Abstract
OBJECTIVE: To examine changes in the quality of primary care experienced and reported by Medicare beneficiaries from 1998 to 2000.
DESIGN: Longitudinal observational study.
SETTING: Thirteen states with large, mature Medicare HMO markets.
PARTICIPANTS: Probability sample of noninstitutionalized Medicare beneficiaries aged 65 and older enrolled in traditional Medicare (FFS) or a Medicare HMO.
MEASUREMENTS AND MAIN RESULTS: We examined 2-year changes in 9 measures derived from the Primary Care Assessment Survey (PCAS). The measures covered 2 broad areas of primary care performance: quality of physician-patient interactions (5 measures) and structural/organizational features of care (4 measures). For each measure, we computed the change in each beneficiary’s score (1998 vs 2000) and standardized effect sizes (ES). Results revealed significant declines in 3 measures of physician-patient interaction quality (communication, interpersonal treatment, and thoroughness of physical exams; P≤.0001). Physicians’ knowledge of patients increased significantly over the 2-year period (P≤.001). Patient trust did not change (P=.10). With regard to structural/organizational features of care, there were significant declines in financial access (P≤.001), visit-based continuity (P<.001), and integration of care (P≤.05), while organizational access increased (P≤.05). With the exception of financial access, observed changes did not differ by system (FFS, HMO).
CONCLUSIONS: Over a 2-year period, the quality of seniors’ interactions with their primary physicians declined significantly, as did other hallmarks of primary care such as continuity, integration of care, and financial access. This decline is in sharp contrast to the marked improvements in technical quality that have been measured over this period. In an era marked by substantial national investment in quality monitoring, measures of these elements of care are notably absent from the nation’s portfolio of quality indicators.
References
Institute of Medicine. Report of a Study: A Manpower Policy for Primary Health Care. Washington, DC: National Academy of Sciences; 1978.
Millis JS. The Millis Commission Report. Chicago, Ill: American Medical Association; 1966.
Starfield B. Primary Care: Concept. Evaluation and Policy. New York, NY: Oxford University Press; 1992.
Alpert J, Charney E. The Education of Physicians for Primary Care. Washington, DC: U.S. DHEW; 1973.
Institute of Medicine. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press; 1996.
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-first Century. Washington, DC: National Academy Press; 2001.
1987 NMES Household Survey and Health Insurance Plans Survey Data (CD-ROM). Agency for Health Care Policy and Research. Center for Cost and Financing Studies. Version AHCPR 98-DP02. Rockville, Md: AHCPR; 1998.
Safran DG. The future of primary care: views from the patient. Ann Intern Med. 2003;138:248–55.
Weiss LJ, Blustein J. Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans. Am J Public Health. 1996;86:1742–7.
Centers for Medicare and Medicaid Services. Medicare Current Beneficiary Survey Data from Access to Care File. Medicare Current Beneficiary Survey 1999. Available at: http://cms.hhs.gov/MCBS/. Accessed February 13, 2004.
Safran DG, Wilson IB, Rogers WH, Montgomery JE, Chang H. Primary care quality in the Medicare program: comparing the performance of HMOs and traditional Medicare. Arch Intern Med. 2002;162:757–65.
Keating NL, Green DC, Kao AC, Gazmararian JA, Wu VY, Cleary PD. How are patients’ specific ambulatory care experiences related to trust, satisfaction, and considering changing physicians? J Gen Intern Med. 2002;17:29–39.
Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA. 1995;273:323–9.
Murphy J, Chang H, Montgomery J, Rogers WH, Safran DG. The quality of physician-patient relationships: patients’ experiences 1996–1999. J Fam Pract. 2001;50:123–9.
Hoffman C, Rice D, Sung H-Y. Persons with chronic conditions: their prevalence and costs. JAMA. 1996;276:1473–9.
Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey tests of data quality and measurement performance. Med Care. 1998;36:728–39.
Centers for Medicare and Medicaid Services. Medicare Managed Care Contract Plans Monthly Summary Report. Washington, DC: CMS; 2002.
Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York, NY: John Wiley; 1978.
McHorney CA, Ware JEJ, Raczek AE. The MOS 36-item short-form health survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31:247–63.
McHorney CA, Ware JE Jr, Lu JF, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): III. Tests of data quality scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32:40–66.
Shea S, Stein AD, Lantigua R, Basch CE. Reliability of the behavioral risk factor survey in a triethnic population. Am J Epidemiol. 1991;133:489–500.
Katz JN, Chang LC, Sangha O, Fossel AH, Bates DW. Can comorbidity be measured by questionnaire rather than medical record review? Med Care. 1996;34:73–84.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis. 1987;40:373–83.
Adams PF, Morano MA. Current Estimates from the National Health Interview Survey, 1994: Supplement on Aging. Vital Health Stat 10. Hyattsville, Md: National Center for Health Statistics; 1995;193:413–60.
Safran DG. Defining Primary Care. A Background Paper Prepared for the Institute of Medicine Committee on the Future of Primary Care. Boston, Mass: New England Medical Center; 1994.
Davies AR, Ware JE, Brook RH, Peterson JR, Newhouse JP. Consumer acceptance of prepaid and fee-for-service medical care: results from a randomized controlled trial. Health Serv Res. 1986;21:429–52.
