The unexpected costs of expertise: evidence from highly specialized physicians

High U.S. spending on health care is commonly attributed to its intensity of specialized, high-tech medical care. A growing body of research focuses on physicians whose medical decisions shape treatment intensity, costs, and patient outcomes. Often overlooked in this research is the assignment of physician skills to patient conditions, which may strongly affect health outcomes and productivity. This matching may be especially important in the case of hospital admissions as high-frequency fluctuations in patient flow make it challenging to maintain effective matches between the best-suited physicians and their patients. This paper focuses on hospitals' responses to demand shocks induced by unscheduled high-risk admissions. I show that these demand shocks result in physician-patient mismatches when hospitals are congested. Specifically, highly specialized physicians who are brought in to treat unscheduled high-risk admissions also treat previously admitted lower-risk patients. This leads to increased treatment intensity for lower-risk patients, which I attribute to persistence in physician practice style. Despite the greater treatment intensity, I find no detectable improvement in health outcomes, which prima facie could be viewed as waste. However, this paper demonstrates that such mismatches mostly happen when the cost of maintaining preferred physician-patient matching is high, which reflects hospitals' conscientious assessment of costs and benefits and should not be simply interpreted as inefficiency. These findings provide vital information for policy-makers looking to identify waste in utilization and create incentives to enhance efficiency in the health care sector.

US Generalist Physicians and Groups That Focused Practice in a Single Care Setting: 2014-2017

BACKGROUND

Some generalist physicians whose training prepared them for primary care practice increasingly practice in a facility (eg, hospitals, nursing homes); however, whether this trend was accompanied by a complimentary rise in generalist physicians who focused their practice on office-based care is unknown.

OBJECTIVES

Our objective in this study was to examine trends in the prevalence of generalist physicians and physician groups that practice in a single setting.

RESEARCH DESIGN

This was a retrospective cross-sectional study of generalist physicians trained in family medicine, internal medicine, or geriatrics. We used 2014-2017 billing data for Medicare fee-for-service beneficiaries to measure the proportion of all patient visits made by physicians in the following care settings: office, outpatient hospital department, inpatient hospital, and other sites.

RESULTS

From 2014 to 2017, the proportion of generalist physicians who narrowed their practice to a single setting increased by 6.69% (from 62.80% to 67.00%, p for trend <0.001). In 2017, 4.63% of physician groups included more than 1 type of setting-based physicians.

CONCLUSIONS

Generalist physicians treating older adults increasingly narrowed their practice focus to a single type of health care setting. This trend was not accompanied by growth among physician groups that included different types of setting-based physicians. Further evaluation of the consequences of these trends on the fragmentation of primary care delivery across different health care settings and primary care outcomes is needed.