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In response:
Submit responseWe appreciate Dr. Peirce’s ad hoc analysis of our data, showing that relatively higher concentrations of generalists in an area are associated with lower per capita Medicare spending. Before addressing the principle (with which we agree), it is necessary to make an important clarification to his finding. Although it is true that spending falls steadily as the percentage of generalists (family practitioners and general internists) rises from 26% (in quintile 5) to 31% (in quintile 1), a quick glance at Table 1 shows that this observation does not apply equally to all generalist physicians. In fact, spending rises as the number (and percentage) of general internists increases. It is family practitioners who are associated with lower Medicare spending. For every additional family practitioner per 100,000 population, per capita end-of-life spending falls by $470 (for general internists, it rises $297). What is interesting is that this occurs despite extremely similar practice styles reported by family practitioners and general internists (1).
We agree with Dr. Peirce that high health care spending is encouraged by a largely fee-for-service system that rewards procedures and other generously reimbursed interventions at the expense of low tech and non- invasive specialties such as family practice, pediatrics, and general internal medicine. There are doubtless other factors that also encourage higher spending – including patient pressures, malpractice fears, and the lure of technological certainty. What is not clear is whether (and why) these factors play out so differently in different geographic areas. It is clear, however, that the type of specialist-based and technology-driven health care practiced in many regions of this country is associated with aggressive spending, with no beneficial effect on patient outcomes (2), health care quality (3), or physician satisfaction. It is extremely unlikely that adding additional physicians (4) – particularly specialist physicians – will improve this situation.
Brenda Sirovich, MD, MS brenda.sirovich@dartmouth.edu VA Outcomes Group Department of Veterans Affairs Medical Center White River Junction, VT
Elliott S. Fisher, MD, MPH Center for Evaluative Clinical Sciences Dartmouth Medical School Hanover, NH 03755
References
1. Sirovich BE, Gottlieb DJ, Welch HG, Fisher ES. Variation in the tendency of primary care physicians to intervene. Arch Intern Med. 2005;165:2252-2256.
2. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138:288- 98.
3. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273-87.
4. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood). 2002;21:140-54.
Conflict of Interest:
None declared
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Look for Locked-in Behavior
Submit responseTo the Editor:
Sirovich and colleagues1 and Berenson in an associated editorial2 make known important findings bringing us closer to understand determinants of higher quality health care and cost containment. To extend this I performed a secondary analysis, regressing the percent generalists on the Dartmouth investigators’ End-of-Life Economic Index in Dollars, using data from their table 1. This showed that for every percent increase in generalist physicians from 26 to 31 there is a reduction in EOL-EI of $1056 (95%CI: -$1796, -$406; R-square = 0.90; p=0.006). With the model accounting for 90 percent of the variance, the proportion of generalists is a powerful determinant of EOL-EI$.
For Berenson’s question: “why policymakers have not taken action,” I suggest we focus attention on the principle of increasing returns and path dependency elaborated by Mayes3 in his book about why universal health care coverage has eluded us. The QWERTY keyboard was among many typing machines that appeared in the 1870s but was the first to “catch on” and be used in ever increasing numbers until it became accepted as the “standard” in the early 20th century. It’s remained so for over 100 years for typewriters and computers in spite of better typing configurations. People are trained in its use; businesses invest in equipment having this configuration; and they build this into the warp and woof of conducting their day-to-day work. This behavior is locked-in, and in this case, allows for greater effectiveness and efficiency4.
But not all locked-in behavior produces efficient behavior and functional systems, witness our present fee-for-service system of physician payment. Howard Brody5, a family physician and ethicist, bemoans that were he to train a patient to treat their plantar warts with duct tape – the subject of a published article – he’d say to himself, “Oh no, there goes our practice’s revenue stream.” On the other hand, he found it near impossible to get several consultants together with one of his patients with a severe chronic illness whose treatments were not working to see if their give and take might produce a better plan; they weren’t paid to do this. Their natural – and I’m sure unconscious – inclination was to stay where they could perform procedures that were more efficient in producing a “revenue stream.” We physicians have locked-in this type of behavior. I suggest that generalist physicians have a moderating effect that keeps use of procedures within a “therapeutic window.” Nonetheless more needs to be done; Mayes suggests we need to look for “critical junctures.” And that is our responsibility.
John C. Peirce, MD, MA, MS Center for the History of Medicine University of Michigan Medical School Ann Arbor, Michigan
References:
1. Sirovich BE, Gottlieb DJ, Welch HG, Fisher ES. Regional variations in health care intensity and physicians perceptions of quality of care. Ann Intern Med. 2006:144:641-649
2. Berenson RA. Editorial: Does more health care spending produce better health and happier doctors? Ann Intern Med. 2006:144:694-696
3. Mayes R. Universal coverage: the quest for national health insurance. Ann Arbor: The University of Michigan Press, 2004
4. Arthur WB. Positive feedbacks in the economy. In: Arthur WB. Increasing returns and path dependency in the economy. Ann Arbor: The University of Michigan Press; 1994, p 1-12
5. Brody H. Duct tape cures warts, or crazy ways to pay doctors. The Grand Rapids Press, April 4, 2006, E3
Conflict of Interest:
None declared