Thursday, July 20, 2017

Unequal treatment: disparities in how physicians are paid

As a family physician and medical school faculty member, I'm naturally a big booster of primary care. America needs more generalist physicians, not fewer, and much of my professional activity involves encouraging medical students to choose family medicine, or, failing that, general pediatrics or general internal medicine. But it's an uphill battle, and I fear that it's one that can't be won without major structural changes in the way that generalist physicians are paid and rewarded for their work.

In a recent Medicine and Society piece in the New England Journal of Medicine, Dr. Louise Aronson (a geriatrician) described visits with two of her doctors, a general internist and an orthopedist. The primary care physician worked in a no-frills clinic, often ran behind schedule, and devoted much of the visit and additional post-visit time to electronic documentation. The orthopedist worked in a newer, nicer office with an army of medical and physician assistants; generally ran on time; and was accompanied by a scribe who had competed most of the computer work by the end of the visit. Although there are undoubtedly a few family doctors with income parity to lower-earning orthopedists, according to Medscape's 2017 Physician Compensation Report, the average orthopedist makes $489,000 per year, while an average general internist or family physician makes around $215,000 per year. Here's what Dr. Aronson had to say about that:

It would be hard, even morally suspect, to argue that the salary disparities among medical specialties in U.S. medicine are the most pressing inequities of our health care system. Yet in many ways, they are representative of the biases underpinning health care’s often inefficient, always expensive, and sometimes nonsensical care — biases that harm patients and undermine medicine’s ability to achieve its primary mission. ...

Those structural inequalities might lead a Martian who landed in the United States today and saw our health care system to conclude that we prefer treatment to prevention, that our bones and skin matter more to us than our children or sanity, that patient benefit is not a prerequisite for approved use of treatments or procedures, that drugs always work better than exercise, that doctors treat computers not people, that death is avoidable with the right care, that hospitals are the best place to be sick, and that we value avoiding wrinkles or warts more than we do hearing, chewing, or walking.


Medical students are highly intelligent, motivated young men and women who have gotten to where they are by making rational decisions. For the past few decades, as the burden of health care documentation has grown heavier and the income gap between primary care physicians and subspecialists has widened, they have been making a rational choice to flee generalist careers in ever-larger numbers.

The cause of these salary disparities - and the reason that more and more primary care physicians are choosing to cast off the health insurance model entirely - is a task-based payment system that inherently values cutting and suturing more than thinking. I receive twice as much money from an insurer when I spend a few minutes to freeze a wart than when I spend half an hour counseling a patient with several chronic medical conditions. That's thanks to the Resource-Based Relative Value Scale, a system mandated by Congress and implemented by Medicare in 1992 in an attempt to slow the growth of spending on physician services. Every conceivable service that a physician can provide is assigned a number of relative value units (RVUs), which directly determines how much Medicare (and indirectly, private insurance companies) will pay for that service.

As new types of services are developed and older ones modified, the RVUs need to be updated periodically. Since the Centers for Medicare and Medicaid Services (CMS) chose not to develop the in-house expertise to do this itself, it farms out the updating task to the Relative Value Scale Update Committee (RUC), a 31-member advisory body convened by the American Medical Association (AMA) and nominated by various medical specialty societies. Here is where the fix is in. Only 5 of the 31 members represent primary care specialties, and over time, that lack of clout has resulted in an undervaluing of Evaluation and Management (E/M) and preventive services (the bulk of services provided by generalist physicians) compared to procedural services. Although an official AMA fact sheet pointed out that some RUC actions have increased payments for primary care, a 2013 Washington Monthly article countered that these small changes did little to alter the "special deal" that specialists receive:

In 2007, the RUC did finally vote to increase the RVUs for office visits, redistributing roughly $4 billion from different procedures to do so. But that was only a modest counter to the broader directionality of the RUC, which spends the vast majority of its time reviewing, updating—and often increasing—the RVUs for specific, technical procedures that make specialists the most money. Because of the direct relationship between what Medicare pays and what private insurers pay, that has the result of driving up health care spending in America—a dynamic that will continue as long as specialists dominate the committee.


We teach our medical students to recognize that inequities in where patients live, work and play are far more powerful in determining health outcomes than the health care we provide. A child living in a middle-class suburb has built-in structural advantages over a child living in a poor urban neighborhood or rural community, due to disparities in economic and social resources. The same goes for how physicians are paid in the U.S. Until the RUC is dramatically reformed or replaced with an impartial panel, the $3 trillion that we spend on health care annually (20 percent of which pays for physician services) will continue to produce shorter lives and poorer health compared to other similarly developed nations.

