All in the Family Practice

ClintonCare's medical-specialty quotas

John Hood | December 1, 1993

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When highly trained experts in the field differ so widely in their views on early treatment--and tend to see problems from their own, sometimes narrow point of view--it is misleading and even dangerous to suggest that preventive care is a panacea for our health care woes. In 1986, when the federal government first approved prostate-specific antigen testing, the American Cancer Society and the test's manufacturer began to call for all men over 50 to undergo the test. By 1990, the number of radical prostatectomies performed in the United States had risen to 16,000, more than all the protestatectomies in 1984,1985, and 1986 combined. No one knows how many of those patients suffered unnecessary surgery.

In her 1986 book, Is Prevention Better Than Cure.?, published by the Brookings Institution, Louise B. Russell cites a study showing that, over the long run, a concerted effort to prevent certain illnesses can generate medical expenses four to six times greater than simply letting the illnesses run their course. Partly this reflects that fact that many people who receive preventive care will not actually develop the anticipated illness, or at least will not develop the most dangerous form of the illness.

And if we must don our green eyeshades to measure costs and benefits to "society" of preventive care, as the Clinton administration suggests, then we should be honest: Expending resources to keep someone from developing an illness may well cost more than letting the illness end in death. Smokers, for example, far from costing the total health-care system money (as Hillary Clinton alleges), may actually save the system a little bit because they tend to die off before they get old enough to start running up huge medical bills.

John J. Whyte, a medical intern at Duke University Medical Center in Durham, North Carolina, offers a perspective on preventive care and general practice from the front lines. Contrary to popular belief, he says, "health promotion and disease prevention usually increase, rather than decrease, medical expenditures." He provides the example of treating high blood pressure. When patients come into Whyte's clinic at Duke, their vital signs are routinely taken. If their blood pressure is high, Whyte will repeat the procedure during that visit and, if it remains high, he'll check them again in two to four weeks. If a patient consistently demonstrates high-blood pressure; he or she will probably go on a relatively expensive medication and visit the doctor often, particularly during the first few months of treatment.

In the late 1970s, researchers at Harvard studied whether such screening and treatment for high blood pressure would save money. They found that for people with moderate or severe high blood pressure, the cost' of treatment were four times as large as any savings "Preventing disease involves risks, which are rarer, mentioned, as well as benefits," Whyte notes. "Due t' the imperfection of medical science, we sometime treat people who do not need to be treated and neglect to treat those who do need treatment."

Setting aside the issue of preventive care, there is still an argument about the relative efficiency of specialists. The evidence that specialists contribute a large amount of waste to the health-care system is not clear. Several studies of medical efficiency currently underway, including the much-ballyhooed Medical Outcomes Study by a national team of researchers, have found that specialists are responsible for more costs per patient than primary-care physicians.

But these studies don't adequately adjust the data to account for differences in the severity of patient illnesses. People with more serious, and thus more costly, conditions are more likely to visit specialists. According to Dr. Roz Diane Lasker and Dr. David W. Shapiro of the Physician Payment Review Commission (a federal agency), generalists in the Medical Outcomes Study "may have seen a substantial number of patients with upper respiratory infections or acute low back pain, whereas cardiologists may be seeing patients referred for evaluation of syncope or the new onset of chest pain." This kind of difference is often not captured in the studies the Clinton administration cites.

Moreover, generalists and specialists are not as easily differentiated as the Clinton administration assumes. Americans are spending a lot more time in specialists' offices than you might think. About 20 percent of U.S. patients receive most of their continuing medical care from specialists, and almost 40 percent make most ~f their visits to a specialist. Many of these specialists already provide basic care to their patients in addition to more-specific treatments. And many managed-care networks are encouraging this trend by including in their preferred-provider lists only those specialists who can treat multiple conditions and who can provide primary care on site.

