Physician Expenditures Research Articles

Hidden Costs in Resident Training: Financial Cohort Analysis of First Assistants in Reduction Mammaplasty.

Background:Graduate medical education (GME) programs are vital to developing future plastic surgeons. However, their cost-efficiency has yet to be contextualized. This cohort quality improvement (QI) project aimed to measure the indirect costs an institution assumes in training surgical residents, by comparing the differences in operative time and procedural charges between a resident and a physician assistant (PA) first-assisting during adolescent reduction mammaplasty.Methods:From 2013 to 2019, adolescent bilateral reduction mammaplasty procedures first-assisted by either a resident or physician assistant were considered for analysis. Financial data, including all hospital and physician expenditures and operation duration, patient demographics, and outcomes data were retrospectively collected.Results:A total of 49 reduction mammaplasty cases were included for analysis. Residents had an average of 5.9 ± 1.5 years of post-graduate surgical training, whereas the PA had 2 years of surgical experience. Procedures first-assisted by a surgical resident took a mean/median of 34 minutes longer and were $3750 more expensive, respectively, than cases first-assisted by a PA (P < 0.01, both).Conclusions:Reduction mammaplasty procedures were longer and accrued higher charges when first-assisted by a surgical resident than by a PA. Although Graduate Medical Education programs are necessary to train the next generation of surgeons, they may result in unintended opportunity costs for teaching hospitals. Federal support to academic medical centers aims to cushion the cost of residential training, but is insufficient to compensate for resident inefficiency. Hospitals may consider incorporating PAs into the Graduate Medical Education paradigm to alleviate administrative burden, lower operational charges, and enhance resident training curricula.

The effect of bariatric surgery on health care costs: A synthetic control approach using Bayesian structural time series.

Surgical measures to combat obesity are very effective in terms of weight loss, recovery from diabetes, and improvement in cardiovascular risk factors. However, previous studies found both positive and negative results regarding the effect of bariatric surgery on health care utilization. Using claims data from the largest health insurance provider in Germany, we estimated the causal effect of bariatric surgery on health care costs in a time period ranging from 2years before to 3years after bariatric intervention. Owing to the absence of a control group, we employed a Bayesian structural forecasting model to construct a synthetic control. We observed a decrease in medication and physician expenditures after bariatric surgery, whereas hospital expenditures increased in the post-intervention period. Overall, we found a slight increase in total costs after bariatric surgery, but our estimates include a high degree of uncertainty.

Doctors and Canadian Medicare: Improving System Performance Requires System Change.

Many of the issues raised and insights provided by Marchildon and Sherar (2018) in their essay on doctors and Canadian medicare are on target. The inadequacy of available data on physician payment, however, calls into question the robustness of some interprovincial comparisons, and when it comes to compensation, comparisons to US physicians would be most relevant. In contrast to their assertion of a steadily increasing growth rate in physician expenditure, a more recent and longer view shows historically low growth in the past few years. Furthermore, the blame assigned to physicians and their medical associations needs to be shared with governments and most of all could be attributed to the lack of system structures and supports for improvement. New governance arrangements at the group or regional levels are needed but are insufficient in themselves. The additional features embodied in the Patient's Medical Home are essential for advancing primary care. Going even further, full population registration, greater availability of alternate payment arrangements, active participation of physicians in healthcare administration and support for meaningful measurement and feedback loops are among the changes required to transform Canadian medicare.

Per-Capita Medicare Expenditures, Primary Care Access, Mortality Rates, and the Least Healthy Cities in America

