Primary Care Redesign and Care Fragmentation Among Medicare Beneficiaries
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services, Center for Medicare & Medicaid Innovation
Many primary care initiatives are being tested, including the Comprehensive Primary Care Plus (CPC+) Initiative. CPC+’s requirements might reduce fragmentation of care.
- Medicare beneficiaries whom we designated as having highly fragmented care (40% of beneficiaries) had a mean of 13 ambulatory visits across 7 practitioners in the year. The most frequent provider of care accounted for only 28% of visits.
- There were no differences in the change in continuity or fragmentation of care for CPC+ vs comparison beneficiaries over the first 3 years of CPC+.
- Future interventions that target fragmentation more directly may be more successful in changing that outcome.
To determine associations between a large-scale primary care redesign—the Comprehensive Primary Care Plus (CPC+) Initiative—and the extent of continuity or fragmentation of ambulatory care for Medicare fee-for-service beneficiaries during the first 3 years of CPC+.
We used a difference-in-differences framework with a comparison group of practices that were similar to CPC+ practices at baseline (eg, practice size, demographics, Medicare spending). Regressions controlled for clustering, baseline patient characteristics, and practice fixed effects. Our study covered January 2016 through December 2019 and included 1,085,707 beneficiaries attributed to 2883 CPC+ practices and 2,274,068 beneficiaries attributed to 6912 comparison practices.
We focused on beneficiaries with highly fragmented care at baseline because they may have changed the most in response to CPC+. Key outcome measures were the numbers of ambulatory visits and unique practitioners, reported by specialty category; the percentage of visits with the usual provider of care (measuring continuity); and the reversed Bice-Boxerman Index (rBBI; measuring fragmentation).
Medicare beneficiaries with high fragmentation (rBBI ≥ 0.85) at baseline (40% of the sample) had a mean of 13 ambulatory visits across 7 practitioners; the most frequent provider of care accounted for only 28% of visits. By contrast, the remaining beneficiaries had a mean of 10 visits across 4 practitioners, with the most frequent provider accounting for 54% of visits. There were no differences in continuity or fragmentation of care for CPC+ vs comparison beneficiaries.
We find no evidence that CPC+ increased continuity or decreased fragmentation of care.