Author Archives: jpwmd

The Problem

The September 27, 2022 issue of the Journal of the American Medical Association (V. 328, No. 12) devoted almost half of its pages to “Firearms and Violence,” in the form of well documented opinion pieces. The effort is chockfull of arresting data.

The first article pointed out that mass shootings get the major portion of publicity on gun violence, but that “only” three percent of deaths from guns are attributable to automatic rifles. The real problem lies with hand guns, especially in regard to suicides.

In the period from 2010 to 2020 in the US, of all firearm deaths (45,222 in 2020, for instance), 60 percent were due to suicides. Looked at a different way, among all suicides, over 50 percent were carried out with firearms. In youth aged 10 to 19 who died by suicide, 42 percent used a firearm, almost always one that a family member owned.

71 percent of people who attempt suicide do so within an hour after deciding to do so. Two thirds of survivors of attempted suicide never try again.

Approaches to the problem

One editorialist in the above cited JAMA issue stated that any serious approach to gun regulation must address firearm suicide. There has been a scattering of somewhat modest attempts to legislate gun control, but these vary significantly by state. Legislation called “Red flag” laws is one initiative, but only 19 states have passed such laws.

These laws allow almost anyone (usually a family member, a friend, a therapist, etc.) to petition a court for an order to prevent someone from accessing a gun. Only nine states have such legislation, but such laws are problematic anyway. They generally require burdensome paper work by the concerned individual who fears for the safety of an individual perceived to be at risk for suicide, and a court appearance is part of the petition. Most importantly, initiating such an action can compromise an important relationship with the person thought to be at risk for suicide.

Child access prevention laws (“CAP”s) require gun owners to secure guns in their homes and not provide a minor with a gun. Laws like these have been linked to a decrease in youth suicides, but most are weak and poorly written.

Given the impulsiveness attending many suicide attempts, I have thought that legislating “cooling off” periods make sense. These measures require a time period between purchase of a firearm and possession. States with waiting periods for handgun purchase have experienced a decrease in suicides overall from 11 to 27 percent compared to states without them. Only nine percent of states have such laws on the books, however, and Oklahoma, in the name of protecting Second Amendment rights, has proscribed them.

In general, there is evidence that states with the fewest laws that regulate guns experience the greatest suicide rates, but studies that support this are weak. This is true of most gun control measures. You can’t randomize people to bestowing guns on their children versus no guns.

Implications

Legislation that meaningfully regulates automatic rifles is important, but it is not where the real money is. In fact, I fear that if our society were, for instance, to outlaw ARs, we might erroneously think that the work on gun control is done. But regulating handguns is where the low hanging fruit lies, and commonsense approaches could save thousands of lives each year.

The

I recently found a spot on my arm that worried me. My regular dermatologist was not available for an appointment as fast as I wanted, so I decided to check out a new dermatology clinic in my town. I got an appointment for the next day, but when I looked up the credentials of the practitioner with whom I was scheduled, I found she was a nurse practitioner, not a physician. I cancelled the appointment as I was distrustful of an organization that did not disclose that I was signing up for an appointment with a nurse practitioner. Had I been told I was not seeing a physician, I probably would have kept the appointment. At any rate, the experience prompted me to look into the training and practice of nurse practitioners and physician assistants (now referred to as “physician associates)–something I have been meaning to do for some time.

Training

Nurse practitioners (NPs) are registered nurses who have completed an NP-focused graduate program. To practice, they have to pass a national certifying exam.

Physicians associates (PAs) have a bachelor’s degree and then undergo a three year PA program with heavy emphasis on clinical training. They too must pass a national certifying exam.

In about half the states, NPs can render care independently, with no physician supervision. PAs require a greater degree of physician supervision, although their association is working to gain greater practice autonomy.

Need

The need for primary care clinicians in the US is a big reason that the movement to NPs and PAs has prospered, as experts in the physician workforce predict an ever greater shortage of physicians. The most alarming statistic is that, currently, 95 million Americans lack access to primary care. In 2004, there were 106,000 NPs, whereas there are 355,000 today. In 2010, there were 89,019 PAs; today there are 159,000. In comparison, there are almost one million practicing physicians in the US, about 40 percent of whom are primary care providers.