Monday, July 17, 2017

Self-monitoring doesn't improve control of type 2 diabetes

"Have you been checking your sugars?" I routinely ask this question at office visits involving a patient with type 2 diabetes, whether the patient is recently diagnosed or has been living with the disease for many years. However, the necessity of blood glucose self-monitoring in patients with type 2 diabetes not using insulin has been in doubt for several years.

A 2012 Cochrane for Clinicians published in American Family Physician concluded that "self-monitoring of blood glucose does not improve health-related quality of life, general well-being, or patient satisfaction" (patient-oriented outcomes) and did not even result in lower hemoglobin A1C levels (a disease-oriented outcome) after 12 months. In their article "Top 20 Research Studies of 2012 for Primary Care Physicians," Drs. Mark Ebell and Roland Grad discussed a meta-analysis of individual patient data from 6 randomized trials that found self-monitoring improved A1C levels by a modest 0.25 percentage points after 6 and 12 months of use, with no differences observed in subgroups. Based on these findings, the Society of General Internal Medicine recommended against daily home glucose testing in patients not using insulin as part of the Choosing Wisely campaign.

Still, the relatively small number of participants in trials of glucose self-monitoring, and the persistent belief that it could be useful for some patients (e.g., recent type 2 diabetes diagnosis, medication nonadherence, changes in diet or exercise regimen), meant that many physicians have continued to encourage self-monitoring in clinical practice. In a 2016 consensus statement, the American College of Endocrinology stated that in patients with type 2 diabetes and low risk of hypoglycemia, "initial periodic structured glucose monitoring (e.g., at meals and bedtime) may be useful in helping patients understand effectiveness of medical nutrition therapy / lifestyle therapy."

In a recently published pragmatic trial conducted in 15 primary care practices in North Carolina, Dr. Laura Young and colleagues enrolled 450 patients with type 2 non-insulin-treated diabetes with A1C levels between 6.5% and 9.5% and randomized them to no self-monitoring, once-daily self-monitoring, or once-daily self-monitoring with automated, tailored patient feedback delivered via the glucose meter. Notably, about one-third of participants were using sulfonylureas at baseline. After 12 months, there were no significant differences in A1C levels, health-related quality of life, hypoglycemia frequency, health care utilization, or insulin initiation. This study provided further evidence that although glucose self-monitoring may make intuitive sense, it improves neither disease-oriented nor patient-oriented health outcomes in patients with type 2 diabetes not using insulin. So why are so many clinicians still encouraging patients to do it?

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This post first appeared on the AFP Community Blog.

Sunday, July 9, 2017

Does health insurance save lives? No: primary care does.

Two recent review articles in the New England Journal of Medicine and the Annals of Internal Medicine discussed the relationship between having health insurance and improving health outcomes (including mortality, i.e., "saving lives"). In my latest Medscape commentary, I analyzed these two articles in the context of the debate over the U.S. Senate's Better Care Reconciliation Act (BCRA), which the Congressional Budget Office has estimated would lead to 22 million more uninsured persons if passed, compared to current law. I concluded that arguments about the effects of gaining or losing health insurance largely miss the point, since any positive effects of insurance are most likely mediated through providing primary care:

It is plausible that the positive effect of insurance on health is real. The next question is, why? It's not because insured people receive more or better care for acute, life-threatening illnesses. Instead, people who gain insurance generally increase their use of preventive services and are more likely to report having a usual source of primary care, which other studies have found is strongly associated with lower mortality. In fact, I would argue that health insurance's positive effects on health are mediated largely through prepaid primary care services.

The American Academy of Family Physicians has joined several other major physician groups in opposing BCRA because absent modifications, it will certainly decrease access to primary care by making insurance unaffordable for low-income and other vulnerable populations who don't qualify for Medicaid or Medicare. But paying for a barely affordable bronze marketplace plan with a $6000 deductible hardly makes primary care affordable, either, outside of a limited list of preventive services. The solution? Make it possible for more people to buy inexpensive primary care without having to go through expensive health insurance.

