User login
Calcium and CV Risk: Are Supplements and Vitamin D to Blame?
This transcript has been edited for clarity.
Tricia Ward: Hi. I’m Tricia Ward, from theheart.org/Medscape Cardiology. I’m joined today by Dr Matthew Budoff. He is professor of medicine at UCLA and the endowed chair of preventive cardiology at the Lundquist Institute. Welcome, Dr Budoff.
Matthew J. Budoff, MD: Thank you.
Dietary Calcium vs Coronary Calcium
Ms. Ward: The reason I wanted to talk to you today is because there have been some recent studies linking calcium supplements to an increased risk for cardiovascular disease. I’m old enough to remember when we used to tell people that dietary calcium and coronary calcium weren’t connected and weren’t the same. Were we wrong?
Dr. Budoff: I think there’s a large amount of mixed data out there still. The US Preventive Services Task Force looked into this a number of years ago and said there’s no association between calcium supplementation and increased risk for cardiovascular disease.
As you mentioned, there are a couple of newer studies that point us toward a relationship. I think that we still have a little bit of a mixed bag, but we need to dive a little deeper into that to figure out what’s going on.
Ms. Ward: Does it appear to be connected to calcium in the form of supplements vs calcium from foods?
Dr. Budoff: We looked very carefully at dietary calcium in the MESA study, the multiethnic study of atherosclerosis. There is no relationship between dietary calcium intake and coronary calcium or cardiovascular events. We’re talking mostly about supplements now when we talk about this increased risk that we’re seeing.
Does Vitamin D Exacerbate Risk?
Ms. Ward: Because it’s seen with supplements, is that likely because that’s a much higher concentration of calcium coming in or do you think it’s something inherent in its being in the form of a supplement?
Dr. Budoff: I think there are two things. One, it’s definitely a higher concentration all at once. You get many more milligrams at a time when you take a supplement than if you had a high-calcium food or drink.
Also, most supplements have vitamin D as well. I think vitamin D and calcium work synergistically. When you give them both together simultaneously, I think that may have more of a potentiating effect that might exacerbate any potential risk.
Ms. Ward: Is there any reason to think there might be a difference in type of calcium supplement? I always think of the chalky tablet form vs calcium chews.
Dr. Budoff: I’m not aware of a difference in the supplement type. I think the vitamin D issue is a big problem because we all have patients who take thousands of units of vitamin D — just crazy numbers. People advocate really high numbers and that stays in the system.
Personally, I think part of the explanation is that with very high levels of vitamin D on top of calcium supplementation, you now absorb it better. You now get it into the bone, but maybe also into the coronary arteries. If you’re very high in vitamin D and then are taking a large calcium supplement, it might be the calcium/vitamin D combination that’s giving us some trouble. I think people on vitamin D supplements really need to watch their levels and not get supratherapeutic.
Ms. Ward: With the vitamin D?
Dr. Budoff: With the vitamin D.
Diabetes and Renal Function
Ms. Ward: In some of the studies, there seems to be a higher risk in patients with diabetes. Is there any reason why that would be?
Dr. Budoff: I can’t think of a reason exactly why with diabetes per se, except for renal disease. Patients with diabetes have more intrinsic renal disease, proteinuria, and even a reduced eGFR. We’ve seen that the kidney is very strongly tied to this. We have a very strong relationship, in work I’ve done a decade ago now, showing that calcium supplementation (in the form of phosphate binders) in patients on dialysis or with advanced renal disease is linked to much higher coronary calcium progression.
We did prospective, randomized trials showing that calcium intake as binders to reduce phosphorus led to more coronary calcium. We always thought that was just relegated to the renal population, and there might be an overlap here with the diabetes and more renal disease. I have a feeling that it has to do with more of that. It might be regulation of parathyroid hormone as well, which might be more abnormal in patients with diabetes.
Avoid Supratherapeutic Vitamin D Levels
Ms. Ward:: What are you telling your patients?
Dr. Budoff: I tell patients with normal kidney function that the bone will modulate 99.9% of the calcium uptake. If they have osteopenia or osteoporosis, regardless of their calcium score, I’m very comfortable putting them on supplements.
I’m a little more cautious with the vitamin D levels, and I keep an eye on that and regulate how much vitamin D they get based on their levels. I get them into the normal range, but I don’t want them supratherapeutic. You can even follow their calcium score. Again, we’ve shown that if you’re taking too much calcium, your calcium score will go up. I can just check it again in a couple of years to make sure that it’s safe.
Ms. Ward:: In terms of vitamin D levels, when you’re saying “supratherapeutic,” what levels do you consider a safe amount to take?
Dr. Budoff: I’d like them under 100 ng/mL as far as their upper level. Normal is around 70 ng/mL at most labs. I try to keep them in the normal range. I don’t even want them to be high-normal if I’m going to be concomitantly giving them calcium supplements. Of course, if they have renal insufficiency, then I’m much more cautious. We’ve even seen calcium supplements raise the serum calcium, which you never see with dietary calcium. That’s another potential proof that it might be too much too fast.
For renal patients, even in mild renal insufficiency, maybe even in diabetes where we’ve seen a signal, maybe aim lower in the amount of calcium supplementation if diet is insufficient, and aim a little lower in vitamin D targets, and I think you’ll be in a safer place.
Ms. Ward: Is there anything else you want to add?
Dr. Budoff: The evidence is still evolving. I’d say that it’s interesting and maybe a little frustrating that we don’t have a final answer on all of this. I would stay tuned for more data because we’re looking at many of the epidemiologic studies to try to see what happens in the real world, with both dietary intake of calcium and calcium supplementation.
Ms. Ward: Thank you very much for joining me today.
Dr. Budoff: It’s a pleasure. Thanks for having me.
Dr. Budoff disclosed being a speaker for Amarin Pharma.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Tricia Ward: Hi. I’m Tricia Ward, from theheart.org/Medscape Cardiology. I’m joined today by Dr Matthew Budoff. He is professor of medicine at UCLA and the endowed chair of preventive cardiology at the Lundquist Institute. Welcome, Dr Budoff.
Matthew J. Budoff, MD: Thank you.
