield B. Adjusted Clinical Groups (ACGs): concept and method. Kuala Lumpur, Malaysia. February 2007.
Starfield B. ACGs: applications. Kuala Lumpur, Malaysia. February 9, 2007.
Starfield B. ACGs in Malaysia? ACG Workshop. Kuala Lumpur, Malaysia. February 9, 2007.
Starfield B. Global trends in primary care development. First ASEAN Regional Primary Care Conference (ARPaC). Kuala Lumpur, Malaysia. February 9, 2007.
Starfield B. Quality indicators in primary care in developing countries. Kuala Lumpur, Malaysia. February 9, 2007.
Starfield B. Imperatives for primary care research. Zaragoza, Spain. February 22, 2007.
Starfield B. Subspecialization in primary care. Madrid, Spain. February 23, 2007.
Starfield B. Global trends in primary care development. Regional Forum for Primary Care Reform. Sophia, Bulgaria (audioconference). April 2, 2007.
Starfield B. The impact of primary care on population health. University of Capetown. Capetown, South Africa. June 5, 2007.
Starfield B. The health services system: Where does primary care fit in? University of Capetown. Capetown, South Africa. June 6, 2007.
Starfield B. Policy-relevant influences on health. University of Capetown. Capetown, South Africa. June 8, 2007.
Starfield B. Global health. University of Capetown. Capetown, South Africa. June 8, 2007.
Starfield B. Primary care research imperatives. University of Capetown. Capetown, South Africa. June 8, 2007.
Starfield B. Challenges for primary care research: co-morbidity. University of Capetown. Capetown, South Africa. June 11, 2007.
Starfield B. Referral from primary care to specialty care. University of Capetown. Capetown, South Africa. June 12, 2007.
Starfield B. The role of specialists in health systems. University of Capetown. Capetown, South Africa. June 12, 2007.
Starfield B. Equity in health and health services. University of Capetown. Capetown, South Africa. June 13, 2007.
Starfield B. Public health and primary care. University of Capetown. Capetown, South Africa. June 15, 2007.
Starfield B. Chronic illness, co-morbidity, and primary care quality. University of Capetown. Capetown, South Africa. June 2007.
Starfield B. Adjusted clinical groups (ACGs): concept and method. 2007 European ACG Conference. Karlskrona, Sweden. September 18, 2007.
Starfield B. Global trends in primary care development. Blekinge Conference. Ronneby, Sweden. September 19, 2007.
Starfield B. Utility of risk factor identification. Sevilla, Spain. October 9, 2007.
Starfield B. Case-mix, primary care, and specialty care. 23^rd Patient Classification Systems/International Conference. Venice, Italy. November 9, 2007.
Starfield B. The contribution of primary care systems to health outcomes. Forum "Meridiano Sanita: Proposals for a New Healthcare System in Italy". Cernobbio, Italy. November 10, 2007.
Starfield B. Perspectiva de la atención primaria en los paises en desarrollo – fortalezas y debilidades por fortalecer: lecciones aprendidas. Videotape presentation at the Curso Internacional de Atención Primaria. Lima, Peru. November 14, 2007 (videotaped presentation).
Starfield B. Chronic care or chronic disease care? Definitions, care models, and strategies. European Leadership Summit on Chronic Care. Amsterdam, Netherlands. December 3, 2007.
Starfield B. Research priorities in primary health care. Belo Horizonte, Brazil. December 14, 2007.
Starfield B. Chronic care, chronic disease care, and primary care: one and the same, or different? Bellagio, Italy. April 2008.
Starfield B. Primary care: questions and answers. Muscat, Oman. April 2008.
Starfield B. International comparisons of primary care. Muscat, Oman. April 2008.
Starfield B. Is chronic (disease) care the same or different from primary care? Muscat, Oman. April 2008.
Starfield B. Looking across the globe: making comparisons of primary care. Singapore. May 2008.
Starfield B. Global perspectives in healthcare transformation – the relevance of primary care. Singapore. May 2008.
Starfield B. Where is the patient in disease management? Singapore. May 2008.
Starfield B. The role of primary care in modern health systems. Seminar on Primary Care in the Northern Dimension. Vilnius, Lithuania. May 23, 2008.
Starfield B. Primary healthcare revisited in a multi-stakeholder landscape. Introduction, Geneva Health Forum 2008, Plenary Panel Discussion 02. Geneva, Switzerland. May 26, 2008.
Starfield B. Equity in health: the role of primary (health) care. J. Douglas Coleman Lecture, Baltimore, MD. June 10, 2008.
Starfield B. Diseases, chronic care, prevention, and primary care: How different? Manchester, UK. October 2008.
Starfield B. Why is general practice of vital importance to both individuals and society? General Practice in Norway 2020. Oslo, Norway. October 30, 2008.
Starfield B. The importance of primary health care in health systems. Qatar-EMRO Primary Health Care Conference. Doha, Qatar. November 2008.
Starfield B. Equity in health services. Qatar-EMRO Primary Health Care Conference. Doha, Qatar. November 2008.
Starfield B. Diseases, chronic care, prevention, and primary care: How different? Barcelona, Spain. December 2008.
Starfield B. Is chronic disease care the same as primary care? Barcelona, Spain. December 2008.
Starfield B. Diseases and prevention: changing concepts. Catalan Cancer Institute. Barcelona, Spain. December 11, 2008.
Starfield B. Primary care and health outcomes in the context of changing health needs. Tel Aviv, Israel. December 16, 2008.

