More Doctors, Better Care? Patient and Physician Inputs, Outputs, and Outcomes of the Clinical Evaluation and Management Process for Medicare Beneficiaries with Chronic Conditions Open Access

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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School	Laney Graduate School
Department	Health Services and Research Health Policy
Degree	PhD
Submission	Dissertation
Language	English
Research Field	Health Sciences, Medicine and Surgery Health Sciences, Health Care Management
Keyword	Medicare Continuity of Care Physician Division of Labor Ambulatory Care Evaluation and Management Chronic Disease Heart Failure Diabetes
Committee Chair / Thesis Advisor	Hockenberry, Jason Michael, Emory University
Committee Members	Rask, Kimberly J, Emory University Howard, David H, Emory University

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