The Effects of Training Institution Practice Costs, Quality, and Other Characteristics on Future Practice

Robert L. Phillips; Stephen M. Petterson; Andrew W. Bazemore; Peter Wingrove; James C. Puffer

doi:10.1370/afm.2044

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Figure 1
Relationships between spending categories of training HSA and practice HSA for 3,075 primary care physicians.
HSA = hospital service area.

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Table 1

Beneficiary, Physician, and Sponsoring Institution Sample Characteristics

	Unweighted Number	Weighted Value^a
Beneficiaries
Beneficiaries, No.	502,920
Patient age
65–74 years	258,161	50.7 (50.6–50.9)
75–84 years	169,880	34.0 (33.8–34.1)
85+ years	74,879	15.3 (15.2–15.4)
Female sex	306,016	61.0 (60.9–61.1)
Patient race/ethnicity
White race	439,966	84.4 (84.3–84.5)
Black race	31,867	7.3 (7.2–7.3)
Other race	5,271	0.8 (0.8–0.8)
Asian race	9,483	2.8 (2.8–2.8)
Hispanic ethnicity	15,567	4.6 (4.5–4.7)
Weighted Charlson Score, median (IQR)		1 (0–2)
Primary care visits, mean (95% CI)		6.8 (6.7–6.8)
Physicians
No. of physicians	3,075
Care provided in hospitals, mean %		12.7 (12.0–13.4)
Sponsoring institution characteristics
No. residents, mean (95% CI)		102.5 (98.8–106.3)
Graduates in rural practice		10.0 (9.7–10.4)
Graduates in primary care		44.5 (43.5–45.4)
Female physicians	1,176	37.6 (35.9–39.3)
Male physicians	1,899	62.4 (60.7–64.1)
International medical graduates	729	28.9 (27.3–30.6)
US medical graduates	2,346	71.1 (69.4–72.7)
General internists	1,398	52.5 (50.8–54.3)
Family physicians	1,677	47.5 (45.7–49.2)
Rural/urban location
Urban	2,291	82.5 (81.2–83.9)
Large rural	488	11.4 (10.3–12.5)
Small rural	161	3.6 (2.9–4.2)
Isolated rural	87	1.3 (0.9–1.7)
Frontier	40	0.9 (0.6–1.3)
Years of practice
0 to 7 y	572	15.6 (14.4–16.9)
8 to 15 y	1,794	59.0 (57.3–60.8)
16 to 19 y	709	25.3 (23.8–26.8)
Practice HSA spending category^b
Low	1,128	26.2 (24.7–27.8)
Average	1,013	29.4 (27.8–31.0)
High	934	44.4 (42.6–46.1)

HSA = hospital service area
Note: Data are derived from 2011 Medicare claims data. Data are weighted and restricted to primary care physicians with 1–19 years of practice and 40 or more Medicare patients, excluding patients with total expenditures greater than $100,000.
↵a Values are % (95% CI) unless otherwise noted.
↵b To standardize training HSA spending, we calculated a standardized z score for HSA spending for each years between 1992 and 2010. The Training HSA Spending groups are Low: −1.50 <z< −0.14, Average: −0.13 <z< 0.46, High: 0.47 <z< 4.50. Each group has approximately the same number of beneficiaries.

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Table 2

Unadjusted Mean and Median Patient Expenditure for Primary Care Physicians, by Practice and Training HSA

