Quantifying the Financial Value of Clinical Specialty Choice and Its Association With Competitiveness of Admissions.

Background The factors influencing medical student clinical specialty choice have important implications for the future composition of the US physician workforce. The objective of this study was to determine the career net present values (NPVs) of US medical students' clinical specialty choices and identify any relationships between a specialty's NPV and competitiveness of admissions as measured by the US Medical Licensing Examination (USMLE) Step 1 scores. Methodology NPVs were calculated using the results of the 2019 Doximity Physician Compensation report, a survey of 90,000 physicians. Mean USMLE Step 1 scores for matched US allopathic seniors in the 2018 National Resident Matching Program were used as a measure of clinical specialties' competitiveness of admissions. We calculated a composite measure of NPV and annual work-hours by dividing each specialty's NPV by the reported average number of hours worked per year. Results In our analysis, orthopedic surgery had the highest NPV ($10,308,868), whereas family medicine had the lowest NPV ($5,274,546). Dermatology and plastic surgery had the highest mean USMLE Step 1 scores (249 for both), whereas family medicine had the lowest (220). Clinical specialties' NPVs were positively associated with mean USMLE Step 1 scores (Pearson's r = 0.82; p < 0.001). Conclusions In this study, we describe associations suggesting that medical students respond to financial incentives in choosing clinical specialties and that these decisions are mediated by USMLE Step 1 scores. This underscores the importance of titrating and aligning incentives to improve the allocation of medical students into clinical specialties.

Variability in asthma quality and costs in children with different Medicaid insurance plans in Maricopa County.

OBJECTIVE: To describe the variation in asthma quality and costs among children with different Medicaid insurance plans. METHODS: We used 2013 data from the Center for Health Information and Research, which houses a database that includes individuals who have Medicaid insurance in Arizona. We analyzed children ages 2-17 years-old who lived in Maricopa County, Arizona. Asthma medication ratio (AMR, a measure of appropriate asthma medication use), outpatient follow-up within 2 weeks after asthma-related hospitalization (a measure of continuity of care), asthma-related hospitalizations, and all emergency department (ED) visits were the primary quality metrics. Direct costs were reported in 2013 $US dollars. We used one-way analysis of variance to compare the health plans for AMR and per member cost (total, ER, and hospital), and the chi-squared test for the outpatient follow-up measure. We used coefficient of variation to identify variation of each measure across all individuals in the study. RESULTS: In 2013, 90,652 children in Maricopa County were identified as having asthma. The average patient-weighted AMR for children with persistent asthma was 0.35, well short of the goal of ≥0.70, and only 36% of hospitalized asthma patients had outpatient follow-up within 2 weeks of hospitalization. AMR, total costs, and ED costs varied significantly (p <.0001) when comparing health plans while hospital costs and outpatient follow-up showed no significant variation. CONCLUSIONS: Targeting appropriate medication use for asthma may help reduce variation, improve outcomes, and increase healthcare value for children with asthma and Medicaid insurance in the US.

Teamwork in health care.

It is becoming increasingly clear that maintaining and improving the health of the population, and doing so in a financially sustainable manner, requires the coordination of acute medical care with long-term care, and social support services, that is, team-based care. Despite a growing body of evidence on the benefits of team-based care, the health care ecosystem remains "resistant" to a broader implementation of such care models. This resistance is a function of both system-wide and organizational barriers, which result primarily from fragmentation in reimbursement for health care services, regulatory restrictions, and the siloed nature of health professional education. To promote the broader adoption of team-based care models, the health care system must transition to pay for value reimbursement, as well as break down the educational silos and move toward team-based and value-based education of health professionals.

Taking steps toward integration.

If patients are to be at the center of health care, then providers should work diligently to better organize the delivery system. In this Perspective, two Mayo Clinic leaders provide their views on why it is necessary for physicians and hospitals to set aside their differences and work together for the good of their patients. They cite successful enterprises nationwide that combine hospital and physician control. Many of them have been recognized as examples.