PURPOSE Medicare beneficiary spending patterns reflect those of the 306 Hospital Referral Regions where physicians train, but whether this holds true for smaller areas or for quality is uncertain. This study assesses whether cost and quality imprinting can be detected within the 3,436 Hospital Service Areas (HSAs), 82.4 percent of which have only 1 teaching hospital, and whether sponsoring institution characteristics are associated. METHODSWe conducted a secondary, multi-level, multivariable analysis of 2011 Medicare claims and American Medical Association Masterfile data for a random, nationally representative sample of family physicians and general internists who completed residency between 1992 and 2010 and had more than 40 Medicare patients (3,075 physicians providing care to 503,109 beneficiaries). Practice and training locations were matched with Dartmouth Atlas HSAs and categorized into low-, average-, and high-cost spending groups. Practice and training HSAs were assessed for differences in 4 diabetes quality measures. Institutional characteristics included training volume and percentage of graduates in rural practice and primary care. RESULTSThe unadjusted, annual, per-beneficiary spending difference between physicians trained in high-and low-cost HSAs was $1,644 (95% CI, $1,253-$2,034), and the difference remained significant after controlling for patient and physician characteristics. No significant relationship was found for diabetes quality measures. General internists were significantly more likely than family physicians to train in high-cost HSAs. Institutions with more graduates in rural practice and primary care produced lower-spending physicians.CONCLUSIONS The "imprint" of training spending patterns on physicians is strong and enduring, without discernible quality effects, and, along with identified institutional features, supports measures and policy options for improved graduate medical education outcomes. Ann Fam Med 2017;15:140-148. https://doi.org/10.1370/afm.2044. INTRODUCTIONP ublic and private payers have embraced value-based health care, and are marching aggressively toward the Triple Aim-better health, better care, and lower costs.1 Simultaneously, the National Academy of Medicine, The Josiah Macy Jr Foundation, and others are calling for greater accountability for more than $15 billion currently spent on Graduate Medical Education (GME), and for more strategic allocation of GME funding.2-8 Most research supporting accountability measures and reform options has focused on the specialties and distribution of graduates, but our recent study exploring the relationship between training and future practice costs found that physician-associated Medicare costs were highly correlated with those of their the physicians ' Hospital Referral Regions (HRR). 9 Educational imprinting is the idea that learners model witnessed behaviors and beliefs, sometimes despite what they are taught, and GME is not immune. These studies demonstrate important relationships between training and subsequent...

PURPOSE Despite considerable investment in increasing the number of primary care physicians in rural shortage areas, little is known about their movement rates and factors influencing their mobility. We aimed to characterize geographic mobility among rural primary care physicians, and to identify location and individual factors that influence such mobility. METHODSUsing data from the American Medical Association Physician Masterfile for each clinically active US physician, we created seven 2-year (biennial) mobility periods during 2000-2014. These periods were merged with countylevel "rurality," physician supply, economic characteristics, key demographic measures, and individual physician characteristics. We computed (1) mobility rates of physicians by rurality; (2) linear regression models of county-level rural nonretention (departure); and (3) logit models of physicians leaving rural practice. RESULTSBiennial turnover was about 17% among physicians aged 45 and younger, compared with 9% among physicians aged 46 to 65, with little difference between rural and metropolitan groups. County-level physician mobility was higher for counties that lacked a hospital (absolute increase = 5.7%), had a smaller population size, and had lower primary care physician supply, but arealevel economic and demographic factors had little impact. Female physicians (odds ratios = 1.24 and 1.46 for those aged 45 or younger and those aged 46 to 65, respectively) and physicians born in a metropolitan area (odds ratios = 1.75 and 1.56 for those aged 45 or younger and those aged 46 to 65, respectively) were more likely to leave rural practice.CONCLUSIONS These findings provide national-level evidence of rural physician mobility rates and factors associated with both county-level retention and individual-level departures. Outcomes were notably poorer in the most remote locations and those already having poorer physician supply and professional support. Rural health workforce planners and policymakers must be cognizant of these key factors to more effectively target retention policies and to take into account the additional support needed by these more vulnerable communities. Ann Fam Med 2017;15:322-328. https://doi.org/10.1370/afm.2096. INTRODUCTIONR ural populations continue to experience relative shortages of the supply of primary care physicians, 1 with associated links to poorer health.2 Difficulties of both recruitment and retention of physicians in rural areas, which greatly contribute to experienced shortages, are well acknowledged. 3,4 There are many reasons for this ongoing workforce supply disparity, including professional, economic, infrastructural, political, educational, and sociocultural aspects. 5 Although considerable research has identified factors that facilitate or impede supply of physicians in rural areas, macro-level empirical evidence of observed rural mobility of physiciansnotably, which are more likely to move and why-is limited.6-9 Additionally, the frequencies with which specific rural physicians move over ...

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Family physicians are increasingly incorporating other health care providers into their practice teams to better meet the needs of increasingly complex and comorbid patients. While a majority of family physicians report working with a nurse practitioner, only 21% work with a behavioral health specialist. A better understanding of optimal team composition and function in primary care is essential to realizing the promise of a patient-centered medical home and achieving the triple aim. (J Am Board Fam Med 2016;29:8 -9.)

There is little relationship between PCGME trainee growth and state need indicators. States should capitalize on opportunities to create explicit linkages between UME, GME, and population need; strategically allocate Medicaid GME funds; and monitor the impact of workforce policies and training institution outputs.