Thursday, February 3, 2011

No Correlation Between Physician Supply and Patient Perception of Quality and Access (including primary care)

The Disease Management Care Blog suspects that a large fraction of its many regular readers work in or with medical settings. On the other side of that door, in the floor above or below you, in the building across the street or at the other end of that phone call, there are patients and doctors doing... well, the doctor-patient... thing. Since the patients and doctors use this "thing" a lot , patients would suffer if it wasn't there, right? If the hospital, or clinic, or system or or network closed its doors, disappeared or was swallowed up by the earth, dissatisfaction, illness, death and other consternation would follow, right?

Well, maybe not. At least, if you asked the patients. That's exactly what David Nyweide (of CMS), Denise Anthony, Chiang-Hua Chang and David Goodman (all of Dartmouth) did. 4,000 randomly selected, nationally representative, elderly and independently living Medicare beneficiaries were surveyed with 12 questions about access to and satisfaction with health care. Those data were correlated with the physician supply in their Medicare-defined "hospital service area" (the DMCB learned there are 3,067 of them). The physician supply in each service area was based on the data from the AMA Physician Masterfile.

2,515 completed the survey with a respectable response rate of 65%. After adjusting for age, gender, race, health status and local income (based on outside data sorted by zip code), there was no association between the local density of physicians and patient perceptions of access, being able to get a test, being able to see a specialist, being satisfied with their care, feeling that they had enough time to talk to the doctor or having a primary care provider. There was also no association between the local supply of primary care and local perceptions of care. There was only a weak association between the local supply of primary care physicians and having one.

The study is limited by being "observational" and only reporting associations. In order to better understand if more primary care causes a change in Medicare beneficiary perceptions, a prospective trail would be required. The study is also silent on the local quality of primary care, access to other health professionals, the limitations of sorting physician supply based on service area (versus more granular counties or zip codes) and the lack of input from managed care Medicare. Last but not least, there may be an association between the local supply of primary care and "hard" measures of health care quality, versus this study that used consumer perceptions.

Despite the limitations, the study should give pause to policymakers, regulators and politicians who think that increasing the physician supply or increasing the primary care physician supply is going to make a difference in voter-beneficiary-patient attitudes about local access or quality of care. It turns out that physician demand vs. supply may be more elastic than anyone considered. This should make persons wonder if pumping more physicians into a community is the "solution" we think it is.

And the DMCB asks why stop there? The NCQA and NQF should take note. Local hospitals argue that they and their physicians' social mission warrants not-for-profit status and being exempt from local taxes. Perhaps one gauge of how well that mission is being fulfilled should be perceptions of access and quality versus a national norm or a historical baseline. Since "Accountable Care Organizations" will be responsible for cost as well as quality, perhaps consumer perceptions like this should be part of the yet-to-be-defined measurement mix. Last but not least, perhaps all those suspect "Top One Hundred" surveys should consider using a variation of this.

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