Higher Primary Care Physician Continuity is Associated With Lower Costs and Hospitalizations

I agree with the comments regarding inadequate analysis. Controls remain too few. Much data is missing. The data that exists is skewed because of poor access to generalist and general specialty physicians that impacts major portions of the US population and as much as half of the Medicare and Medicaid population. These populations continued to be ignored in data, analysis, and awareness. These are populations that have half enough workforce in the basic areas with even less in more specialized care. Also this population has the worst outcomes across infant mortality, maternal mortality, premature death, and longevity. Even within this population there are some that can gain access and the potential for continuity, and others that cannot.

Quality studies rarely meet the test of comparing same or similar populations. Purported differences as measured in studies are difficult to separate from a comparison of two different populations with two different outcomes. Routine data sets are incapable of such analysis. Social determinants, situations, environments, and conditions remain missing in consideration. Selection bias alone is a huge issue for continuity.

For 2621 counties lowest in MD DO NP and PA concentrations with half enough primary care there are higher concentrations of obesity, diabetes, veterans, elderly, poor, COPD, disability, and mental issues. The worst public and private plans are concentrated and practices face the most disruptions, the lowest payments, and the lowest collection rates.

Housing collapse in the few counties with higher to highest concentrations of workforce helps to drive more rapid population growth where deficits exist and where the population has been growing fastest decade after decade since the 1960s. The continued financial compromise of smaller and less organized providers continues to worsen disparities in access and in social determinants - to drive worsening outcomes. Each passing year the various innovations (HITECH to MACRA to PCMH) steal 1 billion more dollars from primary care in counties that only had about 38 billion in 2010.

At least Starfield acknowledged the role of factors related to social and other determinants of health. The families of family medicine continue to repeat the primary care correlation mantras as if more primary care is a solution. But the reality is different because of the disparities that exist and worsen. Outcomes differences are about disparities in people, not primary care.

The real answer to various measures and outcomes involves addressing disparities. Continuing to promote correlation as if it were causation will only delay the necessary improvements in the population with the powerless half growing larger and with worsening outcomes. We should be advocates of our patients, populations, and communities - not ourselves or what we assume will work.

The shortages that contribute to continuity woes are about the places where the populations with the worst public and private insurance plans are concentrated. They had no greater deficits of insurance in 2010 with 40.6% of the uninsured in this 40.2% of the population. They just had the worst plans. These counties only averaged 46 primary care physicians per 100,000. About 25% of generalists and general specialists for vast regions with 40% of the population is insufficient.

Instead of being distracted by quality studies and improvements, primary care researchers would do well to study the usual disruptions that impact small and medium practices most (Mold, Annals FM) and the disruptions arising from past, present, and future innovations. They might discover the financial design as the problem as revenue remains flat, costs of delivery accelerate, and the complexities of practice and of population worsen.

Competing interests: None declared