Poverty, Primary Care and the Cost of Medical Care

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On January 27, 2010 (Health is more than Medical Care) I discussed how the concept in the title of that piece is true. A society that does not provide for the basic needs of its citizens, such as the US, is going to have more sick poor people who end up requiring more health care services at much greater cost. The greater the income disparity in a country, the greater the negative impact of poor population health. Countries that have a national health system can mitigate some of these effects by, at least, providing access to care for those who, through the various negative effects of poverty, suffer the worst health, but they do not prevent it.

This point is illustrated in the latest (of many, over the years and decades) reports on health status in the United Kingdom, commissioned by the government and done by a panel headed by Sir Michael Marmot of the University College – London. The report, “Fair Society, Healthy Lives”, documents the cost to the National Health Service of the ill health of the poor. This is not, of course, news; Marmot’s famous Whitehall studies demonstrate that there is a more or less linear correlation between health (including longevity) and increasing social class; it shows that the problems have not been resolved. In countries with less disparity of wealth and income (class) than the UK, including most of Scandinavia, these disparities in health are less; in the US, where the disparities in wealth and income are greater, so are the disparities in health and their associated cost.

Since, in the US, poor people are more likely to be uninsured (or have Medicare, if they are over 65), their health care costs are largely borne by the public sector. In this sense, the costs of Medicare can, and have, been used as markers for the overall cost of medical care. This assumption has a great deal of validity, because Medicare recipients, the “aged, blind, and disabled”, are highly overrepresented in both the middle and high use segments of the population (see Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009). (It is, however, important to remember that the majority of the 5% of “highest cost” users are not seniors – they include NICU babies, multiple trauma victims, and cancer patients.) The publications of the Dartmouth Atlas of Health Care have demonstrated much geographic variation in cost, and these have been used by a large number of health economist and scholars, as well as the Obama administration, to suggest that a great deal of health spending could be avoided if the “high cost” regions utilized health resources at the same rate as the lower cost areas.

Not everyone agrees with the Dartmouth analysis. Probably their most prominent critic is Dr. Richard Cooper of the University of Pennsylvania’s Wharton School, whose positions I have previously discussed on several occasions (most recently January 7, 2010, Primary Care and Residency Expansion). On his blog, Physicians and Health Care Reform, and in venues such as the on-line public health discussion group “Spirit of 1848”, Dr. Cooper argues that it is poverty rather than “inappropriate” use of health services that drive the differences in Medicare spending in different regions. He illustrates this by maps showing the far greater density of poverty in “high cost” Los Angeles, Miami, and Birmingham, AL compared to “low cost” Rochester, MN, Grand Junction, CO, and Portland, OR.

Many others disagree with Dr. Cooper, not in the sense that they feel that poverty is not a (or the) major determinant of health status, but with his assertion that the cost variations the Dartmouth Atlas identifies are solely an artifact based on prevalence of poverty. Among the most prominent of these critics is Dr. Barbara Starfield, of the Johns Hopkins University, a major health services researcher whom I have also often cited. I believe that Cooper’s argument that the Upper Midwest is richer, and thus healthier, than the Southeast is relying on areas that are too large. His contrasts of the cities above in terms of their concentrations of poverty are accurate, but the argument misses the tremendous difference (cited by Dr. Atul Gawande in his piece “The Cost Conundrum” and its followup “The Cost Conundrum Redux” in the New Yorker) between cities such as McAllen and El Paso, TX. Or, for that matter, between Los Angeles and San Francisco, or Chicago, all of which have varying levels of health costs (i.e., Medicare spending).

The real issue is “what is the implication of either position, or any other, for what to do to address the health needs, and cost of medical care, for the US population?” From much of his previous writing, Dr. Cooper has disparaged the contribution of primary care prevalence to the quality of health care, seeing it as a confounder to the true cause of higher spending, because it is more prevalent in the Upper Midwest than in the high cost areas. The data, from many, many studies in many, many countries, not only those by Starfield and the Dartmouth folks, is that it is not a confounder. Where health systems are built on primary care costs are lower and, more important, quality is higher. This should not be a surprise to anyone who is concerned about the impact of poverty on health status – when poor people can access preventive services and treatment at an earlier stage, where intervention is both less costly and more effective, they will have better health status. Primary care reduces cost.

