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Spending more, getting less?

Impact of physicians' treatment decisions on cost of U.S. health care

Physicians practicing in regions of the United States where health care spending is high are more likely to order tests, referrals and treatments for their patients than those in low spending regions, according to researchers at the Veterans Administration (VA) Outcomes Group and Dartmouth Medical School (DMS). As new data emerges that health care spending has little relationship to health outcomes, these findings point to one reason behind the dramatic variation in the cost of health care across different U.S. regions.

Brenda Sirovich
Brenda Sirovich, lead author of a new study that identifies physician behavior as a cause of regional variation in U.S. health care spending. (photo by Flying Squirrel)

Health care spending varies considerably across the United States--averaging less than $5,000 per year for each Medicare beneficiary in Portland, Ore., and over $10,000 in Miami, Fla. "What hasn't been clear," said the study's primary author, Brenda Sirovich, Staff Physician at the White River Junction VA Medical Center and Assistant Professor of Medicine at DMS, "is whether spending is so different across various areas because the patients are different - in other words, more or less sick - or because the doctors are different. We did this study to find out whether it is in fact differences in doctors, and the decisions they make, that contribute to the large differences in spending that we see."

The study appeared in the Oct. 24 issue of Archives of Internal Medicine and measured the responses of 5,490 primary care physicians to a survey in which they were presented with clinical scenarios and asked how often they would order a specific test, referral or treatment for each patient described. Sirovich and colleagues used Medicare data to characterize spending in the region where each physician practiced, a figure that ranged from an average of $4,911 per capita in the areas of lowest spending to $8,325 in the highest spending areas.

The authors found that physicians who practice in areas of high spending do more-they order more tests, referrals and treatments-than doctors who practice in low spending areas. For example, when presented with a 35-year old man with prolonged back pain and foot weakness after heavy lifting, physicians in high spending regions would order an MRI scan 82 percent of the time. This compared to 69 percent of the time for physicians in low spending regions. For a woman who called complaining of vaginal itching and discharge, physicians in high spending regions would have the patient come in for an office visit 57 percent of the time compared to 45 percent for those in low spending regions.

"The strength of this study," Sirovich argued, "is that we were able to isolate the role of physicians in explaining the huge differences that we see in practice and spending across regions."

In previously published work, these researchers found that providing more medical care was not better in terms of health care quality, satisfaction or outcomes. In fact, on some measures, such as access to preventive care, high spending regions actually fared worse. Those studies suggest "that care in the United States could be just as good or better and cost a lot less-perhaps as much as 30 percent less-if all U.S. regions could safely adopt the more conservative practice patterns of lower-cost regions," said study co-author Elliott Fisher, Professor of Medicine at DMS and also a member of the VA Outcomes Group.

The authors acknowledge that it is unlikely that physician behavior is the sole explanation for higher levels of spending in some regions of the country, noting differences in patient expectations may influence spending as well.

In addition to Sirovich and Fisher, Daniel Gottlieb from the Center for the Evaluative Clinical Sciences at DMS and H. Gilbert Welch, Professor of Medicine and Community and Family Medicine at DMS and Co-Director of the VA Outcomes Group, are co-authors of the study, which was supported by grants from the VA, the Robert Wood Johnson Foundation and the National Institute of Aging. The research was conducted at the VA Medical Center in White River Junction, Vt., where members of the VA Outcomes Group investigate and promote communication of information about the risks and benefits of medical care.

By ANDREW NORDHOFF

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Last Updated: 12/17/08