The Primary Care Shibboleth: Debunking the Myth

Guest Post From Robert E. Harbaugh, MD, FAANS, FACS, FAHA
Director, Institute of the Neurosciences
Distinguished Professor & Chair, Department of Neurosurgery
Professor, Department of Engineering Science & Mechanics
The Pennsylvania State University
Milton S. Hershey Medical Center

At a recent Kaiser Family Foundation healthcare conference, Sustaining Medicare for the Future: What’s Next In the Debt-Reduction Debate?, Bruce C. Vladeck, who served as the Administrator of the Center for Medicare and Medicaid Services (then the Health Care Financing Administration) under President Bill Clinton, opined that healthcare costs “could be controlled by changing what Medicare pays for different services. Primary and chronic care are poorly paid while specialists are overpaid.”  This comes as no surprise, as repeated claims that specialists are overpaid and at the root of all our nation’s healthcare problems, while primary care physicians are underpaid and the linchpin to solving the healthcare cost, quality and access conundrum, is a shibboleth of many healthcare reformers.

Their argument goes something like this:  “If we invested more in primary and preventive care, we could keep people from getting sick and avoid the expenses of costly surgical procedures and other medical interventions.  This would result in improved quality and lower cost.  One way to accomplish this is to increase reimbursement for primary care services and reduce reimbursement for surgical specialty services.  This will incentivize medical students to enter primary care, where we need more doctors, and deter students from entering surgical specialties where we already have too many doctors.”   Bundled payments, Accountable Care Organizations (ACOs) and the Independent Payment Advisory Board (IPAB) are all based, to one degree or another, on these and related arguments.  While it is not fashionable to question such received wisdom, someone needs to point out that every rung of this argument is either rotten or missing.  As Mark Twain said, “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.”

Rung 1 – “If we invested more in primary care we could keep people from getting sick and save money.”

Does anyone really believe this? Some preventive care strategies, such as childhood immunizations, produce net savings because the vaccines are inexpensive and almost everyone is vulnerable to the diseases they prevent.  In this unusual case, the cost of providing preventive care is less than the cost of treating the illnesses they prevent.  However, this is the exception, not the rule.  Much preventive care doesn’t improve health.  For instance, a 2012 analysis of 14 large studies of the value of routine, annual physicals found that they do not lower the risk of serious illness or premature death.  Despite this, almost one-third of U.S. adults get these physicals at an annual cost of $8 billion dollars.  Screening for ovarian cancer, testicular cancer and prostate cancer are other examples where preventive care produces no discernable health benefits.

Another reason preventive care often does not reduce costs is that too many patients need to receive a given preventive service to avert just one illness. If effective preventive care could be provided to only those who would develop the illness, it would be cost-effective.  In reality, primary care physicians need to treat or screen very large numbers of patients in order to prevent one episode of illness. This Number Needed to Treat (NNT) is high because for many diseases, even without preventive care, only a small number of patients would develop the disease that the preventive care is meant to prevent.  Prevention costs money, and untargeted preventive measures will be given to a lot of people who simply won’t benefit.

It should also be noted that preventing illness can be more effectively addressed outside of the doctor’s office.  A brief meeting with a physician who tells patients what they already know isn’t likely to have profound effects in modifying behavior.  Reducing healthcare costs related to trauma, drug abuse, poverty, obesity, lack of physical activity and many other lifestyle issues can be better achieved outside the clinical setting.

Rung 2  “We need to increase reimbursement for primary care services and reduce reimbursement for surgical specialty services.  This will incentivize medical students to enter primary care, where we need more doctors, and inhibit students from entering surgical specialties where we already have too many doctors.”

We need to look at these recommendations very carefully.  For instance, according to the Organization for Economic Co-operation and Development (OECD) Health Database, the United States has a relatively high concentration of primary care physicians and a relatively low concentration of specialists compared to the OECD average of all countries.  In addition, the United States’ ratio of specialist reimbursement to primary care reimbursement is in the middle of the pack.  Despite this, our healthcare costs are by far the highest in the world.  It should also be noted that the growth in physician supply for surgical specialties like neurosurgery has lagged well behind the growth in geriatric medicine, pediatrics, internal medicine, family medicine and obstetrics and gynecology.  However, the projected increased demand for specialty care through 2025 is at least as great as the increased demand for primary care services.  The analysis by the Association of American Medical Colleges (AAMC) in 2010 estimated that 46,100 more primary care physicians will be needed by 2020.  This shortage has been widely reported.  The same analysis demonstrated a similar shortage for specialists – 45,400 — but this finding has been largely ignored.  Attempts to reduce the availability of specialty services in the face of these pending shortages and increased demand for their services will undoubtedly deny lifesaving care for many Americans.  Policymakers should, therefore, think long and hard before adopting measures that will divert additional resources from specialty care.

