When continuity is harmed, the results are decreased quality, additional visits and hidden costs.
Fam Pract Manag. 2000 Nov-Dec;7(10):44.
With health systems rapidly realigning and employers annually rebidding their insurance contracts, the doctor-patient relationship is being disrupted as never before. “My insurance changed” is a common refrain among patients as they leave a practice to seek care from a doctor who is on “the list” of participating providers in their new insurance plan. But how prevalent is this forced disruption in continuity of care? Does it affect the quality of primary care patients receive?
These questions were addressed in a study of 1,839 commercially insured patients seeing 138 family physicians in Northeast Ohio as part of the Direct Observation of Primary Care Study. Twenty-four percent of patients with a managed care insurance plan reported they had been forced to change family doctors in the previous three years because of an insurance change. Although patients with managed care and fee-for-service insurance had similar perceptions of the quality of primary care they received, those patients who were forced to change family physicians reported lower scores on all five measures of the quality of their primary care:1
Interpersonal communication: Is information exchanged easily between the patient and the physician?
The physician's knowledge of the patient: Has the physician accumulated information about the patient's medical history, family medical history and health needs and values?
Coordination of care: Does the physician incorporate information from referrals and previous visits into the patient's current and future medical care?
A preference for seeing their regular physician: Does the patient feel he or she can go to the physician for almost all problems?
Continuity of care: Of all visits made by the patient in a given year, how many were with the patient's regular physician?
A separate study found that patients who were forced to change family doctors because of an insurance change made extra visits to both their old and new doctors as they attempted to maintain continuity and get their immediate health care needs met. Patients who were older, who had a longer, more established relationship with a physician, or who were in the middle of a work-up for a medical problem found this transition particularly difficult.2
These studies show that forced discontinuity engendered by insurance changes not only has an impact on patients' quality of care, but it can also lead to extra visits and hidden costs. Furthermore, these effects are likely to be multiplied many times over, since an insurance change often forces all members of a family to change physicians. The disruption is particularly difficult for older patients and those in the process of receiving care.
These findings raise questions about the true costs and benefits of employers annually rebidding their health insurance contracts. Family physicians can use this information to encourage health systems, insurers and employers to develop systems that foster, rather than disrupt, the doctor-patient relationship.
Illuminating the ‘black box’ of primary care
This article continues our series offering practical lessons from the Direct Observation of Primary Care (DOPC) Study, which was funded by the National Institutes of Health and conducted by the Center for Research in Family Practice and Primary Care, with support from the AAFP. The study demonstrates the complexities of the patient visit, the demands of real-world practice and the value of primary care, issues that policymakers, the public and even clinicians have not fully understood. Researchers used a multi-method approach, including direct observation, to study 4,454 patient visits to 138 family physicians in 84 practice sites.
Dr. Kikano is an associate professor and vice chairman of family medicine at Case Western Reserve University/University Hospitals of Cleveland (CWRU/UHC). Dr. Flocke is an assistant professor of family medicine and oncology at CWRU. Robin Gotler is project coordinator in the Family Medicine Research Division of CWRU. Dr. Stange is a professor of family medicine, epidemiology and biostatistics, oncology and sociology at CWRU/UHC. He is also director of the Center for Research in Family Practice and Primary Care, one of three family practice research centers funded by the AAFP.
1. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract. 1997;45:129–135.
2. Kahana E, Stange KC, Meehan R, et al. Forced disruption in continuity of primary care: The patient's perspective. Socio Focus. 1997;30:177–187.
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