An analysis of Medicare claims(www.jabfm.org) published in the March-April issue of the Journal of the American Board of Family Medicine indicates that even as health care costs continue to spiral, family physicians persistently demonstrate that they provide more bang for the buck than other primary care physicians.
In the analysis, researchers from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care and other institutions examined a year's worth of Medicare claims data to better understand the link between PCPs and spending on unnecessary or inappropriate services, dubbed low-value care. The final analysis included data from more than 6,800 PCPs and almost 1.1 million patients enrolled in Medicare.
The analysis showed that on average, family physicians had lower LVC Medicare spending than physicians who practiced internal medicine or other specialties. The research also suggested that where family physicians practice and the breadth of services they offer are important factors in reducing costs related to LVC.
With the goal of determining whether certain physician characteristics were associated with LVC spending, the analysis was limited to PCPs (i.e., those specializing in family medicine, internal medicine, general practice or geriatric medicine) with Medicare beneficiaries who were not enrolled in HMOs and who received the plurality of their Medicare Part B services from those physicians.
- An analysis of Medicare claims data involving almost 1.1 million patients found that low-value care spending is lower among family physicians than those who practice internal medicine or other primary care specialties.
- Overall, primary care physicians who practiced in the Midwest or in rural areas had lower LVC spending than physicians in urban areas.
- The researchers suggested their findings could be used as a starting point for additional research into LVC spending.
The authors identified eight services deemed to be of low value according to the American Board of Internal Medicine Foundation's Choosing Wisely initiative(www.choosingwisely.org) that were appropriate to this population. The services were
- imaging studies for low back pain within six weeks of diagnosis,
- imaging studies of the brain for simple syncope,
- osteoporosis screening in men younger than 70,
- cardiac screening for low-risk asymptomatic patients,
- prostate cancer screening,
- routine preoperative testing for low-risk surgical procedures,
- screening for carotid artery disease, and
- cervical cancer screening in women 65 and older.
The main outcome, LVC Medicare spending per patient, was calculated by totaling Medicare payments for the eight services and then dividing by the number of attributed patients. Physicians were divided into high or low LVC groups, using LVC spending in the top 20% as the high LVC threshold.
The analysis found mean per-patient LVC spending across the entire sample was $14.67. After adjusting for patient and practice location characteristics, the researchers identified being a family physician as one of the factors associated with lower per-patient LVC spending. On average, family physicians had $1.03 lower LVC spending per patient than internal medicine physicians.
Another finding was that PCPs who practiced in the Midwest or in rural areas had lower LVC spending than those in urban areas. Specifically, per patient LVC spending among PCPs in the Midwest was $2.80 less than among those in the Northeast.
"Perhaps family doctors in rural areas in the Midwest are more likely to have stronger patient attribution, involve fewer specialists, and therefore have less LVC spending," the authors wrote. "Through this method of patient attribution, perhaps this study adds to the evidence for the value of primary care in providing comprehensive, high-value, evidence-based care."
The authors also found another potential advantage to practicing in a rural setting. Previous research that involved family physicians,(www.rrh.org.au) they noted, has indicated that FPs practicing in urban settings tend to have a narrower scope of practice than those in rural areas and are more likely to refer patients to specialists, which may result in higher use of LVC. Other research(www.ncbi.nlm.nih.gov) has shown that an increasingly broad scope of practice among family physicians is associated with significantly lower Medicare costs. Although direct evidence from the analysis was lacking, the authors suggested that "perhaps a broader scope of practice (such as that characteristic of many rural physicians) may lead to a decrease in LVC services."
Finally, the researchers found associations between LVC spending level and physician gender, as well as between spending and patient panel size. Specifically, PCPs in the low LVC group were, on average, more likely to be female than those in the high LVC group (29% vs. 23%), and PCPs with lower LVC spending had, on average, fewer patients than those in the high LVC group (147 vs. 189).
Implications for Future Studies
With estimates showing that more than $210 billion is spent on unneeded medical services each year(www.nap.edu) and that 30% of all Medicare spending is unnecessary,(www.healthaffairs.org) it is clear that health care spending is of great concern to physicians, patients, insurers and government agencies. The authors noted that although their analysis of physician characteristics contained several limitations, it could nevertheless serve as a starting point for additional research in this area.
"By understanding characteristics associated with less LVC, we can begin to strategize on ways to decrease medical waste in the United States," they wrote.
Family Physician Perspective
Amy Mullins, M.D., the AAFP's medical director for quality improvement, told AAFP News that the value of family physicians will increasingly be judged in relation to cost; as such, she thought the findings were important for practicing FPs to be aware of.
In fact, Mullins suggested, the findings could play a factor in shaping future policies related to payment and scope of practice.
"This emphasizes how important full scope of practice is to the well-being of patients and also to the well-being of the health care system," she said.
Mullins also told AAFP News that she would have liked to see the researchers compare LVC spending between primary care physicians and those in other specialties to get a truer picture of the value family physicians and other PCPs provide.
That said, Mullins did not think the results should dictate the type of care family physicians provide.
"What is best for the patient should always come first, not cost," she said.
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