Dietary Calcium vs Coronary Calcium
Ms. Ward: The reason I wanted to talk to you today is because there have been some recent studies linking calcium supplements to an increased risk for cardiovascular disease. I’m old enough to remember when we used to tell people that dietary calcium and coronary calcium weren’t connected and weren’t the same. Were we wrong?
Dr. Budoff: I think there’s a large amount of mixed data out there still. The US Preventive Services Task Force looked into this a number of years ago and said there’s no association between calcium supplementation and increased risk for cardiovascular disease.
As you mentioned, there are a couple of newer studies that point us toward a relationship. I think that we still have a little bit of a mixed bag, but we need to dive a little deeper into that to figure out what’s going on.
Ms. Ward: Does it appear to be connected to calcium in the form of supplements vs calcium from foods?
Dr. Budoff: We looked very carefully at dietary calcium in the MESA study, the multiethnic study of atherosclerosis. There is no relationship between dietary calcium intake and coronary calcium or cardiovascular events. We’re talking mostly about supplements now when we talk about this increased risk that we’re seeing.
Does Vitamin D Exacerbate Risk?
Ms. Ward: Because it’s seen with supplements, is that likely because that’s a much higher concentration of calcium coming in or do you think it’s something inherent in its being in the form of a supplement?
Dr. Budoff: I think there are two things. One, it’s definitely a higher concentration all at once. You get many more milligrams at a time when you take a supplement than if you had a high-calcium food or drink.
Also, most supplements have vitamin D as well. I think vitamin D and calcium work synergistically. When you give them both together simultaneously, I think that may have more of a potentiating effect that might exacerbate any potential risk.
Ms. Ward: Is there any reason to think there might be a difference in type of calcium supplement? I always think of the chalky tablet form vs calcium chews.
Dr. Budoff: I’m not aware of a difference in the supplement type. I think the vitamin D issue is a big problem because we all have patients who take thousands of units of vitamin D — just crazy numbers. People advocate really high numbers and that stays in the system.
Personally, I think part of the explanation is that with very high levels of vitamin D on top of calcium supplementation, you now absorb it better. You now get it into the bone, but maybe also into the coronary arteries. If you’re very high in vitamin D and then are taking a large calcium supplement, it might be the calcium/vitamin D combination that’s giving us some trouble. I think people on vitamin D supplements really need to watch their levels and not get supratherapeutic.
Ms. Ward: With the vitamin D?
Dr. Budoff: With the vitamin D.
Diabetes and Renal Function
Ms. Ward: In some of the studies, there seems to be a higher risk in patients with diabetes. Is there any reason why that would be?
Dr. Budoff: I can’t think of a reason exactly why with diabetes per se, except for renal disease. Patients with diabetes have more intrinsic renal disease, proteinuria, and even a reduced eGFR. We’ve seen that the kidney is very strongly tied to this. We have a very strong relationship, in work I’ve done a decade ago now, showing that calcium supplementation (in the form of phosphate binders) in patients on dialysis or with advanced renal disease is linked to much higher coronary calcium progression.
We did prospective, randomized trials showing that calcium intake as binders to reduce phosphorus led to more coronary calcium. We always thought that was just relegated to the renal population, and there might be an overlap here with the diabetes and more renal disease. I have a feeling that it has to do with more of that. It might be regulation of parathyroid hormone as well, which might be more abnormal in patients with diabetes.
Avoid Supratherapeutic Vitamin D Levels
Ms. Ward:: What are you telling your patients?
Dr. Budoff: I tell patients with normal kidney function that the bone will modulate 99.9% of the calcium uptake. If they have osteopenia or osteoporosis, regardless of their calcium score, I’m very comfortable putting them on supplements.
I’m a little more cautious with the vitamin D levels, and I keep an eye on that and regulate how much vitamin D they get based on their levels. I get them into the normal range, but I don’t want them supratherapeutic. You can even follow their calcium score. Again, we’ve shown that if you’re taking too much calcium, your calcium score will go up. I can just check it again in a couple of years to make sure that it’s safe.
Ms. Ward:: In terms of vitamin D levels, when you’re saying “supratherapeutic,” what levels do you consider a safe amount to take?
Dr. Budoff: I’d like them under 100 ng/mL as far as their upper level. Normal is around 70 ng/mL at most labs. I try to keep them in the normal range. I don’t even want them to be high-normal if I’m going to be concomitantly giving them calcium supplements. Of course, if they have renal insufficiency, then I’m much more cautious. We’ve even seen calcium supplements raise the serum calcium, which you never see with dietary calcium. That’s another potential proof that it might be too much too fast.
For renal patients, even in mild renal insufficiency, maybe even in diabetes where we’ve seen a signal, maybe aim lower in the amount of calcium supplementation if diet is insufficient, and aim a little lower in vitamin D targets, and I think you’ll be in a safer place.
Ms. Ward: Is there anything else you want to add?
Dr. Budoff: The evidence is still evolving. I’d say that it’s interesting and maybe a little frustrating that we don’t have a final answer on all of this. I would stay tuned for more data because we’re looking at many of the epidemiologic studies to try to see what happens in the real world, with both dietary intake of calcium and calcium supplementation.
Ms. Ward: Thank you very much for joining me today.
Dr. Budoff: It’s a pleasure. Thanks for having me.
Dr. Budoff disclosed being a speaker for Amarin Pharma.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
Tricia Ward: Hi. I’m Tricia Ward, from theheart.org/Medscape Cardiology. I’m joined today by Dr Matthew Budoff. He is professor of medicine at UCLA and the endowed chair of preventive cardiology at the Lundquist Institute. Welcome, Dr Budoff.
Matthew J. Budoff, MD: Thank you.
Dietary Calcium vs Coronary Calcium
Ms. Ward: The reason I wanted to talk to you today is because there have been some recent studies linking calcium supplements to an increased risk for cardiovascular disease. I’m old enough to remember when we used to tell people that dietary calcium and coronary calcium weren’t connected and weren’t the same. Were we wrong?
Dr. Budoff: I think there’s a large amount of mixed data out there still. The US Preventive Services Task Force looked into this a number of years ago and said there’s no association between calcium supplementation and increased risk for cardiovascular disease.
