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Original Research |

Primary Care Physicians' Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination

Hoangmai H. Pham, MD, MPH; Ann S. O'Malley, MD, MPH; Peter B. Bach, MD, MAPP; Cynthia Saiontz-Martinez, ScM; and Deborah Schrag, MD, MPH
[+] Article, Author, and Disclosure Information

From the Center for Studying Health System Change, Washington, DC; Health Outcomes Research Group, Memorial Sloan-Kettering Cancer Center, New York, New York; Social and Scientific Systems, Silver Spring, Maryland; and Dana-Farber Cancer Institute, Boston, Massachusetts.

Grant Support: By the National Institute on Aging (grant R01 AG025687-01A1), American Medical Group Association, and Robert Wood Johnson Foundation.

Potential Financial Conflicts of Interest:Grants received: P.B. Bach (National Institute on Aging).

Reproducible Research Statement:Study protocol: Available from Dr. Pham (e-mail, mpham@hschange.org). Statistical code and data set: Not available.

Requests for Single Reprints: Hoangmai Pham, MD, MPH, Center for Studying Health System Change, 600 Maryland Avenue SW, Suite 550, Washington, DC 20024; e-mail, mpham@hschange.org.

Current Author Addresses: Drs. Pham and O'Malley: Center for Studying Health System Change, 600 Maryland Avenue SW, Suite 500, Washington, DC 20024.

Dr. Bach: Memorial Sloan-Kettering Cancer Center, 307 East 63rd Street, New York NY 10021.

Ms. Saiontz-Martinez: Social and Scientific Systems, 8757 Georgia Avenue, 12th Floor, Silver Spring, MD 20910.

Dr. Schrag: Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115.

Author Contributions: Conception and design: H.H. Pham, A.S. O'Malley, P.B. Bach, D. Schrag.

Analysis and interpretation of the data: H.H. Pham, A.S. O'Malley, P.B. Bach, D. Schrag.

Drafting of the article: H.H. Pham, P.B. Bach, D. Schrag.

Critical revision of the article for important intellectual content: H.H. Pham, A.S. O'Malley, P.B. Bach, D. Schrag.

Final approval of the article: H.H. Pham, A.S. O'Malley, P.B. Bach, D. Schrag.

Provision of study materials or patients: H.H. Pham.

Statistical expertise: P.B. Bach, D. Schrag.

Obtaining of funding: H.H. Pham, P.B. Bach.

Administrative, technical, or logistic support: H.H. Pham.

Collection and assembly of data: H.H. Pham, P.B. Bach.

Ann Intern Med. 2009;150(4):236-242. doi:10.7326/0003-4819-150-4-200902170-00004
Text Size: A A A

Background: Primary care physicians are expected to coordinate care for their patients.

Objective: To assess the number of physician peers providing care to the Medicare patients of a primary care physician.

Design: Cross-sectional analysis of claims data.

Setting: Fee-for-service Medicare in 2005.

Participants: 2284 primary care physicians who responded to the 2004 to 2005 Community Tracking Study Physician Survey.

Measurements: Primary patients for each physician were defined as beneficiaries for whom the physician billed for more evaluation and management visits than any other physician in 2005. The number of physician peers for each physician was the sum of other unique physicians that the index physician's primary patients visited plus other unique physicians who served as the primary physician for each of the index physician's nonprimary patients during 2005.

Results: The typical primary care physician has 229 (interquartile range, 125 to 340) other physicians working in 117 (interquartile range, 66 to 175) practices with which care must be coordinated, equivalent to an additional 99 physicians and 53 practices for every 100 Medicare beneficiaries managed by the primary care physician. When only the 31% of a primary care physician's primary patients who had 4 or more chronic conditions was considered, the median number of peers involved was still substantial (86 physicians in 36 practices). The number of peers varied with geographic region, practice type, and reliance on Medicaid revenues.

Limitations: Estimates are based only on fee-for-service Medicare patients and physician peers, and the number of peers is therefore probably an underestimate. The modest response rate of the Community Tracking Study Physician Survey may bias results in unpredictable directions.

Conclusion: In caring for his or her own primary and nonprimary patients during a single year, each primary care physician potentially must coordinate with a large number of individual physician colleagues who also provide care to these patients.

Funding: National Institute on Aging, American Medical Group Association, and the Robert Wood Johnson Foundation.


Grahic Jump Location
Calculating the number of physician peers.

Solid arrows represent a physician being linked to his or her “primary patients” by having billed for the plurality of that patient's evaluation and management visits. Dashed arrows represent linkages to a physician's other “nonprimary patients.” In this example, we calculated the number of peers for physician A by counting physicians B, C, and D each only once and did not include physician A in that count, resulting in a total of 3 peers.

Grahic Jump Location




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Submit a Comment/Letter
Care coordination needs greater emphasis
Posted on February 23, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

The authors' description of the numerous evaluation and management (E&M) also called coordinating functions, that fall on the shoulders of primary care doctors is timely but, insufficiently emphasized(1).

The intensity and scope of E&M activities are underestimated by most health insurers, not just Medicare. They need greater emphasis than that given by the authors. Referring to evaluation and management functions merely as "E&M" as commonly occurs, without going into detail, trivializes them. Policymakers reading the authors' report may infer that evaluation and management activities are of minor importance. If this happens, as has happened for decades, payment for these activities will continue to be greatly disproportionate to the time and energy primary care doctors put into them.

Imagine someone saying that the evaluation and management (E&M) that went into painting the Sistine Chapel required some thought about mixing colors and preparing surfaces to accept paint but, not mentioning that Michelangelo spent hours poring over sketches and planning the overall harmony of his composition and working with his craftsmen.

As part of evaluation and management esponsibilities, the authors didn't include the many reports to home health care agencies and visiting nurse associations that have to be reviewed, signed and returned. Or the numerous nursing home and hospital discharge summaries and medication lists that have to be read and explained to patients. Or the many CAT scans that demonstrate "incidentalomas" that need further testing and explaining. Or the responses to mail-order pharmacies explaining why patients cannot go on generic drugs. And the many telephone calls and walk -in visits that are the hallmark of primary care practices.

One of the hardest yet least recognized of all the E&M functions to describe which explains why it rarely is is spending time with patients, just letting them go on with the narrative of their illness or their life story or how their illness affects those around them and their life situation. This requires energy and compassion and commitment. Most veteran clinicians know that it helps the therapeutic response. Yet, listening to patients, like other activities that fall under the rubric of E&M because it is unquantifiable, almost always is under emphasized. Sometimes these indirect medical functions consume a major portion of a physician's day.

Many well-intentioned apologists for primary care fail to go into the details of evaluation and management. Not mentioning the details, however well- intentioned their reports may be and regardless of the amount of statistical material they may contain, renders them less effective. And primary care's apologists need to be as effective as they can be.


1. Pham HH,O'Malley AS,Bach PB,Sainotz-Martinez C,Schrag D. Primary Care Physicians' Links to other Physicians Through Medicare Patients: The Scope of Care Coordination. Ann Intern Med 2009;150:236-242.

Conflict of Interest:

None declared

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Summary for Patients

How Many Other Doctors Do Primary Care Doctors Need to Coordinate Patient Care With?

The summary below is from the full report titled “Primary Care Physicians' Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination.” It is in the 17 February 2009 issue of Annals of Internal Medicine (volume 150, pages 236-242). The authors are H.H. Pham, A.S. O'Malley, P.B. Bach, C. Saiontz-Martinez, and D. Schrag.


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