Brenda E. Sirovich, MD, MS; Daniel J. Gottlieb, MS; H. Gilbert Welch, MD, MPH; Elliott S. Fisher, MD, MPH
Disclaimer: The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs or the U.S. government.
Acknowledgments: The authors thank James Reschovsky, PhD, of the Center for Studying Health System Change in Washington, DC, for his valuable comments on an earlier draft of the manuscript.
Grant Support: Dr. Sirovich is supported by a Veterans Affairs Career Development Award in HSR&D. This study was supported by a Research Enhancement Award from the Department of Veterans Affairs (03-098) to investigate the harms from excessive medical care. Financial support was also provided by grants from the Robert Wood Johnson Foundation and the National Institute of Aging (PO1 AG19783).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Brenda E. Sirovich, Veterans Affairs Outcomes Group (111B), Veterans Affairs Medical Center, White River Junction, VT 05009; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Sirovich and Welch: Veterans Affairs Outcomes Group, Veterans Affairs Medical Center, White River Junction, VT 05009.
Mr. Gottlieb and Dr. Fisher: Dartmouth College, 7251 Strasenburgh Hall, Hanover, NH 03755.
Author Contributions: Conception and design: B.E. Sirovich, D.J. Gottlieb, E.S. Fisher.
Analysis and interpretation of the data: B.E. Sirovich, D.J. Gottlieb, H.G. Welch, E.S. Fisher.
Drafting of the article: B.E. Sirovich.
Critical revision of the article for important intellectual content: D.J. Gottlieb, H.G. Welch, E.S. Fisher.
Final approval of the article: B.E. Sirovich, D.J. Gottlieb, H.G. Welch, E.S. Fisher.
Provision of study materials or patients: E.S. Fisher.
Statistical expertise: B.E. Sirovich, D.J. Gottlieb, E.S. Fisher.
Obtaining of funding: E.S. Fisher.
Administrative, technical, or logistic support: D.J. Gottlieb.
Collection and assembly of data: D.J. Gottlieb.
Research has documented dramatic differences in health care utilization and spending across U.S. regions with similar levels of patient illness. Although patient outcomes and quality of care have been found to be no better in regions of high health care intensity, it is unknown whether physicians in these regions feel more capable of providing good patient care than those in low-intensity regions.
To determine whether physicians in high-intensity regions feel better able to care for patients than physicians in low-intensity regions.
Physician telephone survey.
51 metropolitan and 9 nonmetropolitan areas of the United States and a supplemental national sample.
10 577 physicians who provided care to adults in 1998 or 1999 were surveyed for the Community Tracking Study (response rate, 61%).
The End-of-Life Expenditure Index, a measure of spending that reflects differences in the overall quantity of medical services provided rather than differences in illness or price, was used to determine health care intensity in the physicians' community. Outcomes included physicians' perceived availability of clinical services, ability to provide high-quality care to patients, and career satisfaction.
Although the highest-intensity regions have substantially more hospital beds and specialists per capita, physicians in these regions reported more difficulty obtaining needed services for their patients. The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50% in high-intensity regions to 64% in the lowest-intensity region (P < 0.001 for the relationship between intensity and perceived ability to obtain hospital admissions); the proportion of physicians who felt able to obtain high-quality specialist referrals ranged from 64% in high-intensity regions to 79% in low-intensity regions (P < 0.001). Compared with low-intensity regions, fewer physicians in high-intensity regions felt able to maintain good ongoing patient relationships (range, 62% to 70%; P < 0.001) or able to provide high-quality care (range, 72% to 77%; P = 0.009). In most cases, differences persisted but were attenuated in magnitude after adjustment for physician attributes, practice characteristics, and local market factors (for example, managed care penetration); the difference in perceived ability to provide high-quality care was no longer statistically significant (P = 0.099).
The cross-sectional design prevented demonstration of a causal relationship between intensity and physician perceptions of quality.
Despite more resources, physicians in regions of high health care intensity did not report greater ease in obtaining needed services or greater ability to provide high-quality care.
Regional differences in expenditures for medical care in the United States have not been associated with better patient outcomes; their effects on physician satisfaction are unknown.
These investigators examined this issue using a survey of a nationally representative sample of physicians. Physicians in high-intensity (high-expenditure) regions perceived lower availability of services and more difficulty providing high-quality care than those in low-intensity regions.
Assessment of regional intensity was based on Medicare utilization and might not reflect intensity in younger age groups.
Higher levels of health care spending do not necessarily improve physician satisfaction.
Table 1. Characteristics of Areas with Varying Levels of Local Health Care Intensity
Proportion of physicians practicing in regions with differing levels of local health care intensity who report being able to obtain the following services when medically necessary.
Proportion of physicians practicing in regions with differing levels of local health care intensity who agree with the following statements about their practice experience.