Quality of Care

As a primary care physician (retired), I have been circumspect about NPs and PAs, as they simply do not have the amount of training physicians undergo. In researching this blog entry, I was ready to call for studies that compared the quality of care rendered by NPs and PAs compared to physicians. In fact, there are many, and many of them are of high quality. In randomized trials, quality control parameters such as glucose control in diabetics and blood pressure control demonstrated no difference between NPs and physicians. Prescribing preventive measures such as vaccines and mammograms also showed no difference. Importantly, patient satisfaction with NPs was no different from physicians’ ratings.

The Future

Given the inability to receive timely care, many patients have begun to accept non-physician care. Wanting to avoid long waits for an appointment with a physician, they often turn to immediate care clinics that are staffed by NPs and/or PAs. Major pharmacy chains are getting into the primary care business too, and given that PAs and NPs earn less than half of primary care practitioners ($115,390 and $111,680 per year, respectively), profit without physicians is greater. And quality does not appear to be compromised.

Given the research data I have cited, I wonder whether I was overtrained. Regardless, it is clear the direction the clinical care workforce is taking–a phenomenon that is being largely driven by patients. And there appears to be no reason to think this trend compromises healthcare.

Most of the information in this post came from the “Medical Economics Journal,” V99, Issue 9, September 2022. It is readily accessible to anyone online.

By the way, my spot was “nothing.”

I think it was Winston Churchill who said that Americans always do the right thing… after trying everything else.

This observation applies in medicine. In a recent blog (see blog entry of February 28, 2022), I detailed the story of drugs and procedures that had leaked into the medical armamentarium without proof of effectiveness, only to eventually fall to the power of well executed studies that demonstrated their uselessness (and possibly their danger). Enter vitamin D.

Vitamin D in its Heyday

About 10 million tests for vitamin D levels are done yearly in the US, and over one-third of US adults over the age of 60 take the supplement. In 2017, consumers spent almost one billion dollars on vitamin D, and Medicare patients incurred a bill of $365 million on testing levels of the vitamin in the blood in 2016.

The leading advocate for vitamin D is Dr. Michael Holick, a Boston University endocrinologist, who, according to a 2018 article by a writer for Kaiser Health News, almost single handedly created the vitamin D sales and testing industry. He has realized significant financial benefit from the drug industry and laboratory testing concerns.

The supplement has enjoyed a remarkable run in recent years, with claims that it prevents cancer, cardiovascular disease, and falls. Among other maladies, it was alleged to improve cognitive function and decrease age-related macular degeneration. Perhaps it most prominent claim to fame was the assertion that it prevents osteoporosis and fractures.

However…

It does none of these things.

Decisive Study on Vitamin D Supplementation

Researchers recently published a state of the art study (prospective, randomized, controlled) in the New England Journal of Medicine (July, 2022) that investigated the usefulness of vitamin D for the prevention of fractures in men over the age of 50 and women over 55. Parts of this study had already examined the effects of vitamin D supplementation on cardiovascular disease and cancer.

25,871 participants were randomized to vitamin D or placebo. Median followup was 5.3 years. Long story short, the placebo group had no different outcomes compared to the vitamin D group, no matter what the level of vitamin D in the blood.

In an editorial that accompanied the above noted research, the writer noted that the trial showed that the “lack of effect for preventing numerous conditions suggests that providers should stop screening for 25-hydroxyvitamin D levels or recommending vitamin D supplements, and people should stop taking vitamin D supplements to prevent major diseases or extend life.”

I predict strong pushback to this definitive study from the manufacturers of vitamin D. They may want to engage the services of the gifted advertisers of Prevagen, another multibillion dollar medicine that is wholly ineffective (see blog entry on May 28, 2022).

Nota Bene: there are legitimate medical indications for vitamin D supplementation. If you are taking vitamin D, you should not unilaterally stop it on the basis of this blog or the article cited in the New England Journal of Medicine. Consult your doctor.

