What’s the point of primary care?
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The story
“The primary care crisis paradox,” by Christopher P. Childers and Thomas C. Tsai
The response
America’s health care challenges will not be solved by choosing between primary care and specialty care. Patients need both. A person managing diabetes needs a primary care physician they trust for ongoing care and a specialist when complications arise. Infants, children, and adolescents need a pediatrician who can monitor growth and development and recognize when specialty care is needed.
As family physicians, pediatricians, and internal medicine physicians, we understand this reality, and we also share the same concern: To build a health care system that makes it easier to get the right care at the right time, Medicare’s outdated physician payment policies and budget neutrality rules need to change. This is important, as Medicare rates influence other payers, including Medicaid, which is the leading source of health care coverage for children in the U.S.
That starts with building a system that values the primary care patients rely on every day, while ensuring they can access specialized care when they need it. Indeed, this is not a zero-sum game.
The evidence behind primary care is resolute and speaks for itself. Adults who have a usual source of primary care are much more likely to receive recommended preventive services for chronic disease — 95.5% compared with 67.6% of adults without that connection point.
Children with a consistent primary care clinician are also more likely to receive vital preventive care, including recommended immunizations, behavioral health screenings, and other services that help families spot small problems before they become big ones. Those visits also provide opportunities to educate and support parents as they navigate everything from nutrition to sleep to healthy development.
For patients already living with chronic disease, that relationship can make a tremendous difference. We know that having a usual source of primary care is associated with fewer emergency department visits and hospitalizations (11% reduction in emergency department visits for adults and 50% reduction in avoidable emergency visits and hospitalizations for children). It is also associated with substantially lower health care costs, about 54% lower for adults with chronic disease and nearly 40% lower for children.
Other research points in the same direction: Each primary care visit is associated with roughly $700 in lower health care costs, and continuity of care can reduce overall spending by up to 10%.
These numbers matter because they represent real people. They represent patients with a family history of cancer who need regular screenings. They represent parents who are trying to keep their children up to date on vaccinations. And they represent families who are spared the stress and cost of preventable ER visits because they have an ongoing relationship with a primary care physician.
The U.S. spends more on health care than other developed nations, yet our outcomes too often fall short. The headlines we read sound bleak, but they should push us toward an honest, data-driven conversation about what people need to live healthier lives. Better health depends on more than physician payment alone. It also requires attention to nutrition, physical activity, housing, behavioral health, parental support, education, and other factors that influence health long before a person arrives at a doctor’s office.
Primary care is not the only solution to America’s health challenges, but it is one of the clearest investments we can make to catch illness early and lower costs, and it should be at the top of the list. At the same time, patients with cancer, kidney disease, complex heart disease, and other serious illnesses must have timely access to specialty care. There are no “sides” in health care, and patients are best served when every part of the health care system has the resources and support it needs to fulfill its role.
The real opportunity is to move beyond policies and narratives that pit specialties against one another. Physicians across every specialty, along with payers and policymakers, must work together toward comprehensive payment reform that strengthens primary care, puts patients first and addresses the upstream factors that shape America’s health. Pointing fingers will not improve outcomes for patients. Working together can.
— Sarah Nosal, M.D., president of the American Academy of Family Physicians; Jan Carney, M.D., M.P.H., president of the American College of Physicians; and Andrew Racine, M.D., Ph.D., president of the American Academy of Pediatrics
The response
The article “The primary care crisis paradox” misrepresents the rationale for increased investment in U.S. primary care. While highlighting some interesting and important data, the authors focus on primary care’s inaccurate designation as the “sole lever that moves population health,” citing socioecenomic factors as the main determinants of relatively poor life expectancy in the U.S. No one disputes this or suggests any medical specialty that can correct all of society’s failures.
The real narrative on the value of primary care extends far beyond population health metrics — rather, it is about fragmented care, poor time-sensitive access, and task work overload that limits PCPs clinical efficacy and work sustainability. These issues absolutely demand primary care payment reform and reprioritization. MedPac data does show that primary care access for Medicare patients compares favorably to the population at large (where 20%-25% of patients have no usual source of care) and most are able to see their PCP within two weeks. That works for wellness exams and routine follow-ups, but not for acute illness and more urgent matters. These patients end up in costly urgent care centers and crowded emergency rooms which disrupt continuity of care. Treating more patients in less time in understaffed offices while managing burgeoning patient portal messages and inbox tasks has stolen from PCPs time to thoughtfully evaluate and care for patients. The result — more non-essential referrals to specialists who are also capacity constrained.
