Fluoridation: Dental health for all

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Fluoridation of the water supply is one of the great public health benefits of the 20^th century. It is also one of the persistently more controversial. Ideological opposition (to “the government” doing anything) has mixed with paranoia (they are poisoning us) to create a pretty sustained grass-roots movement, one that has blocked this effort in many places in the country. Now, according to Lizette Alvarez’ article in the NY Times “Looking to save money, more places decide to stop fluoridating the water” (October 14, 2011), saving money has been added to these arguments. The threat is that communities which have had the benefits of fluoridated water will lose them. This is apparently the what is happening in Pinellas County, Florida (the Clearwater/St. Petersburg area), as well as in Fairbanks, Alaska.

The situations in Florida and Alaska may well be different, however. The decision in Fairbanks is apparently tied to the relatively high levels of naturally-occurring fluoride in the water there, which would make fluoridation an unnecessary cost. In Florida, however, the decision seems to be driven by cost as well as the same issues I note above. “I’m in opposition to putting a medical treatment into the public drinking water supply without a vote of the people who drink that water,” said Norm Roche, a newly elected Republican county commissioner who spent 10 years doing policy research for the county Water Department and who led the turnaround effort. “We had a dozen to 15 doctors, dentists, dental hygienists and chemists here who want us to continue this practice but who could not agree themselves on how best to use fluoride.” The article does not further define what Mr. Roche means by “how best to use”, leaving us to imagine if this is an issue of putting it in the water vs another method (fluoridated toothpaste, fluoride treatments at home, fluoride varnishes by health providers) or disagreement as to whether it should be used at all.

In fact, the medical and dental community are pretty much in agreement that fluoride is good for preventing tooth decay, and that dental caries are a major cause of disability both medically and socially. It is hard for a child with a toothache to concentrate at school, not to mention the teasing that can come from having a mouthful of rotting teeth. This latter continues into adulthood; people with bad teeth (or no teeth) are seen as less smart and less competent, and are less likely to be hired in most jobs.

Fluoride works. In my “middle years”, my Chicago dentist had a pretty good idea of my age because he knew when the water in New York City, where I grew up, was first fluoridated. My “6-year molars” were covered with filled cavities (necessitating, all those years later, a lot of restoration work by him), while my “12-year molars”, which erupted after fluoridation, were almost cavity-free.  I sure remember getting all those cavities filled, before dentists had high-speed drills or used anesthesia for such a simple, common procedure. My childhood self would certainly advocate for fluoride to prevent that discomfort!

There are, indeed, side effects to high levels of fluoride, whether naturally occurring or otherwise. The main sign of “fluorosis” is “marble teeth disease”, with “grotesque” brown staining of the teeth. It was an investigation into this condition in Colorado Springs in 1909 that led to the discovery both that the cause was high fluoride levels in the water, and that these teeth had virtually no decay (“The Story of Fluoride”, from the National Institutes of Dental and Craniofacial Research). This led to work that identified a level of fluoride that could be added to drinking water that was sufficient to prevent decay but too low to produce this condition.

After spending most of my life in New York and Chicago, one of the most dramatic things to catch my attention early in my stay in San Antonio, Texas, were the young children with stainless steel teeth, whose mouths distressingly reminded me of “Jaws”, the James Bond villain (albeit without the points!). I soon learned two things: 1) the stainless steel teeth were the result of having a great pediatric dental program at our dental school which could fix the mouths of children whose “baby teeth” had all rotted out, allowing them to be both pain-free and able to eat, and 2) the water in San Antonio was not fluoridated, which was a major cause (in combination with other behaviors, such as use of sugared drinks in baby bottles, feeding sugared soft-drinks to young children beyond the bottle years,  and “bottle propping” which leaves the milk – and milk sugar – in the baby’s mouth) of the decay the led to the need for such repair. While only a small percentage of children in San Antonio had such stainless steel teeth, a very large percentage had significant and disabling tooth decay.

