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A previous post, Holes in the Bottom of the Boat, introduced the topic of waste in the system.  Any solution to the healthcare crisis that does not focus on cost-containment will fail.  I raised some anger with people who felt that I was not “free market” enough.  I can live with that.

Now I want to focus on the role of primary care physicians in this mix.  I am, after all, a primary care physician; and I am also, after all, mixed up (so I am perfect to address this problem).  By primary care physicians, by the way, I mean internists, family physicians, pediatricians, and any other specialty that will take on the overall care of the patient.  Some specialties, like OB/GYN, endocrinology, and nephrology will play the dual roles of specialist and PCP.

Buzz Word

Preventive medicine has become a buzz word, especially in this election season.  In the debate last night, Obama said that he would save money for the system through the use of electronic medical records and through prevention.  The subject of EMR and cost is a whole other beast that I will go after later.  The real question is whether preventive medicine actually saves money.

In an article in the NY Times (hat tip to Kevin), Gilbert Welch addresses this:

Senator John McCain argues that “the best care is preventative care,” and his health care reform plan claims that “by emphasizing prevention” and other measures “we can reduce health care costs.” Senator Barack Obama’s plan says, “Simply put, in the absence of a radical shift towards prevention and public health, we will not be successful in containing medical costs or improving the health of the American people.”

It may sound like common sense. But it is still a myth.

But the medical model for prevention has become less about health promotion and more about early diagnosis. Both candidates appear to have bought into it: Mr. Obama encourages annual checkups and screening, Mr. McCain early testing and screening.

It boils down to encouraging the well to have themselves tested to make sure they are not sick. And that approach doesn’t save money; it costs money.

So the whole premise that prevention saves money is wrong?  Clearly Welch focuses on early prevention; and his argument seems pretty sound:

Early screening is like the “check engine” light in your car. It can alert you to problems that need to be fixed, but too often it picks up trivial abnormalities that don’t affect performance, like one sensor’s recognizing that another sensor isn’t sensing.

And if we look hard enough, we’ll probably find out that one of your check-engine lights is on.

Overdiagnosis occurs even among what were once considered uniformly deadly diseases.

When it comes to cancer, for example, there is a very broad spectrum of diseases. Some kill rapidly, some progress slowly, and some do not progress at all.

That is why some doctors recommend “watchful waiting” for men with early prostate cancer: most cases never prove fatal. It was because of concerns about overdiagnosis that the United States Preventive Services Task Force recently recommended against prostate cancer screening in men over 75. Similar phenomena have been documented in early-stage breast cancer, lung cancer and melanoma.

The point is this:

• Early screening on a population that is not getting screened will incur a cost up-front.
• More screening will not only lead to more diagnosis, but also to overdiagnosis.
• Overdiagnosis leads not only to increased cost, but some harm to the patient.
• Many of the common screening procedures are not based on sound scientific data.

The counter-argument to this is: by preventing cancer, heart disease, and complications from diabetes, you will save enough money on the back-side to offset the upfront cost.  Perhaps.  But the data for this are often scarce, and in some diseases the data go against the cost-effectiveness of screening.

What’s it worth?

There is not debate that preventing unnecessary death is a good thing.  The real questions revolve around the value of screening.  This value comes in two flavors:

• The lives saved or made significantly better by the preventive intervention.
• The ROI: how much money does it take to save (or improve) one life.

Should PSA screening, mammography, and colonoscopy be paid for by the federal government?  The question is not simply an economic one.  PSA and colonoscopy have recently been recommended against for people over age 75.  This is not an economic recommendation, it is a recommendation based on the fact that the impact on the quality and/or quantity of life is not enough to justify the procedure.

Let’s assume, however, that the intervention does save lives (which is being done by the candidates and other policy folks).  The plan to recoup money by doing prevention is still something that is on very shaky ground.  Preventive medicine’s premise is that it is better to prevent a disease than to treat it.  This may be true, but the financial benefit may take many years to realize.  Planning on saving money through screening tests is not a good idea.

What about saving lives?  Isn’t it worth spending money just to save lives?  Since the discussion is over where to best spend money, the answer is often “no", since finite resources need to be sent to where they do the most good.  To figure out if this is the case, the value (both medical and financial) should be clearly known.

Do I think that it is worthwhile getting mammograms on women over 50?  Yes.  Some debate the data (and I am glad they do), but that seems to be money well-spent.  What about colonoscopy?  Medically, I think it is a good idea.  The question I can’t answer is the financial ROI.  Will they pay for “facility fees” that hospitals and gastroenterologists charge in addition to the fee to do the colonoscopy itself?  That raises the cost significantly. 

The real value of PCP’s

I do think primary care saves money; but not by ordering screening tests.  The best prevention a primary care physician can do – and the reason the candidates should be clamoring to increase our number – is that we can prevent unnecessary testing.

For example: if you go to the neurosurgeon with sciatic nerve pain that has gone on for 2 weeks and is excruciatingly painful, what do you think the chance that the doctor will order an MRI scan?  Fairly high.  Why?  Because they are used to seeing a population of people with much more severe disease.  This is because these people usually come to the PCP first.  When I see someone with these symptoms, I give them a prednisone pack, pain medications, and a handout on sciatica.  90% of these people get better.  The remaining 10% I send to physical therapy and, if the symptoms are not responding or are getting worse, order an MRI scan.  Only those people who have failed conservative therapy end up seeing the neurosurgeon.

This is true with chest pain, abdominal pain, and many other problems.  I see the general population, while the specialist sees a select sick population.  If I am doing my job right (which some PCP’s don’t), then my care will be much cheaper than that of a specialist.

Oh yes, and the specialist can charge significantly more for simply seeing the patient in the office than I can.  Just why they can sit in a room asking questions better than I can is not clear to me.

The other value of PCP’s is the prevention of Emergency Room visits.  When a child goes to the ER with a fever, the chance of the ED physician ordering labs and a chest x-ray is much, much higher than the chance I will do the same.  This is not mainly because of a particularly sick population, but instead due to the fact that the legal environment pushes them to practice “defensive medicine.”  Plus, I can bring the patient back in a day or two while the ED physician does not usually follow-up on the patient.

Change the Rhetoric

I do believe in preventive medicine.  I do think that it is worth spending money to save lives.  But I hate the fact that politicians are using it to spin their plans.  Once the numbers come out showing it does not save money, prevention will lose its good perception.

Instead of pushing prevention, push primary care.  There is little doubt that the PCP shortage will cost people a lot of money.  How do you push primary care?  Stop making it so frustratingly difficult to do.  Our margins are small and responsibility is huge.  If PCP’s will save a lot of money, wouldn’t it be worth it to invest a little more in them?