Advanced primary care vs (or is?) direct primary care

One of my most popular Twitter retweets this month highlighted a graphic from the Wall Street Journal showing that in 2014, middle-income households spent 25 percent more on health care than they did in 2007, but 6 to 18 percent less on other basic needs such as housing, transportation, food, and clothing. I commented: Too much of HC debate about "who pays"; not enough questioning "why does HC cost so much?"

One good answer is that lots of health "care" is worthless or harmful, but incentives baked into the U.S. health system push doctors to provide (and be paid handsomely for) it anyway. Shannon Brownlee first told this story in her book Overtreated (and revisited it in this recent review for The Lancet); Atul Gawande described unnecessary medical care as an "avalanche" in his New Yorker profile "Overkill"; and David Epstein called it an "epidemic" in his Atlantic article "When Evidence Says No, but Doctors Say Yes." The bottom line: instead of improving health, many medical interactions are merely opportunities for something bad to happen. (For a timely example, see this NPR article about the harms of screening for cardiac disease in teenage athletes.)

Doctors generally aren't paid to provide quality health care rather than more health care (quantity). A more catchy phrase for this idea among health policy wonks is "moving from volume to value." After more than a decade of trying, mostly unsuccessfully, to cut doctors' fees to compensate for steady increases in the volume of health care services, Congress passed legislation that empowered the Center for Medicare and Medicaid Services to create a quality payment program. Physicians can enroll in one of two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

In December, the American Academy of Family Physicians published an 11-page position paper that proposed an APM called "Advanced Primary Care." My friend and fellow family physician Richard Young has been dissecting the nitty-gritty details of the proposal in a series of posts on his blog, here, here, and here. It's clear to me that some smart people at the AAFP invested a great deal of time and energy into its development, addressing thorny issues such as how to adjust for social risk factors that make even the best physicians' quality measures look bad and could, if not taken into account, have the unintended effect of reducing access to health care for those who need it the most. It's also extremely complicated, and I have no idea if it would improve quality or lower costs.

Family physician-turned-financial planner and Forbes blogger Carolyn McClanahan has been arguing that a simpler strategy for reducing the nation's health care bills that doesn't involve rationing care for the poor is to remove primary care services from health insurance entirely. This is a strategy that direct primary care advocates have championed; by eliminating administrative burdens and inflated charges for low-cost services, it results in unhurried in-person visits, more flexibility to provide care by phone or electronic communications, and truly personalized care. But McClanahan added a new twist: make basic primary care free to all by giving community health centers enough funding and capacity to provide services to every American who desires it. (Those who would still prefer to see a private family doctor could presumably pay a monthly fee to be part of a direct primary care practice.) Her plan is worth a long look: you can read an abridged version on Jacksonville.com or a more detailed proposal here.

Although it's been hard for me to see much upside to the Trump presidency, revisiting the Affordable Care Act doesn't need to be bad news. A Hillary Clinton presidency and a Republican-controlled Congress would have likely resulted in continued stalemate: no ACA repeal, but no forward progress in repairing its significant flaws, either. Instead, the political impetus to imagine something better than the health system status quo may galvanize positive change. Family medicine leaders can continue to tinker on the margins, developing iterative proposals for "advanced" primary care that won't make our specialty any more appealing to medical students than the 2004 Future of Family Medicine project or the 2013 Family Medicine for America's Health initiative did. Or they can choose to commit fully to a vision of a health system where everyone has a family doctor, that doctor doesn't change when health insurance changes, and "advanced" primary care means direct primary care.

For medical schools, mission statements matter

Over the years, applicants whom I've interviewed for positions in the first-year medical student class at Georgetown have often asked how our school's mission statement influences the educational experiences and clinical services we provide:

Guided by the Jesuit tradition of Cura Personalis, care of the whole person, Georgetown University School of Medicine will educate a diverse student body, in an integrated way, to become knowledgeable, ethical, skillful, and compassionate physicians and biomedical scientists who are dedicated to the care of others and health needs of our society.

