More experienced doctors incur lower treatment costs, finds study

BMJ 2012; 345 doi: (Published 06 November 2012) Cite this as: BMJ 2012;345:e7486
  1. Bob Roehr
  1. 1Washington, DC

Doctors in Massachusetts with the least experience incurred 13.2% greater costs for treating patients than their most senior counterparts, shows an analysis by the RAND Corporation that appeared in Health Affairs.1 The findings applied across diseases and medical specialties.

The study looked at anonymised insurance claims records for 1.13 million patients aged 18-65 years who were enrolled in one of four commercial health plans in Massachusetts in 2004-5, before the implementation of major healthcare changes in the state. It matched the records with 12 116 doctors, who were stratified into five groups according to years of experience in treating patients (<10, 10-19, 20-29, 30-39, and ≥40 years).

Overall the study found that the most experienced doctors provided the least costly care and that the costs increased with each successively less experienced group (respectively by 2.5%, 6.5%, 10%, and 13.2% more to treat the same condition).

That finding surprised the study’s lead author, Ateev Mehrotra, particularly because it was not a working hypothesis for the study. “But what reassures me is that there appears to be a kind of dose response, a nice gradient” across the range of experience that held true regardless of the condition treated, he told the BMJ.

The main questions the researchers sought to answer were whether malpractice claims resulted in more defensive medicine; whether larger group practices delivered more efficient care; and whether greater resistance to adopting electronic health records, anecdotally more common among older doctors, resulted in costlier care. However, they found no significant associations in those analyses.

The cost differential could not be explained by the average age of the patient seen or by the proportion of patients who were “new” to the doctor treating them. It seemed to be driven by high cost outlier patients.

“When we examined the cost distribution of patients cared for by physicians at the different levels, median costs were similar, but the costs of patients at the ninety-fifth percentiles of costs were much higher among physicians with less experience,” the authors wrote.

One policy implication is that less experienced doctors might become “the losers, excluded from selective networks” of care that are forming with the consolidation of healthcare, Mehrotra said.

He said that it would be interesting to see whether the same differences in cost with doctors’ experience were seen in fully integrated healthcare systems, such as Kaiser Permanente, that use guidance on standard care and prompts embedded into electronic health records.

Mehrotra also thought it important that medical schools and societies do a better job of including “judicious use of resources” as a regular part of training. The “Choosing wisely” campaigns recently initiated by medical specialty societies is a step in this direction, he said.2

One limitation of the study was that it measured service usage but not health outcomes, said Mehrotra.


Cite this as: BMJ 2012;345:e7486