- Regions with more primary care providers saw less Medicare spending on end-of-life care compared to areas with less primary care practices, a recent Annals of Family Medicine study found. Medicare spending during the last two years of life was $3,870 less per patient in regions with higher primary care provider involvement.
Using 2010 Medicare claims data, researchers uncovered that greater primary care concentration areas decreased Medicare spending because patients tended to receive lower-cost and lower-intensity care.
“Chronically ill adults living in regions with greater primary care physician involvement experience less hospital and ICU care in their last 6 months of life and are less likely to have more than 10 physicians involved in their care,” wrote study authors. “In addition, these regions have less costly end-of-life care, despite lower rates of hospice use.”
Based on the 306 hospital referral regions and over 1.1 million Medicare beneficiaries studied, Medicare spending during the last two years of life went from $69,030 in areas with less primary care providers to $65,160 in areas with greater levels.
End-of-life Medicare spending reductions stemmed from less fragmented care and more primary care visits. About 37 percent of decedents in regions with higher primary care involvement saw 10 or fewer providers in the last six months of life versus 42.4 percent of decedents in low primary care involvement regions.
Decedents were also more likely to see their primary care providers compared to other specialists during the last six months of life. The interquartile range of primary care to specialist end-of-life visits was 0.77 to 1.21 with high versus low primary care regions.
Regions with greater primary care involvement also had less ICU use, contributing to lower Medicare spending. Decedents only spent 2.9 days on average in the ICU during the last six months of life compared to 4.29 ICU days for decedents in low involvement areas.
However, researchers pointed out that areas with more primary care providers also contained less specialists and ICU beds even though each region’s provider density was similar.
The study also showed that hospice enrollment rates were lower in regions with more primary care providers. Areas with the greatest number of primary care providers saw the lowest hospice enrollment rates with 44.5 percent of decedents.
About half of decedents in low primary care involvement regions spent time in hospice.
Researchers noted that “greater primary care physician involvement is associated with less hospice use is a paradox worthy of further investigation.”
Hospice care is provided to patients who no longer wish to continue treatment because the patients are nearing the end of their lives. Under hospice care, patients tend to avoid expensive treatments and adverse healthcare events, such as hospitalizations.
The study, however, found that more primary care involvement was actually linked to less hospice use. Researchers explained that primary care providers may avoid pushing terminally ill patients into hospice care because of the negative perception of ending a long-standing relationship. Primary care providers also may not recognize a prognosis of less than six months to live because of the long-standing relationship.
Hospice facilities also tended to be more concentrated in areas with less primary care providers, potentially contributing to lower enrollment rates.
“This study provides preliminary evidence that the involvement of primary care physicians is a source of regional variation in end-of-life care,” concluded study authors. “In addition, it is promising that areas of high primary care physician involvement appear to have lower-intensity, lower-cost care.”
“Given the size of the aging population and the magnitude of the primary care physician infrastructure, further work to understand and optimize the role of primary care physicians will be critical to improve care of the dying.”