The Lost Pillar: Does Continuity of Care Still Matter?

As a family physician in my early fifties who has cared for some of the same patients over 20 years, I wholeheartedly agree with Dr. Loxterkamp’s essay about the lost pillar of continuity. In addition to the issues that he spells out, we also need to address several additional barriers to continuity as a medical community.

As he mentions, the culture of medicine has changed, and much change started at the administrative level. “Back in the day,” hospital and other health care administrators were people who grew up in their communities and remained a part of them. Now, like other industries, administrators bounce around from job to job. People living thousands of miles away make critical healthcare decisions for a community they are not a part of. These “leaders” will never personally feel the repercussions of those decisions, and their effects last longer than the administer does in their job position. As many hospital administrators have little continuity in their communities, that culture has unfortunately permeated down to the physician level.

Another barrier to continuity is due to insurance coverage. Large healthcare systems prioritize the insurance plans tied to their hospital system and don’t contract with all available insurance plans in their community, including Medicaid. As insurance costs increase, employers will understandably change insurance plans for their employees to keep costs down. As a result, when I used to work for a healthcare system, due to decisions by an executive or a patient’s employer, I found myself out of network and unable to continue to see my patients. In my current position with a small, independent practice, we often get left out of “premier” plans that funnel patients towards employed physicians associated with the health plan. It is frustrating that many family physicians want to continue to care for our patients, but insurance companies tie our hands.

Finally, I worry about how much physician burnout plays a role in eroding patient continuity. A few years ago, I was at a seminar on physician burnout led by a non-physician. She wanted us to think about how people would talk about us as physicians when we retire or at our funeral. She seemed somewhat shocked when I (who was likely some mild suffering burnout at that point) commented that the same things I want to be remembered for may contribute to burnout. While patients appreciate me always being available, always saying yes, and always being willing to see their friends and family as new patients, this ultimately creates additional work stress. If we could eliminate the nonsensical busy work and data entry that physicians are now being forced to do, more physicians would be willing to focus on developing meaningful patient relationships. Unfortunately, many physicians suffering burnout and working in dysfunctional systems, their only options are to say no to this additional work or ultimately leave their practice. Both of these options, however, damage the continuity we should strive for in primary care.

No, Dr. Loxterkamp, continuity does not matter, not to those who run health care (which we as docs have allowed to be run mostly by hospitals), no matter their nice words and slick ads. Nor does access or advocacy matter. I work across the state in the foothills of Maine, where for over 15 years I saw everyone the day they called and was on time for appointments. They saw me and only me. Now I may work (one day a week) in the same system as you. I do acutes and MAT. I work with fabulous people, but in a place so inefficient that, with all sorts of layers of staff, I still see the same number of folks I saw when I did it myself. We cover for the other two practices in the network. One NP has no openings till April. I work for Teladoc also, and no one can ever get an appointment—they may not even have a doc at all. The reasons are the ones you know. Doctors have been silent, and now, employed by complex health care systems, they have no idea why things went wrong. They are so shielded. In my former system, a recent survey said 62% of docs were indifferent. We have let hospitals systems make processes difficult. We have put up with multiple websites to do referrals—often to people WE as PCPs are getting paid; we cannot be gatekeepers to XRT for breast cancer, but I must "refer" patients on my dime. Doctors are unwilling to actually DO anything, even if they knew what they could do. Some of us write a bit, but we are watching a society in decline, a pretty little planet being destroyed. Health care is a house of cards where every entity is out for themselves and the big eat the small and access? Continuity? No. No, it does not matter really.