Rung 3 – “We need to remove the monetary incentives that lead surgeons to operate on patients solely for monetary reasons.”

Frankly, this is beyond insulting.  The vast majority of surgical specialists in the U.S. recommend surgery only when they believe it is the best option for their patients.  Much has been made of the variability in Medicare cost, utilization and quality from one region of the country to another as documented in the Dartmouth healthcare maps.  What isn’t widely reported, however, is that for surgical procedures with clear indications, such as hip fracture, this variability is minimal.  When surgical indications are nebulous, variability increases.  But rather than a blanket policy to decrease reimbursement for surgical procedures, organized neurosurgery is addressing this issue through the use of prospective clinical data registries.  Collecting clinical data will allow us to clarify the surgical indications, rather than deciding a priori that performing fewer procedures is the best alternative.

Finally, I would like to finish this missive with a personal perspective.  My practice deals primarily with cerebrovascular disease and neurocritical care and my time in the operating room is a small fraction of my clinical responsibilities. In addition to performing surgery, I manage my patients on the hospital floor and in the neurocritical care unit, take call and cover the emergency room for neurosurgical issues.  I see patients in my outpatient clinic, where I discuss risk factor reduction, medical management and monitor my patients for their response to therapy.  With my pre-operative patients, post-operative patients and patients who will never need an operation I have the same costs to operate a medical clinic as my primary care colleagues, but I pay a lot more for medical liability coverage.

For a carotid endarterectomy, my most common operation, Medicare pays about $1000, which covers my services for immediate preoperative care, surgical care and all postoperative care for 90 days.  In my practice, carotid surgery is recommended almost exclusively for symptomatic, severe carotid stenosis – where we have excellent data indicating that low risk endarterectomy is highly effective for stroke prevention.  Unlike the unfocused preventive care discussed above, the NNT to prevent one stroke at two years is six.  In other words, I practice preventive care that is highly effective and precisely targeted to the group most likely to benefit.  Despite all this, I am not counted among those preventive care physicians who Bruce Vladeck credits with being the answer to rising healthcare costs.  Instead, I am one of those overpaid surgical specialists who are part of the problem.  Someone needs to explain this to me.

This entry was posted in Access to Care, Coding and Reimbursement, Guest Post, Health, Healthcare Costs, Medicare, Quality Improvement and tagged , , , , , , , , , , . Bookmark the permalink.

9 Responses to The Primary Care Shibboleth: Debunking the Myth

  1. Ann Stroink says:

    Well stated Robert.

