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Research ArticleOriginal Research

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 and James C. Puffer
The Annals of Family Medicine March 2017, 15 (2) 140-148; DOI: https://doi.org/10.1370/afm.2044
Robert L. Phillips Jr
1The American Board of Family Medicine, Inc, Lexington, KY
MD, MSPH
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  • For correspondence: bphillips@theabfm.org
Stephen M. Petterson
2The Robert Graham Center, Washington, DC
PhD
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Andrew W. Bazemore
2The Robert Graham Center, Washington, DC
MD, MPH
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Peter Wingrove
2The Robert Graham Center, Washington, DC
BS
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James C. Puffer
1The American Board of Family Medicine, Inc, Lexington, KY
MD
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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 NumberWeighted Valuea
    Beneficiaries
    Beneficiaries, No.502,920
    Patient age
     65–74 years258,16150.7 (50.6–50.9)
     75–84 years169,88034.0 (33.8–34.1)
     85+ years74,87915.3 (15.2–15.4)
    Female sex306,01661.0 (60.9–61.1)
    Patient race/ethnicity
     White race439,96684.4 (84.3–84.5)
     Black race31,8677.3 (7.2–7.3)
     Other race5,2710.8 (0.8–0.8)
     Asian race9,4832.8 (2.8–2.8)
     Hispanic ethnicity15,5674.6 (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 physicians3,075
    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 practice10.0 (9.7–10.4)
     Graduates in primary care44.5 (43.5–45.4)
    Female physicians1,17637.6 (35.9–39.3)
    Male physicians1,89962.4 (60.7–64.1)
    International medical graduates72928.9 (27.3–30.6)
    US medical graduates2,34671.1 (69.4–72.7)
    General internists1,39852.5 (50.8–54.3)
    Family physicians1,67747.5 (45.7–49.2)
    Rural/urban location
     Urban2,29182.5 (81.2–83.9)
     Large rural48811.4 (10.3–12.5)
     Small rural1613.6 (2.9–4.2)
     Isolated rural871.3 (0.9–1.7)
     Frontier400.9 (0.6–1.3)
    Years of practice
     0 to 7 y57215.6 (14.4–16.9)
     8 to 15 y1,79459.0 (57.3–60.8)
     16 to 19 y70925.3 (23.8–26.8)
    Practice HSA spending categoryb
     Low1,12826.2 (24.7–27.8)
     Average1,01329.4 (27.8–31.0)
     High93444.4 (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.

    • View popup
    Table 2

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

    Practice HSA Spending CategoryTraining HSA Spending CategoryaNo. PhysiciansExpenditure/Patient in Practice HSA
    Estimated Mean,b $ (95% CI)Difference $P ValuecEstimated Median,b $ (95% CI)Difference $P Valuec
    All levelsLow1,1217,454
    (7,235–7,673)
    Reference2,567
    (2,425–2,710)
    Reference
    Average9268,011
    (7,733–8,288)
    557
    (129–985)
    .012,957
    (2,757–3,158)
    390
    (71–708)
    .02
    High1,0289,097
    (8,785–9,409)
    1,644
    (1,253–2,034)
    <.0013,637
    (3,393–3,882)
    1,070
    (779–1,361)
    <.001
    Low
     ($6,102-$8,683)
    Low6156,943
    (6,657–7,229)
    Reference2,337
    (2,126–2,548)
    Reference
    Average2607,437
    (6,847–8,027)
    493
    (−158–1,145)
    .142,888
    (2,351–3,426)
    551
    (−24 to 1,126)
    .06
    High2537,676
    (7,017–8,334)
    732
    (110–1,355)
    .023,051
    (2,419–3,683)
    713
    (163–1,264)
    .01
    Average
     ($8,691-$9,879)
    Low3247,944
    (7,478–8,409)
    Reference2,771
    (2,488–3,054)
    Reference
    Average3357,570
    (7,175–7,965)
    −374
    (−1,098–350)
    .312,758
    (2,529–2,987)
    −14
    (−533 to 506)
    .96
    High3548,701
    (8,146–9,255)
    757
    (72–1,441)
    .033,668
    (3,220–4,116)
    897
    (405–1,388)
    <.001
    High
     ($9,880-$16,542)
    Low1827,749
    (7,306–8,193)
    Reference2,723
    (2,497–2,948)
    Reference
    Average3318,600
    (8,131–9,070)
    851
    (−56–1,758)
    .073,130
    (2,818–3,441)
    407
    (−212–1,026)
    .20
    High4219,721
    (9,261–10,181)
    1,972
    (1,138–2,805)
    <.0013,802
    (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.