Table 2. Characteristics of Physicians in the Sample
Appendix Table 1. Factors Associated with Physicians' Perceived Ability To Obtain Hospital Admissions
Appendix Table 2. Factors Associated with Physicians' Perceived Ability To Obtain Referrals to High-Quality Specialists
Appendix Table 3. Factors Associated with Physicians' Perceptions of Their Ability To Provide High-Quality Care
Appendix Table 4. Factors Associated with Physicians' Career Satisfaction
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John C. Peirce
University of Michigan Medical School
May 9, 2006
Look for Locked-in Behavior
To the Editor:
Sirovich and colleagues1 and Berenson in an associated editorial2 make known important findings bringing us closer to understand determinants of higher quality health care and cost containment. To extend this I performed a secondary analysis, regressing the percent generalists on the Dartmouth investigators' End-of-Life Economic Index in Dollars, using data from their table 1. This showed that for every percent increase in generalist physicians from 26 to 31 there is a reduction in EOL-EI of $1056 (95%CI: -$1796, -$406; R-square = 0.90; p=0.006). With the model accounting for 90 percent of the variance, the proportion of generalists is a powerful determinant of EOL-EI$.
For Berenson's question: "why policymakers have not taken action," I suggest we focus attention on the principle of increasing returns and path dependency elaborated by Mayes3 in his book about why universal health care coverage has eluded us. The QWERTY keyboard was among many typing machines that appeared in the 1870s but was the first to "catch on" and be used in ever increasing numbers until it became accepted as the "standard" in the early 20th century. It's remained so for over 100 years for typewriters and computers in spite of better typing configurations. People are trained in its use; businesses invest in equipment having this configuration; and they build this into the warp and woof of conducting their day-to-day work. This behavior is locked-in, and in this case, allows for greater effectiveness and efficiency4.
But not all locked-in behavior produces efficient behavior and functional systems, witness our present fee-for-service system of physician payment. Howard Brody5, a family physician and ethicist, bemoans that were he to train a patient to treat their plantar warts with duct tape "“ the subject of a published article "“ he'd say to himself, "Oh no, there goes our practice's revenue stream." On the other hand, he found it near impossible to get several consultants together with one of his patients with a severe chronic illness whose treatments were not working to see if their give and take might produce a better plan; they weren't paid to do this. Their natural "“ and I'm sure unconscious "“ inclination was to stay where they could perform procedures that were more efficient in producing a "revenue stream." We physicians have locked-in this type of behavior. I suggest that generalist physicians have a moderating effect that keeps use of procedures within a "therapeutic window." Nonetheless more needs to be done; Mayes suggests we need to look for "critical junctures." And that is our responsibility.
John C. Peirce, MD, MA, MS Center for the History of Medicine University of Michigan Medical School Ann Arbor, Michigan
1. Sirovich BE, Gottlieb DJ, Welch HG, Fisher ES. Regional variations in health care intensity and physicians perceptions of quality of care. Ann Intern Med. 2006:144:641-649
2. Berenson RA. Editorial: Does more health care spending produce better health and happier doctors? Ann Intern Med. 2006:144:694-696
3. Mayes R. Universal coverage: the quest for national health insurance. Ann Arbor: The University of Michigan Press, 2004
4. Arthur WB. Positive feedbacks in the economy. In: Arthur WB. Increasing returns and path dependency in the economy. Ann Arbor: The University of Michigan Press; 1994, p 1-12
5. Brody H. Duct tape cures warts, or crazy ways to pay doctors. The Grand Rapids Press, April 4, 2006, E3
Brenda E Sirovich
VA Medical Center, White River Junction, VT
July 12, 2006
We appreciate Dr. Peirce's ad hoc analysis of our data, showing that relatively higher concentrations of generalists in an area are associated with lower per capita Medicare spending. Before addressing the principle (with which we agree), it is necessary to make an important clarification to his finding. Although it is true that spending falls steadily as the percentage of generalists (family practitioners and general internists) rises from 26% (in quintile 5) to 31% (in quintile 1), a quick glance at Table 1 shows that this observation does not apply equally to all generalist physicians. In fact, spending rises as the number (and percentage) of general internists increases. It is family practitioners who are associated with lower Medicare spending. For every additional family practitioner per 100,000 population, per capita end-of-life spending falls by $470 (for general internists, it rises $297). What is interesting is that this occurs despite extremely similar practice styles reported by family practitioners and general internists (1).
We agree with Dr. Peirce that high health care spending is encouraged by a largely fee-for-service system that rewards procedures and other generously reimbursed interventions at the expense of low tech and non- invasive specialties such as family practice, pediatrics, and general internal medicine. There are doubtless other factors that also encourage higher spending "“ including patient pressures, malpractice fears, and the lure of technological certainty. What is not clear is whether (and why) these factors play out so differently in different geographic areas. It is clear, however, that the type of specialist-based and technology-driven health care practiced in many regions of this country is associated with aggressive spending, with no beneficial effect on patient outcomes (2), health care quality (3), or physician satisfaction. It is extremely unlikely that adding additional physicians (4) "“ particularly specialist physicians "“ will improve this situation.
Brenda Sirovich, MD, MS email@example.com VA Outcomes Group Department of Veterans Affairs Medical Center White River Junction, VT
Elliott S. Fisher, MD, MPH Center for Evaluative Clinical Sciences Dartmouth Medical School Hanover, NH 03755
1. Sirovich BE, Gottlieb DJ, Welch HG, Fisher ES. Variation in the tendency of primary care physicians to intervene. Arch Intern Med. 2005;165:2252-2256.
2. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288- 98.
3. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273-87.
4. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood). 2002;21:140-54.
Sirovich BE, Gottlieb DJ, Welch HG, Fisher ES. Regional Variations in Health Care Intensity and Physician Perceptions of Quality of Care. Ann Intern Med. 2006;144:641–649. doi: 10.7326/0003-4819-144-9-200605020-00007
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