I also discovered that efforts to pass fluoridation had been defeated in San Antonio on at least two occasions in the past few decades. The opposition was largely from right-wing, John Birch Society, anti-government groups, but also included those who were from the other end of the political spectrum but believed in “natural” health, and thus opposed addition of fluoride. In 2002, an initiative spearheaded by the Mayor of San Antonio, finally led to passage of fluoridation for that city. During this campaign, virtually all the major politicians, all the dentists, physicians, and public health people, and most of the foundations and money were for the initiative. Nonetheless, it passed by only 52% of the vote. The good news here, I guess, is that it is an example of the power of regular people, not very well funded, to resist change being imposed on them. Unfortunately, it was contrary to their health interests.

As I note, the opposition was not solely from the right. During my time in San Antonio, I frequently attended open meetings of a group of progressives in a local Mexican restaurant. Primarily mainstream liberal Democrats, and including the late San Antonio New Deal mayor and newspaper columnist, Maury Maverick, the group was diverse, including socialists and “Greens” and even libertarians, whose interests in lack of government restrictions and privacy invasions gave them common cause. These last two groups, the Greens and libertarians, were opposed to fluoridation. The national Green presidential candidate, Ralph Nader, on a stop in San Antonio, even came out in opposition to the initiative. As a health care provider, I did my best to argue for the benefits of fluoridation, but was unable to win them over.

One argument made they made (at least the libertarians) was that “fluoride might be beneficial, but the government should not put it in our water supply”. Parents could use fluoridated toothpaste or fluoride rinses on their children’s teeth, or bring them to the dentist for fluoride varnish. Well, they could, but often they didn’t, and it was the children who would suffer the caries and their long-term consequences. Indeed in the ‘90s a new syndrome, dubbed “yuppie baby carie syndrome” was identified in children of well-off parents who made their infant formula with bottled water. (The causes of caries from bottle propping and unfluoridated water are well-described in the Wikipedia entry on “Early Childhood Caries”.) Of course, the spread of bottled water to a much wider socioeconomic group makes this even a bigger potential problem. Indeed, some water from natural springs contains minerals, sometimes including fluoride, while the bigger mass-products products from Coke – Dasani – and Pepsi – Aquafina – are municipal tap water that has been “purified” and thus do not.  (This does not even begin to touch on all the environmental costs of bottled tap water, from plastic bottles to transporting tap water from one part of the country to another, but that’s another story.)

San Antonio, and more recently San Diego, are victories for fluoridation, while many cities, such as Wichita, remain unfluoridated, and others, such as Pinellas County and Fairbanks are going the other way. If Fairbanks has sufficient natural fluoride, then supplementation is an unnecessary cost. For those communities without adequate natural fluoride, it is a big mistake.

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No way to run a hospital, no way to run a healthcare system

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In a  feature article in the NY Times on October 2, 2011, “Nowhere to go, except room 516” (retitled “Stuck in bed, at hospital’s expense” on-line), John Leland tells the story of Raymond Fok, a man admitted to a NYC hospital for a stroke while on his way to his kidney dialysis appointment, and hospitalized for 19 months. The reason for his extended hospitalization was not his medical illness. Although that illness was very significant, including both his kidney failure requiring dialysis and the stroke that resulted from bleeding into his brain, these are common conditions which almost never lead to hospitalization for more than a couple of weeks. Most often people in such situations are discharged to a skilled nursing facility (SNF) for rehabilitation, although occasionally people who recover very well and have a supportive family can go home, often with home-based physical therapy.

The reason that Mr. Fok did not leave the hospital was because there was nowhere for him to go. An undocumented resident of the city in which he had lived for 23 years, he was uninsured and ineligible for publicly-funded coverage (eg, Medicaid).  No nursing home, skilled nursing, or rehab facility would take him without a source of funding. Although only 58, had he been legally in the US, he would have been eligible for Medicare because of his need for kidney dialysis. It was not just that his family didn’t have money; they were not to be found. He had limited information to share with them, and it was a year before a family member was “discovered” visiting him. His wife and 2 sons are also undocumented, although his 18 year old daughter, born in the US, is a citizen. Finally he did go home, after accumulating a cost to New York Downtown Hospital of $1.4 million. Medicaid did end up paying for some of it. About $114,000, or 10%. The hospital absorbed the rest of the cost.

