The Impact of Interpersonal Continuity of Primary Care on Health Care Costs and Use: A Critical Review.

PURPOSE: Interpersonal continuity has been shown to play an essential role in primary care's salutary effects. Amid 2 decades of rapid evolution in the health care payment model, we sought to summarize the range of peer-reviewed literature relating continuity to health care costs and use, information critical to assessing the need for continuity measurement in value-based payment design. METHODS: After comprehensively reviewing prior continuity literature, we used a combination of established medical subject headings (MeSH) and key words to search PubMed, Embase, and Scopus for articles published between 2002 and 2022 on "continuity of care" and "continuity of patient care," and payor-relevant outcomes, including cost of care, health care costs, cost of health care, total cost of care, utilization, ambulatory care-sensitive conditions, and hospitalizations for these conditions. We limited our search to primary care key words, MeSH terms, and other controlled vocabulary, including primary care, primary health care, family medicine, family practice, pediatrics, and internal medicine. RESULTS: Our search yielded 83 articles describing studies that were published between 2002 and 2022. Of these, 18 studies having a total of 18 unique outcomes examined the association between continuity and health care costs, and 79 studies having a total of 142 unique outcomes assessed the association between continuity and health care use. Interpersonal continuity was associated with significantly lower costs or more favorable use for 109 of the 160 outcomes. CONCLUSIONS: Interpersonal continuity today remains significantly associated with lower health care costs and more appropriate use. Further research is needed to disaggregate these associations at the clinician, team, practice, and system levels, but continuity assessment is clearly important to designing value-based payment for primary care.

Measuring Outcomes: Lessons From the World of Public Education.

The quality and efficiency of American health care are increasingly measured using clinical and financial data with a goal of improving clinical practice. Proponents believe such efforts can improve outcomes, motivate clinicians, and inform the public about quality. Detractors point to problems with the accuracy of these measures and the risk of creating perverse incentives for both physicians and patients. Drawing on lessons from similar performance management policies in public education, we provide guidance about this trend for primary care physicians and health care policy makers. We argue that public school teacher evaluations that use value-added modeling foretell specific pitfalls for the use of similar models to evaluate physician effectiveness, and that unintended consequences of performance management in both education and health care can include the narrowing of purpose, deprofessionalization, and a loss of local/community control.

Health is primary: Family medicine for America's health.

PURPOSE: More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to "renew the specialty to meet the needs of people and society," some of which bore important fruit. Family Medicine for America's Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim). METHODS: Family Medicine for America's Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included. RESULTS: The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly $20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM. CONCLUSIONS: Family Medicine for America's Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.

Storylines of family medicine III: core principles-primary care, systems and family.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'III: core principles-primary care, systems, and family', authors address the following themes: 'Continuity of care-building therapeutic relationships over time', 'Comprehensiveness-combining breadth and depth of scope', 'Coordination of care-managing multiple realities', 'Access to care-intersectional, systemic, and personal', 'Systems theory-a core value in patient-centered care', 'Family-oriented practice-supporting patients' health and well-being', 'Family physician as family member' and 'Family in the exam room'. May readers develop new understandings from these essays.

A model for a standardized national family medicine graduate survey.

BACKGROUND AND OBJECTIVES: Accreditation requirements mandate that family medicine residency programs perform surveys of graduates. As part of the Preparing the Personal Physician for Practice (P4) Project, we developed a model for a standardized national graduate survey to be used to assess practice characteristics of graduates, including the implementation of features of the Patient-centered Medical Home (PCMH). METHODS: We conducted a content analysis of residency graduate surveys from the 14 programs involved in the P4 project to identify common elements of importance to residencies. We then designed a new graduate survey as a core measure of the P4 Project. It included practice characteristics, assessment of training, and the status of features of the PCMH. RESULTS: Categories of variables common to the graduate surveys of the P4 programs included physician and practice characteristics, work load, scope of practice, career satisfaction, and assessment of training. We found variability among programs in the number of procedures and residency content areas listed on any individual program survey, with the number of procedure ranging from 0--21, and the number of content areas ranging from 0-61. The only PCMH feature included on any P4 program survey was the status of an electronic medical record. CONCLUSIONS: Graduate surveys from individual residency programs vary widely. Using a standardized national survey instrument would provide important information to understand the national practice characteristics and scope of practice in family medicine as well as to track the implementation of PCMH features among residency graduates.

Revolutionary leadership and family medicine education.

Reform of the payment and delivery systems in American health care is now being discussed at the highest levels of business and government. Family medicine educators, researchers, and program leaders have an opportunity to provide substantial leadership to this process in their own communities and nationally. To do so, they must reconsider the assumptions made in creating our current systems of practice and education, and this will require new leadership skills that focus on innovation and adaptability. It will also require a more aggressive willingness to test new ideas and a new scientific method to prove or disprove their value. This essay outlines essential elements of such leadership for those responsible for the education of future generations of family physicians.

Defining basic health benefits: lessons learned from the Oregon Health Plan.

The Oregon Health Plan was instituted in 1994 with the goal of assuring basic health care for everyone in the state. The plan used an innovative public process to rank health services as its method of defining basic health care benefits. Due to its inability to constrain health care costs and an economic recession in the state, many of the plan's core elements are no longer operational. This essay outlines lessons learned from the Oregon Health plan's successes and failures and describes a new process of health reform that began in Oregon in 2007.

Are we serious about teaching professionalism in medicine?

