Triage
Benjamin Sommers & Sara Rosenbaum
Health Affairs, February 2011, Pages 228-236
Abstract:
The Affordable Care Act will extend health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges. But by definition, eligibility for these programs is sensitive to income and can change over time with fluctuating income and changes in family composition. The law specifies no minimum enrollment period, and subsidy levels will also change as income rises and falls. Using national survey data, we estimate that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will. To minimize the effect on continuity and quality of care, states and the federal government should adopt strategies to reduce the frequency of coverage transitions and to mitigate the disruptions caused by those transitions. Options include establishing a minimum guaranteed eligibility period and "dually certifying" some plans to serve both Medicaid and exchange enrollees.
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Party Control, Policy Reforms, and the Impact on Health Insurance Coverage in the U.S. States
Jeff Cummins
Social Science Quarterly, March 2011, Pages 246-267
Objectives: One of the major policy concerns at the federal and state level is the rising number of individuals without health insurance. The purpose of this article is to investigate whether party control of government and various state reforms impact the percentage of the state population without health insurance.
Methods: Using data from 1987-2007, I empirically examine whether party control and five state policy reforms reduce the uninsured population.
Results: The results show that Republicans are more effective than Democrats at the state level at reducing insurance gaps and that three of five policy reforms explored appear to significantly expand insurance coverage.
Conclusions: The results provide valuable insight into which components of health-care reform at the national level may help address the health insurance problem.
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David Alter, Therese Stukel, Alice Chong & David Henry
Health Affairs, February 2011, Pages 274-283
Abstract:
Lower socioeconomic status is commonly related to worse health. If poor access to health care were the only explanation, universal access to care should eliminate the association. We studied 14,800 patients with access to Canada's universal health care system who were initially free of cardiac disease, tracking them for at least ten years and seven months. We found that socially disadvantaged patients used health care services more than did their counterparts with higher incomes and education. We also found that service use by people with lower incomes and less education had little impact on their poorer health outcomes, particularly mortality. Countries contemplating national health insurance cannot rely on universal health care to eliminate historical disparities in outcomes suffered by disadvantaged groups. Universal access can only reduce these disparities. Our findings suggest the need to introduce large-scale preventive strategies early in patients' lives to help change unhealthy behavior.
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Paul Heidenreich et al.
Circulation, forthcoming
Background: Cardiovascular disease (CVD) is the leading cause of death in the United States and is responsible for 17% of national health expenditures. As the population ages, these costs are expected to increase substantially.
Methods and Results: To prepare for future cardiovascular care needs, the American Heart Association developed methodology to project future costs of care for hypertension, coronary heart disease, heart failure, stroke, and all other CVD from 2010 to 2030. This methodology avoided double counting of costs for patients with multiple cardiovascular conditions. By 2030, 40.5% of the US population is projected to have some form of CVD. Between 2010 and 2030, real (2008$) total direct medical costs of CVD are projected to triple, from $273 billion to $818 billion. Real indirect costs (due to lost productivity) for all CVD are estimated to increase from $172 billion in 2010 to $276 billion in 2030, an increase of 61%.
Conclusions: These findings indicate CVD prevalence and costs are projected to increase substantially. Effective prevention strategies are needed if we are to limit the growing burden of CVD.
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Hospital Spending and Inpatient Mortality: Evidence From California: An Observational Study
John Romley, Anupam Jena & Dana Goldman
Annals of Internal Medicine, 1 February 2011, Pages 160-167
Background: Evidence shows that high Medicare spending is not associated with better health outcomes at a regional level and that high spending in hospitals is not associated with better process quality. The relationship between hospital spending and inpatient mortality is less well understood.
Objective: To determine the association between hospital spending and risk-adjusted inpatient mortality.
Design: Retrospective cohort study.
Setting: Database of discharge records from 1999 to 2008 for 208 California hospitals included in The Dartmouth Atlas of Health Care.
