More Primary Care at End of Life Lowers Costs

Too many specialists overwhelm a primary care provider's ability to coordinate care and can lead to more intense, and costly treatment.

Regions of the country with greater primary care physician involvement in the last six months of life appear to have lower-intensity, lower-cost end-of-life care, according to research by published in the January/February 2017 issue of Annals of Family Medicine.

For purposes of the study, "primary care involvement" was defined as the ratio of PCP to specialist visits. The following interview with researcher Claire K. Ankuda, MD, MPH, with the Robert Wood Johnson Clinical Scholars Program at the University of Michigan Health System in Ann Arbor, and colleagues about the significance of these findings has been lightly edited.

HealthLeaders Media: Your study found that there was lower Medicare spending in the last two years of life in regions with more primary care physician involvement ($65,160 vs. $69,030). Can you put those numbers into context for healthcare leaders?

Claire Ankuda, MD: While the absolute dollar amount of around $4,000 over two years may not seem like a tremendous amount, even to some people within the healthcare industry, it's very significant if you think about the sheer number of Medicare beneficiaries we're talking about.

It's also important to understand that this is not a randomized controlled trial. We are really comparing regions of the country, so we did adjust for other factors that are different from place to place and which might also impact cost. With that in mind, our estimates are likely quite conservative.

HLM: In instances where there is more PCP involvement, where do the savings come from?

Ankuda: We know that a lot of what drives cost at the end of life are things like intensive care use and acute care hospital stays.

In our study, we found that the regions where PCPs were more involved at the end of life had less intensity of care, meaning fewer ICU days and such, which is likely what's really driving the cost savings.

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Others have done good work to probe what drives this decision-making. A study published in the Annals of Family Medicine, for example, demonstrated the considerable role that PCPs have in coordinating care. It's possible that coordination really does keep people home in this critical time.

Previous research has also found that PCPs' role in coordinating care can become somewhat overwhelmed when there are too many specialists involved, which makes sense. It's one thing if you're a PCP and your patient is seeing two other physicians, but it's another thing if all of a sudden they are seeing five, seven, or 10 other physicians, who are all prescribing different medications and maybe have slightly different perspectives on that patient's illnesses and prognosis. It can be very difficult to coordinate that.

HLM: Your study uses claims data from 2010, before the advent of codes for chronic care management and advance care planning. Are you hopeful that these reimbursement changes will help optimize primary care and cost savings even further?

Ankuda: I'm very hopeful, certainly about some of the additional codes that doctors can bill for. Now you can have a conversation with a patient about his or her advanced directive or goals of care and bill for that, which is great. You can also get paid for the after-hours work that you and people in your clinic are doing to help coordinate care. That's really critical.

Potentially, the bigger shift is in some of the alternative payment models that we're now thinking about more, which can be more flexibly used by clinic teams to help meet the needs of patients and improve care at all stages of life.

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