Physicians graduated outside the U.S. offer better care for Medicare patients with complex needs

A study by a Massachusetts General Hospital (MGH) research team indicates that internal medicine physicians who are graduates of medical schools outside the U.S. care for Medicare patients with more complex medical needs than those cared for by graduates of American medical schools. Their report, published online in the Journal of General Internal Medicine, has implications for a potential impact of Federal immigration policies on access to care for Medicare patients and potentially for others.

"International medical graduates represent almost one quarter of U.S. practicing physicians and a third of primary care physicians," says McKinley Glover IV, MD, MHS, of the MGH Department of Radiology, lead and corresponding author of the report. "We know they are more likely than domestic graduates to practice in underserved and rural areas, and our study - suggesting they also care for sicker patients - adds important information."

Given the current nationwide shortage of primary care physicians and the number of international medical graduates who provide primary care services, the MGH team set out to improve understanding of the needs of the patients they serve. To do so they analyzed information from the Center for Medicare and Medicaid Services (CMS) Physician Compare database, which includes background information for physicians participating in Medicare. They included physicians listed as practicing internal medicine, excluding subspecialties, and determined whether they were graduates of domestic or international medical schools based on physician profiles on Doximity.

Information on Medicare patients cared for by each physician was based on the CMS risk scores that are calculated for patients based on age, gender and previously documented health problems and reported in the CMS Provider Utilization and Payment Data File. A risk score of 1.0 would reflect a Medicare beneficiary predicted to have average health care costs, while a score of 1.5 would indicate a beneficiary whose costs would be expected to be 50 percent higher.

Among the almost 75,000 internal medicine physicians included in the study, 52 percent were graduates of domestic medical schools, 30 percent were international medical graduates, and the status for the other 18 percent was unknown. While the average risk score of all Medicare patients was 1.73, among patients of domestic graduates the average score was 1.45, while patients of international medical graduates had an average risk score of 1.94. After adjustment for several characteristics related to physicians and their practices, the average scores for Medicare patients cared for by international medical graduates remained significantly higher.

Senior author Jason H. Wasfy, MD, MPhil, MGH Division of Cardiology, says, "Studies have shown that the U.S. health care system has been increasing its reliance on international medical graduates to counteract the growing physician shortage. Our findings add to previous literature by demonstrating that international medical graduates generally care for sicker Medicare beneficiaries. Although policies that restrict or discourage international medical graduates from entering and practicing in the U.S. probably would not have an impact on care for several years, there is a real concern about restrictive immigration policies reducing access to primary care for the sickest Americans."

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