As you mentioned, there are a couple of newer studies that point us toward a relationship. I think that we still have a little bit of a mixed bag, but we need to dive a little deeper into that to figure out what’s going on.
Ms. Ward: Does it appear to be connected to calcium in the form of supplements vs calcium from foods?
Dr. Budoff: We looked very carefully at dietary calcium in the MESA study, the multiethnic study of atherosclerosis. There is no relationship between dietary calcium intake and coronary calcium or cardiovascular events. We’re talking mostly about supplements now when we talk about this increased risk that we’re seeing.
Does Vitamin D Exacerbate Risk?
Ms. Ward: Because it’s seen with supplements, is that likely because that’s a much higher concentration of calcium coming in or do you think it’s something inherent in its being in the form of a supplement?
Dr. Budoff: I think there are two things. One, it’s definitely a higher concentration all at once. You get many more milligrams at a time when you take a supplement than if you had a high-calcium food or drink.
Also, most supplements have vitamin D as well. I think vitamin D and calcium work synergistically. When you give them both together simultaneously, I think that may have more of a potentiating effect that might exacerbate any potential risk.
Ms. Ward: Is there any reason to think there might be a difference in type of calcium supplement? I always think of the chalky tablet form vs calcium chews.
Dr. Budoff: I’m not aware of a difference in the supplement type. I think the vitamin D issue is a big problem because we all have patients who take thousands of units of vitamin D — just crazy numbers. People advocate really high numbers and that stays in the system.
Personally, I think part of the explanation is that with very high levels of vitamin D on top of calcium supplementation, you now absorb it better. You now get it into the bone, but maybe also into the coronary arteries. If you’re very high in vitamin D and then are taking a large calcium supplement, it might be the calcium/vitamin D combination that’s giving us some trouble. I think people on vitamin D supplements really need to watch their levels and not get supratherapeutic.
Ms. Ward: With the vitamin D?
Dr. Budoff: With the vitamin D.
Diabetes and Renal Function
Ms. Ward: In some of the studies, there seems to be a higher risk in patients with diabetes. Is there any reason why that would be?
Dr. Budoff: I can’t think of a reason exactly why with diabetes per se, except for renal disease. Patients with diabetes have more intrinsic renal disease, proteinuria, and even a reduced eGFR. We’ve seen that the kidney is very strongly tied to this. We have a very strong relationship, in work I’ve done a decade ago now, showing that calcium supplementation (in the form of phosphate binders) in patients on dialysis or with advanced renal disease is linked to much higher coronary calcium progression.
We did prospective, randomized trials showing that calcium intake as binders to reduce phosphorus led to more coronary calcium. We always thought that was just relegated to the renal population, and there might be an overlap here with the diabetes and more renal disease. I have a feeling that it has to do with more of that. It might be regulation of parathyroid hormone as well, which might be more abnormal in patients with diabetes.
Avoid Supratherapeutic Vitamin D Levels
Ms. Ward:: What are you telling your patients?
Dr. Budoff: I tell patients with normal kidney function that the bone will modulate 99.9% of the calcium uptake. If they have osteopenia or osteoporosis, regardless of their calcium score, I’m very comfortable putting them on supplements.
I’m a little more cautious with the vitamin D levels, and I keep an eye on that and regulate how much vitamin D they get based on their levels. I get them into the normal range, but I don’t want them supratherapeutic. You can even follow their calcium score. Again, we’ve shown that if you’re taking too much calcium, your calcium score will go up. I can just check it again in a couple of years to make sure that it’s safe.
Ms. Ward:: In terms of vitamin D levels, when you’re saying “supratherapeutic,” what levels do you consider a safe amount to take?
Dr. Budoff: I’d like them under 100 ng/mL as far as their upper level. Normal is around 70 ng/mL at most labs. I try to keep them in the normal range. I don’t even want them to be high-normal if I’m going to be concomitantly giving them calcium supplements. Of course, if they have renal insufficiency, then I’m much more cautious. We’ve even seen calcium supplements raise the serum calcium, which you never see with dietary calcium. That’s another potential proof that it might be too much too fast.
For renal patients, even in mild renal insufficiency, maybe even in diabetes where we’ve seen a signal, maybe aim lower in the amount of calcium supplementation if diet is insufficient, and aim a little lower in vitamin D targets, and I think you’ll be in a safer place.
Ms. Ward: Is there anything else you want to add?
Dr. Budoff: The evidence is still evolving. I’d say that it’s interesting and maybe a little frustrating that we don’t have a final answer on all of this. I would stay tuned for more data because we’re looking at many of the epidemiologic studies to try to see what happens in the real world, with both dietary intake of calcium and calcium supplementation.
Ms. Ward: Thank you very much for joining me today.
Dr. Budoff: It’s a pleasure. Thanks for having me.
Dr. Budoff disclosed being a speaker for Amarin Pharma.
A version of this article appeared on Medscape.com.
Will primary care physicians be COVID-19’s next victims?
In a recently published editorial, Tom Frieden, MD, MPH, former head of the Centers for Disease Control and Prevention, argued that primary care is in deep trouble, its long-standing financial problems exacerbated by the fallout from the COVID-19 pandemic. Those arguments resonated with Kenny Lin, MD, MPH, a family physician, professor at Georgetown University School of Medicine, and a regular contributor to Medscape. He spoke with Dr. Frieden about his concerns.
Dr. Lin: Why did you feel that it was important to write this piece focused on primary care?
Dr. Frieden: I’m glad you asked that question. Given all that is going on, one might ask, what is the importance of primary care? We’ve got this epidemic going on that requires public health and hospital systems. Why voice concern about primary care now?
It’s really striking to see that the number of visits has plummeted. Because of our payment structure, that means incomes have plummeted. We’re hearing about doctors’ offices getting boarded up and shuttering. As I write in the piece, it’s one thing for a theater or a restaurant or another important community entity to shut because of economic downturn, and these are real losses, but to lose their only primary care practice or one of the few in an area really is a matter of life and death for many communities.