Ware JE, Snyder MK, Wright WR. Results regarding scales constructed from the patient satisfaction questionnaire and measure of other health perceptions. In: Development and Validation of Scales to Measure Patient Satisfaction with Health Care Services, I. Development and Validation of Scales to Measure Patient Satisfaction with Health Care Services. Springfield, VA: National Technical Service; 1976; NTIS publication PB:288–330.
United States Congress Office of Technology Assessment. The Quality of Medical Care: Information for Consumers. U.S. Congress Report OTA-H-386. Washington, DC: U.S. Government Printing Office; 1988:231–43.
Sox HC, Margulies I, Sox CH. Psychologically mediated effects of diagnostic tests. Ann Intern Med. 1981;95:680–5.
Murray A, Safran DG. The Primary Care Assessment Survey: a tool for measuring, monitoring, and improving primary care. In: Maruish ME, ed. Handbook of Psychological Assessment in Primary Care Settings. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.; 2000:623–51.
Ware JE, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability. Med Care. 1996;34:220–33.
Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: Manual and Interpretation Guide. Boston, Mass: New England Medical Center; 1993.
Hargraves JL, Wilson IB, Zaslavsky A, et al. Adjusting for patient characteristics when analyzing reports from patients about hospital care. Med Care. 2001;39:635–41.
Zaslavsky AM, Zaborski LB, Ding L, Shaul JA, Cioffi MJ, Cleary PD. Adjusting performance measures to ensure equitable plan comparisons. Health Care Finance Rev. 2002;22:109–26.
Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis. Eval Program Plann. 1983;6:185–210.
Smith R, Woodward N, Wallston B, Wallston K. Health care implications of desire and expectancy for control in elderly adults. J Gerontol. 1998;43:P1-P7.
Haug M, Ory MG. Issues in elderly patientpprovider interactions. Res Aging. 1987;3:3–44.
Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians getting shorter? N Engl J Med. 2001;344:198–204.
Stafford RS, Saglam D, Causino N, et al. Trends in adult visits to primary care physicians in the United States. Arch Fam Med. 1999;8:26–32.
Counte M. The emerging role of the client in the delivery of primary care to older Americans. In: Ory MG, Cooper J, Siu A, eds. Special Supplement to Health Services Research. Organizational Issues in the Delivery of Primary Care to Older Americans; 1998;32:402–23.
Kizer KW. Establishing health care performance standards in an era of consumerism. JAMA. 2001;286:1213–7.
Robinson JC. The end of managed care. JAMA. 2001;285:2622–8.
DiMatteo MR. Enhancing patient adherence to medical recommendations. JAMA. 1994;271:79–83.
DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol. 1993;12:93–102.
Francis V, Korsch BM, Morris MJ. Gaps in doctor-patient communication: patients’ response to medical advice. N Engl J Med. 1969;280:535–40.
Safran DG, Murray A, Chang H, Montgomery JE, Murphy J, Rogers WH. Linking doctor-patient relationship quality to outcomes. J Gen Intern Med. 2000;15(suppl):116.
Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–20.
Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med. 1985;102:520–8.
Greenfield S, Kaplan SH, Ware JEJ, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3:448–57.
Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152:1423–33.
Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155:1877–84.
Safran DG, Montgomery JE, Chang H, Murphy J, Rogers WH. Switching doctors: predictors of voluntary disenrollment from a primary physician’s practice. J Fam Pract. 2001;50:130–6.
Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553–9.
Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: lessons from plaintiff depositions. Arch Intern Med. 1994;154:1365–70.
Hickson GB, Clayton EW, Entman SS, et al. Obstetricians’ prior malpractice experience and patients’ satisfaction with care. JAMA. 1994;272:1583–7.
Health Care Financing Administration. Medicare Managed Care Compare. Health Care Financing Administration [cited October 15, 1998]. Available at: http://www.medicare.gov/mphCompare/home.asp. Accessed February 13, 2004.
Health Care Financing Administration. Medicare+Choice: Changes for the Year 2000. Health Care Financing Administration. Available at: http://www.hcfa.gov/medicare/mgdcar1.htm. Accessed February 13, 2004.
Achman L, Gold M. Report No. 533. Medicare+Choice: Beneficiaries Will Face Higher Cost-sharing in 2002. New York, NY: The Commonwealth Fund; 2002.
Safran DG, Neuman P, Schoen C, et al. Prescription drug coverage and seniors: how well are states closing the gap? Health Aff (Millwood). 2002;21:W253-W268.
Laschober MA, Kitchman M, Neuman P, Strabic AA. Trends in Medicare supplemental insurance and prescription drug coverage, 1996–1999. Health Affairs—Web Exclusive. 2002;21(February 27):W127-W138.
Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press; 2003.
Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998–1999 to 2000–2001. JAMA. 2003;289:305–12.
National Committee for Quality Assurance. State of Managed Care Quality 2000. Washington, DC: NCQA; 2000.
National Committee for Quality Assurance. State of Managed Care Quality, 2001. Washington, DC: NCQA; 2001.
Author information
Authors and Affiliations
Corresponding author
Additional information
This research was supported by grant number R01 HS09622 from the Agency for Healthcare Research and Quality and the National Institute on Aging.
Rights and permissions
About this article
Cite this article
Montgomery, J.E., Irish, J.T., Wilson, I.B. et al. Primary care experiences of medicare beneficiaries, 1998 to 2000. J GEN INTERN MED 19, 991–998 (2004). https://doi.org/10.1111/j.1525-1497.2004.30381.x
Issue Date:
DOI: https://doi.org/10.1111/j.1525-1497.2004.30381.x