Medical professionalism is an increasingly common topic of discussion in the medical education literature. Much of the recent literature on this subject addresses areas of weakness in the educational curricula of medical schools and residency programs. But students are living a world in which professional behavior is being redefined, often in ways that run contrary to the medical education curriculum. This article outlines three fundamental challenges that powerfully affect the ability to promote professionalism in students and young physicians. To overcome these challenges, the author suggests four steps that can be taken in the medical education community. First, medical schools should address cost and access to care as first-order intellectual problems and should encourage research programs in these areas. Second, schools should develop programs to humanize science and restore scientific integrity beyond the requirements of compliance programs. Next, medical school leaders should celebrate those who best embody moral leadership in the profession. Finally, the medical education community should acknowledge that the availability of affordable health care to the public depends on the practice choices of medical school graduates and should accept greater responsibility for this outcome.

Residency applicants' perspectives on family medicine residency training length.

BACKGROUND AND OBJECTIVES: The Future of Family Medicine report advocated experimentation with 4-year residency training models. This study examines residency applicants' opinions about extending the length of residency training and seeks to determine which features of an extended program would be most desirable to applicants. METHODS: We conducted a cross-sectional, descriptive, self-administered survey of residency applicant interviewees at Oregon's three family medicine residency training programs in 2004-2005. The survey included questions about demographics, factors influencing specialty choice, desirability of longer training programs, and desirability of certain types of additional training. RESULTS: A total of 155 surveys were returned, for an 89.1% response rate. Only 6% of respondents indicated that length of training was "very important" to their specialty choice; 85.0% indicated a preference for a 4-year program with or without specific experiences; 77.2% indicated that extended training would either increase their likelihood of choosing family medicine or would not affect their decision; and 79.3% indicated that a 4-year residency would not make them less likely to choose family medicine over other primary care specialties. Pregnancy care, trauma care, adolescent/child health, and procedural skills were the most commonly desired areas for additional training. CONCLUSIONS: Lengthening training to 4 years would have a neutral or positive effect on applicants' interest in family medicine training in Oregon.

Interpersonal continuity of care and care outcomes: a critical review.

PURPOSE: We wanted to undertake a critical review of the medical literature regarding the relationships between interpersonal continuity of care and the outcomes and cost of health care. METHODS: A search of the MEDLINE database from 1966 through April 2002 was conducted by the primary author to find original English language articles focusing on interpersonal continuity of patient care. The articles were then screened to select those articles focusing on the relationship between interpersonal continuity and the outcome or cost of care. These articles were systematically reviewed and analyzed by both authors for study method, measurement technique, and quality of evidence. RESULTS: Forty-one research articles reporting the results of 40 studies were identified that addressed the relationship between interpersonal continuity and care outcome. A total of 81 separate care outcomes were reported in these articles. Fifty-one outcomes were significantly improved and only 2 were significantly worse in association with interpersonal continuity. Twenty-two articles reported the results of 20 studies of the relationship between interpersonal continuity and cost. These studies reported significantly lower cost or utilization for 35 of 41 cost variables in association with interpersonal continuity. CONCLUSIONS: Although the available literature reflects persistent methodologic problems, it is likely that a significant association exists between interpersonal continuity and improved preventive care and reduced hospitalization. Future research in this area should address more specific and measurable outcomes and more direct costs and should seek to define and measure interpersonal continuity more explicitly.

Envisioning a New Health Care System for America.

BACKGROUND AND OBJECTIVES: Between August 2013 and April 2014, eight family medicine organizations convened to develop a strategic plan and communication strategy for how our discipline might partner with patients and communities to build a new foundation for American health care. An outline of this initiative, Family Medicine for America's Health (FMAHealth), was formally announced to the public in October 2014. The purpose of this paper and the five papers to follow is to describe the guiding principles of FMAHealth in greater detail. FMAHealth is taking place at a pivotal point in the history of American health care, when the deficiencies of our overly expensive, underperforming health care delivery system are becoming more apparent than ever. By forming strategic partnerships to implement this initiative, family medicine seeks to define a new approach to health system leadership, care delivery, education, and research. This will require substantial reorientation of existing priorities and reimbursement systems, which are focused on delivering services, instead of on improving health. Family medicine is committed to engaging and empowering patients, their families and communities, and other health care professionals to establish a more equitable, effective, and efficient delivery system--a system in which health is the primary design element and the "Triple Aim" is the guiding principle.

A New Foundation for the Delivery and Financing of American Health Care.

BACKGROUND AND OBJECTIVES: For the past decade, primary care practices across America have worked to implement a practice model called the Patient-Centered Medical Home (PCMH) to revitalize practice, better support clinicians and patients, improve efficiency, and facilitate growth in primary care capacity. In spite of substantial progress, this work has not been matched by sufficient change in the payment system to allow these goals to be accomplished. Nevertheless, improving the quality and availability of primary care remains essential to achieving the goals of the Triple Aim (better health care, better population health, and containment of health care costs). For this to occur, the PCMH model of care must be further refined, and the payment system for primary care must be completely restructured. The need for these changes is urgent. In October 2014, the discipline of family medicine announced a comprehensive strategic plan called Family Medicine for America's Health (FMAHealth). FMAHealth proposes to expand the PCMH care model by fully integrating our nation's behavioral/mental health, public health, and primary care systems to create a new foundation for American health care. Accomplishing these ambitious goals will require a broad coalition of private and public interests across the health care disciplines as well as patients, communities, government, and businesses. These changes require additional infrastructure that existing financing systems do not adequately support, so comprehensive payment reform is essential for large-scale dissemination and sustainability of this model. The new payment model must reward value rather than volume of service and must provide a secure financial foundation for practices designed to care for patients and communities at affordable costs.