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J Gen Intern Med. 2016 Nov;31(11):1278-1286. doi: 10.1007/s11606-016-3745-8. Epub 2016 Jun 3.

Variation in Specialty Outpatient Care Patterns in the Medicare Population.

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Duke Clinical Research Institute and Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
Centers for Medicare & Medicaid Services, Baltimore, MD, USA.
Brookings Institution, Washington, DC, USA.
CVS, Woonsocket, RI, USA.



Multiple payment reform efforts are under way to improve the value of care delivered to Medicare beneficiaries, yet few directly address the interface between primary and specialty care.


To describe regional variation in outpatient visits for individual specialties and the association between specialty physician-specific payments and patient-reported satisfaction with care and health status.


Retrospective cross-sectional study.


A 20 % random sample of Medicare fee-for-service beneficiaries in 2012.


Regions were grouped into quartiles of specialist index, defined as the observed/expected regional likelihood of having an outpatient visit to a specialist, for ten common specialties, adjusting for age, sex, and race. Outcomes were per capita specialty-specific physician payments and Medicare Current Beneficiary Survey responses.


The proportion of beneficiaries seeing a specialist varied the most for endocrinology and gastroenterology (3.7- and 3.9-fold difference between the highest and lowest quartiles, respectively) and least for orthopedics and urology (1.5- and 1.7-fold difference, respectively). Multiple analyses suggested that this variation was not explained by prevalence of disease. Average specialty-specific payments were strongly associated with the likelihood of visiting a specialist. Differences in per capita payments from lowest (Q1) to highest quartiles (Q4) were greatest for cardiology ($89, $135, $172, $251) and dermatology ($46, $64, $82, $124). Satisfaction with overall care (median [interquartile range] across specialties: Q1, 93.3 % [92.6-93.7 %]; Q4, 93.1 % [92.9-93.2 %]) and self-reported health status (Q1, 37.1 % [36.9-37.7 %]; Q4, 38.2 % [37.2-38.4 %]) was similar across quartiles. Satisfaction with access to specialty care was consistently lower in the lowest quartile of specialty index (Q1, 89.7 % [89.2-91.1 %]; Q4, 94.5 % [94.4-94.8 %]).


Substantial regional variability in outpatient specialist visits is associated with greater payments with limited benefits in terms of patient-reported satisfaction with care or reported health status. Reducing outpatient physician visits may represent an important opportunity to improve the efficiency of care.

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Conflict of interest statement

Compliance with Ethical Standards Disclaimer Dr. Clough was employed by the Centers for Medicare & Medicaid Services during the time in which the study was conducted. The views expressed in this manuscript are those of the authors, and do not necessarily represent the policy or views of the Centers for Medicare & Medicaid Services. Conflict of Interest The authors declare that they do not have a conflict of interest.

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