New York Downtown is in an area in which there are many immigrants, a large percentage of whom are not in the US legally. The hospital may not have many patients whose length of stay, and cost of care, are quite as much as Mr. Fok’s, but they certainly end of caring for a much higher percent of people who can and do pay little or nothing as do hospitals in neighborhoods that are more well to do neighborhoods (although, it turns out, Mr. Fok and his family live in Brooklyn, a long distance from NY Downtown). It seems a little unfair, kind of like a roll of the dice or a game of Russian roulette, that this hospital should have to bear the cost of his care because he ended up there.

It would not be unfair if the hospitals in New York, or in the United States, were “all in it together”. If they were not in competition with one another. If getting paid for services were not dependent on the luck of whether the people who need care are insured, or eligible for insurance. But that is not the case. In Canada, for example, most hospitals are not publicly-owned, but they are funded by a global budget negotiated with the health ministry of the Province in which they are located. And, of course, Canadian Medicare is a single-payer national health insurance program that means that all people are covered by insurance.

In the United States, however, hospitals compete. Rather than having a rational basis for creating health resources – enough beds, enough x-rays and MRI and CT machines, enough operating rooms, etc. – for the population of a community, it is “every hospital for itself”. In more densely populated communities, services are frequently duplicated (or triplicated, or quadruplicated!) A community of a certain size may “need”, say, one MRI machine. But if a particular hospital has that MRI machine, it gives them a competitive advantage over other hospitals; now each other hospital “needs” one. So we have too many. Thirty years ago the federal government supported local “PSRO”s that made such decisions, but they were very unpopular (with the “losers”). Today we have each hospital trying to build bigger, fancier units for the care of certain profitable conditions like cancer or heart disease, in hopes of attracting patients (insured patients, of course) to their institution rather than to a competitor. That is, we build an oversupply of resources to care for certain conditions (the ones for which reimbursement is profitable) and for certain patients (those who live in metropolitan areas and are insured).

On the other hand, we have communities, primarily rural communities, where there are no hospitals, and where people have to drive long distances for care. The state of Kansas is among those with the largest number of “critical access” hospitals, usually very small and the only ones in the county. They are rarely profitable, but are kept alive because they receive both county funds and enhanced reimbursement from government payers (Medicare and Medicaid). Despite this extra funding, the majority are losing money; if only operating revenue is considered, most are (see the graphics).

What kind of a health system is this? In urban areas we overbuild capacity of beds, imaging systems, and the like, and hospitals compete for paying patients, especially those whose diseases, such as cancer and heart disease, have a high-margin of profit. In rural areas, patients often have to commute long distances for care. The result is that if you are insured and have a high-profit-margin disease, you are a sought after customer; if you are not, or live in a rural area, you are probably out of luck.

And, if you are such a patient and no one wants to pay for you but you find your way to the hospital, like Raymond Fok, then the hospital is out of luck. This is no way to run healthcare. It is no way to run a society.

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PSA redux: The USPSTF finally recommends NOT getting it!

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The US Preventive Services Task Force (USPSTF), the independent group of physicians and scientists who make recommendations to the government, medical community, and American people on the value of screening tests, recently came out with a new recommendation on the use of laboratory tests for Prostate Specific Antigen (PSA) in screening for prostate cancer.  It recommended AGAINST it --in their terms, a “D” recommendation. Previously, USPSTF had recommended against PSA screening for men over the age of 75, but had not taken a position for or against screening in younger men (an “I” recommendation, insufficient evidence to recommend for or against screening).

My belief is that this is a good, appropriate, and very overdue recommendation which will come as no surprise to those who have read this blog for some time. I, and guest authors, have addressed this issue several times (PSA Screening: What is the value?, Mar 21, 2009; PSA Screening: “One of Medicine's Great Success Stories"?, Oct 27, 2009 (by Robert Ferrer);, Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?, Mar 15, 2011). In addition I have often linked to and cited the work of Kenny Lin, MD, who writes the Common Sense Family Doctor blog, and resigned from the Agency for Healthcare Quality and Research (AHRQ) as a member of the USPSTF support team in November, 2010, over his perception that these recommendations were being delayed by political considerations. Dr. Lin has also written about PSA testing often  (including  "It is time to stop this [PSA] June 21, 2011, PSA testing: will science finally trump politics? Feb 28, 2011) and has recently addressed the new recommendations on Oct 7, 2011, Shannon Brownlee on the pros and cons of early cancer screening.