PurposeTo determine whether several measures of health care expenditures, access, and outcomes for the 25 recently identified “least healthy cities in America” differed from those in the rest of America. MethodsFor 2004 and 2013, we obtained publicly available price-, age-, sex-, and race-adjusted hospital service area per-capita Medicare expenditures; age-, sex-, and race-adjusted Medicare mortality rates; and 2 indicators of primary care access: the proportion of enrollees having at least one ambulatory visit to a primary care clinician and the per-capita discharge rate for ambulatory care sensitive conditions. Using population weighting, we used Student t test for expenditure data and the chi-squared test for access and outcomes data to compare results of the 25 least healthy cities in aggregate to the rest of America. ResultsIn both years examined, the 25 least healthy cities had substantially (about $500 per capita per year) and statistically significantly higher total per-capita Medicare Part A and Part B expenditures than the rest of America: about 4/5 of this difference was due to higher hospital and skilled nursing facility expenditures; physician expenditures were modestly lower in the 25 least healthy cities. While a greater proportion of Medicare beneficiaries in the least healthy cities had a primary care clinician both years, mortality and ambulatory care sensitive condition admission rates were substantially higher in the least healthy cities. ConclusionsPolicymakers and health system executives should work together to determine the best asset allocation across determinants of health that maximizes value creation from a community health perspective.

The contingency of medicare physician spending on population densities and sizes

The exploration of the spatial association between Medicare physician spending and population densities and sizes could possibly facilitate the investigation of the causal mechanisms beneath the variation in medical care. We acquired the U.S. Medicare physician expenditures and regional demographic and geographic data in 2006 from the Dartmouth Atlas of Health Care. Six geographic units—states, counties, Hospital Referral Regions, Hospital Service Areas, Metropolitan Statistical Areas, and state non-Metropolitan Statistical Areas—were used as units of study. Pearson correlation analysis, multivariable regression, and partial correlation analysis were employed. Among six geographic units, Pearson correlation coefficients between Medicare physician expenditures and logarithmic population densities ranged from 0.42 to 0.63 (p < 0.05 for all), and between the expenditures and logarithmic population sizes from 0.31 to 0.65 (p < 0.05 for all). When population health, differential demand, market structure, and data reporting bias were controlled, population densities and sizes were positively associated with Medicare physician expenditures in most models. Population densities and sizes could explain considerable amounts of regional variation in Medicare physician spending. We concluded that Medicare physician spending was contingent on population densities and sizes. Because population densities and sizes are produced by more fundamental qualities such as natural environments and resources and thus are not easily manipulated, they are suggestive in health policy studies. Further research might investigate population distribution associated properties such as geographic distribution of health care resources, spatial dynamics of medical technology distribution, and cultural and psychological factors.

Yearly Clinical Laboratory Test Expenditures for Different Medical Specialties in a Major Canadian City.

Very little is known about the relative contributions of physician specialty groups and individual physicians to overall clinical laboratory expenditures. The objectives of this study were to determine the costs of clinical laboratory test expenditures attributable to 30 medical specialties and the associated per capita physician expenditures for an entire major Canadian city. Only chemistry, hematology, and microbiology tests were included in this study. Retrospective cohort study involving all physicians in Calgary, Canada, and surrounding areas (n = 3,499) and secondary data on laboratory test orders. Data were obtained on approximately 20 million test requests. The mean clinical laboratory test expenditure, in Canadian dollars, per physician was $27,945 for all physicians combined. Total expenditures by primary care physicians (family physicians and general practitioners) accounted for 58% of total expenditures. There was wide variation in clinical laboratory test expenditures among specialties and on a per capita basis within medical specialties.

Diagnosing Senescence: Contributions to Physician Expenditure Increases in British Columbia, 1996/97 to 2005/06

Conventional wisdom holds that Canada suffers from a physician shortage, yet expenditures for physicians' services continue to increase rapidly. We address this apparent paradox, analyzing fee-for-service payments to physicians in British Columbia in 1996/97 and 2005/06. Age-specific per capita expenditures (adjusted for fee changes) rose 1% per year over this period, adding $174 million to 2005/06 expenditures. We partition these increases into changes in the proportion of the population seeing a physician; the number of unique physicians seen; the number of visits per physician; and the average expenditure per visit. Expenditures on laboratory and imaging services, particularly for the elderly and very elderly, have increased dramatically. By contrast, primary care services for the non-elderly appear to have declined. The causes and health consequences of these large changes deserve serious attention.