Hospitals and many subspecialist physicians are not happy about the potential for cuts in Medicare because they already think that Medicare spends too little. That is, it does not pay “enough” for the extraordinarily costly high-tech interventions that they make their profit on. I suggest that Medicare spends too much on this kind of care, rather than paying a lot more for the preventive and primary care services that would make this kind of tertiary intervention necessary less often. Medicare should not simply make revisions to its payment schedule, it should completely turn it on its head so that a day of managing multiple complex medical and social problems and doing preventive care by a primary care doctor generates more money than a day of doing procedures such as endoscopies, catheterizations, and the like. (Note that I am not suggesting we invert the incomes, just the amount that these doctors earn relative to each other; the net cost should be dramatically reduced.)

This would, of course, encourage more medical students to enter primary care, which would be a good thing for the health of us all. Simply increasing the number of funded-by-Medicare residency positions will not do that, but rather would just generate more hoping-for-high-income sub- and sub-subspecialists, whose overall effect on health status is, from a population perspective, small. (For example, I benefit, for sure, if my brain tumor is excised or my cerebral bleed drained, and I definitely want access to its benefit, for me and you and the poor; however, if there were no neurosurgery at all, the impact on the health status of populations would be minimal.)

More important, it would free up a lot more money for addressing the overall social problems of poverty, while now the cost of medical care, exceeding 17.3% of the GDP (CMS report by Truffer CJ, et al, in Health Affairs, February 4, 2010) threatens to choke off any other social spending. As articulately stated by Bob Phillips of the Graham Center (personal communication), giving the “…poor the same access to excess that all of the rest of us have in order to lift them from disparity would only hurt them more. Economically, health care is starving the services that do help reduce disparities--education, social services, day care, Head Start, food stamps, etc. They are all suffering right now in state budgets because healthcare is devouring state budgets (health care consumed 1/3rd of all fed/state tax dollar s in 2008,[1] (and probably more now that tax revenue is down)”. This is demonstrated by the 2005 study by Boston University’s Sager and Socolar[2] and shown in the attached graphic, from the Graham Center’s presentation on the topic. Obviously, there would still need to be a decision by our society to spend the savings on social services (rather than, say, tax rebates to the wealthiest Americans, or war), but, other than war, there is hardly a less useful way to improve the health status of the poor than by spending it on more high cost tertiary and quarternary care medical centers staffed by more and more sub-sub-specialists.


[1] Sessions S and Lee PR,”Using Tax Reform to Drive Health Care Reform: Putting the Horse Before the Cart” JAMA. 2008;300(16):1929-1931
[2] Sager A, Socolar D, Health Costs Absorb One-Quarter of Economic Growth, 2000 – 2005 Recent Federal Report Unintentionally Obscures Massive Rise Physicians’ Decisions Key to Controlling Cost. Data Brief No. 8 - 9 February 2005. http://www.healthreformprogram.org/.

"Uncomplicated" Primary Care?

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I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.[1],[2],[3],[4],[5] Indeed, there are studies that show that health disparities in infant mortality and low birthweight can be virtually eliminated by a greater presence of primary care.[6]

However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position, as well as rebuttals from some of those he has criticized. In a recent publication supported by the Physician’s Foundation, a group comprised primarily of state and local medical societies, “Physicians and their practices under health care reform: a report to the president and the congress”, Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from the Executive Summary they note:

"Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care"

This is quite a strong statement in opposition to what I, and many others, have been saying in support of the importance of primary care to the health of the public, so of course one looks for the supporting data, especially for the striking dismissal of the work of Starfield and others as “a statistical anomaly”; however the data isn’t there. Presumably, when people are so distinguished and feel their positions so strongly, such data is unnecessary. One distinguished colleague put forward this definition:

Statistical anomaly: A consistent finding, in multiple nations and health systems that disagrees with my current self-interest and bias.

That says it very well. If you have no data to justify publication in peer-reviewed journals, you can continue to perpetrate your ideas in foundation-sponsored opinion pieces.

