Unequal treatment: physician payment disparities and their health consequences

As a family physician and medical school faculty member, I'm naturally a big booster of primary care. America needs more generalist physicians, 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 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 $3.5 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.

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This post first appeared on Common Sense Family Doctor on July 20, 2017.

Apps that detect atrial fibrillation may not improve health

The March 15 issue of American Family Physician included a recommendation statement from the U.S. Preventive Services Task Force (USPSTF) and Putting Prevention Into Practice case study on screening for atrial fibrillation with electrocardiography (ECG). The USPSTF concluded that current evidence is insufficient to assess the balance of benefits and harms of testing for atrial fibrillation in primary care patients without suggestive symptoms. In an accompanying editorial that I solicited, cardiologists John Mandrola and Andrew Foy discussed several potential downsides of ECG screening for atrial fibrillation: low prevalence, a high number needed to screen to prevent one stroke, high costs, false positive results, and uncertainty about the effects of anticoagulants in persons with subclinical atrial fibrillation.

At the American College of Cardiology (ACC) meeting last month, Dr. Mandrola interviewed Dr. Mintu Turakhia, a co-principal investigator of the Apple Heart Study, regarding initial findings reported at the conference. More than 400,000 U.S. adults with Apple Watches installed a paired smartphone app that used an algorithm to analyze heart rate variability and notified users if five out of six samples over a 48-hour period suggested an irregular heart rate. Of the 2100 individuals (~0.5%) who received these notifications, the positive predictive value for ECG-confirmed atrial fibrillation was 84%. The app's sensitivity and false negative rate are unknown because users who did not receive notifications did not have ECG monitoring. Also, the study was not designed to evaluate health outcomes. In a Medscape commentary, Dr. Mandrola chided the ACC for calling so much attention to these preliminary, disease-oriented data:

Given the stark inequities of care in the United States and globally, I question the morality of dedicating this much attention to a study on a low-risk population, a group that already enjoys relatively excellent health. ... Smart watches and digital health will deliver oodles more information. This, along with hype, will surely enrich the makers of devices, and in turn the medical industry. I remain skeptical that it will improve the human condition. It could even make us sicker.

A planned pragmatic randomized trial will enroll adults age 65 years and older to determine if screening for atrial fibrillation and other heart rhythm abnormalities using the Apple Watch app leads to reduced stroke rates and/or improved cardiovascular health. In the meantime, family physicians will likely start seeing more patients for evaluation of possible cardiac rhythm abnormalities detected by wearable devices. A recent JAMA article reviewed the limitations of such devices at detecting atrial fibrillation, tachycardia, and bradycardia and offered a suggested approach to evaluation and management.

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This post first appeared on the AFP Community Blog.

Patients, Populations and Policy: Season 1, Episode 2

This is the second of two podcast episodes that I created specifically for my first-year medical student class. It discusses the evolution of physician payment, the major components of the Affordable Care Act, and proposals for future health care reforms. If you haven't yet listened to episode 1, which provides some basic background information on the U.S. health system, you can find it here. And I don't intend to stop at two episodes, so if you like what you hear, please subscribe to the podcast feed to receive notifications when I release more later this year. My P3 podcast will also soon be available on ITunes, Google Play, Spotify, and Stitcher. Thanks for listening!

Patients, Populations and Policy: podcast episode 1 of 2

Nonselective full-tuition scholarships don't produce more primary care physicians

Last August, I wrote about NYU School of Medicine's decision to award full tuition scholarships to all current and future medical students, and my skepticism that this generous policy would achieve my alma mater's stated goals of recruiting a more socioeconomically diverse student body and sending more graduates into primary care fields. I was not the only person to gently criticize NYU's approach to these important issues; a few days later, Kaiser Health News editor and former emergency medicine physician Elisabeth Rosenthal wrote in a New York Times opinion piece that "instead of making medical school free for everyone, NYU - and all medical schools - should waive tuition only for those students who commit to work where they are needed most." As an example, she pointed to selective scholarships awarded by NYU's law school each year to 20 students who commit to careers in low-wage public service. Dr. Rosenthal also argued that since academic medical centers receive billions of dollars in public funds to train new doctors and don't pay taxes due to their nonprofit status, "Every academic medical center should see training the medical work force America needs not as charity but as an obligation, a 'community benefit' of the highest order."

As for increasing diversity, another laudable goal, Dr. Billy Thomas wrote in a JAMA Viewpoint:

If medical school admissions processes continue to be weighted toward metrics [e.g., GPAs, MCAT scores] and the number of minority, disadvantaged, and marginalized applicants remains stagnant, attempts to diversify the health care workforce will fall far short, despite reduced or free tuition. ... The NYU program may increase diversity at NYU, but taken in context with the stagnant national applicant pool, the increased enrollment at NYU may result in a “zero sum effect” on the national health care workforce as it relates to diversity and, by extrapolation, have no significant effect on our efforts to reduce health disparities and improve population health.

When I interviewed prospective Georgetown medical students this year, NYU usually came up in conversation, from the medical diploma hanging on my wall, if nothing else. Of course they had all applied to NYU, and if accepted, they'd most likely attend, no matter how much they loved Georgetown or Hopkins or Harvard or anywhere else without free tuition. Indeed, total applications increased by almost 50 percent, and applications from underrepresented groups more than doubled.

