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.
METHODS
We 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.
RESULTS
The unadjusted, annual, per-beneficiary spending difference between physicians trained in high-and low-cost HSAs was 1,644(95%CI, 1,253–2,034),andthedifferenceremainedsignificantaftercontrollingforpatientandphysiciancharacteristics.Nosignificantrelationshipwasfoundfordiabetesqualitymeasures.Generalinternistsweresignificantlymorelikelythanfamilyphysicianstotraininhigh-costHSAs.Institutionswithmoregraduatesinruralpracticeandprimarycareproducedlower-spendingphysicians.CONCLUSIONSThe“imprint”oftrainingspendingpatternsonphysiciansisstrongandenduring,withoutdiscerniblequalityeffects,and,alongwithidentifiedinstitutionalfeatures,supportsmeasuresandpolicyoptionsforimprovedgraduatemedicaleducationoutcomes.