Patients: 2 545 352 patients hospitalized during 1999 to 2008 with 1 of 6 major medical conditions.
Measurements: Inpatient mortality rates among patients admitted to hospitals with varying levels of end-of-life hospital spending.
Results: For each of 6 diagnoses at admission-acute myocardial infarction, congestive heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and pneumonia-patient admission to higher-spending hospitals was associated with lower risk-adjusted inpatient mortality. During 1999 to 2003, for example, patients admitted with acute myocardial infarction to California hospitals in the highest quintile of hospital spending had lower inpatient mortality than did those admitted to hospitals in the lowest quintile (odds ratio, 0.862 [95% CI, 0.742 to 0.983]). Predicted inpatient deaths would increase by 1831 if all patients admitted with acute myocardial infarction were cared for in hospitals in the lowest quintile of spending rather than the highest. The association between hospital spending and inpatient mortality did not vary by region or hospital size.
Limitation: Unobserved predictors of mortality create uncertainty about whether greater inpatient hospital spending leads to lower inpatient mortality.
Conclusion: Hospitals that spend more have lower inpatient mortality for 6 common medical conditions.
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Direct medical cost of overweight and obesity in the USA: A quantitative systematic review
A.G. Tsai, D.F. Williamson & H.A. Glick
Obesity Reviews, January 2011, Pages 50-61
Abstract:
To estimate per-person and aggregate direct medical costs of overweight and obesity and to examine the effect of study design factors. PubMed (1968-2009), EconLit (1969-2009) and Business Source Premier (1995-2009) were searched for original studies. Results were standardized to compute the incremental cost per overweight person and per obese person, and to compute the national aggregate cost. A total of 33 US studies met review criteria. Among the four highest-quality studies, the 2008 per-person direct medical cost of overweight was $266 and of obesity was $1723. The aggregate national cost of overweight and obesity combined was $113.9 billion. Study design factors that affected cost estimates included use of national samples vs. more selected populations, age groups examined, inclusion of all medical costs vs. obesity-related costs only, and body mass index cut-offs for defining overweight and obesity. Depending on the source of total national healthcare expenditures used, the direct medical cost of overweight and obesity combined is approximately 5.0% to 10% of US healthcare spending. Future studies should include nationally representative samples, evaluate adults of all ages, report all medical costs and use standard body mass index cut-offs.
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Estimates of National Health Care Expenditures Associated With Disability
Wayne Anderson et al.
Journal of Disability Policy Studies, March 2011, Pages 230-240
Abstract:
We estimated adult national health care expenditures associated with disability by type of care and payer. These estimates represent the "additional" health care expenditures associated with disability over and above any non-disability-related health care expenditures. Multivariate analyses were performed using the Medical Expenditure Panel Survey, and supplemented with administrative data. Total national disability-associated health care expenditures (DAHE) were $397.9 billion in 2006, representing 26.7 percent of national health spending. Expenditures for people in institutions, such as nursing facilities, were the largest category of DAHE. In terms of source of payment, Medicaid DAHE were the highest at $161.1 billion, followed by Medicare DAHE with $119.0 billion. Together, the Medicare and Medicaid programs incurred 70.4 percent of total health care dollars associated with disability. Policy makers should consider initiatives that will help to prevent or delay disability and to improve the organization and delivery of services to people with disabilities.
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Seniors' Perceptions Of Health Care Not Closely Associated With Physician Supply
David Nyweide, Denise Anthony, Chiang-Hua Chang & David Goodman
Health Affairs, February 2011, Pages 219-227
Abstract:
We conducted a national random survey of Medicare beneficiaries to better understand the association between the supply of physicians and patients' perceptions of their health care. We found that patients living in areas with more physicians per capita had perceptions of their health care that were similar to those of patients in regions with fewer physicians. In addition, there were no significant differences between the groups of patients in terms of numbers of visits to their personal physician in the previous year; amount of time spent with a physician; or access to tests or specialists. Our results suggest that simply training more physicians is unlikely to lead to improved access to care. Instead, focusing health policy on improving the quality and organization of care may be more beneficial.
