Senior physicians may care for fewer Medicaid patients and minority/ethnic patients than junior physicians

For immediate release: December 13, 2023

Senior doctors in the same practices in Boston, Massachusetts, may avoid seeing minority and low-wage Medicaid patients compared with junior doctors, according to a new study led by the Harvard T.H. Chan School of Public Health.

It’s a well-known secret that in some practices, older doctors push patients who pay lower insurance, as well as minority patients, toward more junior doctors in the practice. But this is rarely discussed publicly, said lead author Michael Barnett, associate professor of health policy and management. Our study finds evidence supporting this hidden practice, raising concerns that a two-tiered system of physician seniority promotes racial and economic segregation.

The research was published in JAMA Network Open on December 13, 2023.

Researchers used 2017 claims data from athenahealth and 2021 claims data from Medicare, representing more than 134 million patients and nearly 200,000 physicians, to analyze the differences between patients seen by the most junior doctors compared with those seen by the most senior doctors . Researchers classified physicians according to practice type perceptions (e.g., primary care or endocrinology); procedural (any surgical or procedural specialty); or non-office (e.g., emergency medicine or radiology) and evaluated patient cohorts within each group.

The study found gaps in perceptions and procedural expertise among junior and senior physician patient panels by patient insurance type and race and ethnicity. In the AthenaHealth data, senior cognitive physicians saw 1.6% fewer Medicaid patients and 1.2% fewer minority patients compared with junior cognitive physicians; senior proceduralists saw 2.9% fewer Medicaid patients and 1.2% fewer minority patients. The number of patients decreased by 1.7%. The same trend was observed in the Medicare data, confirming that these findings are not the result of a specific data source. Although the greatest differences were observed among procedural physicians, no significant differences were observed among out-of-office physicians because they did not see patients during scheduled visits.

The researchers said the lack of variation among non-office physician patient groups suggests other specialties may use their own discretion in deciding who to book patients. Cognitive and procedural specialists may be deterred by lower Medicaid reimbursement rates or higher administrative burdens, thus reducing the number of these patients. Because Medicaid patients are more likely to be racial and ethnic minorities, this may also contribute to racial disparities. The researchers noted that patient selection may also play a role in the differences.

Barnett said it was unclear whether senior doctors provided higher quality care than junior doctors. But in my experience as a primary care physician, many patients want to see a more experienced doctor. Our research shows that even within the same clinic, patients may encounter barriers in who they see because of who they are and what insurance they can afford. Addressing these barriers and expanding patient access to physicians of all types and levels is critical to building a more equitable health care system.

Racial and ethnic differences in physician qualifications and insurance coverage of patients treated, Hannah T. Neprash, David C. Chan, Ateev Mehrotra, Michael L. Barnett, JAMA Network Open, December 13, 2023, doi: 10.1001 /jamanetworkopen.2023.47367

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Maya Brownstein


The Harvard T.H. Chan School of Public Health brings together dedicated experts from multiple disciplines to educate a new generation of global health leaders and develop powerful ideas to improve the lives and health of people around the world. As a community of leading scientists, educators, and students, we work together to bring innovative ideas from the laboratory into people’s lives, not only making scientific breakthroughs but also working to transform personal behavior, public policy, and health care practice. Each year, Harvard Chan School’s more than 400 faculty teach more than 1,000 full-time students from around the world and train thousands more through online and executive education programs. Founded in 1913 as the Harvard-MIT School of Health Officials, the college is considered the oldest public health professional training program in the United States.

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