Continuity of Care for Medicare Patients Declined Significantly

Continuity of care is an important element in the provision of quality health care. Continuity of care is defined as continuity in information, in care management, and in the doctor-patient relationship. The hope is that on-going interactions between the patient and their physicians will increase knowledge about the patient’s preferences, the health knowledge of the patient, and establish a trusting care relationship. Relationship continuity is especially important for older adults with a long and complex medical history. Disruptions in this relationship can lead to disruptions in care, misunderstandings, and poor clinical treatment.

Collaborating researchers at the University of Texas and the Medical College of Wisconsin have recently published the results of a study that tracks continuity of care for older adults during hospitalization. Most research before now has focused on continuity of care in outpatient settings and does not follow what happens to care after a hospitalization. This study was designed to address this gap in the literature.

Using enrollment and insurance claims data, the researchers sampled 5% of national Medicare beneficiaries older than 66 years to produces a retrospective cohort study of over 3 million hospital admissions between 1996 and 2006. The researchers were primarily interested in the percentage of patients who had been visited at the hospital by an outpatient physician they had seen in the previous year or their primary care physician.

The researchers found that the percentage of patients being provided with some form of continuity of care dropped from 51% seeing any outpatient physician or primary and 44% seeing their primary care physician in 1996 to 39% and 32% respectively. The greatest drop in continuity of care was in hospitalizations occurring on weekends, at academic or teaching hospitals, in large metropolitan areas, and in New England.

After further analysis, the researchers discovered that nearly 1/3 of decrease in continuity of care stemmed from a corresponding rise in the increased use of hospital based doctors during the study time-period.  Furthermore, Medicare contains financial disincentives for continuity of care because it allows for the reimbursement of only one generalist clinician for care in the hospital. Outpatient physicians have little incentive to follow their patients during hospitalization. Reform efforts should target incentives for outpatient physicians to become more involved in the hospitalizations of their patients.

This decline in continuity of care indicates that the current system is fragmented to the point where the relationships necessary to transfer clinical information from in-patient to out-patient settings are either non-existent or limited by financial considerations.

 

Source: Sharma, G., Fletcher, K., Zhang, D. et al. 2009. Continuity of outpatient care and inpatient care by primary care physicians for hospitalized older adults. JAMA 301(16): 1671-1680.

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