BACKGROUND: Specific components of family medicine associated with reduced health care costs are not well understood. We examined whether people who received “family care,” the sharing of a personal physician across familial generations, had lower health care expenditures than those who received “individual care” that lacked generational continuity.
METHODS: We studied 1728 children and 2543 adults using a data subset of the 1987 National Medical Expenditure Survey, a representative sample of the civilian noninstitutionalized US population, to examine the relationship between care category and total health care expenditures, adjusting for potential confounders and effect modifiers. Survey respondents from households with either a married or a single woman aged 18 to 55 years as head of household and at least 1 child younger than 18 years were included. Only individuals reporting a family physican (FP) or general practitioner (GP) as their personal doctor were examined, since intergenerational family care is provided almost exclusively by FPs and GPs.
RESULTS: Family care provided by an FP or GP was associated with 14% lower expenditures for adults ($51), after adjustment for covariates (P = .04), compared with individual care provided by a family or general practitioner. Although not statistically significant, for children family care was associated with 9% lower expenditures ($19).
CONCLUSIONS: These findings suggest that family care provided by FPs or GPs is associated with lower health care costs. Policies promoting family care may reduce health care costs.
The need to contain costs is dramatically reshaping the health care landscape in the United States. As managed care has increasingly emphasized primary care tension has been growing between approaches to health care delivery led by specialists and those led by primary care physicians. Primary care is associated with lower costs,1,2 and for many conditions equivalent or better outcomes in comparison with specialist care.1-4 However, the mechanisms of such cost savings remain largely unexplored. We examined whether people who received intergenerational family care, the sharing of a personal physician across familial generations, had lower health care expenditures than those who did not.
Within primary care, family physicians have been shown to use relatively fewer resources, while providing equal quality care for several conditions.3,5 Could the emphasis on the family within family medicine explain some of these cost savings? The idea that patients should be treated in the context of their family and community has long been a core tenet of family medicine6-9 and was reiterated in the 1996 Institute of Medicine report on primary care.10 Since the family has been shown to influence both health status11 and health care utilization,12,13 proponents of family care believe it improves primary care quality,6,14-18 although supporting evidence for this belief is limited.19-23 Recently reported findings from the Direct Observation of Primary Care Study provide insight into some of the reasons why emphasizing the family may reduce costs.24,25 Medalie and colleagues24 found that study physicians devoted a significant proportion of time addressing issues related to family members, and Flocke and coworkers25 reported that the provision of care to a second family member occurred in 18% of outpatient visits, with the secondary patient present during only half the visits.
Using data from the National Medical Expenditure Survey (NMES), we previously reported that intergenerational family care, defined as the provision of primary care within a family by a shared personal physician for at least 1 adult and 1 child, was widespread, occurring in 35% of US families. Compared with other patterns of personal physicians within families, family care occurred more often in families residing in nonmetropolitan regions and outside of the Northeast, and in families with a woman as the head of household who was less educated, older, more likely to have Medicaid health insurance, and had higher unhealthy behavior scores.26
Because no previous studies have looked into the relationship between intergenerational family care and health care expenditures, we examined this issue using the 1987 NMES. This survey was conducted at a time when relatively unrestricted access to physicians in the health care system was the predominant mode of delivery in the United States. A significant relationship between family care and cost savings during this time would provide support for current policies promoting family care within managed health care on a fiscal, as well as ideologic, basis. We hypothesized that total health care expenditures for individuals would be lower when family care occurred, after adjusting for a number of potential confounders.
Methods
Sample
We analyzed data from the Household Survey component of the NMES.27 This component was a 1-year cross-sectional survey of nearly 35,000 individuals from approximately 14,000 households representing the US civilian noninstitutionalized population in 1987. The survey used a stratified, multistage area probability design with oversampling of minorities, the poor, the disabled, and the elderly. Four interviews were completed in 1987 to collect information regarding medical care, health expenditures, and health insurance coverage. Subjects completed a self-administered questionnaire that included a request for the name of their usual personal physician and selection from a checklist of that physician’s specialty type. We included in our study individuals who identified family physicians (FPs) or general practitioners (GPs) and who met our definitions of family care and individual care families. Approximately 50 families with a single man as the head of household were excluded because there were too few of them for meaningful analysis. Another 50 families with missing expenditure information were also excluded from the analyses. The final sample included 1714 children and 2516 adult men and women from families with either a married or a single woman aged 18 to 55 years as a head of household and at least 1 child younger than age18.