Dr. Lin: I agree. In my own practice we haven’t had to furlough anyone, but we’ve put people on forced paid time off. We’ve been reallocating physicians to other parts of our health system. It is definitely a concern. A solo practitioner or someone in a rural practice would most likely be even much more heavily hit. You’ve argued that the neglect of our public health system on a national level has led to many preventable deaths from COVID-19. Do you feel that something similar has happened in primary care? How could a stronger, better-funded primary care infrastructure better prepare us for the next pandemic?
Dr. Frieden: All over the world, we see an overemphasis on hospital care and an underemphasis on primary care, outpatient care, family medicine. As a result, we pay more. We have larger risks, and we don’t prevent diseases that we could prevent. It’s fundamentally about the economic incentives of our health care system. Of course, that often reflects the political reality of different profit centers and cost centers of care. That won’t change with tweaking around the edges. It will only change if we change the way we pay for health care. Money talks. We need to start paying at least part of what we pay based on health outcomes.
Many years ago a colleague and I wrote an article, “Health Care as If Health Mattered.” If you step back and look at how we pay for health care, very little, if any, of our payment structure is based on how much health the care system delivers. Part of that can be addressed by going to capitated models, which I think do better. But you have also got to put into those capitated systems some quality and outcome measures that are both valid and not too burdensome to report on. That’s not easy. We could talk a lot about some of the information systems and payment systems, but I think the bottom line is that we need to be able to deal not only with health emergencies, but also with preventive care, care of chronic diseases, and behavioral health care in ways that maximize health.
One of the ways to do that is simple, monthly, capitated payments along with what I call a registry-based outcomes system.
I’m a tuberculosis specialist by training. In tuberculosis there really is a great information system. We track every single patient who has been diagnosed, and we hold every clinician accountable for whether or not they’ve successfully treated that patient. An optimal health care system should do the same with treatment of hypertension, diabetes, seizure disorder, and other common conditions in which treatment makes a really big difference. Preventive care, especially vaccine delivery, is another example.
I understand that physicians will point out that patients may not come in for that care, or they’re hard to deal with, or they refuse recommended treatment. We don’t expect 100%. But we should expect that, if we’re paying for health care, we should get health.
To do that, I think we need much more support for primary care, both in terms of the absolute amount of dollars going in and the administrative support. Some of our systems are so complicated that you can’t manage them without a billing department. How does a one- or two-physician practice deal with systems that will take dozens of hours a week to manage? You have to deal with the administrative complexity, the structure of the incentives, and the structure of care.
I think these are all things that we have to address. But for a minute, let’s helicopter up and look at the big picture. Without additional help from Congress, tens of thousands of primary care physicians could go out of business in the coming weeks. This is a crisis, and this will be very hard to rebuild. We don’t have a strong, resilient primary care infrastructure today, and if we’re not careful it’ll be even weaker as we try to rebuild.
It has been encouraging to see some of the care innovations that have occurred in response to the pandemic. I’m particularly encouraged by the widespread interest in and support for telemedicine. Telemedicine is a very important way of making care safer, more accessible, less expensive, more efficient. There have been a lot of restrictions on it, not just in the United States but globally, for many years. It’s really interesting to see those restrictions rapidly change. I give credit to the Centers for Medicare & Medicaid Services for quick changes in this area.
Now, telemedicine isn’t a cure-all. There are lots of things you can’t do from a distance. It’s a pale reflection of reality, compared with an in-person first visit with a patient. But it’s a whole lot better than nothing. If we look at some of the best health systems in the United States, they’ve gone to as much as 80% of clinical visits done by telemedicine. I don’t think we’re going to go back. Even if COVID is no longer the threat that it is today, if you can do things more quickly, more efficiently, and more conveniently for both patients and doctors, do them. Obviously, it won’t be all visits, but it could be a large proportion of visits and an important part of strengthening our primary care system.
My initiative, Resolve to Save Lives, which is part of the global health organization Vital Strategies, has done work in the area of public health around the world. I am really struck by how weak primary care systems are in so many countries. Strong primary care systems are the exception rather than the rule, but they’re also a best buy in health care. They’re crucially important, and they’re going to work differently in different countries, in different states, in different communities. We need to do a better job of supporting primary care, building primary care, and paying for primary care.
Dr. Lin: You’ve identified two needs. The immediate need is that primary care practices need revenue now to not have to close in the immediate aftermath or the ongoing COVID epidemic, but also there’s the long term, the percentage of health care dollars that are going to primary care in the long term. You pointed out in your article that currently 5% or less of health care spending is in primary care, which is a lot less percentage-wise than in many other countries. I think the question always comes up is that we want to increase that share, but the money has to come from somewhere. Where is that extra money going to come from? Dr. Frieden: I’m not an expert in health care finance, but one thing I’ve learned over the years is that one person’s waste, fraud, and abuse is somebody else’s profit center. It’s not going to be easy. On the one hand, we do need to think about more efficient ways to organize primary care; on the other hand, we have to figure out a way to internalize some of the savings. If you give good primary care and, therefore, someone doesn’t get hospitalized, you can actually lose money in the current system, whereas you’re saving the system a lot of money by preventing that hospitalization.
I think our health system does have significant inefficiencies in terms of the number of tests and interventions that are done that are really not proven to help patients. It has been demonstrated for decades now that the usual economic incentives don’t operate in health care. In health care, supply often generates demand. The number of gallbladder operations is proportional not to population but to the number of gallbladder surgeons. That’s a problem, and it’s a problem that we’re going to have to assess. “Gatekeeper” is an unpleasant word, but if a primary care practitioner could be the advocate for patients so that we’re not pushing for patients to get more care or to get less care but to get the right care, we have the potential to reduce costs while improving quality.
Dr. Lin: You accurately point out that the fee-for-service payment system has been the major culprit in the declining revenues of primary care practices since the start of the pandemic. But for the majority of primary care physicians, including myself, fee-for-service is all that we’ve ever known. Do you think that primary care is ready for such an abrupt financing change, particularly in a very short period of time?Dr. Frieden: You’re certainly accurate in saying that nothing about health care finance is easy. Trying to address these problems at the national or state level has been extremely difficult. I think that the pilot programs in Medicare are very important. Medicaid is a particular challenge because it’s a state-based program and many of the costs are driven by nursing home and long-term care. When you take those costs out, the actual funding per patient or per provider is quite low in most places.
