Lawrence P. Casalino

Objective: To investigate whether the acquisition of physician practices by Optum, a subsidiary of United Health Group (UHG), influences patient volume and service prices, particularly, for patients enrolled in health insurance plans competing with UHG. Study Setting and Design: We employed a novel database cataloging health insurer acquisitions of physician practices to identify those acquired by Optum—the nation's largest payvider (vertically integrated payer‐provider)—from 2007 to 2023. These data were integrated with non‐UHG commercial health insurance claims for practices acquired between 2015 and 2019. Using a stacked difference‐in‐differences design, we analyzed relative changes in prices and office visits across 12 Optum‐acquired practices compared to a control group. Adjustments were made for physician profiles, practice characteristics, and calendar‐year fixed effects to ensure robust estimates. Principal Findings: From 2007 to 2023, Optum acquired 44 physician practices, employing 7828 physicians by 2023. Postacquisition, we found no statistically significant average change in prices for most acquired practices relative to controls. However, the single largest acquisition was associated with a relative price increase of 4.5% (95% CI: [1.2%, 7.8%]; p = 0.02) for established patient visits. Preacquisition trends showed prices at acquired practices rising faster than controls. Additionally, Optum acquisitions were linked to suggestive declines in claim volume 1–1.5 years postacquisition, though this shift was predominantly driven by the largest acquired practice, indicating variability in outcomes across the sample. Conclusions: Optum's acquisition of physician practices did not broadly result in significant price changes for evaluation and management services provided to patients with competing insurance plans, despite higher baseline prices at acquired practices. Suggestive reductions in patient volume emerged postacquisition, but effects were inconsistent. Extended follow‐up research is warranted to evaluate whether these acquisitions reshape local healthcare market dynamics over time.

Access to telehealth care has increased markedly in recent years, especially for patients in the Medicare Advantage (MA) program. Given the unique features of MA, such as capitated payment and provider networks, understanding the impact of telehealth availability on quality, costs, and utilization is important for informing coverage and payment decisions. We compared quality and utilization outcomes among MA beneficiaries with varying access to telehealth, using MA encounter data from a 20% national random sample of enrollees from 2019 to 2021. We found that high-telehealth access was associated with a 13.4% decrease in in-person evaluation and management (E&M) visits, relative to the period prior to the pandemic onset. Given that this decrease was offset by increases in telehealth E&M visits, there was no change in total E&M visits. High-telehealth access was also associated with a 4.8% decrease in total emergency department (ED) visits, but no differences in preventable ED visits, total hospital admissions, or ambulatory care-sensitive admissions. Increases in telehealth-delivered E&M visits among MA beneficiaries with high-telehealth access offset decreases in in-person-delivered E&M visits. These findings may help clinicians and policymakers contextualize the relationship between broader access to telehealth for MA enrollees and various types of health care utilization.

Importance: Altruism—putting the patient first—is a fundamental component of physician professionalism. Evidence is lacking about the relationship between physician altruism, care quality, and spending.Objective: To determine whether there is a relationship between physician altruism, measures of quality, and spending, hypothesizing that altruistic physicians have better results.Design, Setting, and Participants: This cross-sectional study that used a validated economic experiment to measure altruism was carried out between October 2018 and November 2019 using a nationwide sample of US primary care physicians and cardiologists. Altruism data were linked to 2019 Medicare claims and multivariable regressions were used to examine the relationship between altruism and quality and spending measures. Overall, 250 physicians in 43 medical practices that varied in size, location, and ownership, and 7626 Medicare fee-for-service beneficiaries attributed to the physicians were included. The analysis was conducted from April 2022 to August 2024.Exposure: Physicians completed a widely used modified dictator-game style web-based experiment; based on their responses, they were categorized as more or less altruistic.Main Measures: Potentially preventable hospital admissions, potentially preventable emergency department visits, and Medicare spending.Results: In all, 1599 beneficiaries (21%) were attributed to the 45 physicians (18%) categorized as altruistic and 6027 patients were attributed to the 205 physicians not categorized as altruistic. Adjusting for patient, physician, and practice characteristics, patients of altruistic physicians had a lower likelihood of any potentially preventable admission (odds ratio [OR], 0.60; 95% CI, 0.38-0.97; P = .03) and any potentially preventable emergency department visit (OR, 0.64; CI, 0.43-0.94; P = .02). Adjusted spending was 9.26% lower (95% CI, −16.24% to −2.27%; P = .01).Conclusions and Relevance: This cross-sectional study found that Medicare patients treated by altruistic physicians had fewer potentially preventable hospitalizations and emergency department visits and lower spending. Policymakers and leaders of hospitals, medical practices, and medical schools may want to consider creating incentives, organizational structures, and cultures that may increase, or at least do not decrease, physician altruism. Further research should seek to identify these and other modifiable factors, such as physician selection and training, that may shape physician altruism. Research could also analyze the relationship between altruism and quality and spending in additional medical practices, specialties, and countries, and use additional measures of quality and of patient experience.

Medical groups, health systems, and professional associations are concerned about potential increases in physician turnover, which may affect patient access and quality of care. To examine whether turnover has changed over time and whether it is higher for certain types of physicians or practice settings. The authors developed a novel method using 100% of traditional Medicare billing to create national estimates of turnover. Standardized turnover rates were compared by physician, practice, and patient characteristics. Traditional Medicare, 2010 to 2020. Physicians billing traditional Medicare. Indicators of physician turnover-physicians who stopped practicing and those who moved from one practice to another-and their sum. The annual rate of turnover increased from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and increased modestly in 2018 to 7.6%. Most of the increase from 2010 to 2014 came from physicians who stopped practicing increasing from 1.6% to 3.1%; physicians moving increased modestly from 3.7% to 4.2%. Modest but statistically significant (P < 0.001) differences existed across rurality, physician sex, specialty, and patient characteristics. In the second and third quarters of 2020, quarterly turnover was slightly lower than in the corresponding quarters of 2019. Measurement was based on traditional Medicare claims. Over the past decade, physician turnover rates have had periods of increase and stability. These early data, covering the first 3 quarters of 2020, give no indication yet of the COVID-19 pandemic increasing turnover, although continued tracking of turnover is warranted. This novel method will enable future monitoring and further investigations into turnover. The Physicians Foundation Center for the Study of Physician Practice and Leadership.

