Physician Workforce, Primary Care and 40 V.K.Chetty, Life - PowerPoint PPT Presentation

Physician Workforce, Primary Care and Life Expectancy at Physician Workforce, Primary Care and 40 V.K.Chetty, Life Expectancy at 40 Benjamin Petrie and Larry Culpepper V.K.Chetty, Benjamin Petrie and Larry Culpepper February,2018

Raj Chetty,...David Cutler JAMA study Physician Workforce, Primary Care and The Association Between Income and Life Expectancy in Life Expectancy at the United States, 2001-2014 JAMA 2016 40 V.K.Chetty, Benjamin Petrie and Larry Culpepper

Raj Chetty,...David Cutler JAMA study Physician Workforce, Primary Care and The Association Between Income and Life Expectancy in Life Expectancy at the United States, 2001-2014 JAMA 2016 40 Most cited among 20,276 articles in JAMA, Altmetric V.K.Chetty, Benjamin score 3,873, second only to Pres.Obama’s article. Petrie and Larry Culpepper

Raj Chetty,...David Cutler JAMA study Physician Workforce, Primary Care and The Association Between Income and Life Expectancy in Life Expectancy at the United States, 2001-2014 JAMA 2016 40 Most cited among 20,276 articles in JAMA, Altmetric V.K.Chetty, Benjamin score 3,873, second only to Pres.Obama’s article. Petrie and Larry Culpepper Major Conclusions using 14 billion observations

Raj Chetty,...David Cutler JAMA study Physician Workforce, Primary Care and The Association Between Income and Life Expectancy in Life Expectancy at the United States, 2001-2014 JAMA 2016 40 Most cited among 20,276 articles in JAMA, Altmetric V.K.Chetty, Benjamin score 3,873, second only to Pres.Obama’s article. Petrie and Larry Culpepper Major Conclusions using 14 billion observations 1 Gap in life expectancy (LE) between the richest 1% and poorest 1% of individuals was 14.6 years

Raj Chetty,...David Cutler JAMA study Physician Workforce, Primary Care and The Association Between Income and Life Expectancy in Life Expectancy at the United States, 2001-2014 JAMA 2016 40 Most cited among 20,276 articles in JAMA, Altmetric V.K.Chetty, Benjamin score 3,873, second only to Pres.Obama’s article. Petrie and Larry Culpepper Major Conclusions using 14 billion observations 1 Gap in life expectancy (LE) between the richest 1% and poorest 1% of individuals was 14.6 years 2 Geographic differences in LE for individuals in the lowest income quartile significantly correlated with health behaviors such as smoking (r=0.69, P.001), but not significantly correlated with access to medical care

Major Conclusions Contd. Physician Workforce, Primary Care and Life Expectancy at 40 V.K.Chetty, Benjamin 3 Measures of health insurance coverage and spending (the Petrie and Larry fraction of uninsured and risk-adjusted Medicare spending Culpepper per enrollee) not significantly associated with LE for individuals in the bottom income quartile.

Father and Son Controversies Physician Workforce, Primary Care and Life Expectancy at 40 V.K.Chetty, Are Physicians services really uncorrelated with patients Benjamin Petrie health ? and Larry Culpepper Health Insurance coverage does not affect life expectancy ? or are these due to some statistical problems ? This study already quoted by opponents of Obama Care!

A Simple Model The production relation is Physician Workforce, Primary Care LE = β 1 ( M ) + β 2 ( F ) + β 3 ( Z ) (1) and Life Expectancy at Choose M and F to minimize cost of LE, i.e., 40 the last dollars spent on a specialist and a PCP must increase V.K.Chetty, Benjamin LE by the same amount. Petrie and Larry Then, Culpepper ∂ β 1 F ∗ = 1 + 1 ∂ M r + M (2) ∂ β 2 ∂ F where LE : Expected Life Expectancy M : MDs per 10,000 population F : fraction of PCPs 1 + r : ratio of fee for services of specialists to PCPs

Practical Decision Rule Physician Workforce, Primary Care and Life Rule depends on four observable variables Expectancy at 40 1 Physician density : M V.K.Chetty, Benjamin 2 Marginal effects of increasing physicians without changing Petrie and Larry the proportion of PCPs: β 1 ( M ) Culpepper 3 Marginal effects of substituting PCPs by specialists: β 2 (F) and 4 Ratio of fees for services of specialists to PCPs: (1+r) How to estimate β 1 ( M )& β 2 ( F )?

Big Data: Benefits and Problems Physician Three errors in empirical studies: (1) Sampling Errors- Workforce, Primary Care small samples; (2) Measurement Errors (3) Specification and Life Errors - selection of variables and specifying functional Expectancy at 40 forms. V.K.Chetty, Benjamin With millions and billions of observations, sampling errors Petrie and Larry will disappear; t-values will be 200 or 300 ! Culpepper Many variables may be statistically significant, but are they clinically significant? No need to specify any functional form such as linear, quadratic etc. choice of functional forms could be completely data driven! No need for prior restrictions Main Problem: Sound knowledge of subject needed to measure well, assess clinical significance & use the results!