It’s hard enough to reorganize if you’ve got ample resources, but to reorganize when they are insufficient is particularly hard. I would say only that there are no quick and simple answers to this question, but there is a widespread understanding that what we’re doing now doesn’t make sense. We pay top dollar and we get – despite fantastic doctors and fantastic hospitals – lousy outcomes. I’m a public health physician. I’m an internal medicine and infectious disease specialist. Fundamentally, I look at the data. If you think of our health care system as a patient, the patient is not doing well. We’re not functional to the degree we need to be, particularly when you think of what an enormous outlier our per capita expenditures are [compared with other developed countries] – almost twice the average upper-income country and 25% more than any other upper-income country.
Now, anyone who tells you that change is going to be pain-free is not leveling with you. In addition to things like telemedicine, we have to make much more use of team-based care and task sharing. There are lots of things that doctors are doing these days that they really shouldn’t.
Dr. Lin: In your recent op-ed, you noted the pivot to telehealth that primary care practices have made very quickly in response to the pandemic. That certainly was the experience for my practice. But what are some other strategies that you think are important to support the goal of better care delivery in our primary care practices?Dr. Frieden: Another really important innovation is team-based care. There are lots of things that doctors are doing today that nurses, nurse practitioners, physician assistants, and community health workers can do better and for less money. Frankly, I think that should increase the job satisfaction of physicians, to be doing work that is specific to the physician, requiring either more patient interaction or advanced reasoning or experience.
In my own field of tuberculosis control, I learned how to treat tuberculosis because the nurse at the TB clinic kept correcting me because that’s all she did. She did tuberculosis care, so she had seen everything. Even though I’d finished an infectious disease fellowship and internal medicine residency, the public health nurse knew TB a whole lot better than I did.
Similarly, as we work on hypertension control, you can protocolize most of this care and do a much better job. That’s been proven for more than 40 years, and yet we still don’t do it.
One of the big parts of being able to do more with the same or fewer resources is going to be more team-based care. That’s really a task-sharing approach. I think of that as a triple win: You get better care for lower costs with more employment. What’s not to like?
Dr. Lin: I’m hopeful, as you are, that many of these innovations that have been made by necessity will persist beyond the duration of COVID-19. As you said, the health care system has been really difficult to change, and it often takes something like this to galvanize enough consensus that things need to change.
Dr. Frieden: I think the bottom line here is that we should pay our primary health care providers to keep us healthy and ensure that we have a payment system that lets them do that without risking bankruptcy. That’s not too much to ask of our system. It’s important for our health. It’s important for our economy. It’s important for our communities.
Dr. Lin teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician. Follow him on Twitter. He has served as a director, officer, partner, employee, adviser, consultant, or trustee for MedStar Georgetown University Hospital and received income in an amount equal to or greater than $250 from UpToDate, Wiley-Blackwell, and American Academy of Family Physicians.
Dr. Frieden is a physician with advanced training in internal medicine, infectious disease, public health, and epidemiology. He has served as director of the Centers for Disease Control and Prevention and as commissioner of the New York City Health Department. Currently he is president and CEO of Resolve to Save Lives. Follow him on Twitter. Thomas R. Frieden, MD, MPH, has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
In a recently published editorial, Tom Frieden, MD, MPH, former head of the Centers for Disease Control and Prevention, argued that primary care is in deep trouble, its long-standing financial problems exacerbated by the fallout from the COVID-19 pandemic. Those arguments resonated with Kenny Lin, MD, MPH, a family physician, professor at Georgetown University School of Medicine, and a regular contributor to Medscape. He spoke with Dr. Frieden about his concerns.
Dr. Lin: Why did you feel that it was important to write this piece focused on primary care?
Dr. Frieden: I’m glad you asked that question. Given all that is going on, one might ask, what is the importance of primary care? We’ve got this epidemic going on that requires public health and hospital systems. Why voice concern about primary care now?
It’s really striking to see that the number of visits has plummeted. Because of our payment structure, that means incomes have plummeted. We’re hearing about doctors’ offices getting boarded up and shuttering. As I write in the piece, it’s one thing for a theater or a restaurant or another important community entity to shut because of economic downturn, and these are real losses, but to lose their only primary care practice or one of the few in an area really is a matter of life and death for many communities.
Dr. Lin: I agree. In my own practice we haven’t had to furlough anyone, but we’ve put people on forced paid time off. We’ve been reallocating physicians to other parts of our health system. It is definitely a concern. A solo practitioner or someone in a rural practice would most likely be even much more heavily hit. You’ve argued that the neglect of our public health system on a national level has led to many preventable deaths from COVID-19. Do you feel that something similar has happened in primary care? How could a stronger, better-funded primary care infrastructure better prepare us for the next pandemic?
Dr. Frieden: All over the world, we see an overemphasis on hospital care and an underemphasis on primary care, outpatient care, family medicine. As a result, we pay more. We have larger risks, and we don’t prevent diseases that we could prevent. It’s fundamentally about the economic incentives of our health care system. Of course, that often reflects the political reality of different profit centers and cost centers of care. That won’t change with tweaking around the edges. It will only change if we change the way we pay for health care. Money talks. We need to start paying at least part of what we pay based on health outcomes.
Many years ago a colleague and I wrote an article, “Health Care as If Health Mattered.” If you step back and look at how we pay for health care, very little, if any, of our payment structure is based on how much health the care system delivers. Part of that can be addressed by going to capitated models, which I think do better. But you have also got to put into those capitated systems some quality and outcome measures that are both valid and not too burdensome to report on. That’s not easy. We could talk a lot about some of the information systems and payment systems, but I think the bottom line is that we need to be able to deal not only with health emergencies, but also with preventive care, care of chronic diseases, and behavioral health care in ways that maximize health.
One of the ways to do that is simple, monthly, capitated payments along with what I call a registry-based outcomes system.
