Patient sharing among physicians and costs of care: a network analytic approach to care coordination using claims data

Abstract

Background: Improving care coordination is a national priority and a key focus of health care reforms. However, its measurement and ultimate achievement is challenging.

Objective: To test whether patients whose providers frequently share patients with one another-what we term 'care density'-tend to have lower costs of care and likelihood of hospitalization.

Design: Cohort study

Participants: 9,596 patients with congestive heart failure (CHF) and 52,688 with diabetes who received care during 2009. Patients were enrolled in five large, private insurance plans across the US covering employer-sponsored and Medicare Advantage enrollees

Main measures: Costs of care, rates of hospitalizations

Key results: The average total annual health care cost for patients with CHF was $29,456, and $14,921 for those with diabetes. In risk adjusted analyses, patients with the highest tertile of care density, indicating the highest level of overlap among a patient's providers, had lower total costs compared to patients in the lowest tertile ($3,310 lower for CHF and $1,502 lower for diabetes, p < 0.001). Lower inpatient costs and rates of hospitalization were found for patients with CHF and diabetes with the highest care density. Additionally, lower outpatient costs and higher pharmacy costs were found for patients with diabetes with the highest care density.

Conclusion: Patients treated by sets of physicians who share high numbers of patients tend to have lower costs. Future work is necessary to validate care density as a tool to evaluate care coordination and track the performance of health care systems.

Figure 1.

Simplified care density network map. Doctors are represented by circles (A to F). Four patients are represented by different types of lines (solid light, solid heavy, large dashed, and small dashed lines). Each patient saw 3 doctors (and thus 3 pairs of doctors). Doctors are connected to one another if they shared in the care of a patient. The weight (strength) of connections between pairs of doctors represents the number of shared patients: the doctor pair AD is given a weight of 3, pair DF a weight of 2, and pairs AB, BD, CD, DE, EF, and AF a weight of 1. For each patient, the care density represents the sum of the weights of his/her doctor pairs divided by the number of doctor pairs he/she sees.

Figure 2.

Regression adjusted estimates of the impact of medium and high care density compared to low density on annual costs of care for patients with CHF and diabetes.