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How individuals choose health insurance: An experimental analysis
Arthur Schram & Joep Sonnemans
European Economic Review, forthcoming
Abstract:
An individual choosing a health insurance policy faces a complex decision environment where a large set of alternatives differ on a variety of dimensions. There is uncertainty and the choice is repeated at least once a year. We study decisions and decision strategies in a laboratory experiment where we create a controlled environment that closely mirrors this setting. We use an electronic information board that allows to carefully monitor the individual's decision strategy. The number of alternatives, switching costs, and the speed at which health deteriorates are varied across treatments. We find that most subjects' search is based more on attributes than on policies. Moreover, we find that an increase in the number of alternatives increases decision-making time; makes subjects consider a lower fraction of the available information; makes it more likely that subjects will switch; and decreases the quality of their decisions. The introduction of positive costs of switching makes people switch less often but improves the quality of their decisions. Finally, if health deteriorates only gradually, individuals tend to stick to their current policy too long.
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Daniel Carpenter, Justin Grimmer & Eric Lomazoff
Regulation & Governance, December 2010, Pages 383-407
Abstract:
Safety regulation - in the form of pre-market approval, licensure, screening, and product entry limitations - governs numerous market realms, including consumer finance. In this article, we ask whether the effects of safety regulation go beyond safety and affect consumers' beliefs about the distribution of products they can use. We model "approval regulation," where a government regulator must approve the market entry of a product based upon observable, unbiased, and non-anticipable experiments. We show that even if regulator and firm disagree about only quality standards, the disagreement induces the firm to provide more information about its product than it would in the absence of regulation. Put differently, purely first-order disagreements in regulation generate second-order consequences (more certainty about product quality). These second-order consequences of regulation are sufficient to generate first-order effects among end-users (more consumption of superior products), even when users are risk-neutral. In other words, even if approval regulation produces little or no improvement in safety or quality, it still aggregates information useful to "downstream" product users; these users will exhibit higher consumption and will more readily switch to superior products. In contrast with libertarian analyses of entry regulation and licensure, the model predicts that entry restrictions may be associated with greater product or service utilization (consumption) as well as with greater price sensitivity among consumers. Because contemporary cost-benefit analyses ignore these second-order effects, they are unlikely to capture the possible confidence effects of approval regulation.
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A model for allocating CDC's HIV prevention resources in the United States
Arielle Lasry et al.
Health Care Management Science, March 2011, Pages 115-124
Abstract:
The Division of HIV/AIDS Prevention (DHAP) at the Centers for Disease Control and Prevention has an annual budget of approximately $325 million for funding HIV prevention programs in the U.S. The purpose of this paper is to thoroughly describe the methods used to develop a national HIV resource allocation model intended to inform DHAP on allocation strategies that might improve the overall effectiveness of HIV prevention efforts. The HIV prevention resource allocation problem consists of choosing how to apportion prevention resources among interventions and populations so that HIV incidence is minimized, given a budget constraint. We developed an epidemic model that projects HIV infections over time given a specific allocation scenario. The epidemic model is then embedded in a nonlinear mathematical optimization program to determine the allocation scenario that minimizes HIV incidence over a 5-year horizon. In our model, we consider the general U.S. population and specific at-risk populations. The at-risk populations include 15 subgroups structured by gender, race/ethnicity and HIV transmission risk group. HIV transmission risk groups include high-risk heterosexuals, men who have sex with men and injection drug users. We consider HIV screening interventions and interventions to reduce HIV-related risk behaviors. The output of the model is the optimal funding scenario indicating the amounts to be allocated to all combinations of populations and interventions. For illustrative purposes only, we provide a sample application of the model. In this example, the optimal allocation scenario is compared to the current baseline funding scenario to highlight how the current allocation of funds could be improved. In the baseline allocation, 29% of the annual budget is aimed at the general population, while the model recommends targeting 100% of the budget to the at-risk populations with no allocation targeted to the general population. Within the allocation to behavioral interventions the model recommends an increase in targeting diagnosed positives. Also, the model allocation suggests a greater focus on MSM and IDUs with a 72% of the annual budget allocated to them, while the baseline allocation for MSM and IDUs totals 37%. Incorporating future epidemic trends in the decision-making process informs the selection of populations and interventions that should be targeted. Improving the use of funds by targeting the interventions and population subgroups at greatest risk may lead to improved HIV outcomes. These models can also direct research by pointing to areas where the development of cost-effective interventions can have the most impact on the epidemic.