Payment reform is not about “robbing Peter to pay Paul.” It is about more fairly reimbursing cognitive work which in turn can invigorate primary care, expand the workforce, and improve continuity. This will result in improved specialty access for those who truly need it. Primary and specialty care should not point fingers. We need each other and patients desperately need us both.
— Jeffrey Millstein, Penn Medicine
The story
“Banning gender-affirming care doesn’t protect children — it makes it harder to help them,” by Kavitha Ranganathan
The response
In her opinion essay, Dr. Kavitha Ranganathan refers to the Society for Evidence-Based Gender Medicine (SEGM) as an “anti-trans group.” That description is inaccurate and misrepresents both our organization and our mission. SEGM is a nonprofit organization dedicated to advancing evidence-based medical care for children, adolescents, and young adults with gender dysphoria. Our work focuses on evaluating the scientific literature, supporting and conducting systematic reviews of evidence, evaluating clinical practice guidelines, and fostering higher-quality research in a field where important questions remain unanswered. We collaborate with researchers and clinicians from more than 30 countries, many of whom hold differing views on aspects of clinical practice yet share a commitment to improving the evidence base used to inform patient care for vulnerable youth.
We reject the characterization that SEGM’s work is anti-trans. We believe that all individuals deserve dignity, compassion, and respect. Our work deals with the scientific evidence underlying medical interventions and the standards by which that evidence should be evaluated, not broader political or ideological debates. We believe that young people experiencing gender dysphoria deserve compassionate care informed by the best available evidence, accompanied by transparent discussion of both the potential benefits and risks of clinical interventions.
Where uncertainty exists, the appropriate response is not to suppress scientific debate, but to strengthen the evidence through rigorous ethical research. The suggestion that evaluating the quality of evidence is itself “anti-trans” incorrectly conflates scientific inquiry with political advocacy. Medicine advances through the continual testing of assumptions, critical appraisal of published research, and open debate about the strength and limitations of the available evidence. These principles are foundational to evidence-based medicine across all fields and should be applied no differently in pediatric gender medicine.
Ultimately, our goal is the same as that of many clinicians and researchers working in this field: to improve the quality of research and the quality of clinical care for young people experiencing gender dysphoria. Achieving that goal requires open scientific inquiry, respectful dialogue, and a commitment to following the evidence wherever it leads. Reducing legitimate scientific disagreement to accusations of prejudice undermines that effort. Mischaracterizing those engaged in scientific inquiry discourages constructive dialogue and ultimately serves neither patients nor the advancement of evidence-based care.
— William Malone, Society for Evidence-Based Gender Medicine
The response
Great, well-written, informative, and persuasive article. Hope it helps move the needle. We practice for our patients, not the government.
— Karen Kinsell, M.D.
The story
“Who benefits from classifying obesity as a disease?” by Max Moser
The response
In my practice as an independent obesity doctor, I see so much out there promoting “willpower” and lifestyle changes as the superior method to weight loss over using GLP-1s.
But the truth is, it takes a comprehensive approach that includes pharmacological intervention to help my patients find success. Food noise is a well-documented dopamine reward circuit that operates very similarly to addiction. Without GLP-1s, many patients struggle to remain consistent with their weight loss plan, even if they can find some success without the medication. Sustaining a habit is already difficult.
For obesity, a condition that can lead to worse comorbidities like diabetes and heart disease, patients must feel empowered to use every tool at their disposal to help prevent and reverse this disease. I use the word “disease” intentionally in response to “Who benefits from classifying obesity as a disease?”
The author clarifies that the problem isn’t whether we call obesity a disease; it’s that commercial incentives are driving the designation, to which I strongly disagree. The author questions framing obesity as a disease because he insists that commercial incentives align with disease framing, but alignment is not proof of distortion. In 2013, the American Medical Association declared obesity a disease years before GLP-1s existed as blockbusters. Additionally, the World Health Organization (WHO) classified it as a chronic disease in 1997. The disease framing predates the commercial windfall by decades.