On August 7, I posted a piece on the high price of insulin. A physician friend pointed out that the figures I quoted would result in about a $90,000 per month cost of an average insulin user. This would exceed even the greatest ambition of the drug companies, Instead of the cost per unit of insulin, I should have written cost per vial of insulin. This correction does not change the import of the posting, to wit, that insulin prices in the United States are eight times higher, or so, than in other developed countries.

Apologies.

37 million people in the United States have diabetes, seven million of whom require insulin.  Insulin* is a hormone that regulates the level of blood sugar in the body and is necessary for life.  The cost of insulin for insured patients ranges from $334 to $1000 per month, and this cost represents a tripling in the last decade.  These prices are the highest in the developed world.  In Canada, for instance, the cost per unit of insulin is $12, whereas the cost in the U.S. is $98.70.  

Early this year, the House of Representatives passed President Biden’s Build Back Better bill, which would cap the cost of insulin at $35 for a 30 day supply.  It stalled in the senate.  A recently negotiated “Inflation Reduction Act” (action pending in Congress as of this writing) promises to cap out-of-pocket drug expenses at $2,000 per year for those enrolled in Medicare drug plans and cap insulin costs at $35 per 30 days (There would be no effect on the cost of insulin in private insurance plans).

I will let an endocrinologist (a physician who specializes in the care of diabetic patients) from Mayo Clinic illustrate the consequences of not being able to afford insulin:

Alec Smith was 23 when he was diagnosed with type 1 diabetes. He worked as a restaurant manager in Minnesota. At age 26, he could no longer stay on his mother’s health care insurance plan and needed to find his own coverage. On June 1, 2017, he was on his own. The insurance available to him came with a $7600 deductible and a monthly premium of approximately $440. Because he could not afford this, Alec decided to temporarily forego insurance coverage and purchase insulin with cash. Unfortunately for him, the cash price of insulin was far beyond his means.  He decided to try and ration the amount of insulin he took till he had enough savings to purchase insurance. Sadly, on June 27, 2017, he was found dead in his apartment of diabetic ketoacidosis

Of course the big question is WHY IS INSULIN SO EXPENSIVE in the United States?

The pharmaceutical industry says that the high cost of developing drugs is the reason for the high prices.  Of course insulin has been in medical use for a hundred years, and the most commonly used preparations currently (“analogs”) have been available for about 20 years.  So I do not understand how recent research has caused the price of insulin to triple in the last decade.

I think a better explanation for the high price of insulin lies in the fact that three companies control 90 percent of the insulin market.  This virtual monopoly “serves” a vulnerable population that  must buy the preparations, regardless of the cost, or risk the fate of Alec Smith.  

Or maybe lobbying has something to do with it (do you think?).  In 2021, $3.77 billion was spent to lobby Congress and federal agencies.  At the top of the list of industries that spent the most on lobbying was the “Pharmaceutical Research and Manufacturers of America,” coming in at $187,414,530 in expenditures.

Consumer Medical Decisions in the Marketplace  

There is nothing illegal about any of this.  The drug companies are simply maximizing profit, an activity on which our market driven economy is based.  The underlying question is whether healthcare should even be subject to the rules of capitalism.  

There are many advocates of making healthcare more market based, that is, confer more decision making power on the consumer.  If people can research washing machines before purchasing one, why not let them, unrestrained by labyrinthine insurance rules, shop for a cardiac surgeon?  

The trouble is that healthcare does not obey the rules of the marketplace.  Insurance policies limit choice, and geographical constraints also restrict alternatives.  And of course, even for the most sophisticated medical consumers, trying to penetrate the fine print in insurance policies is almost impossible.  

But there are even bigger obstacles to informed medical decision making.  If you find yourself in an emergency department with acute appendicitis, how can you be expected to look around for a surgeon you like?  And of course emotion clouds judgment.  How can anyone be expected to make rational decisions for an incapicated loved one with a life threatening illness?

The marketplace mostly works admirably when it comes to buying a car.  For healthcare, the marketplace is an awkward fit at best.

