The Primary Care Shibboleth: Debunking the Myth

By Robert E. Harbaugh, MD, FAANS, FACS, FAHA

Originally posted on February 7, 2013

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. Screening for ovarian cancer, testicular cancer and prostate cancer are other examples where preventive care produces no discernible 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 calls 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 $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. 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.

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19 Responses to The Primary Care Shibboleth: Debunking the Myth

  1. Bobby Gladd says:

    “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.”
    __

    Gotta keep the doors open, ‘eh? Looking forward, as reliable mobile apps linked to a variety of biometric sensors proliferate, how much of that “$8 billion” will be diverted there — and will it still get counted in the NHE?

  2. You said that “their” argument was: “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.”

    These arguments do seem simplistic and incomplete. But did Vladek, or any other individual, other than Dr Harbaugh, say this?

  3. It has been four days since my comment, and I see no reply.

    I can find no source of the three sentence quote above other than Dr Harbaugh, at least on Google. Again, if someone did make this argument, it is oversimplified and incomplete, and I have no problem with Dr Harbaugh refuting it. But I would like to see its source.

    On the other hand, if Dr Harbaugh made up this argument so he could easily refute it, that would be an example of a straw man argument, a type of logical fallacy. Note that on our blog, Health Care Renewal (http://hcrenewal.blogspot.com), we have frequently noted how logical fallacies have been used the US health care status quo (look here: http://hcrenewal.blogspot.com/search/label/logical%20fallacies ), a status quo that has enriched a lot of people and hence is resilient to change.

    By the way, there are plenty of good arguments for the importance of primary/ generalist care. Most are not nearly as simplistic as the three rung approach refuted by Dr Harbaugh. For a recent concise example, see: Starfield B. Politics, primary healthcare and health: was Virchow right? J Epidemiol Comm Health 2011; 65: 653-655. http://jech.bmj.com/content/65/8/653.full
    Maybe, as an exercise, Dr Harbaugh could see about debunking it.

  4. Robert Harbaugh says:

    To be clear, I said nothing to denigrate primary care physicians. I think that most primary care physicians, like most specialty care physicians, provide extremely valuable services to our patients for all the right reasons. I am tired of hearing that the solution to the significant problems of US healthcare is to reduce reimbursement for specialty providers and that preventive care will significantly reduce costs.

    • Joshua Uy says:

      It’s not that preventive care will reduce costs, it’s primary care that will reduce costs. Not by saving money, but by keeping specialists from over testing and over treating.

    • Mike Turner says:

      Robert, I think you are right in many respects. Just review the USPHS recommendations for preventive care – they recommend essentially nothing being done. Many studies actually support the fact that preventive exams are not helpful. Primary care physicians ARE under compensated however – THANKS to the RVU methodology. BUT, I agree with you that ‘robbing Peter to pay Paul’ is certainly at play here since THE HEALTHCARE PIE IS ONLY SO BIG. It ain’t growing because there ain’t any more money – simple economics right?. No one wants to go into primary care given the financials. Your comments about the primary care workforce are enlightening – once one considers internists, sub-specialists, NPs and PAs who deliver primary care out there.

      At the end of the dayI think that clearly we are moving into the realm of RATIONING care. The table is simply being set – has been set. Unfortunately, primary care groups eagerly signed on in support of RATIONING – either they know this would be happening OR they have been ‘played’ once again by the promise of a ‘seat at the table’.

      As I have watched the evolution and promotion of the medical home, I see no statistics suggesting this as a panacea to our healthcare woes. Certainly, the medical home has been successful in promoting quality in a cost efficient manner in certain select populations. Unfortunately, the medical home has been swept up and interfaced into the ACO concept. While the ACO baits physicians with the concept of potential ‘profit sharing’ with the government, the medical home actually becomes a rationing entity within the ACO – a variation of the ole ‘gatekeeper concept’ with teeth.

      I am a huge primary care supporter. While primary care has the greatest potential to facilitate quality care at less cost, culturally and politically WE missed the boat. The table has already been set, the incentives dangled, and the leadership took the hook, line and sinker to our detriment. I predict that primary care will slowly atrophy as more primary care physicians retire and the primary care workforce is progressively populated by foreign physicians, NPs and PAs. Clearly, the average medical student has figured out the game and I see no hopes of this changing in the future.

