More Doctors, Better Care? Patient and Physician Inputs, Outputs, and Outcomes of the Clinical Evaluation and Management Process for Medicare Beneficiaries with Chronic Conditions Öffentlichkeit
Johnston, Kenton J (2015)
Published
Abstract
This dissertation explores the trade-off between patient
continuity of care and physician division of labor in ambulatory
care of older adults with chronic conditions. It does so in the
context of ongoing innovation in the organization, delivery, and
payment of physician services in the United States. The physician
evaluation and management office visit is the setting in the health
care system where physicians routinely perform the core clinical
tasks of patient diagnosis, treatment, referral, and follow-up. The
challenge is performing the core clinical tasks for diverse
patients with complex care needs and shared with multiple providers
over time. The challenge is even greater for older adults with
chronic conditions who are especially reliant on regular
guideline-concordant care to maintain their functional status and
quality of life. As a result, I take the clinical evaluation and
management process and associated patient and physician inputs,
outputs, and outcomes for Medicare beneficiaries with diabetes
and/or heart failure as my foci.
For a nationally representative population of Medicare
fee-for-service beneficiaries with diabetes and/or heart failure I
find that division of labor between primary care and specialist
physicians exerts a clear benefit for increasing provision of
guideline-concordant medical care and for preventing future adverse
health outcomes and hospitalization. This benefit exists in spite
of the corresponding loss in observed patient continuity of care.
In addition, I find the largest benefit for specialized physician
involvement that is the most disease-relevant.
The most important implication of this research is that it is critical for Medicare beneficiaries with chronic conditions such as diabetes and heart failure to have at least one annual evaluation and management visit with a disease-relevant specialist, in addition to annual involvement with a primary care physician. Medicare policy makers should consider how to incentivize scheduled annual involvement of disease-relevant specialists for beneficiaries with complex chronic conditions. Lastly, to the extent that the current trend toward physician affiliation with multi-specialty group practices leads to more shared management of patients with chronic conditions by primary care and specialist physicians, the result predicted by this study is improved quality of care and better health outcomes.
Table of Contents
1. Introduction and Background ................................................................................................. 1
2. Study Aims.............................................................................................................................. 10
3. Theoretical Framework ......................................................................................................... 11
4. Study Design ........................................................................................................................... 15
4.1. Data Sources................................................................................................................ 15
4.2. Study Population and Timeframe................................................................................. 16
4.3. Study Variables............................................................................................................ 18
5. Demand and supply side predictors of shared clinical evaluation and management of
Medicare beneficiaries with chronic conditions by multiple physicians ............................. 25
5.1. Research Questions and Empirical Approach............................................................... 25
5.2. Results.......................................................................................................................... 28
6. Rethinking continuity of care: the impact of observed continuity of care on quality of
care and health outcomes for Medicare beneficiaries with chronic conditions .................. 32
6.1. Research Questions and Empirical Approach............................................................... 32
6.2. Results.......................................................................................................................... 37
7. More Doctors, Better Care? The effect of shared clinical evaluation and management of
Medicare beneficiaries with chronic conditions by multiple physicians ...........................................47
7.1. Research Questions and Empirical Approach............................................................... 47
7.2. Results.......................................................................................................................... 50
8. Summary of Findings ............................................................................................................. 58
9. Discussion ............................................................................................................................... 69
9.1. Study Limitations and Strengths................................................................................... 69
9.2. Conclusions and Implications ...................................................................................... 71
10. References .............................................................................................................................. 80
About this Dissertation
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