Primary Care Physician Characteristics Associated With Low Value Care Spending

Tyler W. Barreto, MD; Yoonkyung Chung, PhD; Peter Wingrove, BS; Richard A. Young, MD; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; Winston Liaw, MD, MPH


J Am Board Fam Med. 2019;32(2):218-225. 

In This Article

Abstract and Introduction


Background: Previous work has shown that $210 billion may be spent annually on unnecessary medical services and has identified patient and hospital characteristics associated with low value care (LVC). However, little is known about the association between primary care physician (PCP) characteristics and LVC spending. The objective of this study was to assess this association.

Methods: We performed a retrospective analysis by using Medicare claims data to identify LVC and American Medical Association Masterfile data for PCP characteristics. We included PCPs of adults aged 65 years and older who were enrolled in Medicare in 2011. We measured Medicare spending per attributed patient on 8 low value services.

Results: Our final sample contained 6,873 PCPs with 1,078,840 attributed patients. Lower per-patient LVC Medicare spending was associated with the following PCP characteristics: allopathic training, smaller Medicare patient panel, practiced family medicine, practiced in the Midwest region, were a recent graduate, or practiced in rural areas. The largest associations were seen in Medicare patient panel size and geographic region. The average per-patient LVC spending was $14.67. LVC spending among PCPs with small patient panels was $3.98 less per patient relative to those with larger panels. PCPs in the Midwest had $2.80 less per patient LVC spending than those in the Northeast.

Conclusion: Our analysis suggests that LVC services are associated with specific PCP characteristics. Further research should assess the strength of these associations, and future policy efforts should focus on systemic interventions to reduce LVC spending.


Total health care spending in 2015 reached $3.2 trillion and comprised 17.8% of the gross domestic product.[1] One concern is that a significant proportion of this spending is in unnecessary care. The authors of a National Academy of Medicine report defined unnecessary services as "overuse—beyond evidence-established levels, discretionary use beyond benchmarks; [and] unnecessary choice of higher-cost services," and found that $210 billion per year is spent on unnecessary services.[2] Another study found that 30% of all Medicare spending is unnecessary.[3]

Studies have attempted to characterize patient and regional characteristics associated with unnecessary services, often referred to as low value care (LVC). One study compared LVC services received in Medicaid and commercial insurance patients finding 14.9% of Medicaid patients and 11.4% of commercial insurance patients received at least 1 LVC service in the year. There was no association between insurance type and likelihood of LVC.[4] A study looking specifically at safety net populations showed no difference in LVC based on insurance type or based on whether the patient was seen at a safety-net clinic or by non-safety-net physicians.[5] Others have shown hospital-based practices and areas with a higher specialist to primary care physician (PCP) ratio are associated with more LVC.[6,7] Mafi et al.[7] found significantly more unnecessary computer tomography and magnetic resonance imaging (8.3% vs 6.3%) and specialty referrals (19% vs 7.6%) in hospital-owned practices than in physician-owned practices.

Identifying LVC events within claims data has proven difficult. Studies select specific LVC services based on generally accepted guidelines, such as Choosing Wisely and the United States Preventive Services Task Force.[8–11] For each LVC service, there are situations in which receiving the service would not be deemed low value. For example, back imaging is not considered low value in a patient with known cancer. Schwartz et al.[12] defined claims based measures of LVC by looking at a more specific and more sensitive version of each LVC service. As expected, they found more beneficiaries receiving LVC services when using the more sensitive measure.[12] It is also difficult to compare LVC studies because there is variability in the measure of LVC depending on the service measured, how it is being measured, and the population for which it is being measured. Colla et al.[6] showed a wide range of annual prevalence from 1.2% to 46.5% depending on which LVC service is measured. The population is another concern, as different studies have used different data sets, including Medicare data, Medicaid data, and commercial insurance data. The LVC use patterns and necessary interventions in, for example, the Medicare population may be different from the commercially insured population.

Despite the complexity of measurement, it is important to assess and understand LVC services particularly in this setting of increasingly greater health care costs.[1] Past studies have identified regional and patient characteristics and clinic settings associated with LVC, but no study to our knowledge has focused on individual physician characteristics.[5] In this study, we aimed to assess the characteristics of physicians who have patients with lower LVC spending.