I’m a tuberculosis specialist by training. In tuberculosis there really is a great information system. We track every single patient who has been diagnosed, and we hold every clinician accountable for whether or not they’ve successfully treated that patient. An optimal health care system should do the same with treatment of hypertension, diabetes, seizure disorder, and other common conditions in which treatment makes a really big difference. Preventive care, especially vaccine delivery, is another example.
I understand that physicians will point out that patients may not come in for that care, or they’re hard to deal with, or they refuse recommended treatment. We don’t expect 100%. But we should expect that, if we’re paying for health care, we should get health.
To do that, I think we need much more support for primary care, both in terms of the absolute amount of dollars going in and the administrative support. Some of our systems are so complicated that you can’t manage them without a billing department. How does a one- or two-physician practice deal with systems that will take dozens of hours a week to manage? You have to deal with the administrative complexity, the structure of the incentives, and the structure of care.
I think these are all things that we have to address. But for a minute, let’s helicopter up and look at the big picture. Without additional help from Congress, tens of thousands of primary care physicians could go out of business in the coming weeks. This is a crisis, and this will be very hard to rebuild. We don’t have a strong, resilient primary care infrastructure today, and if we’re not careful it’ll be even weaker as we try to rebuild.
It has been encouraging to see some of the care innovations that have occurred in response to the pandemic. I’m particularly encouraged by the widespread interest in and support for telemedicine. Telemedicine is a very important way of making care safer, more accessible, less expensive, more efficient. There have been a lot of restrictions on it, not just in the United States but globally, for many years. It’s really interesting to see those restrictions rapidly change. I give credit to the Centers for Medicare & Medicaid Services for quick changes in this area.
Now, telemedicine isn’t a cure-all. There are lots of things you can’t do from a distance. It’s a pale reflection of reality, compared with an in-person first visit with a patient. But it’s a whole lot better than nothing. If we look at some of the best health systems in the United States, they’ve gone to as much as 80% of clinical visits done by telemedicine. I don’t think we’re going to go back. Even if COVID is no longer the threat that it is today, if you can do things more quickly, more efficiently, and more conveniently for both patients and doctors, do them. Obviously, it won’t be all visits, but it could be a large proportion of visits and an important part of strengthening our primary care system.
My initiative, Resolve to Save Lives, which is part of the global health organization Vital Strategies, has done work in the area of public health around the world. I am really struck by how weak primary care systems are in so many countries. Strong primary care systems are the exception rather than the rule, but they’re also a best buy in health care. They’re crucially important, and they’re going to work differently in different countries, in different states, in different communities. We need to do a better job of supporting primary care, building primary care, and paying for primary care.
Dr. Lin: You’ve identified two needs. The immediate need is that primary care practices need revenue now to not have to close in the immediate aftermath or the ongoing COVID epidemic, but also there’s the long term, the percentage of health care dollars that are going to primary care in the long term. You pointed out in your article that currently 5% or less of health care spending is in primary care, which is a lot less percentage-wise than in many other countries. I think the question always comes up is that we want to increase that share, but the money has to come from somewhere. Where is that extra money going to come from? Dr. Frieden: I’m not an expert in health care finance, but one thing I’ve learned over the years is that one person’s waste, fraud, and abuse is somebody else’s profit center. It’s not going to be easy. On the one hand, we do need to think about more efficient ways to organize primary care; on the other hand, we have to figure out a way to internalize some of the savings. If you give good primary care and, therefore, someone doesn’t get hospitalized, you can actually lose money in the current system, whereas you’re saving the system a lot of money by preventing that hospitalization.
I think our health system does have significant inefficiencies in terms of the number of tests and interventions that are done that are really not proven to help patients. It has been demonstrated for decades now that the usual economic incentives don’t operate in health care. In health care, supply often generates demand. The number of gallbladder operations is proportional not to population but to the number of gallbladder surgeons. That’s a problem, and it’s a problem that we’re going to have to assess. “Gatekeeper” is an unpleasant word, but if a primary care practitioner could be the advocate for patients so that we’re not pushing for patients to get more care or to get less care but to get the right care, we have the potential to reduce costs while improving quality.
Dr. Lin: You accurately point out that the fee-for-service payment system has been the major culprit in the declining revenues of primary care practices since the start of the pandemic. But for the majority of primary care physicians, including myself, fee-for-service is all that we’ve ever known. Do you think that primary care is ready for such an abrupt financing change, particularly in a very short period of time?Dr. Frieden: You’re certainly accurate in saying that nothing about health care finance is easy. Trying to address these problems at the national or state level has been extremely difficult. I think that the pilot programs in Medicare are very important. Medicaid is a particular challenge because it’s a state-based program and many of the costs are driven by nursing home and long-term care. When you take those costs out, the actual funding per patient or per provider is quite low in most places.
It’s hard enough to reorganize if you’ve got ample resources, but to reorganize when they are insufficient is particularly hard. I would say only that there are no quick and simple answers to this question, but there is a widespread understanding that what we’re doing now doesn’t make sense. We pay top dollar and we get – despite fantastic doctors and fantastic hospitals – lousy outcomes. I’m a public health physician. I’m an internal medicine and infectious disease specialist. Fundamentally, I look at the data. If you think of our health care system as a patient, the patient is not doing well. We’re not functional to the degree we need to be, particularly when you think of what an enormous outlier our per capita expenditures are [compared with other developed countries] – almost twice the average upper-income country and 25% more than any other upper-income country.
Now, anyone who tells you that change is going to be pain-free is not leveling with you. In addition to things like telemedicine, we have to make much more use of team-based care and task sharing. There are lots of things that doctors are doing these days that they really shouldn’t.
Dr. Lin: In your recent op-ed, you noted the pivot to telehealth that primary care practices have made very quickly in response to the pandemic. That certainly was the experience for my practice. But what are some other strategies that you think are important to support the goal of better care delivery in our primary care practices?Dr. Frieden: Another really important innovation is team-based care. There are lots of things that doctors are doing today that nurses, nurse practitioners, physician assistants, and community health workers can do better and for less money. Frankly, I think that should increase the job satisfaction of physicians, to be doing work that is specific to the physician, requiring either more patient interaction or advanced reasoning or experience.