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Health Affairs, February 2011, Pages 312-321
Abstract:
Medicare began covering the use of carotid stents to treat arterial blockages in 2005 under an innovative policy requiring hospitals to meet quality-of-care benchmarks before seeking reimbursement. By restricting carotid stent provision to a smaller subset of US hospitals than those typically adopting new cardiovascular technologies, this policy could have disproportionately reduced the availability of this technology for minority, low-income, and rural patients. Such patients are often served by hospitals less able than others to meet increasingly stringent quality requirements. However, our analysis of hospitals that provided stents during 2005-07 demonstrated that although 21-38 percent fewer hospitals offered stents than offered other types of interventional cardiovascular procedures, such as heart bypass grafts, stents were no less available in localities with substantial poor, black, or rural populations than they were in other areas. Our study provides important evidence that the carotid stent coverage policy met its goal of limiting the adoption of the technology by hospitals that weren't well prepared to provide it-while still maintaining equitable availability of the technology. Therefore, it may be a useful model for future Medicare coverage decisions.
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The economic burden of obesity worldwide: A systematic review of the direct costs of obesity
D. Withrow & D.A. Alter
Obesity Reviews, February 2011, Pages 131-141
Abstract: In the last decade, the prevalence of obesity has increased significantly in populations worldwide. A less dramatic, but equally important increase has been seen in our knowledge of its effects on health and the burden it places on healthcare systems. This systematic review aims to assess the current published literature on the direct costs associated with obesity. A computerized search of English language articles published between 1990 and June 2009 yielded 32 articles suitable for review. Based on these articles, obesity was estimated to account for between 0.7% and 2.8% of a country's total healthcare expenditures. Furthermore, obese individuals were found to have medical costs that were approximately 30% greater than their normal weight peers. Although variations in inclusion/exclusion criteria, reporting methods and included costs varied widely between the studies, a lack of examination of how and why the excess costs were being accrued appeared to be a commonality between most studies. Accordingly, future studies must better explore how costs accrue among obese populations, in order to best facilitate health and social policy interventions.
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Wen-Ying Sylvia Chou et al.
Journal of Health Communication, Winter 2010, Pages 147-156
Abstract: Consumer satisfaction ratings of health care quality represent a commonly used measure of health care performance. Identifying factors associated with ratings will help us understand the relative influence of individuals' sociodemographic and health characteristics on satisfaction level, thus informing policy making and clinical practice. Existing research has yielded mixed results on key predictors of consumer ratings. Using nationally representative data, this study aims to identify factors associated with Americans' ratings of health care quality. Data from 2008 Health Information National Trends Survey (HINTS) were analyzed using weighted multinomial logistic regressions to estimate consumer ratings. Predictor variables included demographics, health status, care access, and attitude and perceptions about health. Overall ratings were positively skewed; 70% of respondents rated care as "excellent" or "very good." Minority race, psychological distress, not having had cancer, not having a regular health care provider, not having health insurance, lacking confidence in self-care, and avoidance of doctors were significantly associated with lower ratings. The study identifies the psychosocial characteristics associated with lower consumer ratings. The results highlight the importance of using multiple approaches to assess quality of care, including considering patient characteristics, and contribute to the evidence base for evaluating overall quality of care at the dawn of health care reform.
