Abstract
Declining primary care visit rates and increasing specialist visit rates among older adults with multimorbidity raise questions about the presence, specialty, and outcomes associated with usual clinicians of care for these adults. To examine trends in the presence and specialty of usual clinicians and the association with preventive care receipt and spending. This survey study used repeated cross-sectional analyses of Medicare Current Beneficiary Survey data from 2010, 2013, and 2016. Participants were community-dwelling Medicare Advantage and traditional Medicare members with at least 2 chronic conditions. Data were analyzed from March 1, 2020, to February 5, 2021. Trends and factors associated with self-reported usual clinician presence and specialty. Multivariable regression was used to examine associations between usual clinician presence and specialty with preventive care receipt and spending, controlling for respondent sociodemographic and clinical characteristics. A total of 25 490 unweighted respondent-years were examined, representing 90 324 639 respondent-years across the United States. Overall, 58.4% of respondent-years belonged to women, and the mean (SD) age of respondents was 77.5 (7.5) years. From 2010 to 2016, those reporting usual clinicians dropped from 94.2% to 91.0% (P < .001). Across study years, respondents were more likely to report a usual clinician if they were women (adjusted marginal difference [AMD], 2.5 percentage points; 95% CI, 1.5-3.5 percentage points) or had higher income (≥$50 000 vs <$15 000: AMD, 2.2 percentage points; 95% CI, 1.1-3.4 percentage points) and less likely if they were Black beneficiaries (vs White: AMD, -2.8 percentage points; 95% CI, -4.3 to -1.3 percentage points) or had traditional Medicare (vs Medicare Advantage: AMD, -3.2 percentage points; 95% CI. -4.1 to -2.3 percentage points). Among 23 279 respondents with usual clinicians, those reporting specialists as their usual clinicians decreased from 5.3% to 4.1% (P < .001). Across the study period, respondents were more likely to report specialists as their usual clinicians if they had traditional Medicare (vs Medicare Advantage: AMD, 2.3 percentage points; 95% CI, 1.6 to 2.9 percentage points), were Black or non-White Hispanic (Black vs White: AMD, 1.5 percentage points; 95% CI, 0.2 to 2.8 percentage points; non-White Hispanic vs White: AMD, 3.8 percentage points; 95% CI, 1.9 to 5.7 percentage points), or lived in the Northeast (vs Midwest: AMD, 3.6 percentage points; 95% CI, 2.1 to 5.2 percentage points). Compared with those without usual clinicians, respondents with usual clinicians were more likely to receive all examined preventive services, such as cholesterol screening (AMD, 6.7 percentage points; 95% CI, 5.4 to 8.1 percentage points) and influenza vaccines (AMD, 11.6 percentage points; 95% CI, 9.2 to 14.0 percentage points). Among respondents with usual clinicians, those reporting specialist usual clinicians (vs primary care) were less likely to receive influenza vaccines (AMD, -5.6 percentage points; 95% CI, -9.2 to -2.1). In this study, older adults with multimorbidity were less likely to have a usual clinician over the study period, with potential implications for preventive care receipt. Our results suggest a key role for usual clinicians, especially primary care clinicians, in vaccination uptake for this population.
Highlights
For the growing population of older adults with multimorbidity (Ն2 chronic conditions),[1] having a usual clinician of care has been associated with better health outcomes, less high-acuity utilization, and lower costs.[2,3,4,5] These usual clinicians can play a key role in providing whole-person continuous care, coordinating care across care settings and clinicians, and ensuring patients’ preventive care needs are met
Respondents were more likely to report a usual clinician if they were women or had higher income (Ն$50 000 vs
Respondents were more likely to report specialists as their usual clinicians if they had traditional Medicare, were Black or non-White Hispanic (Black vs White: AMD, 1.5 percentage points; 95% CI, 0.2 to 2.8 percentage points; non-White Hispanic vs White: AMD, 3.8 percentage points; 95% CI, 1.9 to 5.7 percentage points), or lived in the Northeast
Summary
For the growing population of older adults with multimorbidity (Ն2 chronic conditions),[1] having a usual clinician of care has been associated with better health outcomes, less high-acuity utilization, and lower costs.[2,3,4,5] These usual clinicians can play a key role in providing whole-person continuous care, coordinating care across care settings and clinicians, and ensuring patients’ preventive care needs are met. In addition to having a usual clinician, the specialty of this clinician may have implications for care quality and utilization outcomes. Having a specialist instead of a PCP as one’s usual clinician—as defined using office visit claims data—has been associated with greater spending and lower continuity among traditional Medicare (TM) beneficiaries, while another study found lower rates of emergency department visits and of potentially preventable hospitalizations among those with a specialist as their usual clinician.[21,22] It remains unknown how usual clinician specialty relates to outcomes when considering patients’ self-reported usual clinicians or when including the more than one-third of all Medicare beneficiaries enrolled in Medicare Advantage (MA), for whom network design may lead to greater reliance on primary care.[23]
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