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Philip Musgrove Doctors, Dollars & Quality Health Affairs, January/February 2009; 28(1): w89-w90. [Extract] [Full Text] [PDF] [Reprints & Permissions]

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Test The Primary/Specialty Care Hypothesis

John J. Frey   ( 5 December 2008 )

Cooper Is Answering The Wrong Question

Barbara Starfield, Leiyu Shi, James Macinko   ( 10 December 2008 )

Re: Test The Primary/Specialty Care Hypothesis

Philip Musgrove   ( 16 December 2008 )

Test The Primary/Specialty Care Hypothesis 5 December 2008
John J. Frey, Professor of Family Medicine, University of Wisconsin School of Medicine and Public Health Send comment to journal: Re: Test The Primary/Specialty Care Hypothesis john.frey{at}fammed.wisc.edu John J. Frey	To test Musgrove and Cooper's hypothesis that it is simply more doctors, not the mix of specialty/generalists that makes a difference in access, quality, and cost, why not close down all generalist training programs, which are well on their way toward that goal anyway with the choices made by U.S. medical students, and see what happens? Managing complex multiple comorbidities, managing urgent and unorganized health complaints, or providing primary and secondary preventive care to large populations of chronically ill would be done by an increasing cadre of subspecialty providers. It would prove interesting for Cooper's next analysis. The choice for America should either be developing a robust primary care base or allowing professional Brownian movement of specialists to fill the gaps in care that would develop. Growing the physician supply in the current costly, market-driven, underperforming system seems a foolish way to resolve the debate.
Cooper Is Answering The Wrong Question 10 December 2008
Barbara Starfield, University Distinguished Professor Johns Hopkins Bloomberg School of Public Health, Leiyu Shi, James Macinko Send comment to journal: Re: Cooper Is Answering The Wrong Question bstarfie{at}jhsph.edu Barbara Starfield, et al.	Buz Cooper, in his paper “States with More Physicians Have Better-Quality Health Care,” has come up with an answer (“more is better”) to the wrong question. The issue is the impact of health services on health, not on the quality of care. Although, on average, higher physician density is inconsistently related to better health outcomes [1], there is a consistent set of evidence that what really matters in improving population health is not the number of physicians but, rather, what those physicians do. The availability of an adequate supply of primary care physicians has been consistently identified with better health. Not only is this association robust across outcomes (mortality, life expectancy, potential years of life lost, self-rated health), units of analyses (nations, states, counties, individuals), and time frames, but there is good evidence for specific mechanisms linking the way primary care physicians in general practice function with better health outcomes; simply put, person- rather than disease-centered care matters. At the population level, the more the physicians, the greater the resources available to intervene, regardless of whether the intervention is of high quality, is superfluous, or is dangerous. As Phillip Musgrove writes, “Having more specialists raises quality less per additional doctor than having more generalists does. Having too many specialists out of a given total of doctors implies higher costs and lower quality of care.” Such an imbalance is also likely to produce worse health outcomes overall, not just less efficient ones. Cooper’s missive does little to challenge the existing evidence for the benefits of primary care on health, which relies on a strong methodological foundation of multivariate, time series, and quasi-experimental evidence and based not only on measures of primary care physician-to-population ratios. [2] In fact, evidence from studies examining health outcomes of people whose regular source of care is a primary care physician, and from studies showing that the stronger the achievement of primary care functions the better the outcomes, is even more persuasive than evidence regarding workforce numbers. That is why it is critical to take seriously the importance of essential primary care functions (including person- (not disease-)focused care over time, comprehensiveness of services, and coordination of care), and to use populationwide health outcomes rather than indirect disease-specific proximate ones as measures of the overall impact of health services resources. Suboptimal practice does harm, no matter the number of physicians. Too few true primary care physicians and a surfeit of specialists is bad for population health, bad for the economy, and even worse for health equity. References 1. Chen, L., T. Evans, S. Anand, J. I. Boufford, H. Brown, M. Chowdhury, M. Cueto, et al. "Human Resources for Health: Overcoming the Crisis." Lancet 364, no. 9449 (2004): 1984-1990. 2. Starfield, B., L. Shi, and J. Macinko. "Contribution of Primary Care to Health Systems and Health." Milbank Quarterly 83, no. 3 (2005): 457-502.
Re: Test The Primary/Specialty Care Hypothesis 16 December 2008
Philip Musgrove, Deputy Editor Health Affairs Send comment to journal: Re: Re: Test The Primary/Specialty Care Hypothesis pmusgrove{at}projecthope.org Philip Musgrove	Professor Frey refers to "Musgrove and Cooper's hypothesis," which is inaccurate; the hypothesis is Cooper's alone. My Preface to his article and the replies by Baicker-Chandra and by Skinner et al. was intended only to introduce the issues in contention. It does not take a stand for or against Cooper's reasoning. Cooper argues that more of both kinds of physicians per capita are good for health care quality, and the evidence supports that view. But this does not refute the original research by Baicker and Chandra, who showed that the existence of more specialists reduces quality, if it comes at the expense of having fewer general practitioners (GPs). These are two distinct questions: Cooper looks at each type of physician separately, whereas Baicker-Chandra hold constant the total number of doctors and consider the effect of substituting one kind for the other. Cooper's analysis actually agrees with theirs, since his own results show that the presence of more specialists has a much smaller (about one-tenth as large) effect on quality than the presence of more GPs has. Two further points are worth mention but were not covered in the Preface. First, while Cooper's main finding concerned the relation between numbers of doctors and quality of care, he also found large differences among states that are independent of that relation and depend on socioeconomic or cultural factors that merit closer study. Second, both his analysis and that of Baicker-Chandra are conducted at a very high level of aggregation (averages over entire states), whereas much more finely grained research on these relations has been done; by using each state's ranking on quality, both authors discard the cardinal information contained in the original quality data. Perhaps it is time to get beyond such relatively simple analyses.