In my own field of tuberculosis control, I learned how to treat tuberculosis because the nurse at the TB clinic kept correcting me because that’s all she did. She did tuberculosis care, so she had seen everything. Even though I’d finished an infectious disease fellowship and internal medicine residency, the public health nurse knew TB a whole lot better than I did.
Similarly, as we work on hypertension control, you can protocolize most of this care and do a much better job. That’s been proven for more than 40 years, and yet we still don’t do it.
One of the big parts of being able to do more with the same or fewer resources is going to be more team-based care. That’s really a task-sharing approach. I think of that as a triple win: You get better care for lower costs with more employment. What’s not to like?
Dr. Lin: I’m hopeful, as you are, that many of these innovations that have been made by necessity will persist beyond the duration of COVID-19. As you said, the health care system has been really difficult to change, and it often takes something like this to galvanize enough consensus that things need to change.
Dr. Frieden: I think the bottom line here is that we should pay our primary health care providers to keep us healthy and ensure that we have a payment system that lets them do that without risking bankruptcy. That’s not too much to ask of our system. It’s important for our health. It’s important for our economy. It’s important for our communities.
Dr. Lin teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician. Follow him on Twitter. He has served as a director, officer, partner, employee, adviser, consultant, or trustee for MedStar Georgetown University Hospital and received income in an amount equal to or greater than $250 from UpToDate, Wiley-Blackwell, and American Academy of Family Physicians.
Dr. Frieden is a physician with advanced training in internal medicine, infectious disease, public health, and epidemiology. He has served as director of the Centers for Disease Control and Prevention and as commissioner of the New York City Health Department. Currently he is president and CEO of Resolve to Save Lives. Follow him on Twitter. Thomas R. Frieden, MD, MPH, has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
In a recently published editorial, Tom Frieden, MD, MPH, former head of the Centers for Disease Control and Prevention, argued that primary care is in deep trouble, its long-standing financial problems exacerbated by the fallout from the COVID-19 pandemic. Those arguments resonated with Kenny Lin, MD, MPH, a family physician, professor at Georgetown University School of Medicine, and a regular contributor to Medscape. He spoke with Dr. Frieden about his concerns.
Dr. Lin: Why did you feel that it was important to write this piece focused on primary care?
Dr. Frieden: I’m glad you asked that question. Given all that is going on, one might ask, what is the importance of primary care? We’ve got this epidemic going on that requires public health and hospital systems. Why voice concern about primary care now?
It’s really striking to see that the number of visits has plummeted. Because of our payment structure, that means incomes have plummeted. We’re hearing about doctors’ offices getting boarded up and shuttering. As I write in the piece, it’s one thing for a theater or a restaurant or another important community entity to shut because of economic downturn, and these are real losses, but to lose their only primary care practice or one of the few in an area really is a matter of life and death for many communities.
Dr. Lin: I agree. In my own practice we haven’t had to furlough anyone, but we’ve put people on forced paid time off. We’ve been reallocating physicians to other parts of our health system. It is definitely a concern. A solo practitioner or someone in a rural practice would most likely be even much more heavily hit. You’ve argued that the neglect of our public health system on a national level has led to many preventable deaths from COVID-19. Do you feel that something similar has happened in primary care? How could a stronger, better-funded primary care infrastructure better prepare us for the next pandemic?
Dr. Frieden: All over the world, we see an overemphasis on hospital care and an underemphasis on primary care, outpatient care, family medicine. As a result, we pay more. We have larger risks, and we don’t prevent diseases that we could prevent. It’s fundamentally about the economic incentives of our health care system. Of course, that often reflects the political reality of different profit centers and cost centers of care. That won’t change with tweaking around the edges. It will only change if we change the way we pay for health care. Money talks. We need to start paying at least part of what we pay based on health outcomes.
Many years ago a colleague and I wrote an article, “Health Care as If Health Mattered.” If you step back and look at how we pay for health care, very little, if any, of our payment structure is based on how much health the care system delivers. Part of that can be addressed by going to capitated models, which I think do better. But you have also got to put into those capitated systems some quality and outcome measures that are both valid and not too burdensome to report on. That’s not easy. We could talk a lot about some of the information systems and payment systems, but I think the bottom line is that we need to be able to deal not only with health emergencies, but also with preventive care, care of chronic diseases, and behavioral health care in ways that maximize health.
One of the ways to do that is simple, monthly, capitated payments along with what I call a registry-based outcomes system.
I’m a tuberculosis specialist by training. In tuberculosis there really is a great information system. We track every single patient who has been diagnosed, and we hold every clinician accountable for whether or not they’ve successfully treated that patient. An optimal health care system should do the same with treatment of hypertension, diabetes, seizure disorder, and other common conditions in which treatment makes a really big difference. Preventive care, especially vaccine delivery, is another example.
I understand that physicians will point out that patients may not come in for that care, or they’re hard to deal with, or they refuse recommended treatment. We don’t expect 100%. But we should expect that, if we’re paying for health care, we should get health.
To do that, I think we need much more support for primary care, both in terms of the absolute amount of dollars going in and the administrative support. Some of our systems are so complicated that you can’t manage them without a billing department. How does a one- or two-physician practice deal with systems that will take dozens of hours a week to manage? You have to deal with the administrative complexity, the structure of the incentives, and the structure of care.
I think these are all things that we have to address. But for a minute, let’s helicopter up and look at the big picture. Without additional help from Congress, tens of thousands of primary care physicians could go out of business in the coming weeks. This is a crisis, and this will be very hard to rebuild. We don’t have a strong, resilient primary care infrastructure today, and if we’re not careful it’ll be even weaker as we try to rebuild.
It has been encouraging to see some of the care innovations that have occurred in response to the pandemic. I’m particularly encouraged by the widespread interest in and support for telemedicine. Telemedicine is a very important way of making care safer, more accessible, less expensive, more efficient. There have been a lot of restrictions on it, not just in the United States but globally, for many years. It’s really interesting to see those restrictions rapidly change. I give credit to the Centers for Medicare & Medicaid Services for quick changes in this area.