Of course, a lot of people do not think that this recommendation is a good thing. Two large groups, in particular, oppose the new recommendations: urologists and others who earn their livings treating prostate cancer and “advocacy” groups, supported by many high-profile (as well as just regular folks) men who have survived prostate cancer. Many of these men are quoted in Gardner Harris’ NY Times article “US panel says no to prostate screening for healthy men”, October 7, 2011. One of those who is quoted (actually not in the published NY Times piece, but in another version of Harris’ article published in the Seattle Times, is my colleague Brantley Thrasher, MD, Chair of the Department of Urology at the University of Kansas Medical Center, who said, "It appears to me that screening is accomplishing just what we would like to see: diagnose and treat the disease while it is still confined to the prostate and, as such, still curable."

I like Brant Thrasher, I think he is a good and knowledgeable doctor and great surgeon, but I strongly disagree with him on this one.  As much as we would like, and believe me as a family doctor I would like, and Kenny Lin would like, a test that could find disease early while it was still curable and make a difference in people’s live, PSA is not that test and, at this point prostate cancer is not that disease. These are two separate issues, so let’s take them separately.

PSA is not a good test. Yes, it is often, maybe usually, elevated in men with prostate cancer. Of course, in some men with prostate cancer it is not above the “normal” cutoff. This has led some advocates of PSA screening to suggest use of “PSA velocity”: check it yearly and watch the rate of rise rather than the absolute value. But the bigger problem for PSA as a screening test is that it is often elevated in men who do not have prostate cancer but just have a big prostate (“hypertrophy”, almost universal in men above a certain age), or even DO have cancer, but the very-slow-growing-that-is-not-going-to-kill-you-before-you-die-of-something-else kind, which is by far the most common variety. These men are subjected to ultrasounds, biopsies, and treatments that cause significant morbidity (impotence, incontinence of urine, and “radiation proctitis” of the rectum and anus, developing congestive heart failure from hormone treatment, to name a few) with no benefit.  Baylor physician and panel chair Virginia Moyer notes in the Times article that “This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does.” In 2010, Richard Ablin, PhD, who discovered the a prostate specific antigen (but not the PSA test) in 1970, called use of the test “a public health disaster” and “not much better than a coin toss.” (“The Great Prostate Mistake”, NY Times, March 9, 2010.

But the bigger issue is that there is no good evidence that treatment of any kind – surgical, radiation, hormonal – makes any difference in the outcome of prostate cancer. Surgeons like Brant Thrasher think it does, and he may be some day proven correct , at least in some circumstances, currently there is much more evidence supporting that it doesn’t than that it does. If you have the common, less-aggressive kind of prostate cancer, you won’t die from it, with or without treatment. If you have the rarer, highly-aggressive kind, you will probably die from it, with or without treatment.  The Times article notes that  “…advocates for those with prostate cancer promised to fight the recommendation. Baseball’s Joe Torre, the financier Michael Milken and Rudolph W. Giuliani, the former New York City mayor, are among tens of thousands of men who believe a P.S.A. test saved their lives.” They may believe it, but they are probably (I obviously don’t have access to their medical records) wrong. The test diagnosed prostate cancer, they were treated for prostate cancer, and they are alive. QED. But it’s false logic, an association that doesn’t demonstrate cause. If they are alive now, they would be alive (at least as far as the prostate cancer is concerned) without the treatment. And they wouldn’t have those “little” problems like incontinence and impotence that seem like a small price to pay for not dying of cancer, but are a big price if the treatment didn’t make any difference. The famous folks who have died of prostate cancer, like Frank Zappa, died despite treatment.

The Times quotes Thomas Kirk, of Us TOO, the nation’s largest advocacy group for prostate cancer survivors, saying “The bottom line is that this is the best test we have, and the answer can’t be, ‘Don’t get tested.’” He’s wrong. That is the answer. We not only need a test that can distinguish the “bad” kind of prostate cancer that will kill you from the kind that probably won’t, we need treatments that evidence shows makes a difference in survival and quality of life if you do have the bad kind. In the meantime, getting tested is likely to create more harm than benefit.

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Healthful Behaviors: Why do people adopt them? Or not?

