Q&A: Continuity of primary care lowers health costs

Key takeaways:

• Continuity of care leads to better health care utilization and lower costs.
• Health care systems should consider ways to improve continuity, but to do this, they need to find a way to measure it.

Higher continuity of care has consistently been linked to better patient outcomes, and health care systems should consider ways to better the practice, according to researchers.

Continuity of care — the ongoing relationship between patients and their physicians and a core attribute of high-quality primary care — plays an essential role in positive outcomes, Andrew Bazemore, MD, MPH, senior vice president of research and policy for the American Board of Family Medicine, and colleagues wrote in Annals of Family Medicine. The COVID-19 pandemic highlighted the importance of these continuous, trusting relationships as disinformation and patient distrust spread, they added.

Continuity been shown to improve overall trust in physicians, especially among populations disproportionately affected by the pandemic such as Black people, older adults and low-income women, they wrote.

In their article, Bazemore and colleagues summarized the peer-reviewed literature relating to health care costs and continuity of care. This information, they wrote, is critical to assessing the need for continuity measurement in value-based payment design.

Healio spoke with Bazemore about their findings, the importance of continuity of care, how it can be improved and more.

Healio: Will you briefly describe your study’s findings?

Bazemore: The health care system has evolved rapidly in the past 20 years, so I worked with a team of researchers to find and summarize all the academic literature on the impact of longitudinal patient-doctor relationships. We examined 83 peer-reviewed articles overall between the years 2002 and 2022. In the end, this body of evidence tells us that when patients and doctors have continuous relationships over time, it leads to lower health care costs and more appropriate kinds of care. That’s a big insight for health plans and policymakers: if we can find ways to support long-term relationships between physicians and patients, we all win. We also think more research is needed into the levels at which continuity is impactful — for example, at the level of the practice, the health care team or even the health system. In the end, we know that continuity is an important attribute of a high-performing, person-centered health system.

Healio: Why is continuity of care important?

Bazemore: Long-term doctor-patient relationships are both a hallmark of the primary care profession and foundational to its salutary effects. Having a continuous relationship over time with a primary care physician improves diagnostic accuracy, reduces costs and increases patient trust and professional satisfaction. These longitudinal healing relationships are rewarding. They also help improve physician burnout and reduce turnover at a time when 40% of physicians report they are mentally or financially fragile following the COVID-19 pandemic. Continuous relationships mean a lot to patients, too: they are associated with higher patient satisfaction.

Healio: What are the clinical implications of your findings?

Bazemore: The clear and consistent pattern of higher continuity leading to lower undesirable utilization and costs should drive health systems to consider ways to improve continuity of primary care at the health system, practice and clinician levels. When patients and family caregivers are part of an ongoing, long-term relationship with a physician, their health is better in a wide range of chronic disease areas including diabetes, asthma, cancer and dementia. There is substantial evidence that continuous doctor-patient relationships lead to lower costs, including total costs, ED costs, nursing home costs and hospital admissions costs, as well as utilization. Long-term relationships can also lead to better primary care utilization. According to one study, the loss of longitudinal relationships in primary care results in $979 million in excess health care expenditures for public and private insurers annually.

Healio: How can continuity of care be improved?

Bazemore: First, we need to measure it. Incorporating a measure of continuous relationships in federal, national and state payment programs would go a long way toward elevating continuous relationships as a priority. Second, we need to pay for it. Having a measure would open the door to paying physicians to deepen their relationships with patients, including things like spending more time together — something we know they both want. Finally, health systems need to change simple protocols in their schedule, patient portals and daily operations at the practice level to ensure patients always see their same physician.

Healio: Are there any significant disparities in continuity of care — for example, between rural vs. urban patients? If so, how can those be improved?

Bazemore: Obviously, it is easier to achieve continuity in rural areas with fewer physicians and in small and solo (practices); this is one of the reasons that we need to work to preserve such practices in an era where they face considerable pressures to consolidate. Small primary care practices have also been demonstrated to disproportionately care for vulnerable populations.

One of the foundational elements required to achieve health equity is trust between doctors and patients. Long-term, continuous relationships are the foundation for trust. Patients who trust their doctors more may be more likely to seek help when they need it and more likely to follow through with medication and treatment plans, which enables better health outcomes.

In fact, in a recent survey by the American Board of Family Medicine, almost all respondents agreed that continuity is an enabler of more equitable care, including more than half who reported continuous doctor-patient relationships have a significant effect on equitable care.

Healio: Is there anything else you’d like to add?

Bazemore: If nothing else, this paper reminds us that continuity remains a foundational element in explaining how primary care achieves positive outcomes. It is too often neglected in an increasingly fragmented approach to care delivery and in desperate need of more attention, measurement and improvement if our health system wishes to achieve its aims for high quality and equitable care.

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