A ‘hidden practice’: Senior physicians see fewer underrepresented patients

Key takeaways:

• Senior physicians had fewer patients from underrepresented racial and ethnic groups and those with Medicaid vs. their junior colleagues.
• The finding may be due to factors like lower reimbursement rates.

Senior physicians cared for fewer patients in underrepresented racial and ethnic groups as well as those with Medicaid compared with their junior colleagues within the same practice, a study published in JAMA Network Open found.

“It’s a widely known ‘secret’ that in some practices, the older doctors push patients with lower-paying insurance, and by extension patients of minority races, to the more junior doctors in their clinic. But this is rarely discussed openly,” Michael L. Barnett, MD, MS, an associate professor of health policy and management at Harvard T. H. Chan School of Public Health, said in a press release. “Our study finds evidence to back up this hidden practice, which raises concerns of a two-tiered system by physician seniority that promotes racial and economic segregation.”

For their study, the researchers analyzed 2017 claims data from the electronic health record vendor athenahealth and compared them with 2021 Medicare claims data. They classified physicians into cognitive, procedural and non-office-based groups.

Overall, there were 28,895 physicians across 6,166 practices with 29,705,902 patients in the athenahealth database and 170,022 physicians across 18,970 practices with 104,588,217 patients in the Medicare database.

For cognitive and procedural physicians in athenahealth, Barnett and colleagues reported that the Medicaid share of patients was 17.39% for the most junior physician vs. 15.29% for the most senior physician, a seniority gap of 2.1 percentage points (95% CI, 2.45-1.75 percentage points). The Medicare database yielded a similar seniority gap of 2.25 percentage points (95% CI, 2.51-2 percentage points).

When looking at underrepresented racial and ethnic groups, the seniority gap was:

• 1.36 percentage points (95% CI, 1.63-1.1 percentage points) in athenahealth; and
• 0.96 percentage point (95% CI, 1.21-0.7 percentage points) in Medicare claims.

The largest gaps were seen among procedural physicians, with seniority gaps of:

• 2.85 percentage points (95% CI, 3.34-2.35 percentage points) in athenahealth; and
• 3.24 percentage points (95% CI, 3.61-2.86 percentage points) in Medicare claims.

The researchers suggested that cognitive and procedural physicians could be influenced by factors like lower reimbursement rates or greater administrative challenges for Medicaid enrollees.

These trends were not seen among non-office-based specialists, a result that Barnett and colleagues had correctly hypothesized “given that these patients and physicians have less choice.”

The researchers also pointed out that the analysis was observational, “so results should be interpreted as hypothesis-generating associations.”

“It’s far from clear that senior physicians provide higher quality care than junior physicians,” Barnett said. “But in my experience as a primary care physician, many patients want to see a more experienced physician. Our study suggests that patients may encounter barriers on who they can see, even in the same practice, based on who they are and what insurance they can afford.”

Ultimately, “addressing these barriers and widening patient access to all kinds and levels of physicians is essential to a more equitable health care system,” Barnett concluded.

References:

• Neprash H, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.47367.
• Senior physicians may care for fewer patients with Medicaid and from racial/ethnic minorities than junior physicians. https://www.eurekalert.org/news-releases/1010768. Published Dec. 13, 2023. Accessed Dec. 13, 2023.