[EQ] Doctors, Dollars & Quality

Doctors, Dollars & Quality

Health Affairs, doi: 10.1377/hlthaff.28.1.w91 - Published online December 4, 2008

Table of Contents

From The Editor Susan Dentzer

“……..examining the connections among the supply of doctors, the composition of the physician workforce, the quality of health care, and health spending. It is critically important to establish just what these connections are. The United States faces a number of major and potentially competing challenges: improving the health status of the population; expanding health coverage and access to care; coping with a future of aging and chronically ill individuals; and constraining the growth of health spending. Policymakers clearly need to understand how to get the biggest bang for the buck in improving health and in delivering high-quality health care. Among the top priorities is determining whether or not the nation needs more physicians, and of what sort, to accomplish these goals….”

Preface

Philip Musgrove, Deputy Editor, Health Affairs

“…..Does the United States have enough doctors, given the enormous demand for health care and forecasts about a future filled with aging and chronically ill baby boomers? And do we have the right mix of doctors--since specialists "cost" more to produce than general practitioners, are paid more under current reimbursement systems, and prescribe more health care to boot? …”

 

States With More Physicians Have Better-Quality Health Care

Richard A. Cooper, is a professor of medicine in the Leonard Davis Institute at the Wharton School, University of Pennsylvania, in Philadelphia.

“…..As efforts begin to expand the physician workforce in response to deepening shortages of physicians, attention has focused on the value of what physicians do. There is a widely held belief that states with more specialists have poorer-quality health care, while quality is better in states with more family physicians. This is myth. Quality is better in states with more physicians, both specialists and family physicians. Access depends on total physician supply, irrespective of specialty. Population density, per capita income, and regional factors all influence this relationship, but the data are unequivocal….”

States With More Health Care Spending Have Better-Quality Health Care: Lessons About Medicare

Richard A. Cooper, is a professor of medicine in the Leonard Davis Institute at the Wharton School, University of Pennsylvania, in Philadelphia.

“….Based on broad measures of health system quality and performance, states with more total health spending per capita have better-quality care. This fact contrasts with a previous finding that states with higher Medicare spending per enrollee have poorer-quality care. However, quality results from the total funds available and not from Medicare or any single payer. Moreover, Medicare payments are disproportionately high in states that have a disproportionately large social burden and low health care spending overall. These and other vagaries of Medicare spending pose critical challenges to research that depends on Medicare spending to define regional variation in health care….”

Cooper's Analysis Is Incorrect

Katherine Baicker is professor of health economics at the Harvard School of Public Health and a research associate at the National Bureau of Economic Research (NBER) in Cambridge, Massachusetts.
 Amitabh Chandra is an assistant professor of public policy at Harvard's Kennedy School of Government and a faculty research fellow at the NBER.

“….In his papers, Richard Cooper finds positive associations between health care quality and both specialist and generalist physicians, but he misinterprets his results. Instead of undermining the findings of our study, which found higher quality in areas with more generalists relative to specialists, his results bolster ours: they suggest that the effect of generalists on quality is ten times larger than that of specialists. Furthermore, his rejection of multiple regression in favor of exclusive reliance on isolated correlations precludes him from gauging the relative contributions of specialists, generalists, and other factors. Unfortunately, these deficiencies mean that we can learn little from Cooper's analyses…”

The Elusive Connection Between Health Care Spending And Quality

Jon Skinner is the John Sloan Dickey Third Century Professor in Economics in the Department of Economics, Dartmouth College, in Hanover, New Hampshire.
Amitabh Chandra is a professor in the Kennedy School of Government, Harvard University, in Cambridge, Massachusetts.
David Goodman is a professor of pediatrics and of community and family medicine at Dartmouth Medical School and associate director of the Center for Health Policy Research at Dartmouth.
Elliott Fisher is director of the Center for Health Policy Research and a professor of medicine and of community and family medicine, Dartmouth Institute for Health Policy and Clinical Practice

“…..Richard Cooper has shown a positive association between health care quality and "total spending" at the state level, but he does not appear to understand the limitations of this total spending measure; simply adjusting for median age causes the significant positive correlation to disappear. Cooper also finds that some third factor--we think that it is "social capital"--is the key to explaining health care quality. Cooper may believe that this result challenges three decades of research by the Dartmouth group. Instead, it supports the group's view that improved efficiency--and not more doctors and hospital beds--is central to improving quality…”

More Is More And Less Is Less: The Case Of Mississippi

Richard A. Cooper, is a professor of medicine in the Leonard Davis Institute at the Wharton School, University of Pennsylvania, in Philadelphia

“….One can't help but admire the vigor with which some members of the Dartmouth group defend their core belief that "more is less." But polemics aside, some questions still linger. Does Mississippi actually have more specialists (as represented in Katherine Baicker and Amitabh Chandra's Exhibit 6), and does it spend more on health care (as in their Exhibit 1) than almost every other state? And can Mississippi, which ranks near the bottom in health care quality, lift its status by simply improving its health care productivity, as Jon Skinner and colleagues suggest? If these questions gnaw at you, as they did at me, there's a need to probe further…”

 

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