  5. Pingback: What is a shibboleth? « Training Family Doctors

  6. Pingback: Primary Care Needs Are No Myth | Wing Of Zock

  7. ProudOkie says:

    In his response from the AAFP, Jeffery Cain writes,

    “When a company or an industry becomes truly successful, one of the first real signs of that success is a new level of criticism aimed their way.”

    It is obvious he really didn’t think too hard about this powerful comment. If he is truly correct, then the attacks the he and the AAFP have been launching against Nurse Practioners must mean we are more than truly successful; we are dominating. Thanks for pointing this out Mr. Cain – the AAFP’s continued assault against Family Nurse Practitioners all over this wonderful nation are truly a badge of honor and show just how much progress for customers/patients we truly are making. Your comments are more true than you could have ever known.

  8. Neal Devitt MD, FAAFP, past president, New Mexico Chapter, AAFP says:

    One really should research the issue before posting, not doing so is akin to a physician diagnosing and treating a patient without performing a history and physical. The literature on the relation between access to primary care and the health of the community is robust, particularly the work of Shi and Starfield. In a nutshell, per capita primary care providers and nurses are associated with better indicators of community health while per capita availability of specialty providers and hospital beds have a negative association. The is not to say that one group is doing a bad job but to evaluate the impact of the relative societal investment in these resources on the ultimate health of the community. See:
    Health Status, Health Resources, and Consolidated Structural Parameters: Implications for Public Health Care Policy. Michael K. Miller and C. Shannon Stokes. Journal of Health and Social Behavior. Vol. 19, No. 3 (Sep., 1978), pp. 263-279.
    Primary care, infant mortality, and low birth weight in the states of the USA. Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R, Wulu J.J Epidemiol Community Health. 2004 May;58(5):374-80.
    Starfield, B., Shi, L., Grover,A., Macinko, J. (2005). The effects of specialist supply on population health: assessing the evidence. Health Affairs W(5): 97-107.
    Shi L. The relation between primary care and life chances. J Health Care Poor Underserved 1992; 3: 321–35.
    Leiyu Shi, DrPH, MBA and Barbara Starfield, MD, MPH. The Effect of Primary Care Physician Supply and Income Inequality on Mortality Among Blacks and Whites in US Metropolitan Areas. Am J Public Health. 2001 August; 91(8): 1246–1250.

  9. Joe Johnson MD says:

    Your entire post and argument is based on your own paraphrase of what “they” are saying. I have not heard anyone, anywhere, say more primary care providers will ” keep people from getting sick” ( your Rung 1). What you misread is that better , more comprehensive primary care will help prevent some of the health issues and complications of those issues, like obesity, leading to HTN and diabetes, which then leads to stroke, MI, etc… you know what happens. Certainly unhealthy behaviors will continue to be a problem, but more primary care will help to ameliorate or at least decrease some of the very expensive complications of poor health choices. Its sad to say, but lots of people really need a life coach to instruct them, encourage them and at times, fuss on them for unhealthy behaviors. Primary care does that. I see what you are saying about carotid surgery, but I can see a patient every 3 months to help manage their diet, encourage them on exercise, control their HTN , cholesterol and diabetes for probably less than 1/3 of what it would cost for you to do fix their carotid stenosis that results from inadequately treated HTN, DM, tobacco use etc….I do not think you are overpaid, but the goal is to not even get to the point of needing a procedure.Specialists SHOULD make more than primary care ( you have much longer training, more expensive malpractice etc) but the money tree is limited, and everyone is looking for the biggest bang for the buck.

  10. 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”

    From 2010-2011, the number of US medical graduates who were in neurosurgery increased from 1014 to 1061. During that same time, the number of geriatric fellows increased from 60 to 64. I could only wish that somehow geriatrics was languishing and lagging like neurosurgery. But apparently a person can make statements like the above by ignoring data. (google JAMA Graduate medical education 2011-2012)

    Being accused of doing unnecessary surgery may be “beyond insulting,” but that does not make the statement false. Insulting statements are not inherently false. Unless you refuse to look at data and only look at one’s hurt feelings.
    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
    Obviously a good pubmed search is in order here. Unless it is simply too insulting to look at data.