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Petra Steinorth
Journal of Health Economics, forthcoming
Abstract:
The paper examines the influence of Health Savings Accounts (HSAs) on optimal savings, insurance demand and prevention effort over the course of a lifetime. This paper adds to the literature by investigating HSAs as both a form of insurance and as saving vehicle in an expected utility framework. Assuming no regulatory constraints on the deductible, we show that individuals voluntarily choose a positive deductible and increase their savings with HSAs. If the government-imposed minimum deductible becomes too great, however, individuals may instead choose to remain in traditional insurance. We determine the effect of HSAs on prevention effort. We find that an increased tax subsidy may worsen moral hazard issues. Assuming Partial Risk Aversion to be less than or equal to one, individuals will either invest less in the health preservation effort and more money in the HSA or vice versa. However, they will never increase both effort and savings simultaneously as was intended when HSAs were introduced.
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Health Advocacy Organizations and the Pharmaceutical Industry: An Analysis of Disclosure Practices
Sheila Rothman et al.
American Journal of Public Health, forthcoming
Abstract:
Health advocacy organizations (HAOs) are influential stakeholders in health policy. Although their advocacy tends to closely correspond with the pharmaceutical industry's marketing aims, the financial relationships between HAOs and the pharmaceutical industry have rarely been analyzed. We used Eli Lilly and Company's grant registry to examine its grant-giving policies. We also examined HAO Web sites to determine their grant disclosure patterns. Only 25% of HAOs that received Lilly grants acknowledged Lilly's contributions on their Web sites, and only 10% acknowledged Lilly as a grant event sponsor. No HAO disclosed the exact amount of a Lilly grant. As highly trusted organizations, HAOs should disclose all corporate grants, including the purpose and the amount. Absent this disclosure, legislators, regulators, and the public cannot evaluate possible conflicts of interest or biases in HAO advocacy.
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Katy Backes Kozhimannil et al.
Health Affairs, February 2011, Pages 293-301
Abstract:
Identification and treatment of postpartum depression are the increasing focus of state and national legislation, including portions of the Affordable Care Act. Some state policies and proposals are modeled directly on programs in New Jersey, the first state to require universal screening for postpartum depression among mothers who recently delivered babies. We examined the impact of these policies on a particularly vulnerable population, Medicaid recipients, and found that neither the required screening nor the educational campaign that preceded it was associated with improved treatment initiation, follow-up, or continued care. We argue that New Jersey's policies, although well intentioned, were predicated on an inadequate base of evidence and that efforts should now be undertaken to build that base. We also argue that to improve detection and treatment, policy makers contemplating or implementing postpartum depression mandates should consider additional measures. These could include requiring mechanisms to monitor and enforce the screening requirement; paying providers to execute screening and follow-up; and preliminary testing of interventions before policy changes are enacted.
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Geographic Concentration and Correlates of Nursing Home Closures: 1999-2008
Zhanlian Feng et al.
Archives of Internal Medicine, forthcoming
Background: While demographic shifts project an increased need for long-term care for an aging population, hundreds of nursing homes close each year. We examine whether nursing home closures are geographically concentrated and related to local community characteristics such as the racial and ethnic population mix and poverty.
Methods: National Online Survey Certification and Reporting data were used to document cumulative nursing facility closures over a decade, 1999 through 2008. Census 2000 zip code level demographics and poverty rates were matched to study facilities. The weighted Gini coefficient was used to measure geographic concentration of closures, and geographic information system maps to illustrate spatial clustering patterns of closures. Changes in bed supply due to closures were examined at various geographic levels.
Results: Between 1999 and 2008, a national total of 1776 freestanding nursing homes closed (11%), compared with 1126 closures of hospital-based facilities (nearly 50%). Combined, there was a net loss of over 5% of beds. The relative risk of closure was significantly higher in zip code areas with a higher proportion of blacks or Hispanics or a higher poverty rate. The weighted Gini coefficient for closures was 0.55 across all metropolitan statistical areas and 0.71 across zip codes. Closures tended to be spatially clustered in minority-concentrated zip codes around the urban core, often in pockets of concentrated poverty.
