- Using a primary care provider versus a specialist as the predominant provider of care and care coordination resulted in similar clinical outcomes for Medicare beneficiaries. But Medicare spending was $1,781 lower per beneficiary, a recent Journal of the American Geriatrics Society study unveiled.
Medicare spending was 9 percent less when beneficiaries saw a primary care provider as their main doctor, showed the study of over 3.9 million Medicare beneficiaries who were 65 years or older with at least two chronic conditions between 2011 and 2012.
Medicare could reduce spending by $7 billion annually if all 4 million Medicare fee-for-service beneficiaries with multiple chronic diseases used a primary care provider as their main doctor.
“Primary care providers are achieving similar clinical outcomes with fewer resource inputs or, said another way, appear to be more efficient in the use of resources and hence may provide better value. The magnitude of these savings is greater than many reforms designed to achieve savings in Medicare,” wrote the Dartmouth Institute for Health Policy and Clinical Practice researchers.
Alternative payment models, such as accountable care organizations and patient-centered medical homes, engage primary care providers as care gatekeepers.
However, a 2016 Dartmouth Atlas report revealed that 43 percent of older fee-for-service Medicare beneficiaries saw a specialist for the bulk of their outpatient visits.
With a substantial portion of beneficiaries using specialists as care gatekeepers, researchers explored if specialists improved patient outcomes and lowered healthcare spending compared to primary care providers.
The data revealed that using a primary care provider as the predominate provider of care led to slightly better clinical outcomes. Although the outcome differences were statistically significant because of the large sample size, researchers noted.
Researchers reported the following clinical outcomes for Medicare beneficiaries using specialists as their predominant provider of care:
• 0.2 percent higher mortality compared to beneficiaries using a primary care provider
• 40.3 per 1,000 more hospitalizations
• 7.8 per 1,000 more ambulatory care-sensitive admissions
• 24 percent lower continuity of care scores as measured by the continuity of care index
• 0.5 more total ambulatory visits
Despite modest clinical differences between using a primary care provider or a specialist, researchers found that Medicare spending significantly varied depending on the provider type.
Individuals who met with a primary care provider incurred fewer healthcare costs because they had lower professional fee payments. Primary care providers saw $769 less per beneficiary in the healthcare payments.
“The difference in professional fees was driven largely by visits, procedures, and the miscellaneous category of ‘other’ that includes services such as ambulance transfers, vision and hearing care, chemotherapy or other drugs, and chiropractic care,” researchers stated.
The primary care gatekeepers also reported $510 less per beneficiary in hospitalization and outpatient facility costs, respectively.
But the data uncovered that using primary care providers as the predominate provider of care incurred greater healthcare costs for some healthcare services. Their gatekeeper role resulted in $85 more per beneficiary on late-stage disease or disability services.
They also generated $45 more per beneficiary on home health care.
Additionally, the study found that beneficiaries with multiple chronic diseases were more likely to use a primary care provider as their predominant provider of care. About two-thirds of the individuals studied had a primary care provider as their care gatekeeper.
Most of these individuals saw a general internist with 35 percent of beneficiaries in this group, followed by family medicine providers with 28.3 percent.
The study also revealed that Medicare beneficiaries were more likely to see a primary care provider as their care gatekeeper if they were older, female, dually eligible for Medicare and Medicaid, had diabetes mellitus or dementia, and lived in low-income communities.
For individuals primarily seeing a specialist, most used a cardiologist with 9 percent of beneficiaries.
Another commonly used specialist included hematologists and oncologists with 3.9 percent of beneficiaries.
Researchers pointed out that the specific specialists used by individuals depended on the chronic disease they had. For example, cardiologists acted as care gatekeepers for 18 percent of beneficiaries with coronary artery disease and 14.8 percent with congestive heart failure.
But cardiologists were the primary point of care for just 7.9 percent of beneficiaries with diabetes mellitus and 5.5 percent of those with dementia.
Researchers concluded that promoting alternative payment models that put primary care providers at the center of chronic disease care delivery should result in advanced care coordination. But specialists may not be that far behind.
“This study shows that in usual fee-for-service practice as it occurs across the United States, continuity of care is higher and number of physicians involved in care is lower when a primary care provider is the predominant provider, but those visit patterns do not directly equate with providing better care coordination,” they stated. “It remains possible that a provider who is seen less frequently may be providing a coordinating role through asynchronous care (eg, telephone calls and e-mail).”
They also claimed that Medicare spending differences between primary care providers and specialists may impact alternative payment model participation. Under MACRA, most Advanced Alternative Payment Models, such as ACOs and the Comprehensive Primary Care Plus initiative, emphasize primary care as the nexus for care coordination.
But the concentration of beneficiaries largely seeing a primary care provider significantly varied by region. The proportion of older adults with at least two chronic diseases who engaged with a specialist as their predominant provider of care varied between 21 percent and 57 percent across hospital referral regions.
Also, beneficiaries located in Louisiana, Texas, and Florida mostly saw specialists as their primary care providers.
“New payment incentives that encourage organization around primary care may face steeper challenges to dissemination in regions where specialists play a more dominant role,” researchers stated.
Instead, they suggested that alternative payment models focus on ambulatory care delivery efficiency as a means of improving value rather than using chronic disease management through a primary care provider to reduce costs via fewer hospitalizations and readmissions.