Issues In Continuity of Care for Medicare Patients
By Richard Shank
Researchers at the University of Texas, in collaboration with the Medical College of Wisconsin, recently published the results of a study tracking the continuity of care for Medicare patients during hospitalization.
Continuity of care is an important part of providing quality health care. The continuity of the doctor-patient relationship is especially important for older adults who may have a long and complex medical history. Continuity is important for information sharing and care management. When done effectively, the doctor-patient relationship can be integrated across care environments and through time. Problems with care continuity lead to deteriorations in this relationship and cause disruptions in care, misunderstandings about care history, and poor clinical treatment.
Before this study, most research focused on continuity of care in outpatient settings and did not follow the course of care after a hospitalization. Using enrollment and insurance claims data, the researchers sampled 5% of national Medicare beneficiaries 66 years of age and better which produced a retrospective cohort study of more than 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 a familiar outpatient physician and/or a primary care physician.
The results indicated a significant drop: In 1996, fifty-one percent were visited by outpatient physicians and 44% were visited by their primary care physician; however, these figures dropped to 39% and 32%, respectively, by 2006. The researchers found the greatest impact in weekend hospitalizations, at academic or teaching hospitals, and in large metropolitan areas, particularly New England.
After further analysis, the researchers discovered that nearly one-third of this decrease in the continuity of care was a direct result of an increased use of hospital-based doctors during the study period. It was also found that Medicare itself affects continuity of care because it allows reimbursement for only one generalist clinician during hospital care. Therefore, outpatient physicians have little incentive to follow their patients during hospitalization.
This decline in continuity of care indicates that the relationships necessary to transfer clinical information from inpatient to outpatient settings are either non-existent or unnecessarily limited by the financial constraints of the current Medicare system. Therefore, reform efforts should target incentives for outpatient physicians so they can become more involved in the hospitalizations of their patients.
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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