Variation in Specialty Outpatient Care Patterns in the Medicare Population

Abstract

BACKGROUND: Multiple payment reform efforts are under way to improve the value of care delivered to Medicare beneficiaries, yet few directly address the interface between primary and specialty care. OBJECTIVE: To describe regional variation in outpatient visits for individual specialties and the association between specialty physician-specific payments and patient-reported satisfaction with care and health status. DESIGN: Retrospective cross-sectional study. PATIENTS: A 20 % random sample of Medicare fee-forservice beneficiaries in 2012. MAIN MEASURES: Regions were grouped into quartiles of specialist index, defined as the observed/expected regional likelihood of having an outpatient visit to a specialist, for ten common specialties, adjusting for age, sex, and race. Outcomes were per capita specialty-specific physician payments and Medicare Current Beneficiary Survey responses. KEY RESULTS: The proportion of beneficiaries seeing a specialist varied the most for endocrinology and gastroenterology (3.7-and 3.9-fold difference between the highest and lowest quartiles, respectively) and least for orthopedics and urology (1.5-and 1.7-fold difference, respectively). Multiple analyses suggested that this variation was not explained by prevalence of disease. Average specialty-specific payments were strongly associated with the likelihood of visiting a specialist. Differences in per capita payments from lowest (Q1) to highest quartiles (Q4) were greatest for cardiology ($89, $135, $172, $251) and dermatology ($46, $64, $82, $124 Q4, 94.5 % [94.4-94.8 %]). CONCLUSIONS: Substantial regional variability in outpatient specialist visits is associated with greater payments with limited benefits in terms of patient-reported satisfaction with care or reported health status. Reducing outpatient physician visits may represent an important opportunity to improve the efficiency of care.

Access to medications for medicare enrollees related to race/ethnicity: Results from the 2013 Medicare Current Beneficiary Survey

“…In contrast, medication access was similar for Hispanics compared to non-Hispanic whites in all areas, except for satisfaction with the list of covered medications; for this measure, Hispanics were more satisfied than non-Hispanic whites. While the MCBS is a very comprehensive survey that has been used extensively in health services research, 21–23 this is the first study to examine specific aspects of access to medication related to race/ethnicity and other demographic factors.…”

Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants

“…[ 2 , 3 ] Unwarranted variation has been linked to suboptimal outcomes[ 4 – 8 ] and to increased cost for the same outcome (i.e., inefficient care). [ 9 , 10 ]…”

Association between specialist compensation and Accountable Care Organization performance

“…Accountable Care Organizations (ACOs) are provider groups that coordinate to provide high‐quality care within a spending target for a defined patient population. While ACO leaders have focused care coordination and cost reduction efforts on primary care, 1‐4 specialty care is a major and rising source of ACO spending growth that remains under‐examined 5‐13 . In theory, ACOs may address specialty cost growth by attempting to limit leakage to specialists outside of their organization 14 while encouraging efficient care among specialists within the organization, for example, through sharing performance data with specialists or offering them financial incentives to reduce spending.…”