*For the sake of simplicity, I will use the term “insulin” to include its natural form and the analog form, which mimics the action of natural insulin with advantages in absorption, distribution, metabolism, and excretion.

Leading into 1955, there were about 16,000 cases of polio per year in the United States.  Dr. Jonas Salk produced a vaccine against this terrifying public menace, which he tested on himself, his wife, and his three sons.  Soon after, on April 25th, 1954, a trial was instituted with 1.3 million children as subjects.  It was done with the highest clinical research standards (randomized, controlled, and double blind) and the study found the vaccine to be 80 to 90 percent effective in preventing polio.  A day after the results of the study were released, the vaccine was licensed.  Today, polio does not exist in the United States.*

I received the vaccine in 1955 when I was eight years old.  In later years, my mother spoke to me about the agonizing decision she and my father, and all parents, had to make to allow their children to get vaccinated.  There was no question about the immediate effectiveness and short term safety of the vaccine, but what about long term complications?

Recalling this conversation, I have a lot of sympathy for the difficulty parents face today regarding vaccinating their children against Covid-19.  A month after little kids became eligible for the vaccine, only 5.3 percent of Illinois children have received at least one dose.  As with the polio vaccine, there is no question about the short term safety and efficacy of the Covid vaccine.  But there can be legitimate questions about long term side effects.  Supply issues may be part of the problem for the low numbers, but I wonder how much influence vaccine naysayers may be playing a role in the small numbers. 

Dr. Marty Makary is a surgeon with a masters in public health at The Johns Hopkins University School of Medicine.  He is a prominent critic of the government’s response to the Covid epidemic and has frequently appeared on Fox News (where he faces uncritical, simpering interviewers) with messages that question many of the interventions that the government has undertaken to prevent/treat Covid.  

He published a piece in June of this year about “6 things parents need to know” regarding vaccinating children between 6 months and 5 years of age.  He feels the studies on which the CDC (Centers for Disease Control) based its recommendation to vaccinate were too small to make definitive decisions.  And that, at any rate, 75 percent of children between zero and 17 years of age already had the disease, and were therefore already immune. 

I believe many of his points are worthy of debate, but I am struck by the omission of other important considerations that should go into decision making on whether to administer a Covid vaccine to children.  One is the “Multisystem Inflammatory Syndrome” in children (MIS-C). This is a rare condition that appears to be related to Covid infection.  Its manifestations are protean and can be life threatening.  Vaccination against Covid confers a high level of protection against MIS-C.

What about the “long haul” complications of Covid infection in children?  You can find alarming studies that document symptoms like debilitating lassitude that last for over 120 days after infection, even in some children with minimal or no symptoms at the time of infection. Vaccines have only recently been approved in children, so their effect on the incidence of the long term complications is unknown.  But it is something to consider.

And even if Covid infection in children is not very dangerous, does vaccinating children help to safeguard the adult population, especially the elderly?  Probably.  Computer models have shown that vaccinating children can reduce Covid infections by 11 percent in the general population.  Even if unproven, vaccinating children to reduce the possibility of Covid infection in grandma and grandpa seems like a worthy public health measure.

Finally, vaccinating children may be worthwhile even if they have been infected with Covid.  Considerable evidence exists that “double immunity” (immunity that results from “natural” infection and  vaccine induced immunity) is superior to the immunity gained from getting the infection.

In previous posts, I have decried “misinformation by omission.”  Dr. Makary’s “six things” piece is a good example of this.  I do not believe that cherry picked opinion is helpful to parents who are faced with an understandably difficult decision about vaccinating their children.

*At the time of this writing, the first case of polio in the United States in ten years was reported.

The role of stress in the pathogenesis of disease (how diseases start and progress) has long been the subject of medical research.  

Hypertension (elevated blood pressure sustained over time) has been one of the main targets.  There is no dispute that episodic stress can temporarily elevate blood pressure, but researchers have not been able to link stress with actual hypertension.  In other words, stress does not seem to chronically elevate blood pressure to the point of a higher risk for cardiovascular disease such as strokes and heart attacks.

