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Study finds declining quality of primary care for elderly Medicare patients

Many elderly adults have multiple chronic medical conditions that must be monitored on a regular basis. For these patients, receipt of high-quality primary care is critical. Yet, findings from a recent study show that the quality of seniors' interactions with their primary care physicians declined significantly from 1998 to 2000. In 2000, Medicare-insured seniors reported less thorough discussions about their problems and symptoms, greater difficulty reaching their doctor, and interpersonal treatment that they felt was less caring and more rushed (despite similar length of office visits).

Seniors' financial access to primary care, continuity of care, and integration of care also declined during this period, according to the study, which was supported by the Agency for Healthcare Research and Quality (HS09622) and the National Institute on Aging and carried out by researchers from Tufts-New England Medical Center and Tufts University School of Medicine in Boston.

Specifically, Medicare patients reported paying more for doctor's visits, medication, and other treatments in 2000 than in 1998. The largest declines occurred in the quality of physician-patient interactions. For example, patients said they were less likely to be able to see their regular doctor when they were sick, their doctor often did not help them understand what specialists said about them, and the quality of specialists they were referred to declined over the 2-year period. Patients also reported that they had less access to their doctor when they were sick, called for an appointment, or wanted advice by phone. With the exception of financial access, the observed changes did not differ by system (fee-for-service [FFS] or HMO Medicare).

The declines in financial access and interpersonal quality of care seen in this study are in sharp contrast to changes in technical quality of care that occurred during the same time period. These technical improvements were likely the result of routine monitoring and reporting on measures of technical quality of care using the Health Employer Data and Information Set (HEDIS) and other measures. Thus, the technical aspects of care were getting attention from organizations and individual clinicians leading to steady improvement (i.e., "What gets measured gets attention"). In conclusion, the authors note that similar attention to the interpersonal aspects of quality of care is part of what is needed to correct the observed downward trajectory seen in this study.

The researchers based these findings on analysis of data from the Primary Care Assessment Survey completed by Medicare FFS and HMO beneficiaries in 13 States. Using these data, the investigators evaluated changes from 1998 to 2000 in nine measures covering two broad areas of primary care: quality of physician-patient interactions (five measures) and structural/organizational features of care (four measures).

Details are in "Primary care experiences of Medicare beneficiaries, 1998-2000," by Jana E. Montgomery, Sc.M., Julie T. Irish, Ph.D., Ira B. Wilson, M.D., M.S., and others, in the October 2004 Journal of General Internal Medicine 19, pp. 991-998.

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