Variation in the Tendency of Primary Care Physicians to Intervene
By Brenda E. Sirovich, MD, MS; Daniel J. Gottlieb, MS; H. Gilbert Welch, MD, MPH; Elliott S. Fisher, MD, MPH
Archives of Internal Medicine
October 24, 2005
There is widespread recognition that health care spending varies widely across the United States. Per capita Medicare expenditure in the areas of highest spending is double that in the lowest-spending areas, even though in some cases these represent neighboring areas. Because higher spending does not appear to result in better outcomes or quality of care, there is intense interest in understanding the reasons for the wide variation in utilization of services. Average illness severity varies little across regions; therefore, attention has focused increasingly on the role of physicians who, through their actions and recommendations, control most health care resources and thereby direct most health care spending.
There are, however, competing explanations of how physicians might contribute to higher health care spending. On the one hand, high-spending areas have more physicians per capita, and on average, patients in these areas each see a greater number of physicians. Even if each physician’s shared ordering pattern is identical to those in lower-spending areas, utilization (and spending) per capita would be higher in areas with a greater number of physicians. On the other hand, physicians in high- and low-spending regions may have entirely different ordering patterns.
Specifically, physicians in high-spending areas may be more prone to intervene – to order tests, referrals, and treatments – for individual patients.
We sought to determine whether physician behavior is at least in part responsible for widely varying spending and utilization patterns across the United States – that is, to what extent individual physicians in high-spending regions have a greater tendency to intervene for individual patients.
The sample of primary care physicians consisted of both family/general practitioners (57%) and general internists (43%). Regions in the quintile of highest spending averaged $8325 per capita in annual Medicare spending and
242 physicians per 100,000 persons compared with $6087 per capita and 193 physicians per 100,000 in moderate-spending regions and $4911 per capita and 185 physicians per 100,000 in regions of low spending. The supply of hospital beds and physicians of all specialties was more abundant in regions of higher spending, with the exception of family practitioners, whose numbers declined as local spending increased.
This study shows that widely differing levels of health care spending across the United States reflect the tendency of local physicians to recommend interventions for patients. In high-spending areas, physicians would order further evaluation or treatment for approximately 10 additional patients of every 100 patients seen compared with physicians in low-spending areas.
While we have shown that physicians who practice in areas of higher local health care spending are more prone to intervene, we are unable to distinguish among 3 potential explanations: (1) more aggressive physicians may be attracted to certain areas; (2) physicians may adopt the practice style (or standard of practice) of the community where they locate; or (3) characteristics of the market itself, such as greater difficulty maintaining target incomes in a more competitive marketplace, could lead to a lower threshold for referral and test ordering.
It is unlikely that physician behavior is the sole explanation for higher levels of spending in some areas. Having more specialists or more hospital beds in an area, for example, likely plays a role in higher levels of local spending. It is also possible that – notwithstanding similar end-of-life preferences – differences in patient expectations and demands across different regions impact the level of local health care spending via direct influence on physician decision making. However, in the present study we have been able to show that, when faced with the same patients, physicians in higher-spending areas are more likely to intervene, and this undoubtedly accounts for some portion of the higher spending seen in some US regions.
http://archinte.ama-assn.org/cgi/content/abstract/165/19/2252
Comment: We already know that there is a wide variation in spending in different locations, and that the differences are not explained by the relative health of the populations served. We know that the higher level of spending does not result in higher quality nor does it improve health outcomes. We know that regions with higher spending have excess capacity and an excess concentration of specialists. This study adds to others which demonstrate that physician behavior also drives up spending in high-cost areas.
The design of this study makes it very likely that these physicians believe that they are making optimal choices for their patients’ care. As we consider policy changes that would reduce excess spending in high-cost areas, it is a relief to know that not much attention needs to be directed to efforts to reduce fraud and abuse (except for the rare provider who clearly churns or submits fraudulent claims).
A single payer system can be beneficial because, as a monopsonistic purchaser, it can favorably alter the practice environment. Excess capacity of health care facilities can be controlled through budgeting of capital improvements. Excess concentration of specialists can be controlled by offering differential compensation based on regional needs.
Controlling excess capacity runs the risk of creating excessive queues. Continual monitoring with appropriate adjustments as needed would be required. Not only would we benefit by reducing the waste of over-utilization, but we would also improve access in regions with deficient capacity.
Those who are uncomfortable with a publicly administered process should keep in mind that currently the marketplace is failing to provide the oversight and adjustments that need to be made. We want to continue to spend nearly the same amount on health care, but we want to spend it much better.