EDUCATIONAL IMPRINTING OF EXPENDITURE PATTERNS IN TRAINING

Background Medicare beneficiary spending reflects that of Hospital Referral Regions (N=306) in which physicians trained; an “imprint” sustained for nearly two decades. We tested whether this relationship held at smaller Hospital Service Areas (HSAs) (N=3,436) and also investigated sponsoring institution features, inter-specialty differences, and claims-based, quality measures. Methods We performed multi-level, multivariable analysis of 2011 Medicare claims data for a stratified, random, nationally representative sample of family physicians and general internists who completed residency between 1992 and 2010 and had more than 40 Medicare patients. Practice and training locations were matched with Dartmouth Atlas HSAs and categorized into cost groups. Results Our sample included 3,075 physicians providing care to 502,920 beneficiaries. The unadjusted, annual spending difference between physicians trained in high- and low-cost HSAs was $1,644 [95% CI: $1,253-2,034]. The training and practice spending patterns remained significantly associated after controlling for patient and physician characteristics. General internists were significantly more likely to train in high-cost HSAs. Institutions with more graduates in rural practice and primary care produced lower-cost physicians. There were no significant quality differences across training HSAs, and no association with HSA practice. Conclusions The “imprint” of training spending pattern on residents and their downstream Medicare costs of care remains significant using small health-care spending geographies, 82.4 percent of which contain single training institutions, without discernable quality imprinting. Institution-level results point to training models that produce less costly primary care physicians. These findings support long-standing recommendations and promising programs that could improve the products of graduate medical education.