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Physician-level continuity critical to lower health care costs, hospitalizations

Andrew Bazemore

Higher levels of physician-level continuity were strongly associated with lower total health care costs and hospitalizations, even among seriously ill patients, according to findings recently published in Annals of Family Medicine.

“Despite a variety of definitions and calculations over the last 40 years, little has been done to operationalize continuity as a quality measure linked to policy-relevant outcomes in the United States or other nations,” Andrew Bazemore, MD, MPH, practicing family physician and director of the Robert Graham Center for Policy Studies in Washington, D.C., and colleagues wrote.

“Given current U.S. attention to provider-level vs. practice-level measures in its value-based purchasing reforms, the objective of our study was to examine the relationship between physician-level continuity and health care expenditures and hospitalizations,” they added.

Researchers used Medicare claims data to examine the association between the Usual Provider Continuity index, Bice-Boxerman Continuity of Care, Modified Modified Continuity Index and the Herfindahl Index and characteristics of more than 6,500 primary care physicians and more than 1.4 million patients. They then estimated beneficiary multilevel models to evaluate the association with hospitalizations and expenditures that controlled for physician and beneficiary characteristics.

Bazemore and colleagues found each of the four methods were “highly correlated” with lowering health care costs and hospitalizations, with coefficients ranging from 0.86 to 0.99. Physicians with more years since graduation, those who saw more Medicare patients, and those practicing in rural areas were more likely to provide continuous care. There was also greater continuity tied to similar outcomes for each method.

Researchers used the Bice-Boxerman method to demonstrate results because of its “tight correlations and the National Quality Forum endorsement.” The likelihood of hospitalization in that method was 16.1% lower between the highest and lowest continuity quintiles (OR = 0.839; 95% CI, 0.787-0.893) and the adjusted expenditure for beneficiaries cared for by physicians in the highest quintile was 14.1% lower vs. those in the lowest quintile ($8,092 vs. $6,958; beta = –0.151; 95% CI, –0.186 to –0.116).

“We accounted for a host of personal patient characteristics, including how ill patients were in our analyses, using a technique called regression to make sure that degree of illness alone didn’t explain our findings,” Bazemore told Healio Family Medicine.

He addressed barriers that can hinder physician continuity.

“The concept of longitudinal relationships with one’s patients is fairly intuitive to family physicians. However, that concept is also fragile in an age where family physicians are more constrained in their scope of practice (eg, less inpatient, obstetric, home and nursing home care), less likely to have control over their practice scheduling and own their practices (60% of family physicians are now salaried employees, not practice owners/partners), and more likely to have been trained in an age of working hours and patient handoffs,” Bazemore said.

He suggested that continuity be taught early in a family physician’s career.

“Fostering concepts of continuity begins in residency training, where helping trainees understand the importance of being a personal physician, and of relational, managerial, and administrative continuity is critical. Only a third of family practitioners can name their panel size, and ‘owning’ not only patients, but a panel of patients in this age of population health and value-based purchasing is also important,” Bazemore said.

“Finally, we must make sure that important and positive innovations of the Medical Home, such as Open Access scheduling, extended hours, and team-based care don’t have unforeseen consequences that impair continuous relationships with individual patients,” he concluded. – by Janel Miller

Disclosures: The authors report no relevant financial disclosures.