While I am not a psychologist or psychiatrist, I am both a family physician and a person. As such, I have observed human behavior for a long time. I have noted some psychological behaviors seem to be very common in the people that I have met both personally and professionally.  I won’t say that they are “human nature”, since this phrase almost always refers to something that the speaker believes in or finds dominant in his/her environment, and is usually very culturally bound. However, they are common. One of these is the tendency to deny the magnitude of risk inherent in the risky things we do (or the risks we take because of things we don’t do). At the same time, we magnify the degree of risk inherent in the things we pride ourselves on not doing (or doing, when we see doing them as if beneficial, and not doing them as risky). As a corollary, we are likely to criticize those who adopt the risky behaviors that we do not, or do not adopt the beneficial behaviors that we do. That is, judging others is easy.

Perhaps because many of these potential risks are to our health and safety, these attitudes are common in health care and public health workers. Health professionals who do not smoke, and have never smoked, often severely condemn those who do. But alcohol? A little wine is good for you, right? Maybe, but it depends on who you are. If you have a tendency towards alcoholism, or are pregnant, or are going to drive, it is not good for you. Or for others. Public health workers can strongly advocate for wearing bicycle and motorcycle helmets, and using infant car seats, but it is just possible that once or twice they were late for something and drove too fast or too carelessly. And hopefully didn’t have an accident, but could have, and certainly increased their risk for it. From a risk/benefit point of view (fire trucks and ambulances and police aside), being late for work is NEVER a reason to drive faster or more carelessly; in fact, because there is a natural temptation to do so, conscious governance of that temptation is the beneficial behavior.

The utility of adopting a healthful, or not adopting an unhealthful, behavior is complex. It depends on the likelihood of something bad happening, how bad that thing is, and how many people it affects. So eating unhealthful food and not exercising is bad, but mainly for the person (and their immediate family) if they get sick or die. Smoking in public places, and even more, driving less than carefully or under the influence of alcohol or drugs potentially affects more people. Not immunizing your children because it allows you prevent a common but unpleasant effect (getting a lot of shots) and possibly a bad but extraordinarily rare long-term effect (whether real, like Guillain-Barre from swine flu shots or not, like autism[1] must be balanced against both the risk of their acquiring the disease and its sequelae, as well as the impact on the overall population that results if lots of children, not just yours, are unimmunized.

Not long ago I saw a patient in her early 30s who was pretty obsessed with getting breast cancer. She had no particular risk factors (no first-degree female relatives with it), but had previously talked a physician into ordering a mammogram when she was just 28 (it was normal), and wanted another one. We discussed the risk, but she was pretty fixated on breast cancer. We also talked about other risks, of much more concern to me than to her: smoking 2 packs of cigarettes per day, having 3 different sexual partners and rarely using condoms, and having untreated hypertension. I suggested, strongly but I hope appropriately, that all of these were much greater risks to her health than was breast cancer. I don’t know that I got through.

I imagine that it is pretty easy for health professionals to agree with me about the relative risks for this woman. Why she was so concerned about breast cancer rather than her real risks is another question. Some obsessive neurosis? Excessive effectiveness of breast cancer awareness advertising? I’d suggest that in large part it is about personal responsibility, about whether she would have to take action to prevent a bad outcome. If she were really worried about the risk from blood pressure, from smoking, from unprotected sex with multiple partners (and she should be), she would have to do something, take some action to change her life, to take medicine, to give up an addiction. This would be hard. On the other hand, since there are no clear behaviors she would need to change to avoid breast cancer, this is a safer – that is, less challenging – thing to be concerned about, to be fixated on.

Are the rest of us so different? Even those of us who have almost no dangerous or risky habits or behaviors (are there such? If we apparently have none, there is a fair chance that we might be suffering from obsessive-compulsive disorder, also a potential risk!) Besides, some of us may always take care to wash our hands when using the restroom (and even use our elbows to turn off the water, as I saw a very young man do in a public place the other day), but take the risk of riding our bicycles on public thoroughfares. Or we may practice what we believe to be healthful eating, and may regularly ingest herbs and give our children vitamins that there is little or no data to support doing, but not give them immunizations.