This timeline refutes the notion that classifying obesity as a disease is driven by commercial interests by drugmakers. I also refute the false dichotomy between disease framing and behavioral or environmental approaches. Every major clinical guideline frames pharmacotherapy as adjunct to, not a replacement for, lifestyle and environmental intervention. The piece asserts that disease framing “directs resources away” from these approaches without evidence that clinicians or guidelines abandon them. In my practice, I advocate for access to all possible tools for my patients as health care is a personal, customizable approach. For many patients, GLP-1s are an important piece of a holistic care regimen that includes environmental and lifestyle changes.
By the author’s own admission, determining whether a condition constitutes a disease can influence factors like insurance coverage. Classifying obesity as a disease does not only make clinical sense; it allows those medications to be covered by insurance. From a health equity standpoint, I support disease framing and the subsequent commercial incentives that improve health outcomes and save lives.
— Sera Ramadan
The response
My perspective did not begin in a boardroom or with the arrival of today’s medications. It was formed over years in the exam room, caring for patients whose lives and health were shaped by obesity long before effective medications existed. That clinical experience is why I became an obesity medicine specialist, why I conduct research in the field, and why I now serve as a spokesperson for the Obesity Society and on the steering committee of the American Diabetes Association’s Obesity Association, not the other way around. Medicare began coverage for bariatric surgery for obesity in 2006. For this to happen, obesity must have been assumed to be a disease that had risk of significant complications that merited surgical intervention. Yet I am not aware of any suggestion of commercial motivation behind this decision. I agree with the author that the designation of obesity as a disease has clinical, political, risk, and self-conception implications.
However, the perceived emphasis on pharmacologic therapy as the sole treatment is wrong — it is one part of comprehensive obesity care, including interventions in nutrition, physical activity, and bariatric surgery. Additionally, the risk implications of GLP-1-based medications is misguided. Hypertension, diabetes, and heart failure are also chronic diseases. The return of disease symptoms after stopping effective medications for these conditions is no surprise. Why should obesity be viewed any differently? Likewise, concerns about counterfeit products and off-label cosmetic use do not undermine the appropriate, evidence-based prescribing of GLP-1 medications for obesity. Misuse of a medication is not an argument against its legitimate medical use. By that logic, should prescription opioids for acute pain be abandoned because they have sometimes been prescribed inappropriately?
The self-perception argument is similarly unconvincing. Often, once weight loss has been achieved with medication, people believe they can maintain weight loss without it. However, because obesity is a chronic disease, the underlying biological processes resume when treatment stops, often leading to weight regain. Obesity’s disease framing is not the cause, but the solution. Improving access to effective medication and lifestyle counseling are other solutions. According to GlobalData, GLP-1s are expected to have the greatest impact on the cardiovascular and metabolic disorders market over the next one to three years, and this “opportunity extends well beyond obesity and diabetes.” If so, should more conditions be questioned for their disease classification?
— Wayne Ho, the Obesity Society, American Diabetes Association, USC Keck School of Medicine
The story
“Florida is the first state to require EKGs for high school athletes. This is a mistake,” by Katherine Hofmann
The response
The opinion piece criticizing Florida’s Second Chance Act overlooks reality: No single screening tool is perfect, but relying on medical history and physical evaluation alone leaves too many young people with undetected heart conditions. If 1 in 300 young people has an undetected heart condition, these conditions can hardly be considered rare. Sudden cardiac arrest is the leading medical cause of death in young athletes. Most heart conditions associated with these tragedies are silent. Many have no symptoms or concerning family history and pass their annual sports physical without raising suspicion. An electrocardiogram is not intended to replace a medical history or physical evaluation. It complements them by identifying abnormalities that otherwise would go undetected. Each year, approximately 23,000 children under 18 experience out-of-hospital cardiac arrest. Seventy-five percent of fatalities during sports among NCAA athletes are cardiovascular-related.
Critics cite concerns about false positives, unnecessary testing, and cost. Those concerns deserve thoughtful discussion, but they should be weighed against today’s reality. The International Criteria for ECG Interpretation in Athletes has reduced false-positive rates to approximately 3% when ECGs are interpreted by physicians proficient in these standards. While Black athletes have a higher false-positive rate, they also have a significantly higher risk of sudden cardiac death, including a 21-fold higher rate among Black NCAA basketball players than in an average high school athlete. The law requires affordability and physician proficiency in the International Criteria.