What about cancer?  Again, there is no evidence that stress is implicated in causing cancer.  But there is plenty of research that demonstrates stress can be a major factor in exacerbating established cancer.

So a recent study in the Journal of the American Medical Association caught my attention: “Association of Mental Stress-Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease.”  In other words, does mental stress predict increased risk for future adverse cardiac events?

The exercise treadmill test is the tried and true method for assessing the presence of coronary heart disease (i.e., narrowed arteries that compromise the flow of blood to the heart muscle, causing heart attacks).  Monitored subjects exercise on a treadmill, and electrocardiograms and sophisticated imaging techniques can fairly reliably predict the presence or absence of significant cardiac disease.  It is a very useful method for patients with obscure chest symptoms and/or as a means to follow possible recurrences in patients with established coronary heart disease.  This method induces physical stress.

But what about psychological stress?  Although many studies have found a link between psychological stress and the risk of coronary heart disease,  they are far from definitive—they are small, largely anecdotal, and lacking in ethnic, racial, and gender diversity.  

In contrast, researchers in the study cited above looked at almost 1,000 diverse patients with established coronary heart disease.  They induced mental stress (public speaking challenge) and used sensitive techniques to detect the presence of cardiac ischemia (i.e., decreased blood flow to the coronary arteries).  They then used conventional stress testing (i.e. treadmill exercise) to test for the presence of coronary ischemia in the same population.  All patients were followed for an average of five years and were monitored for subsequent cardiac events.

The results showed mental stress-induced ischemia to be a significant predictor of future heart attacks and deaths.  Patients who displayed conventionally induced ischemia on the treadmill test were also at higher risk of future heart attacks and death, but at only about two-thirds of the rate of patients who displayed mental stress-induced abnormalities.* 

The authors of the study, and an accompanying editorialist, were careful not to make any wild claims about the implications of the work.  Is mental stress ischemia modifiable? Is the test for mental stress reproducible in multiple clinical settings? Should patients with coronary artery disease be screened for mental stress ischemia, and, if so, what interventions might be undertaken?  Should we view stress, along with other known cardiac risk factors such as smoking, obesity, diabetes, hypertension, sedentary lifestyle, and elevated cholesterol, etc., as another factor that should be assessed in the stratification of risk for cardiac disease?

This study is a valuable contribution to answering these questions.  But no one knows for sure what the role of psychological stress is in heart disease.  This issue will be an increasingly important research topic, and much needs to be done.

*Patients who had abnormalities with both physical and mental induced stress had the highest risk.

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When your car needs servicing, you want a mechanic who is honest and reliable.  When you need to hire a lawyer, you want someone who knows your area of need and has a record of success.  Do you exercise the same level of scrutiny when you schedule a colonoscopy?  You should.

Background

Adenomas in the colon (i.e., the large intestine) are benign tumors that have the potential to turn into cancers.  Screening colonoscopies can detect these tumors and the colonoscopist can remove them without doing another procedure.  Widespread screening has reduced colon cancer and related deaths by detecting and removing cancers at a stage when they are more treatable.

How Good Is Your Colonoscopist?

A recent study examined colonoscopists’ adenoma detection rates (ADRs: the percentage of colonoscopies where at least one adenoma was found) in performing colonoscopies and compared the rates to the subsequent development of colon cancers.  Kaiser Permanente’s vast store of medical records supplied the data, and 852,624 colonoscopies were analyzed.  To make a long and somewhat complicated story short, the patients of physicians with lower ADRs had almost double the incidence of colon cancers compared to patients of physicians with higher ADRs (3.10 vs. 1.79 per 10,000 patient years).  And the higher the ADR, the better.  

Measuring Effectiveness

Currently, the minimum ADR for acceptable performance of colonoscopies  is 25 percent, according to an article published in Gastrointestinal Endoscopy in 2014. Alarmingly, in a survey of 250 gastroenterologists who perform more than 80 colonoscopies per month, 20 percent responded that they did not keep track of their ADRs.  Even more alarmingly, the worst performers miss more than 90 percent of the colonic adenomas.  

