ARTICLE IN BRIEF
Neurologists discuss the reasons why practice costs may be higher for younger, less experienced neurologists than those with years of more experience — a finding reported among clinicians in general.
In our rapidly changing health care environment, programs aimed at reducing medical spending are a priority goal. But do they favor certain physicians? For example, are older, more experienced physicians more likely to be found “cost-effective” than younger, less experienced clinicians? According to one study reported in the November issue of Health Affairs, the answer may be yes.
The investigators from the RAND Corporation, a nonprofit policy and research institute, looked at private insurance claims for more than 1 million Massachusetts residents in 2004 and 2005 to create health care cost profiles for more than 12,000 doctors in the state; 420 neurologists were included in the analysis. Compared with physicians who had 40 or more years of experience, overall costs were 13.2 percent higher for doctors with fewer than 10 years of experience, 10 percent higher for physicians with 10 to 19 years of experience, 6.5 percent higher for those with 20 to 29 years of experience, and 2.5 percent higher for those with 30 to 39 years of experience.
“It seems that less-experienced physicians are more likely than more-experienced peers to be penalized by cost profiling policies unless they adapt their practice patterns,” the investigators wrote. Although more specific data are needed, “these analyses may lead to cost-cutting interventions such as training medical residents in appropriate resource use,” they added.
WHAT ABOUT NEUROLOGY?
These findings are in line with what Ralph F. Józefowicz, MD, professor of neurology and medicine at the University of Rochester Medical Center in New York, sees firsthand at his home institution. “Recent graduates of residency programs are used to working in academic centers where tests are abundant and lots of patients are tested — often with expensive tests.” When a patient comes into the emergency room with non-specific symptoms, quick decisions often have to be made on what tests to do, he said.
Recent graduates also often have less experience than older physicians and tend to be made anxious by anxious patients, he said, “and we see many anxious patients with non-specific symptoms in neurology. So an inexperienced physician may order more tests in order to ensure that nothing is being missed.” On the other hand, he said, a more experienced physician with years of practical knowledge is more likely to follow the patient, order fewer tests, and often the symptoms may clear up with time. “Time is a very good test — and it's a very cheap test,” he added.
The study makes common sense, said Joel M. Kaufman, MD, executive director and chief executive officer of Lifespan/Physicians Professional Service Organization and a clinical associate professor of clinical neurosciences (neurology) at the Warren Alpert Medical School of Brown University in Rhode Island.
“Physicians go from residency, where they are surrounded by peers, advised by teachers, and encouraged to look for rare conditions, to a setting where they must make independent decisions. My thought is that a strong mentoring system is the best way for physicians to obtain confidence in their skills. Of course, it will still take years for skills to mature no matter what.”
Also, “more experienced physicians may trust their clinical judgment more or may simply be tired of wasting resources on tests with low utility,” said S. Claiborne Johnston, MD, PhD, associate vice chancellor of research and professor of neurology at the University of California, San Francisco.
Personally, Dr. Józefowicz said that he orders fewer tests now than he used to, and always thinks “twice or three times about obtaining a test — especially if it's expensive and especially if it's not going to alter treatment.” A consideration that he says must be stressed to younger neurologists.
WHAT ABOUT QUALITY OF CARE?
This particular study did not look at the quality of care piece of the cost-efficiency equation, which concerned the commentators.
“The problem is that cost and outcomes don't always go hand in hand. Being cheaper doesn't necessarily mean better. After reading something like this [study] it might be a knee-jerk reaction to say ‘those young doctors just aren't practicing as well as the older or more experienced physicians.’ When it may be that it costs a bit more per interaction, but the end result for that patient was better,” said James C. Stevens, MD, a neurologist at the Fort Wayne Neurological Center in Indiana. In reality, he said, it may have cost the system less in the long run. He added that more data on outcomes in relation to cost are necessary.
The key question is who determines quality? E. Ray Dorsey, MD, associate professor of neurology and director of the Johns Hopkins Parkinson's Disease and Movement Disorders Center at Johns Hopkins School of Medicine in Baltimore, told Neurology Today. A major concern, he said, is that third parties will determine quality based on metrics that matter little to patients, such as costs or documentation.
“Allowing third parties, like CMS, however well-intentioned, will undoubtedly reduce physician autonomy, raise administrative costs related to compliance, and lead to continue unintended consequences (e.g., penalizing neurologists who under MRIs on patients with multiple sclerosis to track disease progression or closely monitor response to treatment) that undermine care,” Dr. Dorsey added.
These study findings point to the fact that the specialty of medicine, like any other specialty, is heterogeneous, Dr. Dorsey said. “These differences [in personality, training, experience, and practice style] can result in differences in care, including quality of care. The sooner we move from a resource-based to a value-based reimbursement that rewards physicians for the quality of care they deliver the better,” he said.
“Medicare is going to start assigning reimbursement to physicians with this type of value-based system. So, whether we want to admit its veracity to claim the value or efficiency of our care, this is likely the way they are going to try and do it,” Dr. Stevens said. Throughout medical school education and neurology training, he said, we learn disease states — how to accurately diagnose them, how to treat them, all of the different possibilities that could explain a person's problems. “But we don't discuss in any fashion the cost of going through that process of evaluation and treatment,” Dr. Stevens said.
Our residents are trained to think about very long differentials, Dr. Johnston told Neurology Today: “It's almost a contest to see who can come up with the rarest condition that could account for a presentation.” This encourages more extensive evaluations which tend to be more costly, he said.
To teach the importance of cost-effective care, we should be scolding residents for ordering an unnecessary test at least as much as we scold them for failing to order a test, Dr. Johnston said, because both mistakes can have significant consequences.
Since this is going to be our world, and our health care system is going to put more emphasis on cost-efficiency, “it behooves educators and all physicians to become more familiar with it,” Dr. Stevens said. “During training, young treating physicians, just as old treating physicians, should be made aware of the costs involved in the care they provide — to the extent that it's possible,” so they can factor this into their practical decision-making. At a medical school level or at a residency training level, he added, neurologists should also be taught the ins and outs of the new incentive programs that the government implements.
Dr. Johnston acknowledged that although some of the differences in spending may be due to treating sicker patients, “most of these differences in costs are likely due to practice patterns, and waste is clearly a part of the picture.” More detailed metrics for unnecessary tests or procedures, like those identified in the “Choosing Wisely” campaign, would be a good start for reducing inefficient spending, he said. (See the Neurology Today Aug. 2 article, “What Diagnostic Tests Are Unnecessary? Neurology Weighs in on ‘Choosing Wisely’”: http://bit.ly/RiTnpQ.)
Essentially, the concern over cost of health care delivery “needs to become part of the fabric of our training programs and our practices. Waste means fewer resources when we need them; it's a fixed-sum game at this point given society's limits on healthcare as a portion of GDP [gross domestic product],” said Dr. Johnston.