    If being insulted and being tired allows a person to make up truths, then this guy ought to keep on writing!

  11. Mike Turner says:

    Actually Harbaugh is fairly accurate in his comments.

    I am surprised that it took a whole team over at the AAFP to articulate a response.

    1- What justification are you using to suggest that sub-specialists and internists should not be included in total numbers of primary care physicians if in fact they are delivering primary care services?

    2- Actually, should we exclude nurse practitioners and physician assistants from the primary care work force as well? Actually, this group will probably exceed Family Practitioners in the next 10 to 20 years.

    3- Less than 20% of medical students entering internal medicine practice primary care for good reason – primary care is not financially viable.

    4- Statistics simply do not support the notion that having more doctors – primary care included – leads to a decrease utilization of healthcare services or improved outcomes.

    5- Sorry Jeffrey, but a goodly number of primary care visits simply represent a confirmation of what the patient already knows. That is why they call primary care ‘gate keepers’.

    6- I agree that continuity of care and relationships are important in controlling healthcare costs and delivering better quality care. However, when looking at statistics in toto, arguing that the medical home is the panacea for our healthcare needs is simply not justified. The medical home has shown limited improvements in quality when applied to specific populations. Even when used in specific populations, the medical home benefit is equivocal. I am not convinced that behavioral change methods are beneficial. At the end of the day, patients are driven by technology and demand answers and results based on use of this technology irregardless of behavioral techniques.

    7- The suggestion that primary care be paid more while specialty (procedural) care be paid less is precisely a ‘robbing peter to pay paul’ phenomenon. The healthcare pie is only so big and is not expanding – especially with the advent of Obamacare. It can not expand – there is only so much money to distribute. Simple economics.

    The problem lies in the creation of RVUs and agreements reached between organized medicine and the government concerning compensation for a given procedure or service. Unfortunately, primary care lost that battle in the beginning and continues to display total ineptitude in dealing with changes to RVU or SRG.

    8- As Harbaugh alluded, there ARE significant studies out there questioning the value of yearly physicals. I would refer you to the USPHS guidelines in any discussion concerning preventive care – ALMOST NOTHING IS RECOMMENDED. You really should take a look.

    I am a huge advocate of Family Medicine and primary care. In the proper context, primary care certainly has the tools at its disposal to improve quality of care at less cost to the system. Primary care should be rewarded for this. However, the monotonous promotion of medical homes and Obamacare while failing at every turn to impact RVU and SRG formulas will NOT lead to primary care success Primary care has not been financially viable for quite some time and NP/PAs are steadily invading the Family Physician’s turf. Don’t expect any of this to change in the future. Primary care is well on its way to becoming a third rail in the world of Obamacare.

  12. Joshua Uy says:

    Got me thinking now….
    Is primary care not worth the emphasis because:
    1. NNT is too high?
    2. QALY saved is too high?
    3. It doesn’t save money (no net savings?)
    4. Money could be better spent on public health measures?
    If 1 and 2, then what is your metric? Does neurosurgery meet your own metric? And how is it justified as a non arbitrary metric?
    If #3, then does that not disqualify secondary prevention (i.e. what neurosurgeons do) from being something worth spending money on? The only way to gain a net savings is to not treat disease (other than vaccines). Should we all just pack up and go home?
    If #4, I strongly agree that money would be better spent on public health measures than medical care.

    Are you saying that your salary is lower than mine because you bill the same CPT office codes but have higher overhead/insurance costs and your surgical fees are global? When I worked as a solo family doc on call 24/7, rounding 7 days a week, I started at $109,000. At Penn as a geriatrician my salary is $130,000. But by the magic of google, your salary is $825,196. High I’m sure because of being chair. Is that how much more valuable neurosurgeons are compared to FP/geriatricians? Somehow I don’t think our clinical revenue is similar. And I don’t think the higher reimbursement is simply swallowed up by higher overhead. I have a sneaking suspicion that neurosurgeons earn more than FP geriatricians.