Conclusions: Nursing home closures are geographically concentrated in minority and poor communities. Since nursing home use among the minority elderly population is growing while it is declining among whites, these findings suggest that disparities in access will increase.
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The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview
Ashly Black et al.
PLoS Medicine, January 2011, e1000387
Background: There is considerable international interest in exploiting the potential of digital solutions to enhance the quality and safety of health care. Implementations of transformative eHealth technologies are underway globally, often at very considerable cost. In order to assess the impact of eHealth solutions on the quality and safety of health care, and to inform policy decisions on eHealth deployments, we undertook a systematic review of systematic reviews assessing the effectiveness and consequences of various eHealth technologies on the quality and safety of care.
Methods and Findings: We developed novel search strategies, conceptual maps of health care quality, safety, and eHealth interventions, and then systematically identified, scrutinised, and synthesised the systematic review literature. Major biomedical databases were searched to identify systematic reviews published between 1997 and 2010. Related theoretical, methodological, and technical material was also reviewed. We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. This systematic review literature was found to be generally of substandard quality with regards to methodology, reporting, and utility. We thematically categorised eHealth technologies into three main areas: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies. Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.
Conclusions: There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and "techno-enthusiasts" as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption.
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Elizabeth Powers & Nicholas Powers
Journal of Disability Policy Studies, March 2011, Pages 195-209
Abstract:
High rates of worker turnover have been a persistent problem in the long-term care industry. Spending on individuals with developmental disabilities represents 20 percent of all long-term care spending and 40 percent of Medicaid spending on long-term care. Using detailed data on the providers of long-term community-based residential services for persons with developmental disabilities, this research examined the consequences of high worker turnover for long-term care costs and whether a wage-subsidy policy to reduce worker turnover would have been cost-effective in this sector. Higher turnover increased state-reimbursed training expenditures, the share of workers engaged in training, and workers' compensation costs. Turnover had no effect on training expenditures that were not reimbursed by the state, nor did it affect residential vacancies. The findings indicated that providers were unlikely to reduce turnover on their own, since its associated costs were either tolerably small or borne by others. An analysis indicated that it was likely socially beneficial for the government to reduce turnover through wage subsidization in this sector.
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Effect of Financial Remuneration on Specialty Choice of Fourth-Year U.S. Medical Students
Kent DeZee et al.
Academic Medicine, February 2011, Pages 187-193
Purpose: To investigate whether financial incentives could reverse the trend of declining interest in primary care specialties among U.S. medical students.
Method: An electronic survey was sent to all U.S. fourth-year MD and DO medical students in 2009 with a Department of Defense service obligation. Students not selecting a primary care residency were asked if a hypothetical bonus paid before and after residency or an increase in annual salary of attendings in primary care specialties would have resulted in these students selecting primary care. Logistic regression was used to determine student characteristics associated with accepting a financial incentive.
Results: The survey response rate was 56% (447/797). Sixty-six percent of students did not apply for a primary care residency. Of these, 30% would have applied for primary care if they had been given a median bonus of $27,500 (interquartile range [IQR] $15,000-$50,000) before and after residency. Forty-one percent of students would have considered applying for primary care for a median military annual salary after residency of $175,000 (IQR $150,000-$200,000). Students who considered primary care but chose a controllable lifestyle specialty (e.g., radiology) were nearly four times more likely to name an influential hypothetical salary than were students who did not consider primary care and chose a noncontrollable lifestyle specialty (e.g., surgery) (67% versus 17%, P < .0001).
Conclusions: U.S. medical students, particularly those considering primary care but selecting controllable lifestyle specialties, are more likely to consider applying for a primary care specialty if provided a financial incentive.