ECG screening isn’t perfect. The question is whether we should continue accepting a standard of care that misses the majority of serious heart conditions in young athletes when a safe, inexpensive, noninvasive test can identify many of them before tragedy strikes. Florida’s Second Chance Act was enacted after years of collaboration among physicians, families affected by sudden cardiac arrest, legislators, athletic leaders, and advocacy organizations. Named in honor of Chance Gainer, the law represents a thoughtful effort to identify hidden heart conditions before they become catastrophic. Suggestions that the law creates inequities overlook the populations most affected. Black youth experience sudden cardiac arrest at higher rates than their peers, are less likely to receive bystander CPR and AED intervention, and therefore have lower survival rates. These disparities were among the reasons the Congressional Black Caucus supported the law.
Every child identified before a catastrophe reminds us that statistics represent real people. Thoughtful debate is healthy, but it should be grounded in current evidence and our shared goal of protecting young athletes.
— Martha Lopez-Anderson, Parent Heart Watch
The story
“Is there a doctor on board? Yes, and airlines depend on it,” by Sriman Swarup
The response
I’ve responded at least four times to the call. Never once was I thanked by the airline staff. In one instance, they refused to open the emergency box because “there would be too much paperwork.” One time they looked at my medical license on my iPhone, and turned up their noses at it and said I wouldn’t be needed. This was after having been woken up in the middle of the night. I’ve never even been offered a few frequent flyer miles, even though I have averted a diversion over Brazil in the middle of the night at one point. I’ll continue to offer my services but reluctantly.
— Peter David Miller
the response
I think Dr. Swarup is on to something. I’ve responded to a handful of medical situations on domestic and international flights over many years of air travel, and fellow health care professionals have occasionally jumped in, and it’s always been appreciated. But some structure would enhance, and any of his recommendations would be welcomed.
— Irv Loh, M.D., Ventura Heart Institute
The story
“I’m an Alzheimer’s specialist. I still missed it in my own father,” by Elizabeth Bevins
The response
Elizabeth Bevins missed Alzheimer’s disease in her own father, a man whose wife had raised concerns with his physician more than once and who went on passing standard cognitive screens. She blames a system that waits for unmistakable decline.
I agree with her, and I would put the failure one step further back, in the tests themselves. The instruments we hand clinicians were built to find this disease at precisely the stage she is arguing we should stop waiting for. Much of my own work has been at the opposite end of the problem, with patients diagnosed as vegetative. The assumption for years was that a patient who could not demonstrate awareness did not possess any. That turned out to be wrong for a meaningful minority of them, whose brains were generating signals our methods were not sensitive enough to pick up. Those signals were often intermittent. Someone might answer questions in the scanner on a Tuesday and show nothing on the Wednesday, not because consciousness had come and gone but because the underlying state fluctuated and our detection was imperfect. An inconsistent signal is not the same as no signal, and it took us a long time to learn that.
Early Alzheimer’s disease and mild cognitive impairment is inconsistent in much the same way. It shows up as the occasional lapse, a change in attention or reasoning that nobody can quite pin down, an emerging reliance on routines that were not needed before, or a spouse who is certain something has changed but cannot say what. Bevins’ father passed a screening test that was never designed to detect any of this. It was built to identify dementia once impairment had become obvious and stable, and on those terms it worked.
This is also why blood-based biomarkers will take us only so far. A test that identifies amyloid years before symptoms appear tells us that a pathological process is underway. It does not tell us whether that process has begun to affect the person, and that is the question Bevins’ mother was raising when she went to the physician, and the one her father’s screening test was never going to answer.
If the cognitive assessment sitting alongside the blood test still cannot separate the earliest impairment from an ordinary bad day, we will get better at detecting the disease without getting any better at recognizing or tracking how and when those early changes begin to matter. We have spent too long mistaking the limits of our tests for the nature of the disease. If we mean to intervene earlier, we will have to measure cognition as sensitively as the biology demands.
— Adrian Owen, University of Western Ontario