I never quite know how to answer this question. Like the aspirational mission statement of my previous employer, the Agency for Healthcare Research and Quality, which was "to improve the health of all Americans," Georgetown's statement doesn't offer an obvious path for how to produce physicians dedicated to the "health needs of our society." Although our Population Health Scholars Track gives select students perspectives and tools to address societal health needs on the population level, Georgetown consistently graduates a majority of medical subspecialists and produces few who will relieve growing national shortages of family physicians and psychiatrists. As for meeting the needs of rural and urban underserved populations, a 2010 study ranked us 102nd out of 141 U.S. medical schools in the percentage of physicians who were practicing in federally designated Health Professional Shortage Areas.

So are medical school mission statements just academic boilerplate, or do they really guide graduate specialty choice and practice location? This was the question that Dr. Christopher Morley and colleagues investigated in a fascinating study published in Family Medicine. A diverse panel of 37 medical students, educators, and administrators reviewed the mission statements of U.S. medical schools and rated them on a 5-point scale for social mission content, defined as "any language that reflects a goal of medical education to train practitioners capable of matching the needs of society and vulnerable populations or for the institution itself to serve vulnerable populations or regions." The mean of panelist ratings for each school's mission statement turned out to be a statistically significant predictor of the percentage of graduates who entered family medicine and the percentage who worked in Medically Underserved Areas/Populations.

As the study authors noted, these interesting associations could be interpreted a number of different ways:

It is not clear from these results if graduate career choice is influenced by the orientation of the institution, or if students who go on to work in these areas of medicine self-select into institutions because of a personal predilection to work in primary care or in underserved communities; however, it appears that medical schools with a proclaimed orientation toward producing physicians in primary care and/or physicians who provide care to underserved populations are achieving these missions.

Incidentally, I don't know how Georgetown's mission statement rated on the scale of social mission content, although I imagine that it would have fallen somewhere in the middle. Also unanswered is the philosophical question of what percentage of schools should be orienting their graduates toward Morley and colleagues' definition of social mission, rather than producing excellent physician-scientists, health executives, or some other standard of accomplishment.

For medical schools, mission statements matter. Perhaps we need a national mission statement for medical education in the United States, one that embraces and expands on the American Association of Medical Colleges' "improve the health of all." This national mission statement would recognize the shortcomings of our current physician workforce and explicitly aim to produce a mix of future medical school graduates who are dedicated and prepared to build the Culture of Health that America so desperately needs.

**

This post first appeared on Common Sense Family Doctor on June 11, 2015.

Obstructive sleep apnea: screening and home testing news

According to a recent article in American Family Physician, obstructive sleep apnea (OSA) is present in 2 to 14 percent of the general adult population, with a higher prevalence in older and obese persons. Most people are unaware of their diagnoses, either because they do not recognize symptoms or do not report them to physicians. Since it is hard to make an asymptomatic person feel better, is there any good reason to screen for OSA in asymptomatic adults? Screening advocates suggest that treating patients with moderate to severe OSA with continuous positive airway pressure (CPAP) reduces hypoxic episodes that could trigger cardiovascular events in patients with known vascular disease. However, a randomized trial seemed to refute this hypothesis. After almost 4 years of follow-up, the group that received CPAP reported slightly less daytime sleepiness, but had the same frequency of cardiovascular events as the control group.

The U.S. Preventive Services Task Force (USPSTF) considered this study and others in issuing a new recommendation statement on January 24th that concluded "the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults." The USPSTF found inadequate evidence that validated questionnaires accurately identify who will benefit from polysomnography (PSG) in asymptomatic populations (as opposed to those with suspected OSA). The Task Force also could not determine if CPAP or mandibular advancement devices improve health outcomes (mortality, cognitive impairment, motor vehicle crashes, and cardiovascular or cerebrovascular events) other than sleep-related quality of life.