Nevertheless, overall, screening colonoscopy reduces the risk of death from colon cancer by about 70 percent.  Think how much better it could be.  For your next colonoscopy, ask your colonoscopist what his or her ADR is.  If the information is not available, find a colonoscopist who keeps track of this vital statistic.

You do not watch television if you have not seen the remarkable ad campaign for Prevagen, an over-the-counter supplement for “brain health.”  The advertising industry has outdone itself with slick, convincing anecdotes that report the amazing benefits of this drug that hit the market in 2007.  These efforts appear to be highly effective in tantalying people to buy the product.  In 2019, Quincy Bioscience, makers of Prevagen, spent $67 million on ads for the product, and realized $165 million in revenue for this product in 2015 (attempts to verify and update these numbers from the company have met with no response)

One little problem: the advertising campaign bears all the marks of fraud.

Background

First, what is the basis of the supplement?  There is a protein in jellyfish, apoaequorin, that is also in the human brain.  The idea is for people to ingest the supplement that has the protein and have it travel to the brain to improve “healthy brain function, sharper mind, and clearer thinking.”  The protein, however, is broken down in the digestive tract and has no chance to take up residence in the brain.

Undaunted, Quincy conducted one trial (serious science would require many studies in multiple settings with diverse populations) of the drug that found a slight advantage for memory in a small number of subjects.  The quality of the research has met with virtually universal derision.

Nevertheless, the FDA (the federal Food and Drug Administration) approved Prevagen as a supplement for over-the-counter sales.  The decision to market Prevagen as a supplement was critical to the approval process.  “Pharmaceuticals” are subject to far more rigorous testing, and, in the words of an executive at Quincy, they did not want to wait for the extended time that would be necessary to approve a drug, rather than a supplement.  In addition, the company was careful to refrain from asserting benefit for a described disease entity, like Alzheimer”s Disease, limiting itself to  claims for improvement in symptoms.  This avoided elevated levels of regulatory scrutiny.

A Fusillade of Criticism and Lawsuits

In recent years, Prevagen has gained notoriety for reasons Quincy had not planned on.  In 2017 the Federal Trade Commission (FTC) and the New York Attorney General sued Quincy Biosciences for making false claims,citing the senselessness of the “science” that underlies the supplement’s supposed benefits,  On the bandwagon of criticism of the inadequacy of the clinical studies that claimed benefit for taking Prevagen, the FTC noted that the company’s own clinical study in actuality showed no statistically significant improvement in memory and cognitive function between those given Prevagen and those given a placebo.  The FDA has opened a case stating that Prevagen did not warn its users that seizures and strokes were some of the many adverse side effects reported by people taking Prevagen.  Curiously, memory impairment and confusion are also possible side effects that the company has chosen to ignore.  Finally, by 2020, seven class action lawsuits have been filed against Quincy regarding allegations of false advertising. 

Failure on Multiple Fronts

Clearly there has been regulatory failure, maybe even mischief, in the approval of Prevagen.  But the libertarian streak in me thinks that people who allow themselves to be entranced by transparently exploitative advertising get what they deserve.  On the other hand, I am very angry at the naked cynicism of a company that pushes a useless, maybe even dangerous, product in the pursuit of profit.

In a recent post, I documented the wide disparity between the incomes of primary care physicians and procedure oriented specialists.  On average, the net incomes of primary care physicians are 69% of specialists’ net incomes.  How did our nation’s customs regarding such a skewed reimbursement policy come about?  I don’t know, but I know how the gap is perpetuated.