Market pressures are working against physicians who overspecialize. A new category of doctors--so-called primary-care specialists--is meeting the needs of patients in a more efficient manner. David Meltzer of the University of Chicago's Pritzker School of Medicine argues that this trend will reduce the need for referrals and multiple workups, particularly for patients with chronic conditions such as hypertension, diabetes mellitus, angina, and osteoarthritis--who account for a substantial share of total doctor visits. As managed-care networks continue to spread, Meltzer contends, "many specialists will find primary-care responsibilities surprisingly attractive."

There's good reason to have a lot of doctors who can provide basic care but who also specialize in one area. "Given the uncertainty about the appropriateness of many medical interventions," Meltzer says, "it is potentially important that specialists can keep up with advances in their areas of specialization that the generalist simply cannot."

Take congestive heart failure. Michael Bristow, a top researcher in the field who has run several clinical trials of experimental heart medicines, told a convention of science writers in January that between 20 percent and 50 percent of American heart-failure patients are being treated with ACE-inhibitors, the most effective treatment available. "The number should be 90 percent," he said, "but the majority of heart-failure patients are managed by family practitioners and internists, and, for whatever reason, the message isn't getting out." Bristow noted that patients seeing cardiologists are twice as likely to get ACE-inhibitors as those seeing family doctors.

Of course, patients may not have enough information to know which "primary-care specialist" they need to see. That's why they've traditionally relied on doctors in general practice to act as gatekeepers, to route patients to specialists and monitor their overall health and drug intake. But these gatekeepers probably don't need to be M.D.s. (See "Market Medicine," March 1992.) Even the Clinton administration has granted the need to allow nurse practitioners, physician assistants, and other non-doctor providers of health care more freedom to serve their patients. In most cases, restrictions on such providers are enacted by states, with plenty of support from doctors' associations. Lifting them would improve the efficiency of the system by matching the services patients need (gatekeeping or specialty care) with appropriately trained people.

Dr. Stuart Bondurant, dean of the University of North Carolina School of Medicine and current chairman of the American Association of Medical Colleges, is surprisingly blunt: "If you had a lot more non-doctor providers, then you wouldn't need so many generalists." Another trend that may reduce the need for G.P. gatekeepers is the computerization of patient records. Once each patient has a "smart card" that contains his medical history, a specialist may not need to confer as often with that patient's primary-care physician.

The goal of health reform should be savvy and cost-conscious consumers and a freer market for care, not a new distribution of producers imposed by Washington. Today's insurance-heavy funding system has weakened the connection between patients and doctors, encouraging the former to consume and the latter to prescribe as much care as possible. The answer to this problem, however, is not government planning to encourage one purportedly efficient form of care over another. "I don't think anyone knows for sure what the specialist quota should be," says Tom Reardon, a trustee of the American Medical Association and a general practitioner in Portland, Oregon, for 33 years. Dr. Gregory Bulkley, the Ravitch Professor of Surgery at Johns Hopkins Hospital in Baltimore, is even more direct: "No central planner can predict the future, and that's just as true for medicine as it is for anything else."

Instead, we should change tax laws and regulations to make it easier for patients to self-insure with Medical Savings Accounts and pocket savings when they forego care. In that way, all doctors--generalists and specialists alike--will be dealing with consumers spending their own money. That will lead to more-efficient consumption at the point of sale, whether the door outside the doctor's office reads "Family Medicine" or "Otorhinolaryngology."

There is evidence to suggest that giving people a choice between consuming care or pocketing their savings will generate the best results, even for preventive and primary care: A study published in the Spring 1990 issue of the journal Inquiry found that a $5.00 office visit copayment for preventive-care services in a Washington state HMO resulted in a 14-percent drop in examinations but did not significantly affect immunization rates for young children, cancer-screening tests received by women, or medication use by people with cardiovascular disease. The study concluded that "small copayments appear to have little impact on the most valuable types of preventive care services."

Yet the Clinton administration distrusts the decisions of patients, preferring decisions made "in the public good" by Donna Shalala and her successors in the federal bureaucracy. It is a frequent mistake of big government liberals to assume that universal rules, prescribed from afar, are better than sometimes messy personal decisions. They believe that an ounce of prevention is always worth a pound of cure--even when you're comparing an ounce of gold and a pound of dross.