Although an insufficient evidence statement is not necessarily a recommendation to not screen, Drs. Sachin Pendharkar and Fiona Clement argued in an editorial in JAMA Internal Medicine that the costs of screening for OSA (not considered by the Task Force) warrant clinicians doing just that. Based on the sensitivity and specificity of one widely used screening tool, and an OSA prevalence of 26% in the Medicare population, the authors estimate that $21 billion would be wasted on negative PSG tests, or $4.4 billion if less expensive home-based sleep studies were used instead.

On a related note, the comparative accuracy of home-based tests versus laboratory PSG in diagnosing OSA has been an actively studied topic. A 2014 practice guideline from the American College of Physicians recommended that portable sleep monitors (limited-channel sleep studies) only be used to diagnose OSA when PSG was not available. However, a randomized non-inferiority trial published in Annals of Internal Medicine found that patient outcomes after limited-channel studies were similar to those after PSG. This finding may be a blow to the for-profit sleep testing industry, but it is undoubtedly good news for my patients.

**

This post originally appeared in the AFP Community Blog.

Tom Price is a physician who doesn't understand cancer screening

If confirmed by the Senate, Dr. Tom Price will become the first medical doctor to lead the U.S. Department of Health and Human Services in 24 years. One might think that having completed medical school and practiced orthopedic surgery before entering politics might give him some extra insight into what works and what doesn't in medicine. But judging by a letter to then-HHS Secretary Kathleen Sebelius that he signed in 2011 objecting to the U.S. Preventive Services Task Force's draft recommendations on prostate cancer screening, Dr. Price either failed to learn anything in evidence-based medicine class or forgot everything he learned.

Price and colleagues wrote: "Since the [prostate-specific antigen] PSA test came into widespread use for cancer detection in the mid-1990s, the rate of deaths due to cancer has fallen by 40 percent." This statement reflects an association, not causation, and there is a serious problem with positing the latter based on the natural history of PSA-detected prostate cancers. In the European Randomized Study of Screening for Prostate Cancer (ERSPC), the only trial to conclude that PSA screening reduced deaths from prostate cancer, it took 9 years to observe any difference in prostate cancer deaths between the screening and control groups. But not only was the prostate cancer death rate falling in the U.S. long before any possible screening effect could have occurred, it was also falling in other countries (such as the United Kingdom) that were not employing PSA as a screening test.

The letter goes on to state that the percentage of potentially "curable" prostate cancers rose from 35 to nearly 90 percent after doctors started routinely screening with PSA, so it's obvious that the test works. Dr. Price, have you heard of lead-time and overdiagnosis bias? Even implementing a completely ineffective screening test, such as chest x-rays for lung cancer, will artificially increase survival rates and inflate the number of cancers amenable to surgery because a large percentage of these would never have been detected at all, if not for the test. (On this erroneous conclusion, Dr. Price is unfortunately in good company: a 2012 survey of primary care physicians found that two-thirds would recommend a cancer screening test supported by irrelevant changes in 5-year survival rates.)

Finally, the letter accused the USPSTF of having "cherry-picked" information rather than reviewing the totality of the evidence on PSA-based, which is laughable since it came in the same paragraph that Price and the other legislators highlighted the Goteburg, Sweden randomized trial (a subset of ERSPC) as "the best designed and controlled study." Talk about cherry-picking! Goteburg also happens to be the country with the most impressive-appearing benefit of screening; most of the other countries involved in ERSPC found no statistically significant mortality benefit, as did the U.S. in our own randomized trial.

These cancer epidemiology concepts I've mentioned aren't difficult to master; I teach them all the time to undergraduates and first-year medical students. Since Dr. Price clearly needs a refresher, I refer him to a previous instructional post I originally wrote for urologists. Patients can understand these concepts too, thanks to this excellent video decision aid that persuaded men to make more evidence-based decisions about PSA screening in a recent study published in Annals of Family Medicine.