  2. Pingback: The Primary Care Shibboleth: Debunking the Myth | Wing Of Zock

  3. Pingback: Wing of Zock “Chart Review” Blog Carnival, March 2013 Edition | Wing Of Zock

  4. Joshua Raines says:

    Dr. Harbaugh,
    I am a 3rd-year family medicine resident from Akron, OH who is preparing to swim out into the murky waters of medicine and attempt to make something of the mess that has become our ailing healthcare system. I normally do not respond to posts on Blogs, but the older I get and more I see and read, the more I have trouble keeping my mouth closed. Regarding Rung #1 I both agree and disagree. First, the days of the yearly physical are singing their swan song and should be taken out to pasture. I am aware of the study you referenced, but if my young memory serves me correct the authors recommended that the time spent on yearly physicals could be better devoted to other aspects of a patient’s care that have more of an impact. I also agree that screening for ovarian, testicular, and to an extent prostate cancer should be taken out to pasture with the yearly physical. I also will admit that I don’t listen the hearts and lungs of every asymptomatic patient that I know well when I see them because my stethoscope is a diagnostic aid, not a screening tool. I also don’t have my patients fast before getting a lipid profile because recent evidence suggests there isn’t much difference between fasting and non-fasting states. Basically, we all do things because “that’s the way it’s always been done (like performing a yearly pelvic exam on an asymptomatic female).” We need more doctors asking “Why do I do what I do (I know, a very existential question)?” and practicing more evidence-based medicine. But regarding “preventive medicine” at large as you note above, I am somewhat befuddled and would ask that you be more specific about which “preventive” services you feel should be nixed. I trust that you aren’t speaking of preventive care such as breast cancer, cervical cancer, or colorectal cancer screening. You do make a valid point that could easily be overlooked: “targeted” preventive services do provide bang for the proverbial buck. This is why there are guidelines for screening that are readily available to all who seek their sage-like guidance. Unfortunately, in the world of preventive medicine and guidelines we do often find the rules not as black and white as indications for some surgery. We often operate in the realm of “not-enough-evidence-to-suggest-for-or-against….” and this can sometimes be seen as ineffective. Lastly, I whole-heartedly agree that there are aspects of a patient’s health that are impacted more outside the four walls of the exam room and beyond the reach of our best-laid plans. These are the social determinants of health and in many ways have more of an impact on patient health than our inventive clinical theatrics. Every once in a while it occurs to me that what I suggest to my patients has to play out in the real world where they have lives that aren’t always accommodating to 30 minutes of daily exercise. Regarding Rung 2: again, you point out something valid: physician shortages loom in EVERY area of healthcare. Right now it seems that the powers-that-be are a little “twitterpated” with primary care and have chosen to focus on this given the plans laid out in the Affordable Care Act. But please don’t throw out the proverbial baby…, well you know. A strong primary care base made up of astute clinicians who base medical decision making on trusted guidelines and in solid evidence can and have shown to keep costs low. Also, maybe rather than trying to manipulate students into choosing a specialty based on fame and riches we try something a little different such as not penalizing those of us who choose the path of medicine with exorbitant loan debt and thievish interest so that choosing a specialty is based more on how you see yourself best utilizing your God-given talents and picking a field based on that. Also, I think that as we move toward new payment models in primary care we may see less physician burn-out since we will be getting paid to do what we do: take care of our patients and coordinate their care, rather than run them through the current fee-for-service mill that pays less and less every year. Regarding Rung 3: Very insulting indeed. I am glad to hear you speak of quality improvement on the part of neurosurgery and I hope that the same can be said for other procedure-oriented fields as well. I will say that your statement about endarterectomy is interesting. I think we must be careful not to blur the lines of prevention and also not forget to discern between disease-oriented outcomes and patient-oriented outcomes. What we both do is prevention (in regard to stroke prevention, as well as other things) but our focus settles on different points in the spectrum – mine being more primary (prevention of an unstable plaque in the first place) and yours more towards secondary (preventing an already known plaque from causing an adverse cerebrovascular outcome). Not that I wish to belittle what you do, much on the contrary.
    I can tell that you are passionate about what you do, and I am glad that there are doctors like you who speak up and contribute to the conversation. I think that there will be people who will be polarized by your posting: some crying, “burn the surgeons.” Others the same of primary care. We all should continue to forge ahead with our patients’ health in mind, but being mindful of wasteful testing and screening (Which the American College of Physicians and other organizations have done recently). I think the larger questions we should be asking of our government and “superiors” are things like why are we all bickering amongst ourselves about our pay anyway when approximately 20 cents of every dollar spent on healthcare in the US goes to administrative costs and the CEO’s of insurance companies make substantially more than ALL OF US and they didn’t give up NEARLY as much as we did and don’t even have to be in the same room as a patient, AND they get to make decisions that affect the care of the people we as physicians serve. Why don’t we look at restructuring an already too-powerful insurance leviathan that recent reports show in 70% of large cities/marketplaces has very little competition and thus, no incentive to offer better coverage and lower premiums. Why are poorer, less-educated people dying 10-12 years younger than their better-educated counterparts? Why are there neighborhoods that have no access to grocery stores but have plenty of fast-food chains and gas stations that cater to snack foods? And why did I end up rambling so much? Why aren’t we doing more to fix the social determinants of health; investing more to problem-solve access rather than increasing defense spending? I think that overall the reforms taking place in pimary care are important for primary care and peripherally important for the rest of medicine as well. I just think that we can’t forget to ask the bigger questions; we shouldn’t get so distracted. If we do, our patients lose and so does this country. Thank you for your time

  5. Joshua Uy says:

    “It should also be noted that the growth in physician supply for surgical specialties like neurosurgery has lagged well behind the growth in geriatric medicine”

    I’ll start with just one point. From 2010 to 2011, the number of neurosurgery residents who were US medical graduates increased from 1014 to 1061 in the United States. The number of geriatric fellows went from 60 to 64. I wish geriatrics were lagging like neurosurgery! But that is what happens when people make up their arguments without data.

    Brotherton SE, Etzel SI. Graduate medical education, 2011-2012. JAMA. 2012 Dec 5;308(21):2264-79. doi: 10.1001/jama.2012.7913.