Reducing health risk is also impacted by societal memory, or the lack thereof. This has been examined in the case of abortion rights, where younger women who have grown up during a period when abortion was legal (if increasingly unavailable, largely resulting from the campaign of terror from violent anti-abortion forces) do not see the urgency of fighting to continue it. It also often true in the case of HIV/AIDS, where young people who did not grow up seeing all their friends die of the disease before effective treatment was available may find themselves adopting the same high-risk behaviors. Or for those who never saw the devastation of epidemics of pertussis or diphtheria, or of measles, or of awful outcomes from Hemophilus influenza infections, to not see immunizing their children as critically important.

In addition, when we as individuals have good outcomes (or don’t have bad ones) we may tend to think it is deserved rather than attributing it to good fortune. We haven’t had car accidents because we are good drivers, not because we are lucky. We think we are healthy because we bike to work, or “eat right”, not because we are young and in a low-risk group. When we are older, we may believe that we are less ill than our friends because we do healthful things like yoga or take certain herbs, not because we lucked out in not getting cancer (or being born into a family with resources who could feed us well and educate us and provide us with other advantages) See also Social Determinants, Personal Responsibility, and Health System Outcomes, Sept 10, 2010).

I am not going to say “let s/he who is without sin cast the first stone”. I would, rather, ask all of us to recognize that an honest appraisal of our own risk behaviors is a first step to understanding those of others, and to helping them, and helping our society, achieve greater health.

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[1] Data on vaccines presented at the recent American Academy of Family Physicians (AAFP) meeting suggest the chance of an adverse vaccine outcome is approximately equal to the chance of winning the lottery, and that of dying from a vaccine about equal to spontaneously having quadruplets.

Are primary care physicians fees a major contributor to the high costs of US healthcare? No.

A recent article in Health Affairs by Miriam J. Laugesen of Columbia University and Sherry A. Glied of the Department of Health and Human Services has generated a lot of attention. “Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared to Other Countries”[1] looked at the amount paid to 1) primary care physicians for office visits, and 2) orthopedic surgeons for hip replacements, in the US, and compared them to five other countries (Australia, Canada, France, Germany, and the United Kingdom). The study also looked at overall physician income in those countries, and at a variety of factors that contribute to both. These factors include the mix of public (primarily Medicare in the US) and private insurance and the ratio of what private insurance pays relative to the public payer, cost and extent of medical education, and overhead expenses. They noted the relative income of primary care physicians to orthopedists in the various countries. Their stated reason for this study is that “The differential in spending on physician services is greater than the overall difference in total health spending between the United States and other nations.”

The concept that a significant portion of the US’ extremely high health care costs is due to high physician reimbursement has long been widely accepted, but the assertion that a part of the blame lies with high primary care incomes is rather new, and is the part of this article that has engendered the most attention. Robert Pear’s NY Times piece on September 7, 2011, “Doctor Fees Major Factor in Health Costs, Study Says” and the response letter from the American Medical Association (AMA) addressed the first part (both/all specialities). The second issue, the article’s focus on the fees of primary care physicians generated pushback from the president of the American Academy of Family Physicians (AAFP), Roland Goertz, who issued strong criticism of the implication that it is primary care physicians who account for the high cost of US healthcare (AAFP President Refutes Claims That Primary Care Physician Incomes Contribute to High Health Care Costs.) More basic information on the economic issues and assumptions that inform this kind of work are described quite clearly by Uwe Reinhardt in a Times “Economix” column on September 18, 2011, “The role of prices in health care spending”.

So what does the Laugesen and Glied study really show? It does show that primary care physicians in the US makes more than primary care physicians in the five other countries, and in some cases a good bit more. It also shows that orthopedic surgeons in the US make a lot more than orthopedic surgeons in other countries. These differences are not due primarily to seeing more patients (patients in those other countries have more visits than do primary care physicians than those in the US, averaging 5.95 per capita per year to the US’ 3.8, and orthopedists do not do significantly more procedures) but rather to the higher fees paid by private insurance in the US.