Comparing federal and state healthcare provider performance in villages targeted by the conditional cash transfer programme of Mexico

This study investigates household out-of-pocket healthcare expenditures (OPH) and preventive care utilization (PHU) to compare federal and state healthcare provider performance in villages targeted by conditional cash transfer (CCT) programmes in poor rural areas of Mexico. Lower OPH and higher PHU are indicative of better performance in the study setting. Log-linear and probit regression models were used to compare outcomes in households from treatment and control villages reached by federal and state healthcare providers. In treatment villages, eligible households receive cash grants from the CCT programme. In control villages, eligible households do not receive cash grants from the CCT programme at the time of the survey. Families who live in treatment villages reported lower OPH (-52.5% for federal and -46.2% for state clinics) and higher PHU (21% for federal and 20% for state clinics) regardless of clinic setting. As the reduction in OPH is higher in areas reached by the federal clinics, it implies better performance from this healthcare delivery system. Additionally, federal clinic outcomes were also more homogeneous because OPH are not significantly different between treatment and control villages. Alternative measures such as drug and physician expenditures, diabetes and hypertension tests and nutritional-supplement receipt confirmed these findings. Mexico has two healthcare delivery systems that cater to identical rural populations. The better-funded and more centralized federal system is more effective at providing health care in poor rural villages of Mexico regardless of CCT participation. State clinics in villages targeted by the CCT programme, however, perform significantly better.

The Impact of Pharmacy-Specific Any-Willing-Provider Legislation on Prescription Drug Expenditures

Many states have implemented some form of Any-Willing-Provider (AWP) legislation, which requires a managed care organization (MCO) to accept any provider, who agrees to the managed care organization’s reimbursement rates, terms, and conditions, into its network. AWP laws may result in larger networks, more patient choice, and greater competition among providers. Opponents cite AWP legislation as prohibiting managed care organizations from selective contracting and obtaining discounts by offering providers a larger volume of patients. Such legislation is therefore argued to prevent MCOs from effectively reducing health care costs. A small literature exists on the effect of these laws on hospital expenditures, physician expenditures, and total health care expenditures. Most studies, however, fail to recognize that the vast majority of the existing laws target pharmacies exclusively, as opposed to more comprehensive laws that also apply to physicians and hospitals. If AWP legislation prevents cost reduction available through selective contracting, then states with such legislation may incur higher health care expenditures. I find that pharmacy-specific AWP legislation is associated with increased pharmaceutical expenditures. This result is robust to several alternative specifications.

Data Watch: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Data Watch: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Expenditures on Mental Health and Addictions for Canadian Provinces in 2003/04

To measure total public and private expenditures on mental health in each province. Data for expenditures on mental health services were collected in the following categories: physician expenditures (general and psychiatrist fees for service and alternative funding), inpatient hospital (psychiatric and general), outpatient hospital, community mental health, pharmaceuticals, and substance abuse. Data for 2 years, 2003 and 2004, were collected from the Canadian Institute for Health Information (hospital inpatient and fees for service physicians), the individual provinces (pharmaceuticals, alternative physician payments, hospital outpatient, and community), and the Canadian Centre on Substance Abuse. Totals were expressed in terms of per capita and as a percentage of total provincial health spending. Total spending on mental health was $6.6 billion, of which $5.5 billion was from public sources. Nationally, the largest portion of expenditures was for hospitals, followed by community mental health expenses and pharmaceuticals. This varied by province. Public mental health spending was 6% of total public spending on health, while total mental health spending was 5% of total health spending. Canadian public mental health spending is lower than most developed countries, and a little below the minimum acceptable amount (5%) stated by the European Mental Health Economics Network.