Data Physician Variables Workforce, Primary Care and Life 1 unit of observation: County Expectancy at 2 Average Life Expectancy at age 40 for 1 st and 4 th income 40 V.K.Chetty, quartiles for men and women Benjamin Petrie 3 Physician Supply: Non-federal MDs/ 10 K and Larry Culpepper Population,seeing patients,75 years or less excluding DOs. 4 PCP: GP,FP,GIM,Peds., ObGyn and DOs excluding PA & NP 5 Proportion Currently Smoking 6 Rate of self-reported exercise during the past month 7 Proportion of Medicare recipients admitted at least once in a year 8 Number of immigrants per 10 K individuals. Sources: AHRF and Raj et al

Life Expectancy, Income and Total MDs 10,000 Population - a Physician Workforce, Primary Care and Life 86.0 Male LE −1st Inc.Quart. Male LE −4th Inc.Quart. Expectancy at 77.0 85.5 40 85.0 76.5 V.K.Chetty, Benjamin 84.5 Petrie 76.0 84.0 and Larry Culpepper 83.5 75.5 0 10 20 30 40 0 10 20 30 40 88.5 Female LE − 4th Inc.Quart. Female LE −1st Inc.Quart. 82.50 88.0 82.25 87.5 82.00 87.0 81.75 86.5 81.50 0 10 20 30 40 0 10 20 30 40 MDs/10,000 Population MDs/10,000 Population

Life Expectancy, Income and Total MDs /10,000 Population - b Physician Workforce, Primary Care and 80 87 Life Expectancy at 86 Life.Exp.Males.Q1 Life.Exp.Males.Q4 40 78 V.K.Chetty, 85 Benjamin 76 Petrie 84 and Larry Culpepper 74 83 15 20 25 15 20 25 84 88 Life.Exp.Females.Q1 Life.Exp.Females.Q4 83 87 82 86 81 85 80 84 15 20 25 15 20 25 Medic.IP.PerCent Medic.IP.PerCent

Life Expectancy, MD Density & Specialty Distribution, Income and Sex Physician Workforce, Primary Care and 90 Life Expectancy at Sex 40 Female Male V.K.Chetty, NA Benjamin Petrie 85 Life Expectancy at Age 40 PCP.percent and Larry 20 Culpepper 30 40 50 60 70 80 Income High Low NA 75 25 50 75 100 MD/10,000 Population

Adjusted State Effects on Life Expectencies Referent: Massachusetts Physician Workforce, Primary Care and Life 4 Expectancy at 40 V.K.Chetty, 3 Benjamin Petrie sex Decrease in LE (years) and Larry Men Culpepper 2 Women income Poor 1 Rich 0 −1 ND MN MT CO ME DC MD WA NC NH MO MS OR OH GA WY WV OK NM RI CT NY UT PA ID FL VT WI NE SD NJ VA DE MI CA IA SC TN LA AL KY AR AZ KS TX IN NV HI IL State

Change in Life Expectancy Years (Adjusted) Physician Supply and Specialty Distribution Physician Workforce, Life.Exp.Males.Q1 0.5 1.0 Primary Care 0.0 0.5 and −0.5 Massachusetts 0.0 Massachusetts Life Oklahama −1.0 Oklahoma Expectancy at −1.5 −0.5 40 10 1517 25 30 40 50 .2 .26 .38.41 .53 .6 V.K.Chetty, Life.Exp.Males.Q4 1.0 Benjamin 0.25 Petrie 0.5 0.00 and Larry 0.0 −0.25 Culpepper −0.5 −0.50 0 10 20 30 40 50 0.2 0.4 0.6 Life Exp.Females.Q1 1.0 0.5 0.0 0.5 −0.5 0.0 −1.0 −0.5 −1.5 0 10 20 30 40 50 0.2 0.4 0.6 Life.Exp.Females.Q4 0.3 0.5 0.0 0.0 −0.3 −0.5 −0.6 −1.0 0 10 20 30 40 50 0.2 0.4 0.6 MD.10000 PCP.MD.Ratio

Life Expectancy (Adjusted) and % Immigrants Physician Workforce, 4 0 Primary Care and 3 Life.Exp.Males.Q1 Life.Exp.Males.Q4 Life Expectancy at −1 2 40 V.K.Chetty, 1 −2 Benjamin Petrie 0 and Larry 0 10 20 30 40 50 0 10 20 30 40 50 Culpepper 4 0.0 3 Life.Exp.Females.Q1 Life.Exp.Females.Q4 −0.5 2 −1.0 1 −1.5 0 −2.0 0 10 20 30 40 50 0 10 20 30 40 50 % Immigrants % Immigrants Figure: 4

GAM Model:Medical Care, Health Behavior And Life Expectancy Physician Workforce, Primary Care and Life Dep. Var. LE-Males(Q1) Expectancy at 40 Ind.Var. edf p-value V.K.Chetty, s(TotMDPop) 2.874 1.02e-07 ∗∗∗ Benjamin Petrie s(PCP.MD) 2.989 1.22e-05 ∗∗∗ and Larry Culpepper s(cur.smoke.q1) 2.989 7.56e-06 ∗∗∗ s(exercise.any.q1) 6.268 0.021 ∗ s(ImigPop) 5.249 < 2e-16 ∗∗∗ s(Medic.IP.%) 2.886 < 2e-16 ∗∗∗ R-sq.(adj) 0.549 Dev. Exp 57.4% GCV = 1.05 Scale est. = 0.99 n = 1,359

Physician Density & PCP-MD Ratios Physician Workforce, Primary Care and Life 0.6 Expectancy at 40 Policy Change V.K.Chetty, Benjamin Petrie 0.5 and Larry PCP.MD.Ratio Culpepper 0.4 Observed Relation 0.3 0 10 20 30 40 MDs per 10,000 Population