    • View popup
    Table 3

    Adjusted Patient Expenditures and Hospitalizations for Primary Care Physicians

    Expenditures (natural log)
    All Primary Care PhysiciansFamily PhysiciansGeneral Internists
    β (95% CI)P Valueβ (95% CI)P Valueβ (95% CI)P Value
    Training HSA spending categorya
     LowReferenceReferenceReference
     Average0.02
    (−0.02 to 0.06)
    .270.03
    (−0.03 to 0.09)
    .320.01
    (−0.05 to 0.07)
    .71
     High0.11
    (0.06–0.15)
    <.0010.11
    (0.05–0.17)
    <.0010.10
    (0.04–0.16)
    <.001
    Practice HSA spending category
     Low ($6,102 to $8,683)ReferenceReferenceReference
     Average ($8,691 to $9,879)0.05
    (0.01–0.09)
    .020.03
    (−0.03 to 0.09)
    .260.07
    (0.01–0.14)
    .02
     High ($9,880 to $16,542)0.08
    (0.04–0.13)
    <.0010.07
    (0.01–0.13)
    .030.11
    (0.05–0.17)
    <.001
    Number of physicians3,0751,3981,677
    Number of beneficiaries502,920268,595234,325
    Hospitalization (yes = 1, no = 0)
    All PC PhysiciansFamily PhysiciansGeneral Internists
    OR (95% CI)P ValueOR (95% CI)P ValueOR (95% CI)P Value
    Training HSA spending categorya
     LowReferenceReferenceReference
     Average1.05
    (0.99–1.12)
    .111.04
    (0.96–1.13)
    .341.04
    (0.94–1.15)
    .46
     High0.97
    (0.90–1.04)
    .361.00
    (0.91–1.11)
    .940.93
    (0.84–1.03)
    .18
    Practice HSA spending category
     Low ($6,102 to $8,683)ReferenceReferenceReference
     Average ($8,691 to $9,879)1.00
    (0.93–1.08)
    .941.03
    (0.94–1.13)
    .510.98
    (0.87–1.11)
    .80
     High ($9,880 to $16,542)1.03
    (0.95–1.11)
    .491.09
    (0.99–1.19)
    .070.99
    (0.88–1.10)
    .82
    Number of physicians3,0751,3981,677
    Number of beneficiaries502,920268,595234,325
    • 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.

    • View popup
    Table 4

    Adjusted Patient Expenditures by Years of Practice

    Years of PracticeYears of Practice
    All Years0–7 Years8–15 Years16–19 Years
    β (95% CI)P Valueβ (95% CI)P Valueβ (95% CI)P Valueβ (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 levela
     Low (−1.49 < z < −0.13)ReferenceReferenceReferenceReference
     Average (−0.14 < z < 0.46)0.02 (−0.02 to 0.06).380.14 (0.03–0.25).01−0.00 (−0.05 to 0.04).860.01 (−0.07 to 0.09).75
     High (0.48 < z < 4.50)0.10 (0.05–0.14)<.0010.23 (0.10–0.37)<.0010.09 (0.03–0.14).0010.04 (−0.05 to 0.13).37
    Practice HSA spending level
     Low ($6,102 to $8,683)ReferenceReferenceReferenceReference
     Average ($8,691 to $9,879)0.05 (0.01–0.09).02−0.01 (−0.12 to 0.11).880.06 (0.01–0.11).020.05 (−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).630.11 (0.06–0.16)<.0010.06 (−0.02 to 0.15).16
    CovariatesbYesYesYesYes
    Patients, No.502,92068,691305,765128,464
    Physicians, No.3,0755721,794709
    • 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.

    • View popup
    Table 5

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

    Hemoglobin A1c TestLDL ScreeningNephropathy ScreeningEye ExamSummary Score
    OR (95% CI)P ValueOR (95% CI)P ValueOR (95% CI)P ValueOR (95% CI)P ValueOR (95% CI)P Value
    Sponsoring Institution Characteristics
     Percent of graduates in rural practice0.98 (0.31–3.04).970.53 (0.19–1.42).200.58 (0.23–1.49).260.91 (0.67–1.24).560.88 (0.67–1.16).35
     Percent of graduates in primary care1.10 (0.58–2.08).761.57 (0.85–2.91).151.43 (0.76–2.68).270.94 (0.75–1.19).621.08 (0.93–1.26).32
     Sponsoring institution size, natural log1.09 (0.98–1.22).121.10 (0.99–1.23).081.12 (1.00–1.25).061.00 (0.96–1.04).921.03 (1.00–1.05).05
    Training HSA spending categorya
     LowReferenceReferenceReferenceReferenceReference
     Average0.98 (0.76–1.25).851.06 (0.85–1.33).591.04 (0.85–1.26).730.95 (0.88–1.02).141.00 (0.95–1.06).95
     High1.06 (0.082–1.38).651.14 (0.91–1.44).261.09 (0.89–1.34).401.01 (0.93–1.09).841.03 (0.97–1.09).38
    Practice HSA spending category
     Low ($6,102 to $8,683)ReferenceReferenceReferenceReferenceReference
     Average ($8,691 to $9,879)1.34 (1.03–1.73).031.23 (0.98–1.55).071.12 (0.90–1.39).300.95 (0.88–1.03).231.06 (0.99–1.12).08
     High ($9,880 to $16,542)1.27 (1.00–1.60).051.38 (1.12–1.71).003.88 (0.70–1.09).240.88 (0.81–0.96).0031.03 (0.97–1.09).29
    CovariatesbYesYesYesYesYes
    • 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.
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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
The Annals of Family Medicine Mar 2017, 15 (2) 140-148; DOI: 10.1370/afm.2044

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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
The Annals of Family Medicine Mar 2017, 15 (2) 140-148; DOI: 10.1370/afm.2044
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