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

Abstract

PURPOSE Medicare beneficiary spending patterns reflect those of the 306 Hospital Referral Regions where physicians train, but whether this holds true for smaller areas or for quality is uncertain. This study assesses whether cost and quality imprinting can be detected within the 3,436 Hospital Service Areas (HSAs), 82.4 percent of which have only 1 teaching hospital, and whether sponsoring institution characteristics are associated. METHODSWe conducted a secondary, multi-level, multivariable analysis of 2011 Medicare claims and American Medical Association Masterfile data for a random, nationally representative sample of family physicians and general internists who completed residency between 1992 and 2010 and had more than 40 Medicare patients (3,075 physicians providing care to 503,109 beneficiaries). Practice and training locations were matched with Dartmouth Atlas HSAs and categorized into low-, average-, and high-cost spending groups. Practice and training HSAs were assessed for differences in 4 diabetes quality measures. Institutional characteristics included training volume and percentage of graduates in rural practice and primary care. RESULTSThe unadjusted, annual, per-beneficiary spending difference between physicians trained in high-and low-cost HSAs was $1,644 (95% CI, $1,253-$2,034), and the difference remained significant after controlling for patient and physician characteristics. No significant relationship was found for diabetes quality measures. General internists were significantly more likely than family physicians to train in high-cost HSAs. Institutions with more graduates in rural practice and primary care produced lower-spending physicians.CONCLUSIONS The "imprint" of training spending patterns on physicians is strong and enduring, without discernible quality effects, and, along with identified institutional features, supports measures and policy options for improved graduate medical education outcomes. Ann Fam Med 2017;15:140-148. https://doi.org/10.1370/afm.2044. INTRODUCTIONP ublic and private payers have embraced value-based health care, and are marching aggressively toward the Triple Aim-better health, better care, and lower costs.1 Simultaneously, the National Academy of Medicine, The Josiah Macy Jr Foundation, and others are calling for greater accountability for more than $15 billion currently spent on Graduate Medical Education (GME), and for more strategic allocation of GME funding.2-8 Most research supporting accountability measures and reform options has focused on the specialties and distribution of graduates, but our recent study exploring the relationship between training and future practice costs found that physician-associated Medicare costs were highly correlated with those of their the physicians ' Hospital Referral Regions (HRR). 9 Educational imprinting is the idea that learners model witnessed behaviors and beliefs, sometimes despite what they are taught, and GME is not immune. These studies demonstrate important relationships between training and subsequent...

The CLE's Role in Preparing New Clinicians to Engage in Quality Improvement Efforts to Eliminate Health Care Disparities

“…Health and health care disparities are inequities among vulnerable populations linked to inadequate care and poor health outcomes. 3 The definitions below are provided as context for these concepts.…”

In This Issue: On-the-Ground Advances & High-Level Influences

“…In a study of the long-term "imprint" of training, Phillips and colleagues find that the spending pattern of physicians training in high cost vs low cost Hospital Service Areas persists long after training. 13 An article by authors from the Patient-Centered Outcomes Research Institute (PCORI) shares an Engagement Rubric developed from multiple sources. Building on decades of prior work in participatory research by others, the PCORI Engagement Rubric provides a framework for involving patients and other stakeholders in all phases of research.…”

Imprinting on Clinical Rotations: Multisite Survey of High- and Low-Value Medical Student Behaviors and Relationship with Healthcare Intensity

“…6 Medical education thus has a responsibility to not only equip students with a nuanced understanding of value, but also support the development of high-value practice patterns aligned with this aim. 7 Prior studies have demonstrated relationships between physicians' experiences during residency and their subsequent knowledge, 8 attitudes, 9 behaviors, 10,11 and patient outcomes 12 related to high-value care. These relationships are evident as early as internship 13 and persist for up to 15 years after training.…”

“…These relationships are evident as early as internship 13 and persist for up to 15 years after training. 10,11 This suggests residency training contributes to an imprinting process whereby learners develop practice patterns resembling those they observe in the learning environment. 11,12 Studies like these highlight the importance of the graduate medical education training environment.…”

“…10,11 This suggests residency training contributes to an imprinting process whereby learners develop practice patterns resembling those they observe in the learning environment. 11,12 Studies like these highlight the importance of the graduate medical education training environment. However, comparatively little is known about the potential impact of regional practice patterns on medical student behaviors and experiences-despite the fact that their professional identity formation is already well-underway.…”