More Comprehensive Care Among Family Physicians Is Associated With Lower Costs and Fewer Hospitalizations

Andrew Bazemore, MD, MPH; Stephen Petterson, PhD; Lars E. Peterson, MD, PhD; Robert L. Phillips Jr, MD, MSPH

Disclosures

Ann Fam Med. 2015;13(3):206-213. 

In This Article

Abstract and Introduction

Abstract

Purpose Comprehensiveness is lauded as 1 of the 5 core virtues of primary care, but its relationship with outcomes is unclear. We measured associations between variations in comprehensiveness of practice among family physicians and healthcare utilization and costs for their Medicare beneficiaries.

Methods We merged data from 2011 Medicare Part A and B claims files for a complex random sample of family physicians engaged in direct patient care, including 100% of their claimed care of Medicare beneficiaries, with data reported by the same physicians during their participation in Maintenance of Certification for Family Physicians (MC-FP) between the years 2007 and 2011. We created a measure of comprehensiveness from mandatory self-reported survey items as part of MC-FP examination registration. We compared this measure to another derived from Medicare's Berenson-Eggers Type of Service (BETOS) codes. We then examined the association between the 2 measures of comprehensiveness and hospitalizations, Part B payments, and combined Part A and B payments.

Results Our full family physician sample consists of 3,652 physicians providing the plurality of care to 555,165 Medicare beneficiaries. Of these, 1,133 recertified between 2007 and 2011 and cared for 185,044 beneficiaries. There was a modest correlation (0.30) between the BETOS and self-reported comprehensiveness measures. After adjusting for beneficiary and physician characteristics, increasing comprehensiveness was associated with lower total Medicare Part A and B costs and Part B costs alone, but not with hospitalizations; the association with spending was stronger for the BETOS measure than for the self-reported measure; higher BETOS scores significantly reduced the likelihood of a hospitalization.

Conclusions Increasing family physician comprehensiveness of care, especially as measured by claims measures, is associated with decreasing Medicare costs and hospitalizations. Payment and practice policies that enhance primary care comprehensiveness may help "bend the cost curve."

Introduction

The Patient Protection and Affordable Care Act (ACA) of 2009 has returned attention to primary care and its role in achieving the nation's Triple Aim of improved population health and patient care with lower costs.[1] Decades of evidence support primary care's potential as an antidote to health care costs, whose growth has outpaced that of the overall economy for decades and may yet accelerate, given our aging, enlarging, and increasingly insured population.[2,3] Among the definitional features of primary care thought to be responsible for its positive impact is comprehensiveness, or the provision of care across a broad spectrum of health problems, age ranges, and treatment modalities. The Institute of Medicine, in an often-referenced 1996 publication on primary care, defined comprehensiveness as "…the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs."[4] The value of this function of primary care was reiterated by the World Health Organization in 2008.[5] To serve as first contact for undifferentiated illness, another primary care principle, requires comprehensiveness to effectively differentiate symptoms and complaints, diagnose and treat where necessary. Likewise, continuity in the physician-patient relationship, one of the most studied of primary care features, relies upon comprehensiveness, as does coordination of the relationship across many settings. In theory, comprehensiveness is supposed to make delivery of "the right care, at the right time, in the right place" and the avoidance of more costly care later more likely.

Among primary care specialties, the traditional scope of family medicine is perhaps the broadest, including care for all patients, for all presenting complaints, across sites, ages, and modalities including inpatient, outpatient, obstetric, pediatric, geriatric, procedures, minor surgeries, and community health functions. Despite broad training, the general scope of care provided by family physicians has been shrinking.[6,7–11] The credentialing and logistical challenges required to work across multiple delivery settings, competitive pressures from a growing array of specialty service providers, lifestyle demands, increasing complexity of chronic disease care, and market incentives to streamline practice leave the majority of family physicians working strictly in nonhospital, office-based settings, while a small but growing number function primarily as hospitalists or in emergency departments and urgent care facilities.[12] Growing evidence reveals both reduction and considerable variation in the range of services offered by family physicians, which may have implications for costs of care.[1,13,14]

Despite these trends, the 2004 Future of Family Medicine Report noted that the discipline was "committed to providing the full basket of clinical services offered by family medicine."[5] With the 2014 release of Family Medicine for America's Health (FMAH), leaders are once again contemplating the future of the discipline, with some questioning whether erosion of scope of practice is a threat to the adaptiveness and pragmatism that shaped the discipline.[16] This matter is of growing importance as policymakers consider new definitions of primary care that go beyond the traditional specialty-based definition, and in some cases, frame primary care as a simple process or seek to narrow its functions in the name of efficiency.[17,18]

Given the considerable advances in health care technology, our aging and more insured population, and considerable variation and decreasing scope of practice by family physicians, it is unknown whether comprehensiveness still has a positive effect on costs. We therefore set out to study the relationship between individual family physicians' comprehensiveness and important outcomes for their patients, namely hospitalization rates and total costs among their Medicare beneficiaries.

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