Several organizations, including the American Academy of Family Physicians (AAFP) and the Association of Departments of Family Medicine (ADFM) have protested this publication to the sponsors, the Physicians Foundation. The Foundation took the position that it commissioned the study but did not endorse it; that it was supportive of primary care, and chose to focus on other findings of the report (such as that socioeconomic differences make a difference in geographic variation, which the Dartmouth Atlas researchers are purported to have ignored in their analysis). The PF states its unequivocal support of primary care in a letter to the President of ADFM: “As for the Physicians Foundation (PF), it would never do anything to damage primary care.” Nonetheless, the AAFP found this inadequate; its formal response to the PF includes the following:

“This report is an attack on decades of sophisticated research that validly supports the value and need for improving access to robust primary care using a thin vein of research that has been publicly demonstrated to be oversimplified and wrong. The authors’ perspectives and opinions are welcome in the debate about how to reform the health system and physician workforce, but this report is largely opinion richly dressed in discredited, unsophisticated research.

This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year[7]. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as “anomalous” and “simple frameworks” without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”

Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care". What is this “uncomplicated primary care” of which you speak? The idea that provision of primary care is simple, unchallenging intellectually, not worthy of the training of a physician, and could be done by someone with much less training, is a position put forward by other specialists and subspecialists that is:

· Common, especially in speaking to medical students,
· Derogatory, and offensive,
· Self-serving, since obviously the services provided by the subspecialists are much more rigorous and difficult, and
· Wrong.

The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult. Yarnall, et. al, in the American Journal of Public Health, identified that it would take 7.4 hours a day for a primary care physician to just provide the preventive services, not to mention all the other services above, especially chronic disease management.[8] One of my residents recently returned from a rotation on cardiology; on her first day she was sent to see a patient and returned in 7 minutes. “That was fast,” said the cardiologist. “You just wanted me to address their heart problem,” the resident, used to caring for many different problems in a family medicine visit, replied. Perhaps this is cognitive dissonance for the subspecialist (or “partialist”), who has to believe that their in-depth knowledge of one particular set of conditions is at a higher level than managing the whole person with all of their complex medical, psychological, and social and economic issues.

Another wise colleague, who believes that “The question of what is intellectually challenging and worthy of training and intellect is a classic example of hubris perpetuated by subspecialists and academic health centers,” asks the following question of his medical students:

“What is more intellectually challenging?
Performing your 2000th knee arthroscopy
Performing your 3000th laparascopic cholestectomy
Performing your 4000th bronchoscopy
Performing your 5000th colonoscopy
Performing your 6000th intubation
Performing your 7000th breast augmentation
Performing your 8000th cataract removal
Reading your 10000th MRI
Seeing you 15000th case of acne (achievable in 7 years seeing 10 case a day 20 days a month 45 weeks a year)

OR

Taking care of a 55 yo with diabetes, hyperlipidemia, hypertension, coronary artery disease, chronic renal insufficiency, who is depressed, has a rash, erectile dysfunction, esophageal reflux and who is taking care of his elder mother with Alzheimer's dementia.”

I just had the opportunity to review the charts of the patients seen by one of my first-year family medicine residents in one clinic session recently. They included:

· Woman with uncontrolled Diabetes, recently discharged from the hospital with diabetic ketoacidosis; marked edema of legs.

· Woman with anhedonia who feels “fat and alone”; no “physical abuse” – boyfriend just pushes her and she feels safe when she locks the door.

· Woman for “well-woman exam”, who came for Pap smear and prevention, with uncontrolled hypertension, very stressed from working her two jobs, having difficulty with her medication.

All had, in addition, other medical problems.

“Uncomplicated” primary care”? Perhaps you would like to take over the comprehensive management of her patient panel, Dr. Cooper?

[1] Baicker K & Chandra A, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”, Health Affairs, 7 Apr 2004;W4.184
[2] [3] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502
[3] Ferrer RL, Hambridge SJ, Maly RC, “The essential role of generalists in health care systems”, Annals of Internal Medicine 2005;142:691-699.
[4] . Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.
[5] Goodman DC, Grumbach K. Does having more physicians lead to better health system performance? JAMA. 2008;299(3):335-337.
[6] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380

[7] Cooper RA, “States with More Physicians Have Better-Quality Health Care,” Health Affairs 28, no. 1 (2009): w91–w102
[8] Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL., Primary care: is there enough time for prevention?, Am J Pub Health, 2003 Apr;93(4):635-41.