Among primary care physicians, the spending patterns in the regions in which their residency program was located were associated with expenditures for subsequent care they provided as practicing physicians, with those trained in lower-spending regions continuing to practice in a less costly manner, even when they moved to higher-spending regions, and vice versa, according to a study in the December 10 issue of JAMA, a theme issue on medical education.
Regional and system-level variations in Medicare spending and overall intensity of medical services delivered to patients represent the collective practice decisions of clinicians in these different systems. Some research suggests that the nature of residency training influences the nature of physician practice, which raises the question of whether exposure to different practice and spending patterns during residency influences physicians' practice patterns and cost of care after training, according to background information in the article.
Candice Chen, M.D., M.P.H., of George Washington University, Washington, D.C., and colleagues examined the relationship between spending patterns in the region of a physician's graduate medical education training and individual physician practice spending patterns after training. The study consisted of an analysis of 2011 Medicare claims data (Part A hospital and Part B physician) for a random, nationally representative sample of family medicine and internal medicine physicians completing residency between 1992 and 2010 with Medicare patient panels of 40 or more patients (2,851 physicians providing care to 491,948 Medicare beneficiaries). Locations of practice and residency training were matched with Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups, with approximately equal distribution of beneficiary numbers.
For physicians practicing in high-spending regions, those trained in high-spending regions had an average spending per Medicare beneficiary per year $1,926 higher than those trained in low-spending regions. For practice in average-spending HRRs, average spending per beneficiary was $897 higher for physicians trained in high- vs low-spending regions. For practice in low-spending HRRs, the difference across training HRR levels was not significant ($533).
Overall, there was approximately a 7 percent difference in spending between physicians trained in the highest and lowest training HRR spending groups, corresponding to an estimated $522 difference between low- and high-spending training regions.
For physicians 1 to 7 years in practice, there was a 29 percent difference in spending between those trained in low- and high-spending regions; however, after 16 to 19 years, there was no significant difference.
"These observations suggest an imprinting of care-related spending behaviors that may take place during residency. Decay of the effect over time would be consistent with a training imprint that wanes because of practice environment. These findings are notable for the initial size and continuation of the association of training with physician spending patterns for up to 15 years after training. This potential imprinting has implications for physician training and potentially for hiring, particularly because major efforts are under way to reduce health care spending," the authors write.
(doi:10.1001/jama.2014.15973; Available pre-embargo to the media at http://media.
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.