Shi presentations

Shi L. US health care: current status and future trend. Presented at Taiwan National Nursing Association Conference. Taipei, Taiwan, Republic of China. October 9, 2007.
Shi L. US primary care oriented community health center: paving the way to quality. Presented at the PAHO Network of Centers of Excellence in Primary Care in the Americas Conference. Belo Horizonte, Brazil. December 11, 2007.
Shi L. Introduction to US Joint Commission International, hospital accreditation and preparation. Presented at Taiwan Hospital Managers Training Workshop. Taipei, Taiwan, Republic of China., December 29, 2007.
Shi L. Introduction to US health care delivery and overview of US hospital and management. Presented at Taiwan Hospital Managers Training workshop. Taipei, Taiwan, Republic of China. December 29, 2007.
Shi L. Introduction to US Joint Commission International, hospital accreditation and preparation. Presented at Beijing University. Beijing, China. January 2, 2008.
Shi L. Primary health care policy and services in the United States: Johns Hopkins Medical Care System experiences: challenges and directions. Presented at National Defense Medical Center. Taipei, Taiwan, Republic of China. May 23, 2008.
Shi L. Health care delivery system in America: challenges and directions. Presented at Tri-Service General Hospital. Taipei, Taiwan, Republic of China. May 23, 2008.
Shi L. Overview of the US hospital industry and the concept of health promoting hospitals. Presented at Symposium of Creating International Competitiveness in Healthcare Industry. Taizhong, Taiwan, Republic of China. May 24, 2008.
Shi L. Advancing primary care to promote holistic health. Presented at Symposium of Promoting Holistic Health – A New Paradigm of Health. Taiwan, Republic of China. August 2, 2008.
Shi L. Implementing tele-medicine to advance quality care. Presented at Symposium of Promoting Innovative Hospital Management. Taiwan, Republic of China. November 22, 2008.
Shi L. Applying the Malcolm Baldrige framework on hospital management to promote quality care. Presented at Symposium of Promoting Innovative Hospital Management. Taiwan, Republic of China. November 22, 2008.
Shi L. The essence of managing hospitals in the 21^st century. Presented at Workshop for Hospital CEOs and Managers in China. Shanghai, People's Republic of China. November 28, 2008.

The time is opportune to build an even more effective force for leadership by the PCPC. Changes in the world's appreciation of the benefits of primary care now make it possible to move forward in expanding the staff, activities, and capacity of the PCPC to contribute even further to providing the evidence base for effective change in health systems, both in the U.S. and abroad. Much remains to be learned in order to meet the new challenges to health services: patient- and population-orientation rather than a sole focus on specific diseases or risk factors; improving responsiveness of health professionals and systems to the problems experienced by patients and populations; moving faster and further to reduce disparities in health across population groups characterized by gender, socioeconomics, race, and ethnicity; and making health services safer and more effective in dealing with health problems.

The proposed expansions are in the following areas:

Apply knowledge of the benefits of primary care to consideration of the imperatives of chronic care and chronic illness.
Consider application of primary care principles to care of the elderly and to the challenges of health problems of the aging.
Better rationalize and achieve, through primary care, the relative priorities of preventive care, care of acute and chronic illnesses, and palliation.
Develop and apply ways of characterizing morbidity burdens of populations that allow better targeting of both primary care and specialist care resources to meet the health-related needs of populations and patients.
Assessment of the adequacy of achieving primary care attributes by patient-centered medical home (PC-MH) demonstrations and developments.
Assessment of progress, both intra-nationally and internationally, in developing primary care-oriented health systems and services

Accomplishments of the Primary Care Policy Center

Unique strengths and capabilities of the Johns Hopkins team:

