Predicting Fragmented Care: Beneficiary, Physician, Practice, and Market Characteristics.

BACKGROUND: Understanding what drives fragmented ambulatory care (care spread across multiple providers without a dominant provider) can inform the design of future interventions to reduce unnecessary fragmentation. OBJECTIVES: To identify the characteristics of beneficiaries, primary care physicians, primary care practice sites, and geographic markets that predict highly fragmented ambulatory care in the United States. RESEARCH DESIGN: Cross-sectional analysis of Medicare claims data for beneficiaries attributed to primary care physicians and practices in 2018. We used hierarchical linear models with random intercepts and an extensive list of explanatory variables to predict the likelihood of high fragmentation. SUBJECTS: A total of 3,540,310 Medicare fee-for-service beneficiaries met the inclusion criteria, attributed to 26,344 primary care physicians in 9300 practice sites, and 788 geographic markets. MEASURES: We defined high care fragmentation as a reversed Bice-Boxerman Index score above 0.85. RESULTS: Explanatory variables explained only 6% of the variation in highly fragmented care. Unobserved differences between primary care physicians, between practice sites, and between markets together accounted for 4%. Instead, 90% of the variation in high fragmentation was unobserved residual variance. We identified the characteristics of beneficiaries (age, reason for original Medicare entitlement, and dually eligible for Medicaid insurance), physicians (comprehensiveness of care), and practices (size, being part of a system/hospital) that had small associations with high fragmentation. CONCLUSIONS: Variation in fragmentation was not explained by observed beneficiary, primary care provider, practice site, or market characteristics. Instead, the aggregate behavior of diverse health care providers beyond primary care, along with unmeasured patient preferences and behaviors, seem to be important predictors.

Communication Gaps Persist Between Primary Care and Specialist Physicians.

A survey conducted with data from 2008 found that physicians often do not communicate with each other at the time of referral or after consultation. Communication between physicians might have improved since then, with the dissemination of electronic health records (EHRs), but this is not known. We used 2019 survey data to measure primary care physicians' perceptions of communication at the time of referral and after consultation. We found that large gaps in communication persist. The similarity between these survey results suggests that despite the dissemination of EHRs, physicians still do not consistently communicate with each other about the patients they share.

Primary care redesign and care fragmentation among Medicare beneficiaries.

OBJECTIVES: To determine associations between a large-scale primary care redesign-the Comprehensive Primary Care Plus (CPC+) Initiative-and the extent of continuity or fragmentation of ambulatory care for Medicare fee-for-service beneficiaries during the first 3 years of CPC+. STUDY DESIGN: We used a difference-in-differences framework with a comparison group of practices that were similar to CPC+ practices at baseline (eg, practice size, demographics, Medicare spending). Regressions controlled for clustering, baseline patient characteristics, and practice fixed effects. Our study covered January 2016 through December 2019 and included 1,085,707 beneficiaries attributed to 2883 CPC+ practices and 2,274,068 beneficiaries attributed to 6912 comparison practices. METHODS: We focused on beneficiaries with highly fragmented care at baseline because they may have changed the most in response to CPC+. Key outcome measures were the numbers of ambulatory visits and unique practitioners, reported by specialty category; the percentage of visits with the usual provider of care (measuring continuity); and the reversed Bice-Boxerman Index (rBBI; measuring fragmentation). RESULTS: Medicare beneficiaries with high fragmentation (rBBI ≥ 0.85) at baseline (40% of the sample) had a mean of 13 ambulatory visits across 7 practitioners; the most frequent provider of care accounted for only 28% of visits. By contrast, the remaining beneficiaries had a mean of 10 visits across 4 practitioners, with the most frequent provider accounting for 54% of visits. There were no differences in continuity or fragmentation of care for CPC+ vs comparison beneficiaries. CONCLUSIONS: We find no evidence that CPC+ increased continuity or decreased fragmentation of care.

Use of eye care and associated charges among the Medicare population: 1991-1998.

OBJECTIVE: To examine trends in the utilization and cost of eye care in the Medicare population. METHODS: Data were obtained from fee-for-service physician claims (Part B) from a 5% sample of Medicare beneficiaries 65 years and older. Use of eye care services and procedures, frequency of ocular diagnoses, and allowed charges were compared for each year from 1991 through 1998. RESULTS: The proportion of beneficiaries receiving eye care increased from 41.4% to 48.1% during the 8-year period. Part B charges attributable to eye care decreased from 12.5% to 10.4%, with annual inflation-adjusted charges per beneficiary decreasing from 235 dollars to 176 dollars (1998 dollars). The proportion of beneficiaries with cataract-related claims increased from 23.4% to 27.3%, accounting for approximately 60% of eye care charges each year; beneficiaries with retinal disease claims increased from 7.8% to 11.4%, capturing 15.4% of eye care charges in 1998, up from 10.7% in 1991; and beneficiaries with glaucoma claims increased from 6.8% to 9.5%, accounting for nearly 10% of eye care charges each year. CONCLUSIONS: The proportion of the Medicare population receiving eye care increased between 1991 and 1998. Nevertheless, eye care costs did not increase, primarily because of constraints in charges associated with the management of cataract.

Race/ethnic disparities in utilization of lifesaving technologies by Medicare ischemic heart disease beneficiaries.

OBJECTIVE: The objective of this study was to explain race/ethnic disparities in hospitalizations, utilization of high-technology diagnostic and revascularization services, and mortality of elderly ischemic heart disease (IHD) patients. DESIGN: A longitudinal Medicare claims database of all Part A hospital and Part B physician services provided elderly patients admitted for IHD in 1997 is used to construct admission, utilization, and mortality rates for whites and blacks, Asians, Hispanics, and American Indians. Z-scores are used to test differences in rates between whites and minorities at the 99% confidence level. Logistic and proportional hazard models are used to predict the likelihood of revascularization and its effects on race/ethnic survival 2 years postdischarge. SETTING: The setting of this study was an acute hospital supplemented by all ambulatory Part B outpatient providers of care. PATIENTS/PARTICIPANTS: Participants included all 700,000 age 65+ Medicare beneficiaries in fee-for-service identified with IHD as a primary diagnosis on admission in 1997. MEASUREMENTS AND MAIN RESULTS: Whites were 26% more likely to be admitted for IHD than blacks, 50% more likely than Asians, 5% more than American Indians, but 3% less likely than Hispanics. Once admitted, elderly blacks and American Indians undergo invasive diagnostic and surgical revascularization far less often than whites (P < 0.01), although blacks are equally as likely as whites to be admitted to an open heart hospital. Controlling for other factors, whites reduce their 2-year mortality by 20% by undergoing revascularization 41% of the time. Blacks gain only 11% as a result of much lower rates and gains to revascularization than whites. Asians and Hispanics were slightly more likely than whites to undergo revascularization but gain less than whites from the procedure. CONCLUSIONS: Despite having similar Medicare health insurance coverage, elderly utilization and IHD mortality rates differ markedly not only between whites and minorities, but within minority groups themselves. A large, nationally representative survey of physicians and patients is needed to distinguish between systemwide "failures to refer" and patient "aversions to surgery" as explanations for lower black rates of surgical interventions.