Another problem: according to an analysis of public data on medical school endowments, enrollment, and tuition expenses by two students at Mount Sinai (which had a brief but unsuccessful merger with NYU in the late 1990s), only 20 of 141 U.S. medical schools are financially positioned to afford going tuition-free for all students. Notably, even NYU shrunk its class size by at least a third from its size at the time of my graduation, presumably to lower the cost of providing every student with a scholarship. Like NYU, Harvard, which unsurprisingly tops the list of wealthy schools, doesn't even have a family medicine department, where establishing one would be an investment more likely to pay off for primary care than simply making school free with no service requirement.

Meanwhile, Dr. Bich-May Nguyen, a family physician with whom I've previously collaborated, just published a report in Family Medicine of a survey of 74 physicians who graduated from two BS/MD programs in Texas from 2003 through 2013 that provided full scholarships for college and medical school. 18 of these physicians went into primary care, which is about average for medical students nationally. Dr. Nguyen and her coauthor noted that the motivations for these physicians' specialty choice were similar to those from surveys of physicians who only received partial or no tuition assistance:

People interested in primary care were also interested in serving underserved or minority populations, health promotion, patient continuity, and patient advocacy. ... The second theme was found in statements supporting high income potential, prestige among colleagues, inpatient hospital care, and quick results from interventions. ... Additionally, the respondents most interested in high incomes did not enter primary care.

Ultimately, there are far less expensive solutions to the problems that NYU was supposedly trying to address by waiving medical school tuition. Want a more diverse student body? Admit more minority and low-income students. Want more students to go into family medicine and primary care? Establish and support departments in those fields, and admit more of the types of students who tend to pursue primary care. They won't necessarily have the highest GPAs or MCAT scores or the social advantages bestowed by wealthy parents (and potential future donors), but as the recent college admissions scandal showed, those things are overrated anyway.

Do subspecialist-led guidelines serve patients better - or worse?

In December 2017, the Health News Review blog posted a story questioning why there had been such extensive news coverage of the American College of Cardiology / American Heart Association hypertension guideline but so little of the American Academy of Family Physicians' announcement that it was not endorsing the guideline (the only other news outlets to have reported this decision are the AAFP's own news publication and Medscape). In this case, the AAFP decided to continue to adhere to blood pressure targets established by the JNC-8 hypertension guideline and its joint guideline with the American College of Physicians for adults aged 60 years or older.

Earlier that year, an editorial in the cardiology journal Hypertension criticized the ACP-AAFP guideline for the lack of "experts" on its panel. The 30 named authors of this 3-page piece, most of whom I suspect did not meet the International Committee of Medical Journal Editors' authorship criteria, collectively have a list of disclosures of commercial conflicts of interest that takes up nearly a column of text. Those concerns aside, Dr. Franz Messerli and colleagues stated correctly that "guidelines are traditionally scripted by a panel of experts who are intimately familiar with the topic in question." They went on to compare the glittering resumes of the JNC-8 panel ("most of them were indeed true experts") with the more pedestrian ones of the ACP/AAFP panel and asserted that the latter's dearth of expertise did not qualify them for guideline development:

As per PubMed, 3 of the 7 guideline authors have never authored an article on hypertension and 1 has coauthored a single study only. Moreover, not one of the authors of the ACP/AAFP guideline is known to be a hypertension specialist certified by the American Society of Hypertension or of the American Heart Association Council for High Blood Pressure. ... No ACP/AAFP guideline author is currently serving on the editorial board of a journal dealing with hypertension. ... The mere fact that you know how and when to prescribe hydrochlorothiazide does not make you an expert in hypertensive cardiovascular disease.

This argument echoed past complaints by subspecialty groups that the U.S. Preventive Services Task Force (USPSTF), made up entirely of primary care clinicians, could not possibly know what it was doing when it recommended fewer screening mammograms (without any radiologists!) or less prostate-specific antigen testing for prostate cancer (without any urologists!)

The question is not whether subspecialists should be involved in developing guidelines for diagnosis and management of common conditions such as hypertension: of course they should be. The question is, on what level? At the guideline review and revision phase (ACP/AAFP) or in developing the key recommendations? The ACC/AHA selected as one of its guideline co-chairs Dr. Paul Whelton, a renowned expert in hypertension who was the principal investigator for the SPRINT study, the only major trial to show that a blood pressure target of 120/80 yielded more benefits than harms compared to a blood pressure target of 140/90 in a selected group of very high-risk patients. In recognition of this intellectual bias, Dr. Whelton was relieved from chairing duties when SPRINT came up, but apparently was able to fully participate in the discussion and vote.

I had the pleasure of meeting Dr. Whelton at a conference a few years ago and came away enormously impressed by his intelligence and equanimity. But it's very hard for anyone to see something - in this case, harms of lower blood pressure thresholds - if your scientific reputation depends on your overlooking it. Also, in my experience as a staffer for the USPSTF, panel members who did not treat the condition being screened for were able to follow the evidence without being biased by clinical experience. Pediatricians who weren't conditioned to order yearly mammograms or obstetrician-gynecologists who never ordered PSA tests were more often assets than liabilities on these topics.

Primary care clinicians, particularly family physicians, have unrivaled expertise in treating the whole person, not only one body part or organ system. As I noted in a Medscape commentary on the ACC/AHA hypertension guidelines, "Cardiologists have the luxury of only needing to be concerned with cardiovascular disease, but the vast majority of my patients with hypertension have comorbid chronic conditions and take several medications. Adding one more anti-hypertensive drug means more potential side effects, medication interactions, and costs to the patient and the health system." Kudos to the AAFP for having the courage to stick with the evidence and buck the one-low-blood-pressure-target-fits-all trend.

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This  post first appeared on Common Sense Family Doctor on December 21, 2017.