Expenditures on Mental Health and Addictions for Canadian Provinces in 2003 and 2004

Objective: To measure total public and private expenditures on mental health in each province. Method: Data for expenditures on mental health services were collected in the following categories: physician expenditures (general and psychiatrist fees for service and alternative funding), inpatient hospital (psychiatric and general), outpatient hospital, community mental health, pharmaceuticals, and substance abuse. Data for 2 years, 2003 and 2004, were collected from the Canadian Institute for Health Information (hospital inpatient and fees for service physicians), the individual provinces (pharmaceuticals, alternative physician payments, hospital outpatient, and community), and the Canadian Centre on Substance Abuse. Totals were expressed in terms of per capita and as a percentage of total provincial health spending. Results: Total spending on mental health was $6.6 billion, of which $5.5 billion was from public sources. Nationally, the largest portion of expenditures was for hospitals, followed by community mental health expenses and pharmaceuticals. This varied by province. Public mental health spending was 6% of total public spending on health, while total mental health spending was 5% of total health spending. Conclusions: Canadian public mental health spending is lower than most developed countries, and a little below the minimum acceptable amount (5%) stated by the European Mental Health Economics Network.

Variability in prescription drug expenditures explained by adjusted clinical groups (ACG) case-mix: A cross-sectional study of patient electronic records in primary care

BackgroundIn view of rapidly increasing prescription costs, case-mix adjustment should be considered for effective control of costs. We have estimated the variability in pharmacy costs explained by ACG in centers using patient electronic records, profiled centers and physicians and analyzed the correlation between cost and quality of prescription.MethodsWe analyzed 65,630 patient records attending five primary care centers in Spain during 2005. Variables explored were age, gender, registered diagnosed episodes of care during 2005, total cost of prescriptions, physician and center. One ACG was assigned to each patient with ACG case-mix software version 7.1. In a two-part model, logistic regression was used to explain the incurrence of drug expenditure at the first stage and a linear mixed model that considered the multilevel structure of data modeled the cost, conditional upon incurring any expense. Risk and efficiency indexes in pharmacy cost adjusted for ACG were obtained for centers and physicians. Spearman rank correlation between physician expenditure, adjusted for ACG, and a prescription quality index was also obtained. Pediatric and adult data were analyzed separately.ResultsNo prescription was recorded for 13% of adults and 39.6% of children. The proportion of variance of the incurrence of expenditure explained by ACGs was 0.29 in adults and 0.21 in children. For adults with prescriptions, the variance of cost explained by ACGs was 35.4%, by physician-center was 1.8% and age 10.5% (residual 52.3%). For children, ACGs explained 22.4% of cost and physician-center 10.9% (residual 66.7%). Center efficiency index for adults ranged 0.58 to 1.22 and for children 0.32 to 2.36.Spearman correlation between expenditure and prescription quality index was -0.36 in family physicians (p = 0.019, N = 41) and -0.52 in pediatricians (p = 0.08, N = 12).ConclusionIn our setting, ACG is the variable studied that explains more variability in pharmacy cost in adults compared to physician and center. In children there is greater variability among physicians and centers not related to case-mix. In our sites, ACG is useful to profile physicians and centers using electronic records in real practical conditions. Physicians with lower pharmaceutical expenditure have higher scores for a prescription quality index.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Vital Signs: Projected Aggregate Physician and Clinical Service Expenditures in the U.S.

Impact of Disease Management on Cost-Effectiveness of Medicare Spending

Findings from the third annual Tufts Center for the Study of Drug Development survey of 22 leading disease and pharmacy benefits managers suggest that incorporation of disease management into Medicare would lower hospital inpatient costs. However, it is unclear whether hospital cost savings would be sufficient to offset increases in pharmacy, physician, and outpatient expenditures as a result of an added combination disease management and pharmacy benefit. Furthermore, the survey indicates that the Centers for Medicare & Medicaid Services (CMS) would likely struggle in recruiting disease managers due to their limited enrollment of Medicare beneficiaries, relative inexperience with contracts that put disease managers at risk, and only sporadic use of randomized design studies to test and prove the efficacy of disease management interventions. Thirteen of the 22 survey respondents are currently considered early compilers per accreditation standards developed by the National Committee on Quality Assurance. However, none of the 22 survey respondents compty with the stringent CMS requirements described in the solicitation for the 2002 disease management demonstration.