Health reform proposals should build on the knowledge that primary care saves lives for a fraction of the cost of a health insurance premium. In the long run, Democrats and Republicans could find common ground between their "Medicare for all" and "covering everyone costs too much" positions by removing primary care from the inefficient insurance system entirely. Instead, Congress should guarantee everyone a family doctor through a community health center or direct-pay primary care, as physician and financial planner Carolyn McClanahan has proposed.

Wednesday, July 5, 2017

Strategies to limit antibiotic resistance and overuse

According to a report from the Centers for Disease Control and Prevention (CDC), more than 2 million Americans become infected with antibiotic-resistant bacteria each year, leading directly to at least 23,000 deaths and contributing indirectly to thousands more. Antibiotic resistance occurs in the community, in long-term care facilities, and in hospital settings. Another CDC report on preventing healthcare-associated infections (also discussed in this American Family Physician article) identified six high-priority antibiotic resistance threats: carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase-producing Enterobacteriaceae, vancomycin-resistant Enteroccocus, multidrug-resistant Pseudomonas, and multidrug-resistant Acinetobacter.

In a 2014 editorial, "Antibiotic resistance threats in the United States: stepping back from the brink," Dr. Steven Solomon and Kristen Oliver from the CDC identified three strategies that family physicians can use to limit antibiotic resistance: 1) Preventing infections through immunizations, standard infection control practices, and patient counseling; 2) Reporting unexpected antibiotic treatment failures and suspected resistance to local or state health departments; and 3) Prescribing antibiotics more carefully. Unfortunately, inappropriate antibiotic prescribing (also known as antibiotic overuse) is common in primary care, particularly for patients with acute viral respiratory tract infections.


Antibiotic overuse is a multifaceted problem with many potential solutions. On Sunday, July 9th at 7 PM Eastern, Dr. Jennifer Middleton (@singingpendrjen) and I (@kennylinafp) will be taking a deep dive into the evidence on the most effective strategies to curb prescribing of unnecessary antibiotics. American Academy of Family Physicians members and paid AFP subscribers can earn 4 free continuing medical education credits by registering for the #afpcme Twitter Chat, reading three short AFP articles, and completing a post-activity assessment. We hope you can join us!

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This post first appeared on the AFP Community Blog.

Thursday, June 29, 2017

Innovations in primary care for underserved populations

Lately, “innovation” is the buzz word that I am hearing most often at conferences and briefings and reading in medical journals. But what counts as innovation in primary care, and how can physicians and patients quickly distinguish true practice-changers from temporary fads? At a conference I attended last year, Ray Rosin, Chief Innovation Officer at Penn Medicine, described three techniques that can be used to rapidly test promising innovations:

Vapor tests, which help innovators determine the demand for a service or program without needing to build the service or program first.

Fake front ends, which "make ideas tangible to help answer the question 'What will people do with it?'"

Fake back ends, which allow "teams to quickly answer the question 'What happens if people actually use it?'"

Even though these techniques require relatively small investments in time and effort, primary care clinicians still need to know about promising innovations in order to test them. One good source for innovations to improve quality and reduce disparities is the Agency for Healthcare Research and Quality's Health Care Innovations Exchange, a searchable database of case studies ("innovation profiles") submitted by health organizations across the nation. Over the past few months, I've also collected several primary care innovations for underserved populations from the new Annals of Family Medicine feature and various other sources.

1) Using QR codes to connect patients to health information - a rural family medicine clinic in Iowa displays QR codes in its waiting room and other areas that, when scanned by a reader on a smartphone or tablet, load general patient education resources or materials related to the specific reason for the patient's visit.

2) Engaging complex patients with drop-in group medical appointments - a stabilizing program for uninsured, low-income patients with complex mental and physical health needs in North Carolina that over the past 6 years has reduced enrollees' hospital utilization by 50% at the cost of $100 per patient per month.

3) Fresh food by prescription - Central Pennsylvania's Geisinger Health system piloted a free, healthy "food pharmacy" for low-income patients with type 2 diabetes and their families on the grounds of one of its hospitals.

4) Telemedicine screening for diabetic retinopathy - Los Angeles County successfully implemented telemedicine screening in its safety net clinics, reducing the wait time for screening from 158 to 17 days and increasing the percentage of all eligible patients screened by more than 40%.

These innovations probably won't work in every underserved setting, but one or more could be worth a try in your clinic or health system, using one of Rosin's rapid-cycle techniques.