title: Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries.
abstract: OBJECTIVE
  Graduate medical education training may imprint young physicians with skills and experiences, but few studies have evaluated imprinting on physician spending patterns.
  
  
  OBJECTIVE
  To examine the relationship between spending patterns in the region of a physician's graduate medical education training and subsequent mean Medicare spending per beneficiary.
  
  
  METHODS
  Secondary multilevel multivariable analysis of 2011 Medicare claims data (Part A hospital and Part B physician) for a random, nationally representative sample of family medicine and internal medicine physicians completing residency between 1992 and 2010 with Medicare patient panels of 40 or more patients (2851 physicians providing care to 491,948 Medicare beneficiaries).
  
  
  METHODS
  Locations of practice and residency training were matched with Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups, with approximately equal distribution of beneficiary numbers. There were 674 physicians in low-spending training and low-spending practice HRRs, 180 in average-spending training/low-spending practice, 178 in high-spending training/low-spending practice, 253 in low-spending training/average-spending practice, 417 in average-spending training/average-spending practice, 210 in high-spending training/average-spending practice, 97 in low-spending training/high-spending practice, 275 in average-spending training/high-spending practice, and 567 in high-spending training/high-spending practice.
  
  
  METHODS
  Mean physician spending per Medicare beneficiary.
  
  
  RESULTS
  For physicians practicing in high-spending regions, those trained in high-spending regions had a mean spending per beneficiary per year $1926 higher (95% CI, $889-$2963) than those trained in low-spending regions. For practice in average-spending HRRs, mean spending was $897 higher (95% CI, $71-$1723) for physicians trained in high- vs low-spending regions. For practice in low-spending HRRs, the difference across training HRR levels was not significant ($533; 95% CI, -$46 to $1112). After controlling for patient, community, and physician characteristics, there was a 7% difference (95% CI, 2%-12%) in patient expenditures between low- and high-spending training HRRs. Across all practice HRRs, this corresponded to an estimated $522 difference (95% CI, $146-$919) between low- and high-spending training regions. For physicians 1 to 7 years in practice, there was a 29% difference ($2434; 95% CI, $1004-$4111) in spending between those trained in low- and high-spending regions; however, after 16 to 19 years, there was no significant difference.
  
  
  CONCLUSIONS
  Among general internists and family physicians who completed residency training between 1992 and 2010, the spending patterns in the HRR in which their residency program was located were associated with expenditures for subsequent care they provided as practicing physicians for Medicare beneficiaries. Interventions during residency training may have the potential to help control future health care spending.
authors.affiliation: Department of Health Policy, Milken Institute School of Public Health, George Washington University, Washington, DC2Dr Chen is now with the Health Resources and Services Administration, Rockville, Maryland.
authors.forename: Candice
authors.initials: C
authors.lastname: Chen
authors.affiliation: Robert Graham Center, Washington, DC.
authors.forename: Stephen
authors.initials: S
authors.lastname: Petterson
authors.affiliation: American Board of Family Medicine, Washington, DC.
authors.forename: Robert
authors.initials: R
authors.lastname: Phillips
authors.affiliation: Robert Graham Center, Washington, DC.
authors.forename: Andrew
authors.initials: A
authors.lastname: Bazemore
authors.affiliation: Department of Health Policy, Milken Institute School of Public Health, George Washington University, Washington, DC.
authors.forename: Fitzhugh
authors.initials: F
authors.lastname: Mullan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005194:Family Practice / Q000191:economics* / Q000193:education; D005260:Female; D006123:Group Practice / Q000145:classification / Q000191:economics; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D007388:Internal Medicine / Q000191:economics* / Q000193:education; D007396:Internship and Residency / Q000706:statistics & numerical data*; D008297:Male; D006278:Medicare / Q000191:economics*; D010820:Physicians / Q000191:economics; D010818:Practice Patterns, Physicians' / Q000191:economics*; D014481:United States