Outcomes in Older Adults with Multimorbidity Associated with Predominant Provider of Care Specialty

Abstract

Background/Objective Most older adults have multiple chronic conditions which lead to costly care that requires coordination across specialties. Yet many in the U.S. use a specialist physician rather than primary care as their predominant provider of ambulatory visits (PPC). As new physician payment models are designed under the Medicare and Chip Reauthorization Act (MACRA), information on whether specialists deliver care as efficiently as primary care to this high cost, high need population is needed. We test whether primary care versus specialty PPC is associated with better outcomes for older adults with multimorbidity. Design Observational study using propensity-score matching. Setting Fee-for-service Medicare, 2011–2012. Participants Beneficiaries over age 65 with multimorbidity. Measurements The independent variable was an indicator for having a specialty (versus primary) care PPC. Main outcomes were one-year mortality, hospitalization, and standardized expenditures, ambulatory visit patterns. Results In 3,934,942 beneficiaries with multimorbidity, two-thirds had a primary care provider as their PPC. Patients with a specialty PPC compared to primary care PPC had higher hospitalizations (40.3 more per 1,000) and higher spending ($1,781 more per beneficiary) but little meaningful difference in mortality (0.2% higher) or preventable hospitalizations. Spending differences stemmed from professional fees ($769 higher per beneficiary), inpatient stays ($572 higher per beneficiary) and outpatient facilities ($510 higher per beneficiary). All p-values <.001. In addition, people with a specialist versus primary care PPC had lower continuity of care and saw a greater number of providers. Conclusions Older adults with multimorbidity with a specialist as their main ambulatory care provider had higher spending and lower continuity of care but similar clinical outcomes as patients whose PPC was in primary care.

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