  6. Joshua Uy says:

    Being accused of doing unnecessary surgery may be insulting, but that does not make the statement false. Insulting statements are not inherently false. Unless you refuse to look at data.
    Up to 30% of surgeries in the US are “unnecessary”
    http://www.nytimes.com/1989/04/16/magazine/unnecessary-surgery.html?pagewanted=all&src=pm
    http://www.npr.org/templates/story/story.php?storyId=125627307
    And neurosurgeons are no exception.
    http://www.surgicalneurologyint.com/article.asp?issn=2152-7806;year=2011;volume=2;issue=1;spage=83;epage=83;aulast=Epstein

    unless it is simply to insulting to look at data.

  7. Steven Silodor says:

    PCP’s are asking to be paid more and not that surgeons be paid less.

    The Powers That Be are manipulating you to pit your specialty against those doing Primary Care. This is classic divide and conquer. Don’t fall into the trap. All physicians and patients must unite.

  8. John A. Wlison says:

    I read Dr. Jeffrey Cain’s response to “The Primary Care Shibboleth: Debunking the Myth,” by Dr. Robert E. Harbaugh, with great interest (http://bit.ly/V1xFsQ). As a neurosurgeon, I was encouraged that Dr. Harbaugh’s post generated interest and a response from our primary care colleagues. However, I viewed Dr. Harbaugh’s post not as an attack on primary care but as a response to the rarely challenged viewpoint that improved access to primary care is the answer to our country’s health care financing crisis.

    Dr. Cain sights “a wealth of published data” that associates increased availability of primary care specialists with improved quality and decreased cost of health care. What Dr. Cain fails to realize is that such an association, if present, fails to demonstrate cause and effect. The implication that increasing numbers of primary care doctors across our country would improve health care outcomes while lowering cost is simply unproven. The argument that populations of patients who regularly see primary care doctors have better outcomes at lower cost fails to account for the obvious selection bias in measuring outcomes in these patients.

    I was also very encouraged to read that the American Academy of Family Physicians agrees that primary care reimbursement should not be increased at the expense of surgical and other specialists. Cain postulates that improved reimbursement for primary care could come from healthcare savings that accrue through the care provided by primary care physicians. Although the feasibility of this remains to be seen, I would agree that gain sharing is an important element in a multi-pronged approach to controlling health care costs. Physicians of all specialties ought to share in the savings that come about from their efforts at improving effectiveness and efficiency of care.

    Above all else, physicians as a profession need to work together to ensure an adequate supply of specialists of all fields necessary for the health and well-being of our patients.

  9. Sean Martin says:

    I really enjoyed reading the blog and the comments it has incited. First, I will give my two cents on the income disparity. I would not argue that neurosurgeons train longer and do far more specialized work, often in highly stressful, life-threatening situations, as opposed to most primary care physicians. As a result, I would not argue they deserve to make more money. However, what strikes me is how large the disparity is.

    I admit, I am not nor have ever been a neurosurgeon, so I cannot attest the accuracy of the information, but I will cite according to Becker’s Hospital Review. The average compensation for a neurosurgeon last year was $690,000. For a family practitioner…$208,000. Both do very well financially by all standards. However, last I checked, medical education costs the same for those who become neurosurgeons as well as family practitioners, meaning their debt burden is the same. Yes, neurosurgeons train longer, but they are paid (admittedly a pittance of what their skills deserve) as opposed to accruing more debt during their post-graduate training.

    Secondly, as I note above, there seems to be a significant discrepancy as to the value afforded to PCPs in our healthcare system relative to neurosurgeons. If you go by training (which would be ridiculous), family practitioners and internists should make 64% of what neurosurgeons do (7 years of medical training vs 11 years). But if you look at value to the system, what should this discrepancy be? Do we really as a society believe neurosurgeons are greater than 3X more valuable to healthcare than PCPs? I do not know if neurosurgeons should be paid less, or if PCPs should be paid more, but I do believe this disparity needs to change somehow.

    Finally, I want to point out the central premise of the blog, which I think has been lost with the back and forth between PCPs and specialists. Dr. Harbaugh’s ultimate premise, in my opinion, is correct: people who think we are going to fix the healthcare system by tweaking physician salaries are crazy. It is not about what we as physicians are paid, it is about how healthcare is delivered and paid for in this country. In this respect, I think Dr. Harbaugh (along with some of the other commenters) makes some excellent points – much of what we do today in healthcare is a waste of time and money. Until we focus on outcome driven value, our system is in deep trouble regardless of what PCPs or specialists are paid.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>