Comparing Comprehensiveness in Primary Care Specialties and Their Effects on Healthcare Costs and Hospitalizations in Me
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Division of General Medicine and Geriatrics, Emory University School of Medicine, Atlanta, GA, USA; 2Robert Graham Center Policy Studies in Family Medicine & Primary Care, Washington, DC, USA; 3Center for Primary Care, Global Health and Social Medicine Harvard Medical School, Boston, MA, USA; 4The American Board of Family Medicine, Washington DC, USA.
J Gen Intern Med DOI: 10.1007/s11606-019-05338-3 © Society of General Internal Medicine 2019
INTRODUCTION
Four essential features of primary care, identified by Barbara Starfield, include the following: first contact, continuity, coordination, and comprehensiveness.1 Comprehensiveness, defined as offering a “range of services broad enough to care for all health needs except those too uncommon to maintain competence,” includes meeting the large majority of each patient’s physical and mental healthcare needs.1 However, while comprehensiveness is thought to be in decline among primary care physicians (PCPs), little has been done to capture its value in policy-relevant terms such as cost and quality, important in this era of value-based purchasing.2 A recent study developed and tested a measure of comprehensiveness among family physicians revealed a modest association with lower healthcare utilization and costs among Medicare patients.3 This paper extends this work by comparing family physicians and general internists in comprehensiveness and its impact on similar outcomes.
METHODS
We obtained all 2011 Part A and Part B Medicare claims for fee-for-service Medicare beneficiaries seen at least once by physicians in a nationally representative sample of PCPs drawn from the 2010 AMA Masterfile, using specialty codes to locate all GIM/FPs without second specialty. We excluded hospitalists (those with more than 80% of their E&M claims delivered in the hospital setting). To link beneficiaries to a PCP, we identified the one who provided most of the E&M Received February 5, 2019 Revised August 6, 2019 Accepted August 27, 2019
office services for each beneficiary. We used the BerensonEggers Typology of Service (BETOS) codes to construct a comprehensiveness measure by capturing the range of services performed by primary care physicians.3 We counted the total number of BETOS codes (excluding services infrequently provided by PCPs) that accounted for 90% of the physician’s services. Our sample is further restricted to patients 65 years or older and to PCPs with 30 or more patients. We used Stata 14.2 to perform multi-level linear regression, controlling for patient- and physician-level characteristics (see note of Table 2).
RESULTS
From the 2011 Medicare data, we identified 1,107,709 beneficiaries cared for by 2682 general internists and 3396 family physicians. General internists and family physicians varied in their provision of services whether using all services or when restricted to the 90% most common services provided by a physician (Table 1). More general internists billed for hospitalbased codes (p < 0.001), while family physicians were more likely to provide care in
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