The Relative Value Scale Update Committee (RUC), created by Congress in 1986, is a body whose members are supposed to be representative of the various specialties of medicine. Although Medicare makes the final reimbursement decisions for physicians, the committee’s recommendations carry great weight with CMS (Centers for Medicare and Medicaid Services).* 

 Here are the areas of medicine represented on the committee:

• Anesthesiology
• Cardiology
• Interventional Cardiology
• Dermatology
• Emergency Medicine
• Family Medicine
• Gastroenterology
• General Surgery
• Geriatric Medicine
• Internal Medicine
• Nephrology
• Neurology
• Neurosurgery
• Obstetrics/Gynecology
• Ophthalmology
• Orthopedic Surgery
• Otolaryngology
• Pathology
• Pediatrics
• Physical Medicine & Rehabilitation
• Plastic Surgery
• Primary Care
• Psychiatry
• Radiology
• Thoracic Surgery
• Urology

Thus, although Primary Care doctors constitute a little over 40% of the practicing physician population, they represent only 16% of the voting members of the RUC.  “Rigged” would be an appropriate term for the composition of this committee that is supposedly representative of the medical community.

Training Choices That American Medical Graduate Make

Graduating medical students seem to be aware of all this.  Their choices for residency training programs correlate with the high incomes associated with the specialties.  A good measure of these preferences is reflected in the percentage of American medical graduates who fill positions in residencies.  Graduating senior medical students are the preferred candidates for residency positions, the balance of unfilled positions going to international medical graduates.  By far, the residency training programs that promise the highest incomes are the most popular, and they fill almost all of their positions with Americans.  Primary care residencies, on the other hand, struggle to reach a 40% fill rate with this group.

Implications for the Quality of Healthcare in the United States

So the pipeline for training primary care doctors is in jeopardy. Does this matter?  A raft of research illustrates the problem with the de facto deemphasis on primary care.  Doctors in primary care specialties do patient centered work, not organ centered work.  They provide integrated healthcare for a large majority of healthcare needs and foster a sustained partnership with patients, all while managing multiple medical conditions. They consult specialists as necessary, coordinating care in what is often a labyrinth of care options.  Studies show this results in a decreased annual number of visits to specialty providers, with less frequent hospitalizations, fewer diagnostic tests, and overall reduced total medical charges. A strong primary care presence helps prevent illness and death, and that it is associated with a more equitable distribution of healthcare in populations. 

The current payment system favors high cost procedures over time spent on evaluation or management of care.  The U.S. has a high ratio of specialists to primary care physicians. 

Remedies

First, let me acknowledge that specialists do good and important work.  My brief is that the imbalance in reimbursement is unfair and bad for healthcare in general.  But fixes to the scandalously imbalanced system are unlikely.  I have shown that the influential body that basically determines parameters for physician reimbursement is heavily stacked against primary care.  And the amount spent on federal lobbying for subspecialty care outnumbers primary care by an almost three to one ratio.  Relying on a feckless Congress for significant reform is quixotic.

Nevertheless, the issue that finds primary doctors to be compensated at a rate that produces incomes that are on average 69% of that of specialists has an easy theoretical fix…close the gap.  There are other issues besides money: the practice of primary care is more challenging–more paperwork and administrative burden, more off hour responsibilities, less perceived prestige.  But a policy that closes the gap in net incomes is surely the first step.

Raising primary care reimbursement is conceptually easy.  However, no one in this economy is looking to increase the nation’s healthcare bill.  And how much to increase primary care physician services?  Increase reimbursement to the point that primary doctors earn 80% of specialists’ incomes?  90%?  Equal?  Given the importance of primary care, maybe even more.

I don’t know what level of increased relative reimbursement for primary doctors would get the job done.  I propose an organic process:  freeze reimbursement for procedures that will close the gap until medical students start choosing primary care training in numbers that will populate primary care training programs to the point of what healthcare experts believe is an optimal ratio of primary care doctors to specialists.  This could take awhile, but the beginning of the fix could start tomorrow.

Homily

I suspect that a large part of the reason for the imbalance between compensation for primary care services as opposed to specialty services is the American tendency to value concrete data.  It is easy to quantify the value of, say, the removal of a diseased appendix, but much more difficult to reward an internist for a deft diagnosi of depression in a patient with multiple somatic complaints. The current payment system favors high cost procedures over time spent on evaluation or management of care.  A wise person once said that the most important things are the hardest to measure. 

*Private insurers generally pay more for healthcare services, but Medicare payments have a great influence on non-governmental insurance plan reimbursement, especially the relative reimbursement for different types of physicians.