Finally from Dartmouth: More is More

The Dartmouth machine has published a rather astounding new paper about the wonderfulness of primary care. The reason that it’s astounding is that it debunks decades of Dartmouth doubletalk and adds to the growing evidence that patients who receive more medical care have better health outcomes. More is more, just as you would expect. Here’s what the Dartmouth team did.

First, using the conventional approach to measuring physician supply (AMA Masterfile), they  counted the number of primary care physicians and found no significant correlation with either Medicare spending or mortality. This directly contradicts earlier claims by Shi & Starfield that areas with more primary care physicians have lower mortality and by Baicker & Chandra that areas with more primary care physicians have lower Medicare spending, both of which are widely quoted. But we now know that neither is true. In fact, they never were.

Like the current study, Shi & Starfield had also failed to find a correlation between mortality and the total supply of primary care physicians, both family practice (FP) and general internal medicine (GIM). The correlation they found was only with FPs, although they called it “primary care.” However, as I’ve explained, this correlation exists because FP training programs (and therefore FPs) are more prevalent in the upper-Midwest, where minorities are sparse, poverty ghettos are rare and mortality rates are low. FP supply has nothing to do with it, and we now know that primary care supply doesn’t correlate with mortality. It never did. Ouch!

The same for Baicker & Chandra’s claim that areas with more primary care physicians have lower adjusted Medicare spending – about 30-40% lower. The current study shows that this isn’t true. In fact, it never really was. Baicker & Chandra’s claim was based on a statistical shell game that I exposed in Health Affairs. They responded that I was wrong, and Susan-the-Editor (and Dartmouth board member) responded with feminine furry, but it turns out that I was right. As the current Dartmouth study shows, areas with more primary care physicians do not have lower adjusted Medicare spending. Ouch again!

Now for the big story. In addition to using the AMA Masterfile, the Dartmouth team counted primary care physicians a new way. They measured how many primary care services were billed and then converted services into the number of FTE physicians that would, if working full-time, be able to supply them. But forget about the conversion. Stick with the measure. It’s a good measure. It measures services per beneficiary. The Dartmouth team found that areas with more primary care services also had more total clinical services (primary care plus specialty care), and these areas also had more Medicare spending. It is areas like these that the Dartmouth group previously called “high spending areas,” where patients were no sicker and didn’t get any better despite all of that added spending. This gave rise to the mantra about the unwarranted use of supply sensitive service needlessly consuming 30% of the health care budget. But the current study found that patients in the high-spending areas were sicker. And despite being sicker, their mortality was lower. Mortality was lower in areas with more physician services and more Medicare spending. More was more. OUCH!

That’s the exact opposite of Elliott Fisher’s conclusion that more care is associated with higher mortality. According to Fisher and colleagues, this added care is not only wasteful. It’s dangerous. Only a few years ago, David Goodman (senior author of the current study) said, “more physicians will make health care worse.” And Susan-the-Editor said “the greater the amount of health care you provide, the more likely it is to kill you,” somewhat awkward syntax but quite damning. And now the Dartmouth team has shown that more health care is associated with lower mortality. Ouch, ouch and ouch again. Three strikes and you’re out.

So how did the new paper spin these observations? It concluded that “a higher level of primary care physician workforce was generally associated with favorable patient outcomes.”  Therefore, medical homes, train more, pay more, bla, bla, bla. But the workforce wasn’t measured. All that was measured was primary care services. And primary  care services where greater where specialty services were greater, and these areas had more Medicare spending. The real conclusion is not about primary care. It’s about medical care. Medicare beneficiaries who received more medical care had better outcomes, even when they are sicker. MORE was MORE.

In publishingcthe same conclusion two years ago, I said “let the simple truth that health care quality is better in states with more physicians, both primary care and specialists, sweep away the myths and permit greater clarity as planners work to solve the crisis in physician supply that now confronts the nation.” Possibly this latest study from Dartmouth will allow us to do just that.


  1. Dana Wilson

    I’d love to get your take on this:
    I gather you’d dismiss the AAFP’s claim that we’ll have a shortage of primary care providers by 2020.
    Also, are you convinced that APN’s and PA’s provide care equivalent to that given by primary care physicians (of all flavors)? I am not, based on anecdotal experience. In any case, whether it’s an MD, an APN or PA, the quality of care is a function of practically unquantifiable variables: good judgement, personal integrity and devotion to duty. As a former Dean, those issues must have kept you awake some nights.

    • buzcooper

      A retired endocrinologist asks some important questions. Here are my answers in reverse order:

      #3. Do I worry about quality of care provided by APNs and PAs? Of course. I worry about the quality of care provided by all providers, physicians included. Some care should be provided by physicians rather than APNs or PAs, just as some should be provided by endocrinologists rather than family physicians. I have to trust that providers at all levels will know their limitations and refer appropriately. But just as we can’t train enough endocrinologists for every diabetic, we can’t train enough primary care physicians for every well baby exam and hypertension follow-up.

      #2. Do I dismiss the claim by the AAFP that there will be 40,000 too few primary care physicians by 2020? Certainly not. I was the first to make that claim. But the primary care shortage is simply part of a larger shortage of 200,000 physicians overall. If we were to fix primary care by shifting physicians from the specialties, shortages would simply be deeper there.

      #1. What is my take on the NYT Op-ed (“Why Medical Schools Should Be Free”) ? Sad. Sad, indeed.
      I am sad that Bach and Kocher found it necessary to repeat the twisted triplet “Doctors shun primary care in favor of highly paid specialties, where there are incentives to give expensive treatments and order expensive tests, an important driver of rising health care costs.” Twist the truth enough and people start believing it. Sad.
      And I’m sad that they fell in with the mindless call for training more of yesterday’s “primary care physicians” when the focus should be on training tomorrow’s generalists, who can serve as consultants to APNs and PAs while taking responsibility for patients with complex, multisystem disease. That spectrum of care is attractive, rewarding and fitting of a medical education at any price, and with enough APNs and PAs, we won’t need nearly as many.

  2. Dana Wilson

    “Some care should be provided by physicians rather than APNs or PAs, just as some should be provided by endocrinologists rather than family physicians.”

    Agreed. But I recall one of our former endocrine Fellows, an M.D., Ph.D., who’d gone into private practice saying “I won’t take a diabetic into my practice unless he’s got a primary care doctor”.

    That sad statement cuts to the very heart of the problem. We must strive to be doctors first and try to be there for patients who ask for our help. We can’t do everything. We can’t cure everything much less know everything; but we can be there when we’re needed.

    F.W. Peabody said it well. That’s why we went into Medicine.

    • buzcooper

      In days past, the view that every patient should have a primary care physician was viable, but in the new math of physician supply, there won’t be enough for everyone, so advance practice nurses will be providing much more primary care. And while most physicians went into medicine to “care” for patients, physician shortages have left many with little time to do so. In a 2002 paper in Health Affairs in which we urged that efforts be made to expand physician supply, we noted that “to do nothing invites public discontent and forces the profession of medicine to redefine itself in an ever more narrow scientific and technological sphere while other disciplines evolve to fill important gaps.” Nothing was done, and that future is upon us.

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