STAT readers weigh in on primary care and obesity

The American Academy of Family Physicians, the American College of Physicians, and the American Academy of Pediatrics have jointly called for Medicare payment reform, arguing that the current system pits primary care against specialty care in a way that hurts patients. In a letter published by the outlet, the three physician groups responded to an earlier opinion piece that framed the tension between primary and specialty care as a crisis requiring difficult choices.

The groups argued that patients need both.

A person managing diabetes, they wrote, needs a primary care physician they trust for ongoing care and a specialist when complications arise.

Children need a pediatrician who can monitor development and recognize when specialty care is needed. The physicians said that Medicare’s outdated payment policies and budget neutrality rules need to change, because Medicare rates influence other payers including Medicaid, the leading source of health coverage for children in the U.S.

The data behind primary care’s value

The letter cited evidence that adults with a usual source of primary care are far more likely to receive preventive services for chronic disease — 95.5% compared with 67.6% of adults without that connection. Children with consistent access to such care are also more likely to receive immunizations, behavioral health screenings, and other care that catches problems early.

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For patients with chronic disease, having a usual source of it is associated with fewer emergency department visits and hospitalizations. The letter noted an 11% reduction in ED visits for adults and a 50% reduction in avoidable visits and hospitalizations for children. Health care costs are about 54% lower for adults with chronic disease who have it, and nearly 40% lower for children.

Each primary care visit is associated with roughly $700 in lower health care costs, the physicians said, and continuity of care can reduce overall spending by up to 10%.

A doctor pushes back on the framing

Dr. Jeffrey Millstein of Penn Medicine responded separately, arguing that the original article misrepresented the rationale for increased investment in primary care. He said the real issue is fragmented care, poor time-sensitive access, and task overload that limits primary care physicians’ clinical effectiveness and sustainability.

Millstein noted that MedPAC data shows access to primary care for Medicare patients compares favorably to the general population, where 20% to 25% of patients have no usual source of care. Most can see their doctor in that field within two weeks. But that works for wellness exams and routine follow-ups, not for acute illness. Those patients end up in urgent care centers and emergency rooms, which disrupts continuity.

“Payment reform is not about ‘robbing Peter to pay Paul,’” Millstein wrote. “It is about more fairly reimbursing cognitive work which in turn can invigorate primary care, expand the workforce, and improve continuity.”

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Obesity as a disease, and who benefits

Dr. Wayne Ho, representing the Obesity Society and the American Diabetes Association, pushed back against the suggestion that classifying obesity as a disease is driven by commercial interests. He argued that the American Medical Association declared the condition a disease in 2013, years before GLP-1 drugs became blockbusters, and the World Health Organization classified it as a chronic disease in 1997.

“This timeline refutes the notion that classifying obesity as a disease is driven by commercial interests by drugmakers,” Ho wrote. He said that in his practice, GLP-1s are one part of a plan that includes nutrition, physical activity, and lifestyle changes.

Ho also addressed the question of insurance coverage. Classifying obesity as a disease allows medications to be covered by insurance, which he framed as a health equity issue. He pointed out that Medicare began covering bariatric surgery for the condition in 2006, which required assuming it was a disease with significant complications meriting surgical intervention — without accusations of commercial motivation at the time.

Florida’s EKG requirement for student athletes

Martha Lopez-Anderson of Parent Heart Watch defended Florida’s Second Chance Act, which requires electrocardiograms for high school athletes.

She argued that relying on medical history and physical exams alone misses too many young people with undetected heart conditions.

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She noted that 1 in 300 young people has an undetected heart condition, and sudden cardiac arrest is the leading medical cause of death in young athletes. Each year, approximately 23,000 children under 18 experience out-of-hospital cardiac arrest, and 75% of fatalities during sports among NCAA athletes are cardiovascular-related.

Lopez-Anderson acknowledged concerns about false positives but cited the International Criteria for ECG Interpretation in Athletes, which has reduced false-positive rates to approximately 3% when interpreted by proficient physicians. She noted that Black athletes have higher false-positive rates but also face a significantly higher risk of sudden cardiac death — including a 21-fold higher rate among Black NCAA basketball players than the average high school athlete.

Doctors responding on planes, and a missed diagnosis

Dr. Irv Loh of the Ventura Heart Institute responded to a piece about physicians responding to in-flight medical emergencies, saying he has answered the call multiple times without thanks from airline staff. In one case, he said, staff refused to open the emergency medical kit because of paperwork concerns. Another time, they looked at his medical license on his phone and said he wouldn’t be needed — after waking him in the middle of the night.

Adrian Owen of the University of Western Ontario responded to an essay about a specialist who missed Alzheimer’s disease in her own father. Owen argued that the problem is not just the system but the tests themselves, which were built to find dementia only once impairment has become obvious and stable. He wrote that early Alzheimer’s shows up as inconsistent lapses that screening tests were never designed to detect, and that blood-based biomarkers alone won’t solve the problem if cognitive assessments still cannot separate the earliest impairment from an ordinary bad day.