Now, telemedicine isn’t a cure-all. There are lots of things you can’t do from a distance. It’s a pale reflection of reality, compared with an in-person first visit with a patient. But it’s a whole lot better than nothing. If we look at some of the best health systems in the United States, they’ve gone to as much as 80% of clinical visits done by telemedicine. I don’t think we’re going to go back. Even if COVID is no longer the threat that it is today, if you can do things more quickly, more efficiently, and more conveniently for both patients and doctors, do them. Obviously, it won’t be all visits, but it could be a large proportion of visits and an important part of strengthening our primary care system.
My initiative, Resolve to Save Lives, which is part of the global health organization Vital Strategies, has done work in the area of public health around the world. I am really struck by how weak primary care systems are in so many countries. Strong primary care systems are the exception rather than the rule, but they’re also a best buy in health care. They’re crucially important, and they’re going to work differently in different countries, in different states, in different communities. We need to do a better job of supporting primary care, building primary care, and paying for primary care.
Dr. Lin: You’ve identified two needs. The immediate need is that primary care practices need revenue now to not have to close in the immediate aftermath or the ongoing COVID epidemic, but also there’s the long term, the percentage of health care dollars that are going to primary care in the long term. You pointed out in your article that currently 5% or less of health care spending is in primary care, which is a lot less percentage-wise than in many other countries. I think the question always comes up is that we want to increase that share, but the money has to come from somewhere. Where is that extra money going to come from? Dr. Frieden: I’m not an expert in health care finance, but one thing I’ve learned over the years is that one person’s waste, fraud, and abuse is somebody else’s profit center. It’s not going to be easy. On the one hand, we do need to think about more efficient ways to organize primary care; on the other hand, we have to figure out a way to internalize some of the savings. If you give good primary care and, therefore, someone doesn’t get hospitalized, you can actually lose money in the current system, whereas you’re saving the system a lot of money by preventing that hospitalization.
I think our health system does have significant inefficiencies in terms of the number of tests and interventions that are done that are really not proven to help patients. It has been demonstrated for decades now that the usual economic incentives don’t operate in health care. In health care, supply often generates demand. The number of gallbladder operations is proportional not to population but to the number of gallbladder surgeons. That’s a problem, and it’s a problem that we’re going to have to assess. “Gatekeeper” is an unpleasant word, but if a primary care practitioner could be the advocate for patients so that we’re not pushing for patients to get more care or to get less care but to get the right care, we have the potential to reduce costs while improving quality.
Dr. Lin: You accurately point out that the fee-for-service payment system has been the major culprit in the declining revenues of primary care practices since the start of the pandemic. But for the majority of primary care physicians, including myself, fee-for-service is all that we’ve ever known. Do you think that primary care is ready for such an abrupt financing change, particularly in a very short period of time?Dr. Frieden: You’re certainly accurate in saying that nothing about health care finance is easy. Trying to address these problems at the national or state level has been extremely difficult. I think that the pilot programs in Medicare are very important. Medicaid is a particular challenge because it’s a state-based program and many of the costs are driven by nursing home and long-term care. When you take those costs out, the actual funding per patient or per provider is quite low in most places.
It’s hard enough to reorganize if you’ve got ample resources, but to reorganize when they are insufficient is particularly hard. I would say only that there are no quick and simple answers to this question, but there is a widespread understanding that what we’re doing now doesn’t make sense. We pay top dollar and we get – despite fantastic doctors and fantastic hospitals – lousy outcomes. I’m a public health physician. I’m an internal medicine and infectious disease specialist. Fundamentally, I look at the data. If you think of our health care system as a patient, the patient is not doing well. We’re not functional to the degree we need to be, particularly when you think of what an enormous outlier our per capita expenditures are [compared with other developed countries] – almost twice the average upper-income country and 25% more than any other upper-income country.
Now, anyone who tells you that change is going to be pain-free is not leveling with you. In addition to things like telemedicine, we have to make much more use of team-based care and task sharing. There are lots of things that doctors are doing these days that they really shouldn’t.
Dr. Lin: In your recent op-ed, you noted the pivot to telehealth that primary care practices have made very quickly in response to the pandemic. That certainly was the experience for my practice. But what are some other strategies that you think are important to support the goal of better care delivery in our primary care practices?Dr. Frieden: Another really important innovation is team-based care. There are lots of things that doctors are doing today that nurses, nurse practitioners, physician assistants, and community health workers can do better and for less money. Frankly, I think that should increase the job satisfaction of physicians, to be doing work that is specific to the physician, requiring either more patient interaction or advanced reasoning or experience.
In my own field of tuberculosis control, I learned how to treat tuberculosis because the nurse at the TB clinic kept correcting me because that’s all she did. She did tuberculosis care, so she had seen everything. Even though I’d finished an infectious disease fellowship and internal medicine residency, the public health nurse knew TB a whole lot better than I did.
Similarly, as we work on hypertension control, you can protocolize most of this care and do a much better job. That’s been proven for more than 40 years, and yet we still don’t do it.
One of the big parts of being able to do more with the same or fewer resources is going to be more team-based care. That’s really a task-sharing approach. I think of that as a triple win: You get better care for lower costs with more employment. What’s not to like?
Dr. Lin: I’m hopeful, as you are, that many of these innovations that have been made by necessity will persist beyond the duration of COVID-19. As you said, the health care system has been really difficult to change, and it often takes something like this to galvanize enough consensus that things need to change.
Dr. Frieden: I think the bottom line here is that we should pay our primary health care providers to keep us healthy and ensure that we have a payment system that lets them do that without risking bankruptcy. That’s not too much to ask of our system. It’s important for our health. It’s important for our economy. It’s important for our communities.
Dr. Lin teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician. Follow him on Twitter. He has served as a director, officer, partner, employee, adviser, consultant, or trustee for MedStar Georgetown University Hospital and received income in an amount equal to or greater than $250 from UpToDate, Wiley-Blackwell, and American Academy of Family Physicians.
Dr. Frieden is a physician with advanced training in internal medicine, infectious disease, public health, and epidemiology. He has served as director of the Centers for Disease Control and Prevention and as commissioner of the New York City Health Department. Currently he is president and CEO of Resolve to Save Lives. Follow him on Twitter. Thomas R. Frieden, MD, MPH, has disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.