Primary Care Needs Are No Myth

By Jeffrey Cain, MD, FAAFP, President, American Academy of Family Physicians

In “The Primary Care Shibboleth: Debunking the Myth,” Dr. Robert E. Harbaugh (a neurosurgeon) does a grave disservice to family physicians and medical students who value the professional satisfaction, intellectual challenges and career-long patient relationships of primary care.

He does so by attacking primary care medicine and denigrating the value of family physicians.

He is misinformed.

Primary care should be the critical foundation of our health care system. A wealth of published, credible data supports the value of primary care and prevention:

Harbaugh wrote, “The United States has a relatively high concentration of primary care physicians and a relatively low concentration of (sub) specialists compared to the OECD average of all countries.” Unfortunately, this statistic is skewed by counting all of “internal medicine” as a primary care specialty, erroneously including medical sub-specialists as primary care. The truth is the ratio of primary care and sub-specialty care proven to produce the best outcomes is now out of balance in the United States and threatens to get worse. Currently less than 20 percent of medical students who enter internal medicine residencies go on to practice primary care.

Harbaugh asks if anyone believes that by investing more in primary care, we can prevent people from getting sick and save money. It may come as a surprise to Dr. Harbaugh, but not only do our nation’s health care policy experts acknowledge the value of investing in primary care, but so do many of the nation’s top business executives.

Harbaugh misses the point of primary care by describing it as “a brief meeting with a physician who tells patients what they already know.” Primary care’s strength is in continuity, the relationships formed with patients over years that allow early detection and intervention in medical illnesses. Family physicians are trained in effective behavioral change methods proven to make a difference in the health of their patients. Investing in primary care and the patient-centered medical home reduces overall system costs by reducing unnecessary hospitalizations and unnecessary emergency department visits.

Overall, Harbaugh fails to acknowledge the very real cost and patient safety differences in primary, secondary, and tertiary prevention. His example from his own practice is the carotid endarterectomy, an example of tertiary prevention. Indeed, if a patient had access to a primary care physician to help control blood pressure, smoking cessation, and prescribe statins when necessary, the patient might even avoid the need for this procedure with its associated high costs and surgical risks.

Furthermore, we cannot hide from the truth. Primary care is among the lowest paid physician specialties in the United States, a travesty given the overall value that primary care brings to our patients, communities, and the health care system. This huge income disparity has a profoundly negative impact on our country’s future workforce. The average medical student today has more than $161,000 in education debt after medical school. Data increasingly show that debt and earning potential are swaying student specialty choice.

To close the gap in medical student specialty choice, the Council on Graduate Medical Education’s 20th report recommended that primary care physicians be paid at 70 percent of sub-specialists’ pay. When our Canadian colleagues faced a similar decrease in primary care student interest 10 years ago, they increased the mean salary of family physicians and now have more medical students entering family medicine than ever.

Harbaugh interprets the data narrowly and quite selectively. The professional societies representing primary care have never advocated “robbing Peter to pay Paul” by increasing payments to primary care physicians at the expense of surgical specialties and other subspecialties. The American Academy of Family Physicians’ position has always been that savings from preventing avoidable emergency department use, hospitalizations, readmissions, procedures and tests will more than pay for improved payment for primary care.

Harbaugh says patients are the priority, and we couldn’t agree more. If we are to address the toughest challenges in medicine, we must respect the value and expertise of all our medical colleagues — primary care and subspecialists alike. By bringing physicians together, we can have a profound and far-reaching impact on medicine. But most importantly, we can do what is best for the health and well-being of our patients.

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0 Responses to Primary Care Needs Are No Myth

  1. John A. Wilson says:

    I read Dr. Jeffrey Cain’s response to “The Primary Care Shibboleth: Debunking the Myth,” by Dr. Robert E. Harbaugh, with great interest. 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 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.

    • Mike Turner says:

      Very nice points sir.

      “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.” VERY TRUE. THERE IS NO PROOF THAT INCREASING NUMBERS OF PRIMARY CARE DOCTORS ACTUALLY IMPROVES HEALTH OUTCOMES. PURE SPECULATION.

      “I was also very encouraged to read that the American Academy of 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.” I SUSPECT THAT JEFF THINKS THAT PHYSICIANS WILL ACTUALLY SHARE COST SAVINGS ACCRUED THROUGH THEIR RATIONING OF CARE FOR MEDICARE, MEDICAID AND THE INSURANCE INDUSTRY. IT IS NICE TO DREAM! SINCE THE AAFP IS INEPT IN MODIFYING THE RULES (RVUs and SGR), THEY ARE TRYING TO SELL PRIMARY CARE ON PARTNERING WITH THE FEDS IN ASSUMING RISK IN RETURN FOR HYPOTHETICAL PROFIT SHARING. WHAT A JOKE!

  2. Joshua Uy says:

    I would love to see data that the high salary differential of neurosurgeons is justified by outcomes (i.e. that it is worth it). Allow me to paraphrase. Until we have data, “such an association, if present, fails to demonstrate cause and effect. The implication that increasing numbers of neurosurgeons across our country would improve health care outcomes while lowering cost is simply unproven. The argument that populations of patients who see neurosurgeons have better outcomes at lower cost fails to account for the obvious selection bias in measuring outcomes in these patients.”
    If neurosurgeons can demonstrate that the money spent on their specialty is more worth it (i.e. Quality adjusted life year saved), then they deserve the differential. Until then, there is nothing to justify their specialty. Is that what Dr Wilson is implying? That we need hard data to justify money spent on each specialty? Then it cuts both ways.

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