The Johns Hopkins PCPC was created through the financial support of the BPHC. Since its inception in 1996, it has carried out studies and analyses for the BPHC. The investment by the BPHC has reaped significant results, as evidenced by the number of rigorous scientific publications and studies conducted through the Johns Hopkins PCPC.
Contributions specifically pertinent to the work of health centers. The Johns Hopkins team has produced the most literature on the nation's vulnerable populations, in particular health centers that serve vulnerable populations, including their sustainability, provider recruitment and retention experiences, financial performance, experience under managed care, preventive care services, quality of care, and comparisons with other health care settings.
Contributions to knowledge and policy concerning primary care. The PCPC team has conducted pioneering research on the association between primary care and health outcomes, the role of primary care in reducing social inequities, and, more particularly, on the role of primary care in mediating the adverse impact of income inequality on health outcomes, in collaboration with BPHC colleagues and other national experts. Studies have been conducted using U.S., state, MSA, county, and individual level data. Since both income inequality and primary care are significantly and independently associated with health indicators, the policy implications are broadened beyond efforts at improving income equality. This is particularly relevant in the U.S., where reduction of income inequality is not a social priority and where characteristics of the market and political economy are inimical to income redistribution. The promotion of primary care is one potential policy strategy to improve health, even in the face of marked disparity in the distribution of income. The Johns Hopkins team has been involved in the development and validation of adult-, child-, and practice/facility-specific primary care assessment tools that capture the principal domains of primary care. These tools can be used to study primary care experience rendered under different health care systems or settings, and for patients with different sociodemographic attributes.They can be used with other outcomes to assess the effect of policy interventions and system changes on the delivery of critical aspects of primary care. Both Drs. Starfield and Shi are national leaders in the research on primary care and health inequities.
The Johns Hopkins team has a strong and nationally known clinical expertise. Not only are the core investigators primary care clinicians and researchers, we have access to nationally known clinical researchers of all specialties. The Johns Hopkins University Adjusted Clinical Groups (originally "Ambulatory Care Groups") Case-Mix System is the nation's most widely used and tested, population-based risk-adjustment tool. The ACG Case-Mix System is a person-focused method of categorizing patients' illnesses. Over time, each person develops a constellation of conditions. Based on the pattern of these morbidities, the ACG approach assigns each individual to a single group (an "ACG"), which permits the effects of a clustering of morbidities to be captured in estimates of resource use. With its strong clinical expertise and ACG technology, the Johns Hopkins team is uniquely positioned to study health center patients and compare them appropriately with national patients.
Extensive knowledge of and experience with data sets. The PCPC has worked extensively with both health center data sets and other national sources of data, including survey data, health services data, and population data on health and resources. Intimate knowledge of these data sets makes it possible to conduct comparative analyses and also to extend analyses to include more and increasingly relevant other characteristics relating to health.
Direct input of research into policy streams. The contributions achieved in collaboration with the BPHC have relevance far beyond their pertinence to the work of health centers. Research and analyses using health center data, both by themselves and by comparison with other types of sources of care, contribute to decision making throughout the U.S. as well as abroad. Results from these studies and analyses have been presented both in published media and prestigious peer-reviewed journals, as well as in numerous forums nationally and internationally. Because of the extensive research, the principals of the PCPC are increasingly called upon to meet with decision makers in various countries. Legislation to improve primary care and executive actions to strengthen primary care have been based heavily on findings of studies in which the PCPC and the BPHC have collaborated. This is the case for industrialized countries such as the U.K., Ireland, Australia, New Zealand, and Spain, as well as developing countries such as Brazil. Continuing and new initiatives of the Administration, and of the Health Resources and Service Administration (HRSA) within it, have available to them evidence that appropriate primary care, as represented by health centers, is associated with reduced disparities across racial and ethnic groups as well as across socioeconomic strata – directly as a result of evaluations and analyses conducted by the PCPC.
Relevance of PCPC work to current and future imperatives. Several challenges are increasingly being posed to the U.S. health services system, including health personnel policy, policies regarding referrals from primary care to secondary and tertiary care, adequacy of specialty care, pay for performance as a result of improvement in quality, and disparities in health across population subgroups. The PCPC is immediately poised, as a result of its extensive work on current health care concerns, to embark on these new and emerging areas.
Areas for expansion, given appropriate resources. PCPC personnel have the capacity to expand into new areas as they become of high priority. Within the past year, questions have been raised about the adequacy of numbers of primary care physicians and specialists in the U.S. Prior work done by the PCPC has provided initial information to inform decisions in this area. Expansions, however, are possible in several areas.
- The role of non-physician personnel in providing adequate primary care. A sizable number of practitioners in health centers are non-physicians. Yet little is known about the balance of types of care provided by physicians and non-physicians, and their relative achievement of high quality care with good outcomes.
- A second area for expansion is referral policy. The PCPC has already produced information on the nature of referrals, and of specialty care in the U.S., and has shown there are considerable concerns about appropriateness, particularly with regard to overuse and potential adverse effects of unnecessary care. Given the difficulties health centers often face in finding back-up specialty care for their patients, this subject is of very high relevance to the health care they provide to patients.
- A third area for expansion concerns disparities in health care. Several reports by the Institute of Medicine document inequalities in care received by many minority populations. These analyses have, for the most part, been unable to control adequately for underlying health status. As a result of work done in related units of the department in which PCPC is housed, we are able to describe and characterize overall morbidity burdens (as well as specific disease burdens) in populations. Tools developed by PCPC could be increasingly applied to analyses of BPHC data.
- The fourth area in which expansion is possible concerns dissemination activities. In conjunction with the BPHC, the PCPC should explore more extensive contacts with media and policymakers, as well as consumer groups, to provide global leadership to inform health policy in wealthy, middle- income, and low-income countries; to produce evidence-based information on the design of health systems around a primary care infrastructure; and to document the effectiveness and efficiency of primary care-oriented health systems and their critical importance to improving equity in health and reducing socioeconomic, racial, ethnic, gender, and other disparities.