I was forwaded a link to this blog post in an email. The author, a neurosurgeon, apparently feels threatened by the new found attention that primary care is receiving. As an academic physician, I suppose he offers an opinion that deserves serious comment. He offers the following as a strawman to knock down:
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.”
He finds the following (which he believes to be incorporated in this argument) to be not supported by evidence:
“If we invested more in primary care we could keep people from getting sick and save money.”
“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 remove the monetary incentives that lead surgeons to operate on patients solely for monetary reasons.”
He then offers the following in the way of conclusion:
For a carotid endarterectomy, my most common operation, Medicare pays about $1,000, 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. [emphasis mine]
Someone already referred him to the work of Barbara Starfield which refutes his entire argument against an investment in primary care. I couldn’t resist formulating a response to his concluding statement:
For a carotid endarterectomy, my most common operation,
Data is real clear: for this operation outcomes are better in centers, and outcomes are better when a dedicated operator does them. Is this his full time job or is he a hobbyist? What are his outcomes? I agree that Primary Care is not the answer to everything, but neither is gonzo surgery…
Medicare pays about $1,000, which covers my services for immediate preoperative care, surgical care and all postoperative care for 90 days.
My specialty colleagues inevitable response, it isn’t the doctors fault….Value based purchasing and bundled payments will change that perspective and make someone responsible for the totality of costs for the 90 days…wonder if he knows that the $1000 might be $500 or even $0 if things don’t go well?
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.
Again, “My practice.” Is the we the royal literature we, the local practice we, or the I think I do a good job we…
Unlike the unfocused preventive care discussed above, the NNT to prevent one stroke at two years is six.
Turns out critical carotid stenosis is not a random event. From this “population based” study:
Prevalence of and risk factors associated with carotid artery stenosis: the Tromsø Study.
Cholesterol, HDL cholesterol, fibrinogen, systolic blood pressure levels and current smoking were independently associated with carotid artery stenosis in both women and men. The presence of carotid stenosis was significantly associated with a history of cerebrovascular disease, coronary heart disease and peripheral artery disease. For each 10% increase in the degree of carotid stenosis, the risk of having had a cerebrovascular event increased by 26%…
I guess he’s worried we’ll cut into his “preventive” mission.
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February 21, 2013 at 3:42 am
Robert C. Bowman, M.D.
Correlation is not causation. One can make a better argument that health care quality is higher in states with better child well being. These are also states that have more reasonable health care costs. Such states have a better child before school, during school, and better education, employment, health care insurance, and other socio-demographic advantages.
At this site the state correlations can be seen demonstrating many correlations with cost and quality and all likely to influence each other in multiple ways. http://www.ruralmedicaleducation.org/quality.htm
How does one account for primary care correlations with higher quality and lower cost? Simple. States with greater child well being tend to have a wider range of socioeconomic types reaching medical school, more family physicians, and more primary care (upper midwest). By the way, the correlations in the US are actually about generalists per 100,000 and not all inclusive primary care.
In the state correlations, Internal medicine and pediatric primary care do not contribute to higher quality or lower costs. This is not because of problems with IM or PD. The reasons have to do with the states with higher levels of IM and PD and patient sociodemographics. Locations dividing into rich and poor (DC, southern states, major city dominated states) tend to have the worst of all situations
1. Highest income types that overspend
2. Lowest income types with lesser quality due to social determinants
3. High proportions of employed workforce involved in health care – with higher health spending and overspending
4. Lowest proportions of primary care
5. Most redundant care with more demand than the specialists can supply
6. Family structures less intact – influencing a number of outcomes
Starfield and others acknowledged social determinants and tried to use simple controls for these variables. These are poor controls as we now know from Hong in JAMA in Pay for Performance and the Oregon Medicaid Randomization. Simple controls fail to be adequate. College grad concentrations were often used, but are not good controls to use.
Until the US has enough primary care workforce (30 years minimum) and workforce reasonably distributed (employed family practice workforce), the arguments about cost and quality are premature. Quality cannot exist until there is access. Cost benefits are not likely until there is enough access. We are far from sufficient access with 33% of our nation putting off needed care, and 40% of so called primary care services not delivered in primary care offices.
Now that I have confused all, might as well add that the most subspecialized services at highest cost with little benefit that are often procedures done late in life – are costs that prevent investments in children in the earliest months and years of life when the benefits accrue throughout an entire life. Even investments in primary care could be considered premature, until our nation does much better in child well being. No improvements in cost, quality, or access will result unless we have figured out how to steadily improve US child well being. No health, economic, education, or other system can survive if we do not turn this around after decades of decline. And if we do turn it around, we will likely need less health care spending for the same result – just as states with the best child well being can spend less on health and on education – with the same or better results.
We are only beginning to see the consequences of failed child well being in any number of nations now wracked with political instability, distrust, and chaos. Oddly it is the very well off that have the most to gain by investing the most in children, since their children and grandchildren will share the nation and the consequences with those left behind. One cannot maintain being “well off” without some stability – stability that is only possible with stable or improving child well being for a nation.
March 1, 2013 at 6:03 am
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