Practice HSA Spending Category	Training HSA Spending Category^a	No. Physicians	Expenditure/Patient in Practice HSA
Practice HSA Spending Category	Training HSA Spending Category^a	No. Physicians	Estimated Mean,^b $ (95% CI)	Difference $	P Value^c	Estimated Median,^b $ (95% CI)	Difference $	P Value^c
All levels	Low	1,121	7,454 (7,235–7,673)	Reference		2,567 (2,425–2,710)	Reference
	Average	926	8,011 (7,733–8,288)	557 (129–985)	.01	2,957 (2,757–3,158)	390 (71–708)	.02
	High	1,028	9,097 (8,785–9,409)	1,644 (1,253–2,034)	<.001	3,637 (3,393–3,882)	1,070 (779–1,361)	<.001
Low ($6,102-$8,683)	Low	615	6,943 (6,657–7,229)	Reference		2,337 (2,126–2,548)	Reference
	Average	260	7,437 (6,847–8,027)	493 (−158–1,145)	.14	2,888 (2,351–3,426)	551 (−24 to 1,126)	.06
	High	253	7,676 (7,017–8,334)	732 (110–1,355)	.02	3,051 (2,419–3,683)	713 (163–1,264)	.01
Average ($8,691-$9,879)	Low	324	7,944 (7,478–8,409)	Reference		2,771 (2,488–3,054)	Reference
	Average	335	7,570 (7,175–7,965)	−374 (−1,098–350)	.31	2,758 (2,529–2,987)	−14 (−533 to 506)	.96
	High	354	8,701 (8,146–9,255)	757 (72–1,441)	.03	3,668 (3,220–4,116)	897 (405–1,388)	<.001
High ($9,880-$16,542)	Low	182	7,749 (7,306–8,193)	Reference		2,723 (2,497–2,948)	Reference
	Average	331	8,600 (8,131–9,070)	851 (−56–1,758)	.07	3,130 (2,818–3,441)	407 (−212–1,026)	.20
	High	421	9,721 (9,261–10,181)	1,972 (1,138–2,805)	<.001	3,802 (3,477–4,127)	1,079 (511–1,648)	<.001

HSA = hospital service area.
Note: Data are derived from 2011 Medicare claims data. Data are weighted and restricted to primary care physicians with 1–19 years of practice and 40 or more Medicare patients, excluding patients with total expenditures greater than $100,000.
↵a To standardize HSA spending, we calculated a standardized z score for HSA spending for each year between 1992 and 2010. The training HSA spending groups are Low: −1.49 to −0.14; Average: −0.13 to 0.46; High: 0.48 – 4.50. Each group has approximately the same number of beneficiaries.
↵b We calculated mean and median Medicare Part A and B spending for each physician’s Medicare patient panel.
↵c P values refer to tests of the equality of means within each practice HSA level, using Low-cost Training HSA as the reference.

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Table 3

Adjusted Patient Expenditures and Hospitalizations for Primary Care Physicians

	Expenditures (natural log)
	All Primary Care Physicians		Family Physicians		General Internists

	β (95% CI)	P Value	β (95% CI)	P Value	β (95% CI)	P Value
Training HSA spending category^a
Low	Reference		Reference		Reference
Average	0.02 (−0.02 to 0.06)	.27	0.03 (−0.03 to 0.09)	.32	0.01 (−0.05 to 0.07)	.71
High	0.11 (0.06–0.15)	<.001	0.11 (0.05–0.17)	<.001	0.10 (0.04–0.16)	<.001
Practice HSA spending category
Low ($6,102 to $8,683)	Reference		Reference		Reference
Average ($8,691 to $9,879)	0.05 (0.01–0.09)	.02	0.03 (−0.03 to 0.09)	.26	0.07 (0.01–0.14)	.02
High ($9,880 to $16,542)	0.08 (0.04–0.13)	<.001	0.07 (0.01–0.13)	.03	0.11 (0.05–0.17)	<.001
Number of physicians	3,075		1,398		1,677
Number of beneficiaries	502,920		268,595		234,325

	Hospitalization (yes = 1, no = 0)
	All PC Physicians		Family Physicians		General Internists
	OR (95% CI)	P Value	OR (95% CI)	P Value	OR (95% CI)	P Value
	Training HSA spending category^a
Low	Reference		Reference		Reference
Average	1.05 (0.99–1.12)	.11	1.04 (0.96–1.13)	.34	1.04 (0.94–1.15)	.46
High	0.97 (0.90–1.04)	.36	1.00 (0.91–1.11)	.94	0.93 (0.84–1.03)	.18
Practice HSA spending category
Low ($6,102 to $8,683)	Reference		Reference		Reference
Average ($8,691 to $9,879)	1.00 (0.93–1.08)	.94	1.03 (0.94–1.13)	.51	0.98 (0.87–1.11)	.80
High ($9,880 to $16,542)	1.03 (0.95–1.11)	.49	1.09 (0.99–1.19)	.07	0.99 (0.88–1.10)	.82
Number of physicians	3,075		1,398		1,677
Number of beneficiaries	502,920		268,595		234,325

