Outpatient care in US shifts toward specialty care

A recent analysis showed that Medicare beneficiaries are receiving more outpatient care from specialists without increased engagement with their primary care providers.

In 2019, the average primary care provider had 83% more physicians treating their panel of Medicare beneficiaries compared with 2000, representing “a substantial expansion of the coordination burden” that primary care providers face, according to researchers.

“There are so many new drugs, technologies and options for patients with chronic illness. A lot of this is exciting, but it also adds lots of doctors to my patients’ care,” Michael L. Barnett, MD, MS, a primary care physician and assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health, told Healio Primary Care. “This can be bewildering for patients and quite a lot of work for me to figure out. I wanted to understand how this observation was playing out on a national scale.”

Barnett and colleagues analyzed data on patients enrolled in fee-for-service Medicare — 6,140,952 in 2000 and 7,165,513 in 2019 — to determine trends in outpatient care delivery and the implications of such trends on primary care coordination. More than three-quarters of each cohort were white, and about 70% of each cohort lived in urban areas.

The researchers wrote that 61.2% of the Medicare beneficiaries had a primary care visit in 2000 compared with 65.7% in 2019. There was little change in the mean annual number of primary care office visits for each beneficiary, which rose from 2.99 to 3 during this same 20-year span, according to Barnett and colleagues. However, the mean number of primary care providers that each beneficiary visited annually rose 36%. Conversely, the mean annual number of visits to a specialty physician rose 20% and the mean number of unique specialists visited rose 34.2%.

In addition, the proportion of Medicare beneficiaries who visited five or more physicians yearly went from 17.5% in 2000 to 30.1% in 2019. A primary care provider’s panel of Medicare beneficiaries saw a median of 52 other physicians in 2000; 20 years later, that number had risen to 95.

“Collectively, these changes translated over the 20-year period into a substantial 83% increase in the total number of other physicians with whom PCPs must theoretically coordinate care for their Medicare panel, with one-third of Medicare beneficiaries not accessing a PCP to coordinate that care,” Barnett and colleagues wrote in Annals of Internal Medicine.

The results indicate that health care is moving in the direction of specialty-based health care and that a “substantial expansion of the quantity and diversity of clinical care that PCPs (if they are available) must follow to understand their panel’s care,” the researchers wrote.

“These results also suggest that the work necessary to follow, understand and coordinate the health care of a patient panel was a more complex and time-consuming task in 2019 than in 2000,” they added.

The findings align with other studies that suggest specialists are more involved in their patients’ care than they were decades ago and affirm that “being a PCP is a different job in 2019 than it was in 2000,” Barnett told Healio Primary Care.

“More specialty care may or may not be a clearly good thing,” he said. “It has pluses and minuses. What is not a good thing is that the complexity of care coordination has increased dramatically in the past 2 decades but there has been little change in payment reform or health care delivery to accommodate this.”

Barnett said that he believes this trend toward specialty outpatient care will continue.

“To improve system performance and respond to expanding care fragmentation, future policy reforms to primary care payment and delivery should account for evolving needs in the time and resources required to appropriately manage the ever-increasing complexity of medical care,” the researchers wrote.