The study also shows, very significantly, and as emphasized by Dr. Goertz, that the ratio between the income of orthopedists and primary care doctors is much higher in the US than in those other countries. This bolsters the argument that, to the extent doctors’ fees contribute to the high cost of health care in the US, it is much more because of specialist rather than primary care, reimbursement.  The authors of the study note that “Most other countries, however, have moved further away from fee-for-service

than the United States has”, and that “Where physicians may charge fees above the national schedule, the practice is consistently more common among orthopedic surgeons than among primary care

physicians, regardless of country.”

A key finding of the study that also supports Goertz’ argument is that [my bold] “Overall, fees paid by Medicare to US physicians for office visits are comparable to those paid by public insurers in several other countries, and fees paid by US private insurers are slightly higher than those paid by private insurers in other countries. In contrast, fees paid by public payers to orthopedic surgeons for hip replacements in the United States are considerably higher than comparable fees for hip replacements in other countries, and fees paid by private insurers in the United States for this service are double the fees paid in the private sector elsewhere .” This is exacerbated by the fact that “In general, Americans are very low users of office visits and relatively high users of hip replacement surgery.”

US orthopedic surgeons earned at least 50% more than those of other countries, and the ratio of primary care to orthopedist income was the lowest in the US, 42%, compared to 60% in other countries. The authors note that “The differences in incomes relative to fees provide more confidence in the overall comparability of the data. They suggest that higher US fees are a consequence not only of higher practice expenses, but also of higher rewards for the skill and time of physicians.” The authors also address the greater cost of medical education to the individual in the US, but conclude that the increased reimbursement more than compensates for this difference. Work by the Graham Center (see figure) shows that medical student specialty choice is highly tied to projected income.

One factor not addressed in most of the commentary on this article is that the authors of the study say “In the United States this definition [of primary care] includes family practice, general practice, internal medicine, obstetrics and gynecology, and pediatrics.” They do this despite the fact that “this” refers to the immediately preceding sentence, which presents the 2008 definition from the Organization for Economic Cooperation and Development (OECD) of a “primary care physician as one who does not limit practice to certain disease categories”. This definition certainly does not include obstetrics/gynecology (OB/GYN). Why, then, do they include OB/GYNs? Unsurprisingly, the answer is largely political; the argument in the US was that many women receive their “primary care” from their OB/GYN. This logic, however, is deeply flawed. To the extent that women do so, they are not receiving comprehensive primary care, because OB/GYNs care for conditions involving the reproductive system and women are more than their reproductive tracts. Lest this be seen primarily as a matter of my personal sensitivity as a family physician, there is a very important issue because including them can dramatically skew the income data. As OB/GYNs are largely surgeons, their fees and income are much higher than those of the other specialties that are actually primary care, and raise the measured income of “primary care” physicians when they are included.

Laugesen and Glied show that “US primary care physicians earn about one-third more than do their counterparts elsewhere” but that “…neither public insurance nor private insurance generalist physician fees for basic office visits are much higher in the United States than in many of the comparison countries. Instead, US primary care doctors do somewhat better overall mainly because a much larger share of their incomes is derived from private insurance. In other countries where private primary care practice is permitted, the market share of this form of practice is relatively small.” They go on to say, however, that “For orthopedic surgeons, the story is quite different. US orthopedic surgeons earn much higher incomes than do their counterparts abroad, and there are more such surgeons per capita here than almost anywhere else. In consequence, comparison countries spend only about one-quarter as much as the United States spends on orthopedic surgeons. Rates of hip replacement surgery are not higher in the United States than elsewhere, although rates of other procedures performed by orthopedic surgeons may be. Much of the difference in earnings appears to be due to differential fees. Public-sector fees for hip replacement surgery in other countries are about half as high, on average, as Medicare fees in the United States.”

Finally, the ratio of primary care physicians (essentially all general and family physicians) to specialty physicians in other countries is much higher than in the US, so this is also an area in which their costs are lower. That is, more care is provided by primary care doctors and less by more expensive (even in those countries) specialists. Thus, the problem with health costs in the US is not the high cost of primary care. It is the private for-profit marketplace and the excessive fees paid by private insurance for surgical procedures and other specialty care that drives physicians’ fees to be so much higher in the US.

Among the many other changes that we need in our health system, two important ones are increasing the percent of our physician workforce that is primary care, and creating greater equity in the reimbursement among physicians.

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[1] Health Affairs, 30, no.9 (2011):1647-1656