Clinical question: For primary care physicians (PCPs), does residency training area affect the pattern of physician spending after training is complete?
Background: Regional and system-level variations in the intensity of medical services provided are common in the U.S. Residency training practice patterns could explain these variations. This study examines the relationship between spending patterns in the region of residency training and individual physician practice spending patterns after training.
Study design: Secondary, multilevel, multivariable analysis of 2011 Medicare claims data.
Setting: Random, nationally representative sample of family and internal medicine physicians completing residency between 1992 and 2010, with Medicare patient panels of 40 or more patients.
Synopsis: Investigators randomly selected 2,851 PCPs who completed residency training from 1992-2010, providing care to 491,948 Medicare beneficiaries. Practice locations and residency training were matched with the Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups.
Physicians practicing in high-spending regions who trained in high-spending regions spent $1,926 more per Medicare beneficiary than those trained in low-spending regions. In average-spending regions, physicians who trained in high-spending regions spent an average of $897 higher than those who trained in low-spending regions. No differences were found in low-spending regions.
This association varied significantly according to years in practice. For physicians in the first seven years of practice, patient expenditures in the highest-spending training HRR were 29% greater than those in the lowest-spending training HRR. After 16 years of practice, this variation disappeared.
Although this study does not establish causality, there may be opportunities to control spending with focused interventions in residency.
Bottom line: Spending patterns vary even within HRRs; however, this study’s findings suggest that physicians’ practice patterns are developed in residency training and that training in high-spending regions likely leads to increased expenditures. Focusing on cost-conscious care during residency training could be a significant option for curtailing healthcare costs in the future.
Citation: Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-2393.