HSA = Hospital Service Area
Note: Data are based on 2011 Medicare Claims. Data are weighted and restricted to primary care physicians with 1–19 years of practice and 40 or more Medicare patients, excluding patients with total expenditures greater than $100,000.
↵a To standardize training HSA spending, we calculated a standardized z score for HSA spending for each year between 1992 and 2010. The training HSA spending groups are Low: −1.49 to −0.14; Average: −0.13 to 0.46; High: 0.48 – 4.50. Each group has approximately the same number of beneficiaries.

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Table 4

Adjusted Patient Expenditures by Years of Practice

	Years of Practice				Years of Practice

	All Years		0–7 Years		8–15 Years		16–19 Years

	β (95% CI)	P Value	β (95% CI)	P Value	β (95% CI)	P Value	β (95% CI)	P Value
Sponsoring institution characteristics
Percent of graduates in rural practice	−0.31 (−0.50 to −0.13)	.001	−0.06 (−0.51 to 0.39)	.79	−0.48 (−0.73 to −0.23)	<.001	−0.14 (−0.43 to 0.15)	.36
Percent of graduates in primary care	−0.19 (−0.32 to −0.06)	.004	−0.25 (−0.61 to 0.11)	.17	−0.13 (−0.30 to 0.04)	.12	−0.28 (−0.51 to −0.05)	.02
Sponsoring institution size, natural log	−0.03 (−0.05 to −0.00)	.03	−0.02 (−0.09 to 0.05)	.53	−0.03 (−0.06 to 0.01)	.10	−0.03 (−0.08 to 0.02)	.20
Training HSA spending level^a
Low (−1.49 < z < −0.13)	Reference		Reference		Reference		Reference
Average (−0.14 < z < 0.46)	0.02 (−0.02 to 0.06)	.38	0.14 (0.03–0.25)	.01	−0.00 (−0.05 to 0.04)	.86	0.01 (−0.07 to 0.09)	.75
High (0.48 < z < 4.50)	0.10 (0.05–0.14)	<.001	0.23 (0.10–0.37)	<.001	0.09 (0.03–0.14)	.001	0.04 (−0.05 to 0.13)	.37
Practice HSA spending level
Low ($6,102 to $8,683)	Reference		Reference		Reference		Reference
Average ($8,691 to $9,879)	0.05 (0.01–0.09)	.02	−0.01 (−0.12 to 0.11)	.88	0.06 (0.01–0.11)	.02	0.05 (−0.03 to 0.13)	.20
High ($9,880 to $16,542)	0.08 (0.04–0.12)	<.001	−0.03 (−0.13 to 0.08)	.63	0.11 (0.06–0.16)	<.001	0.06 (−0.02 to 0.15)	.16
Covariates^b	Yes		Yes		Yes		Yes
Patients, No.	502,920		68,691		305,765		128,464
Physicians, No.	3,075		572		1,794		709

HSA = hospital service area.
Note: Data are based on 2011 Medicare Claims. Data are weighted and restricted to primary care physicians with 1–19 years of practice and 40 or more Medicare patients, excluding patients with total expenditures greater than $100,000.
↵a To standardize training HSA spending, we calculated a standardized z score for HSA spending for each year between 1992 and 2010. The training HSA spending groups are Low: −1.49 to −0.14; Average: −0.13 to 0.46; High: 0.48 – 4.50. Each group has approximately the same number of beneficiaries.
↵b Analyses controlled for the patients’ age, sex, race/ethnicity, number of primary care visits, and comorbidity using the weighted Charlson index.