    How can you say that you do not “denigrate primary care physicians” and that we “provide extremely valuable services” when you say that FP’s are people who “tell patients what they already know” and are unlikely “to have profound effects in modifying behavior”, “much preventive care doesn’t improve health” and as if all we do is sit around and engage in unproven interventions like “screening for ovarian cancer, testicular cancer and prostate cancer”. How is it when you provide counseling to a CEA patient that is valuable but when I see someone after a heart attack and manage lipids that is “untargeted.” So after saying that what you think we do (which is not accurate) is ineffective, what services DO we do that are “extremely valuable?” Somehow you telling someone to quit smoking is telling them something they don’t already know? Can’t have it both ways.

  13. Dave Mittman, PA says:

    I think that you all have lost the sense in common sense. If all you do is measure outcomes on a computer screen, move over and let other people take care of patients. Same with who gets reimbursed more, a neurosurgeon or a family doc, C’Mon. Reimbursement in primary care has not been fair for years. What does that have to do with neurosurgery or any other specialty?

    Let’s look at primary care. It is more than a source for outcomes research that can or can not show results. It is a place where a clinician (MD,PA, NP, DO) can look at a fellow person who has a problem and help them deal with it. In most cases, we can help alleviate the problem and clearly can alleviate the worry for the problem. Is that not important anymore? Is it cost to the system now that becomes the bellwether for one’s ability to practice?
    The physical exam is so much more than a way to pick up pathology that one can find on a CAT scan. What about the “black and blue mark” that makes you start to question the 18 year old who just started dating? Is it from her boyfriend or is she falling more lately? How about the lady who comes in for her dry skin and walks out with a referral for some talk therapy for her newly diagnosed anxiety. What have we all saved the system for that referral? Does it matter, or is it that we helped her that counts? What fear and sadness may we have saved the lady? The elderly man who stopped combing his hair, the lady with forgetfulness, the man getting up too many times at night to urinate, the teen with acne, the weird lesion you just looked at. All people with real concerns. All valid and scary to those people. Not all would go on to kill them. Some might. Anxiety can be mighty debilitating to the system. The obese man who is hypertensive who loses weight, that’s more of a victory, as is the diabetic who is now well controlled.
    If you know the patient well, most of these patients do not need high priced tests. They don’t need super-specialists; they need people who know them and care about them. That’s what medicine used to be about. Now it’s an argument about who should get paid more and who is more valuable than who. And yes, who should even be able to provide it.
    You seem to have forgotten what counts. Or maybe I am just too simplistic?
    Dave Mittman, PA, DFAAPA.

  14. George says:

    That’s well said, Dave.

    And while USPSTF recommendations are great at the end of the day you have to look patients in the face and decide what is best for them. My father had asymptomatic prostate cancer (Gleason score of 8) which was discovered by routine screening by a primary care physician. He had a prostatectomy and has PSAs of 0 for 20 years now. Following surgery, he went back to work for 10 years and continued to pay taxes and contribute to the GNP. I’m fairly convinced that our well-validated preventive guideines would have led to his early and miserabkle death.

    • Dave Mittman, PA says:

      Totally agree. And how do we measure happiness? Don’t mean to be polyanna but have we really lost that? Don’t think everything should be about guidelines.
      Great news about your Dad.
      Dave

  15. Ron Kaufman says:

    Simply put, the academic family doctors in all of their hubris did this to themselves by insisting, against all good judgment, that “family medicine” is its own specialty. Rather than making specialty training the purview of those physicians who learned and gained experience in the field before making the decision to specialize, they made it the goal of the over-eager medical student who sees the family doc and wonders if they got their degree from the Carib or from a DO school.

    You wanna see more primary care? Make all MDs able to practice it, and make residency matching something that established physicians, not wet-behind-the-ears medical students, do.

    But then again, the dumbest people in your class go into family medicine, so such a solution would never happen because it makes sense.

  16. Neal Devitt says:

    It is pathetic that someone without even rudimentary grammar calls others dumb. Read the references I posted on March 4. This post is offensive and should be removed.

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