New Studies Reveal that Fragmented Care Persists Despite Efforts to Improve Primary Care and Care Delivery

High levels of fragmented care persist, according to new research from Mathematica, despite providers’ increased use of electronic health records, more integrated health systems, and several national initiatives designed to improve the quality and continuity of primary care. A series of studies conducted by Mathematica with support from the Centers for Medicare & Medicaid Services explore care fragmentation to shed light on why it happens, the experiences of physicians and patients, and the effects of federal policy interventions intended to strengthen primary care.

Fragmented care occurs when a patient sees many different providers and does not see a single provider for a substantial portion of their visits. High levels of care fragmentation can lead to poor communication and coordination among providers and is associated with increased hospital and emergency department use, unnecessary testing, and increased medical costs.

The studies suggest that initiatives seeking to improve continuity, coordination, and comprehensive care more broadly may have to focus on a broader array of providers beyond the primary care setting if they are going to have an impact. The authors recommend that care systems align incentives across specialists, primary care providers, and other health care entities to reduce fragmentation and improve coordination, including additional support to improve communication across providers. In addition, they indicate that it might be necessary for interventions to specifically target fragmented care.

Although health policy experts agree that fragmented care is a cause of concern, experts still don’t know what drives fragmentation. While some assume that fragmented care might be medically necessary, others are exploring alternative explanations. A study by Mathematica published in Medical Care found that a rich set of characteristics of patients, primary care providers, practice sites, and geographic markets could explain only 6 percent of the variation in whether someone received highly fragmented care. Importantly, consistent with results from other studies, Mathematica did not find that care fragmentation was substantially higher among sicker patients, suggesting that patients’ medical need is not driving high care fragmentation. The study’s authors concluded that highly fragmented care is most likely due to other factors not observed in this study, such as characteristics of practitioners outside primary care settings (particularly specialists) and patients choosing to seek care from multiple providers.

Although care fragmentation seems to be driven in part by patients’ preferences, it is noteworthy that Medicare beneficiaries reported, as described in a study published in Health Services Research, that they were more satisfied with their primary care provider and practice staff when they received more comprehensive care. The findings suggest that patients value having a provider that manages a wider range of their conditions and can address new concerns and symptoms in the primary care setting over being referred to specialists.

Among providers, better communication about patients they share can help counteract some of the consequences of highly fragmented care. But, based on a recent survey, physicians continued to report that they do not consistently communicate with each other about the patients they share, according to a study published in Annals of Family Medicine. Gaps in communication between primary care and specialist physicians were similar in magnitude to a study from more than a decade earlier, despite efforts since that might have improved communication between providers, such as the proliferation of electronic health records, substantial growth in the number and sizes of vertically integrated health systems, and initiatives promoting coordinated care.

Primary care initiatives might not be able to reduce care fragmentation much without substantial incentives that target it directly. According to a study published in the American Journal of Managed Care, Medicare beneficiaries who experienced high care fragmentation did not see any improvement in the first three years of Comprehensive Primary Care Plus, the largest primary care transformation initiative in the United States at the time, involving more than 3,000 practices and more than 17 million patients. These results are notable because Comprehensive Primary Care Plus practices engaged in activities thought to counteract high care fragmentation, such as assigning patients to a practitioner or care team, integrating behavioral health, helping patients and caregivers navigate the health care system, identifying and communicating with specialists, and assisting with care transitions and timely follow-up after hospital or emergency department visits.

These studies were part of a larger body of research funded by the Center for Medicare & Medicaid Innovation. Learn more about how the Innovation Center and Mathematica are advancing understanding of primary care through an evaluation of the Comprehensive Primary Care Plus model.