Disease Risk Prediction Using Structured EHR Data: Can Generalist Large Language Models Match Specialized Clinical Foundation Models? A Comparative Evaluation with Fine-Tuning

Background: Electronic health records (EHRs) with clinical decision support tools are now ubiquitous in healthcare organizations. Clinical foundation models (CFMs) pretrained on large-scale, heterogeneous structured EHR data have emerged as a powerful approach to improve predictive performance and generalizability. Meanwhile, large language models (LLMs) pretrained on broad data sources are being applied to an expanding range of healthcare tasks. However, it remains unclear whether generalist LLMs can match specialized CFMs for disease risk prediction using structured clinical data. Methods: We compared CFMs (Med-BERT, CLMBR) against fine-tuned generalist LLMs (Mistral, LLaMA-2/3/3.1), a clinical LLM (Me-LLaMA), and LLM-generated embeddings paired with simple classifiers (using DeepSeek, Qwen3, and GPT-OSS) on two disease risk prediction tasks: heart failure risk among diabetic patients (DHF) and pancreatic cancer diagnosis (PaCa). Evaluations spanned multi-site EHR data, claims data, and an open-source single-institution benchmark (EHRSHOT). Performance was assessed using the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). Results: On larger EHR and claims cohorts (>30,000 patients), fine-tuned CFMs outperformed fine-tuned LLMs by a small but statistically significant margin (<1% AUROC). The clinical LLM performed comparably to generalist LLMs despite being smaller. On the open-source PaCa cohort (3,810 patients, 199 cases), LLMs achieved slightly higher AUROCs that were not statistically significant (LLaMA-3.1-70B 86.1% vs. Med-BERT 85.3%, p=0.27), but CFMs achieved significantly higher AUPRC (Med-BERT 55.9% vs. LLaMA-3.1-70B 41.1%, p=0.001). Notably, LLM-generated trajectory embeddings paired with logistic regression or a simple MLP, without any LLM fine-tuning, achieved the best overall performance, with AUROC exceeding 90% (Qwen3) and AUPRC reaching 66% (GPT-OSS 20B). Conclusion: LLM-generated embeddings with lightweight classifiers outperformed both fine-tuned CFMs and fine-tuned LLMs on AUROC and AUPRC. While these results demonstrate the potential of generalist models to match or surpass specialized CFMs, their substantially greater computational cost and variable AUPRC performance in the fine-tuning setting warrant caution. We provide a reproducible evaluation framework and codebase to support continued benchmarking.