ICES Study Proves Continuity of Care as Important as a Family Physician

The Institute for Clinical and Evaluative Studies (ICES) released a study titled "The Impact of Not Having a Primary Care Physician Among People with Chronic Conditions" which found that not having a primary care physician resulted in increased ER usage. This phenomenon is well known and should come as no surprise to readers. The more interesting statistics are that those patients with chronic conditions who have low continuity of care (see many different providers) or those who use their primary care provider less than 3 time per year are just as likely to end up in the ER department.

The study found that those without primary care physician where 1.22x more likely to land in the ER. Those with low continuity of care* were 1.55x more likely and a group of chronic care patients with less than 3 visits per year were 1.17x more likely. Each group also carries an additional risk of non-elective hospital admissions equal or greater than that of ER visits.

This raises some interesting public policy questions. There is a push in Ontario to a managed care system where patients are enrolled into a family health team (FHT) for a flat fee. The FHT is then penalized if the patient visits the ER department.

Based on the data presented by ICES however, there is a strong financial incentive for an FHT to enroll a greater number of patients than they can effectively manage. The penalties for one of the patients visiting the ER are relatively small. This might mean that for every 10 patients the FHT is unable to provide adequate continuity of care to only 2 will visit the ER or be admitted to hospital. Care has been rationed at the family practice level. As an example, the provider may ask to see the patient again in a month but no appointment will be available for two.

Assuming that North American models of health care are currently unaffordable a choice has to be made for rationing health care. The current model will place the burden of rationing on the family practice doctor despite evidence that managed care neither lowers costs nor improves quality of care.

I was recently asked by a policy maker "if you could change one thing in health care what would it be". My answer was to allow user fees. As long as there are stipulations for the working & retired poor and their dependants user fees return the choice of rationing care back to the patient and have the potential to increase funding to the system in a manner that is valued by the patient while decreasing usage.** The current push to a flat fee system encourages patient enrollment but does little to improve continuity of care. It also removes the choice for rationing of health care dollars away from patients and may have the undesirable effect of increasing ER visits and unplanned hospital admissions.

*continuity of care is a measure of how many providers the patient saw. There was no distinction made for family health teams in the study.
**a recent NEJM study showed that ER user fees lowered use with a detriment to the patient -- I have not found a study to show the same effect in family practice.