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Table 5

Association Between Sponsoring Institution Characteristics, Training HSA Spending category, and Quality Measures for Diabetic Patients

	Hemoglobin A_1c Test		LDL Screening		Nephropathy Screening		Eye Exam		Summary Score

	OR (95% CI)	P Value	OR (95% CI)	P Value	OR (95% CI)	P Value	OR (95% CI)	P Value	OR (95% CI)	P Value

Sponsoring Institution Characteristics
Percent of graduates in rural practice	0.98 (0.31–3.04)	.97	0.53 (0.19–1.42)	.20	0.58 (0.23–1.49)	.26	0.91 (0.67–1.24)	.56	0.88 (0.67–1.16)	.35
Percent of graduates in primary care	1.10 (0.58–2.08)	.76	1.57 (0.85–2.91)	.15	1.43 (0.76–2.68)	.27	0.94 (0.75–1.19)	.62	1.08 (0.93–1.26)	.32
Sponsoring institution size, natural log	1.09 (0.98–1.22)	.12	1.10 (0.99–1.23)	.08	1.12 (1.00–1.25)	.06	1.00 (0.96–1.04)	.92	1.03 (1.00–1.05)	.05
Training HSA spending category^a
Low	Reference		Reference		Reference		Reference		Reference
Average	0.98 (0.76–1.25)	.85	1.06 (0.85–1.33)	.59	1.04 (0.85–1.26)	.73	0.95 (0.88–1.02)	.14	1.00 (0.95–1.06)	.95
High	1.06 (0.082–1.38)	.65	1.14 (0.91–1.44)	.26	1.09 (0.89–1.34)	.40	1.01 (0.93–1.09)	.84	1.03 (0.97–1.09)	.38
Practice HSA spending category
Low ($6,102 to $8,683)	Reference		Reference		Reference		Reference		Reference
Average ($8,691 to $9,879)	1.34 (1.03–1.73)	.03	1.23 (0.98–1.55)	.07	1.12 (0.90–1.39)	.30	0.95 (0.88–1.03)	.23	1.06 (0.99–1.12)	.08
High ($9,880 to $16,542)	1.27 (1.00–1.60)	.05	1.38 (1.12–1.71)	.003	.88 (0.70–1.09)	.24	0.88 (0.81–0.96)	.003	1.03 (0.97–1.09)	.29
Covariates^b	Yes		Yes		Yes		Yes		Yes

HSA = hospital service area; LDL = low-density lipoprotein.
Note: Data are based on 2011 Medicare Claims. Data are weighted and restricted to primary care physicians with 1–19 years of practice and 40 or more Medicare patients, excluding patients with total expenditures greater than $100,000. For all models, the diabetic beneficiary sample size is 126,666, and the physician sample size is 3,073.
↵a To standardize training HSA spending, we calculated a standardized z score for HSA spending for each year between 1992 and 2010. The training HSA spending groups are Low: −1.49 to −0.14; Average: −0.13 to 0.46; High: 0.48 – 4.50. Each group has approximately the same number of beneficiaries.
↵b See text for list of covariates.

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The Article in Brief

The Effects of Training Institution Practice Costs, Quality, and Other Characteristics on Future Practice

Robert L. Phillips, Jr , and colleagues

Background Previous research has demonstrated that Medicare beneficiary spending reflects that of the 306 Hospital Referral Regions where physicians train. Because these large areas have as much cost variation within as between them, this study sought to determine whether the relationship holds true for smaller areas and for quality.

What This Study Found Based on 2011 Medicare claims data for a nationally representative sample of family physicians and general internists who completed residency training between 1992 and 2011 at the level of the 3,436 US Hospital Service Areas (HSA), spending patterns for Medicare beneficiaries for whom they provided care were similar to the patterns of the HSA in which their sponsoring institution was located. There was no similar relationship for quality.

Implications

The authors conclude these findings of a long-term "imprint" of training support efforts to test interventions in residency training that may bend imprinting toward teaching and modeling behaviors that improve value in health care.