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.