Changes in Health Care Use and Outcomes After Turnover in Primary Care

Abstract

of care may harm patient outcomes, but existing studies of continuity disruption are limited by an inability to separate the association of continuity disruption from that of other physician-related factors.OBJECTIVES To examine changes in health care use and outcomes among patients whose primary care physician (PCP) exited the workforce and to directly measure the association of this primary care turnover with patients' health care use and outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study used nationally representativeMedicare billing claims for a random sample of 359 470 Medicare fee-for-service beneficiaries with at least 1 PCP evaluation and management visit from January 1, 2008, to December 31, 2017. Primary care physicians who stopped practicing were identified and matched with PCPs who remained in practice. A difference-in-differences analysis compared health care use and clinical outcomes for patients who did lose PCPs with those who did not lose PCPs using subgroup analyses by practice size. Subgroup analyses were done on visits from January 1, 2008, to December 31, 2017. EXPOSURE Patients' loss of a PCP. MAIN OUTCOMES AND MEASURESPrimary care, specialty care, urgent care, emergency department, and inpatient visits, as well as overall spending for patients, were the primary outcomes. Receipt of appropriate preventive care and prescription fills were also examined. RESULTSDuring the study period, 9491 of 90 953 PCPs (10.4%) exited Medicare. We matched 169 870 beneficiaries whose PCP exited (37.2% women; mean [SD] age, 71.4 [6.1] years) with 189 600 beneficiaries whose PCP did not exit (36.9% women; mean [SD] age, 72.0 [5.0] years). The year after PCP exit, beneficiaries whose PCP exited had 18.4% (95% CI, −19.8% to −16.9%) fewer primary care visits and 6.2% (95% CI, 5.4%-7.0%) more specialty care visits compared with beneficiaries who did not lose a PCP. This outcome persisted 2 years after PCP exit. Beneficiaries whose PCP exited also had 17.8% (95% CI, 6.0%-29.7%) more urgent care visits, 3.1% (95% CI, 1.6%-4.6%) more emergency department visits, and greater spending

Assessment of Care Handoffs Among Hospitalist Physicians and 30-Day Mortality in Hospitalized Medicare Beneficiaries

“…Recent evidence from primary care that focuses on the potential effects of continuity of care rather than discontinuities in care suggests that continuity may be associated with improved primary care outcomes. 29 Fifth, data on the quality of handoff processes in individual hospitals were lacking, making it impossible to identify what specific processes of care within hospitals could be associated with better handoff outcomes among patients with high illness severity. Relatedly, the frequency and duration of hospitalist work blocks, as well as protocols around handoffs, likely vary significantly across hospitals, and this analysis measured the association between handoffs and mortality across hospitals, even though substantial hospital-level heterogeneity may exist.…”

Breadth and Exclusivity of Hospital and Physician Networks in US Insurance Markets

“…This concern is motivated by research documenting noteworthy disruptions in care and an increased reliance on emergency departments associated with changes in insurance plans. 13 , 14 , 15 , 16 Narrow network plans have also been shown to have lower premiums, 30 yet little is known about whether selection of a less expensive, narrow network plan increases the likelihood that patients would need to find new clinicians once they enroll. Finally, the patient financial protections established by the Patient Protection and Affordable Care Act—such as annual limits on patient out-of-pocket spending and prohibitions on annual and lifetime insurer spending maximums—apply to nearly all private health insurance plans but only for care received by in-network clinicians and hospitals.…”

“…Insurance plan changes decrease the likelihood of establishing a durable primary care relationship, decrease rates of chronic disease control, increase reliance on subspecialists for primary care services, and are associated with greater use of emergency departments. 13 , 14 , 15 , 16 …”

Consolidation of primary care physicians and its impact on healthcare utilization

“…Moreover, recent work by Sabety et al. (2020) find that Medicare beneficiaries who lose their PCP actually substitute to emergency and specialist visits in the short‐run, and thereby increase spending.…”

“…It is worth noting that our instrument is based off physician consolidation and not physician exits. In recent work, Sabety et al (2020) find that provider exits are associated with higher spending due to an immediate shift to increased specialist and emergency care. Instead, we find the exact opposite because we leverage moves associated with consolidations.…”