In this issue of JAMA Internal Medicine, Pany and McWilliams¹ reported that patient experience of an outpatient visit with a specialist was much better (analogous to an increase from median patient experience to the 91st percentile) when the referring primary physician and the specialist co-trained at the same institution. In addition, the authors found that specialists behaved differently when they had co-trained with the referring physician. Specifically, specialists were more likely (for better or for worse) to prescribe a medication and/or to order an imaging study for patients than when they had not trained with the referring physician.

Background Primary care “teamlets” in which a staff member and physician consistently work together might provide a simple, cost-effective way to improve care, with or without insertion within a team. Objective To determine the prevalence and performance of teamlets and teams. Design Cross-sectional observational study linking survey responses to Medicare claims. Participants Six hundred eighty-eight general internists and family physicians. Interventions Based on survey responses, physicians were assigned to one of four teamlet/team categories (e.g., teamlet/no team) and, in secondary analyses, to one of eight teamlet/team categories that classified teamlets into high, medium, and low collaboration as perceived by the physician (e.g., teamlet perceived-high collaboration/no team). Main Measures Descriptive: percentage of physicians in teamlet/team categories. Outcome measures: physician burnout; ambulatory care sensitive emergency department and hospital admissions; Medicare spending. Key Results 77.4% of physicians practiced in teamlets; 36.7% in teams. Of the four categories, 49.1% practiced in the teamlet/no team category; 28.3% in the teamlet/team category; 8.4% in no teamlet/team; 14.1% in no teamlet/no team. 15.7%, 47.4%, and 14.4% of physicians practiced in perceived high-, medium-, and low-collaboration teamlets. Physicians who practiced neither in a teamlet nor in a team had significantly lower rates of burnout compared to the three teamlet/team categories. There were no consistent, significant differences in outcomes or Medicare spending by teamlet/team or teamlet perceived-collaboration/team categories compared to no teamlet/no team, for Medicare beneficiaries in general or for dual-eligible beneficiaries. Conclusions Most general internists and family physicians practice in teamlets, and some practice in teams, but neither practicing in a teamlet, in a team, or in the two together was associated with lower physician burnout, better outcomes for patients, or lower Medicare spending. Further study is indicated to investigate whether certain types of teamlet, teams, or teamlets within teams can achieve higher performance.

Physicians’ professional ethics require that they put patients’ interests ahead of their own and that they should allocate limited medical resources efficiently. Understanding physicians’ extent of adherence to these principles requires understanding the social preferences that lie behind them. These social preferences may be divided into two qualitatively different trade-offs: the trade-off between self and other (altruism) and the trade-off between reducing differences in payoffs (equality) and increasing total payoffs (efficiency). We experimentally measure social preferences among a nationwide sample of practicing physicians in the United States. Our design allows us to distinguish empirically between altruism and equality–efficiency orientation and to accurately measure both trade-offs at the level of the individual subject. We further compare the experimentally measured social preferences of physicians with those of a representative sample of Americans, an “elite” subsample of Americans, and a nationwide sample of medical students. We find that physicians’ altruism stands out. Although most physicians place a greater weight on self than on other, the share of physicians who place a greater weight on other than on self is twice as large as for all other samples—32% as compared with 15 to 17%. Subjects in the general population are the closest to physicians in terms of altruism. The higher altruism among physicians compared with the other samples cannot be explained by income or age differences. By contrast, physicians’ preferences regarding equality–efficiency orientation are not meaningfully different from those of the general sample and elite subsample and are less efficiency oriented than medical students.

Despite reports of a physician burnout epidemic, there is little research on the relationship between burnout and objective measures of care outcomes and no research on the relationship between burnout and costs of care. Linking survey data from 1,064 family physicians to Medicare claims, we found no consistent statistically significant relationship between seven categories of self-reported burnout and measures of ambulatory care–sensitive admissions, ambulatory care–sensitive emergency department visits, readmissions, or costs. The coefficients for ambulatory care–sensitive admissions and readmissions for all burnout levels, compared with never being burned out, were consistently negative (fewer ambulatory care–sensitive admissions and readmissions), suggesting that, counterintuitively, physicians who report burnout may nevertheless be able to create better outcomes for their patients. Even if true, this hypothesis should not indicate that physician burnout is beneficial or that efforts to reduce physician burnout are unimportant. Our findings suggest that the relationship between burnout and outcomes is complex and requires further investigation.

In this issue of JAMA Internal Medicine, Bruch and colleagues¹ inform us that during the past decade, private equity firms have acquired or invested in large numbers of obstetrician-gynecologist medical groups. Most of these acquisitions and investments occurred during the past 3 years. Given the difficulty of identifying such acquisitions and investments, it is likely that their true number is even larger than Bruch and colleagues report, despite the labor-intensive methods the authors employed to identify them. Identify all potential conflicts of interest that might be relevant to your comment. Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. Err on the side of full disclosure. If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response. Not all submitted comments are published. Please see our commenting policy for details.

This Viewpoint discusses the importance of structuring value-based purchasing models around principles of physician professionalism to ensure that measures that