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High-Value Care Culture Among the Future Physician Workforce in Internal Medicine

Gupta, Reshma MD, MSHPM; Steers, Neil PhD; Moriates, Christopher MD; Wali, Soma MD; Braddock, Clarence H. III MD, MPH; Ong, Michael MD, PhD

doi: 10.1097/ACM.0000000000002619
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Purpose Training in high-spending regions correlates with higher spending patterns among practicing physicians. This study aimed to evaluate whether trainees’ exposure to a high-value care culture differed based on type of health system in which they trained.

Method In 2016, 517 internal medicine residents at 12 California graduate medical education programs (university, community, and safety-net medical centers) completed a cross-sectional survey assessing perceptions of high-value care culture within their respective training program. The authors used multilevel linear regression to assess the relationship between type of medical center and High-Value Care Culture Survey (HVCCS) scores. The correlation between mean institutional HVCCS and Centers for Medicare and Medicaid Services’ Value-Based Purchasing (VBP) scores was calculated using Spearman rank coefficients.

Results Of 517 residents, 306 (59.2%), 83 (16.1%), and 128 (24.8%) trained in university, community, and safety-net programs, respectively. Across all sites, the mean HVCCS score was 51.2 (standard deviation [SD] 11.8) on a 0–100 scale. Residents reported lower mean HVCCS scores if they were from safety-net-based training programs (β = −4.4; 95% confidence interval: −8.2, −0.6) with lower performance in the leadership and health system messaging domain (P < .001). Mean institutional HVCCS scores among university and community sites positively correlated with institutional VBP scores (Spearman r = 0.71; P < .05).

Conclusions Safety-net trainees reported less exposure to aspects of high-value care culture within their training environments. Tactics to improve the training environment to foster high-value care culture include training, increasing access to data, and improving open communication about value.

R. Gupta is interim chief value director, UCLA-Olive View Medical Center, assistant professor, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, and director, Evaluation and Outreach, Costs of Care, Boston, Massachusetts.

N. Steers is biostatistician, VA Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, and adjunct associate professor of medicine and sociology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.

C. Moriates is assistant dean for healthcare value, associate chair of quality, safety and value, and associate professor, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, and director of implementation, Costs of Care, Boston, Massachusetts.

S. Wali is chair, Department of Medicine at Olive View–UCLA Medical Center, and professor and executive vice chair of medicine for affiliated University of California, Los Angeles hospitals, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.

C.H. Braddock III is vice dean for education, David Geffen School of Medicine, and professor, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.

M. Ong is professor, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, and chief, Hospitalist Division, Greater Los Angeles VA Health Care System, Los Angeles, California.

Funding/Support: None reported.

Other disclosures: R. Gupta was supported by the VA Office of Academic Affiliations through the VA/Robert Wood Johnson Clinical Scholars Program. C. Moriates receives royalties from McGraw-Hill for the textbook Understanding Value-Based Healthcare, outside of the submitted work, and is director of implementation at Costs of Care.

Ethical approval: This study was approved by institutional review boards at all 12 sites.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A635.

Correspondence should be addressed to Reshma Gupta, UCLA Health, 10945 Le Conte Ave., Suite 1401, Los Angeles, CA 90095; telephone: (310) 562-9096; email: Rgupta@mednet.ucla.edu; Twitter: @ReshmaGuptaMD.

Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.