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Most Causes of Healthcare Fragmentation Not Related to Medical Need

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Most of the reasons why American patients receive care from multiple providers are related to numerous modifiable causes such as patient preferences, physician referrals and health system factors —not medical need—according to a qualitative study by Weill Cornell Medicine researchers.  

“The results of our study show that fragmentation is not just a function of sicker patients seeing more providers,” said first author Dr. Lisa Kern, an associate professor of medicine and of healthcare policy and research at Weill Cornell Medicine. “Our study identified more than 40 reasons why patients receive care from multiple providers, only a few of which related to medical need.”

For the study, published Feb. 20 in the Journal of General Internal Medicine, Dr. Kern and her colleagues conducted focus groups with 46 participants—25 patients and 21 primary care providers—at an academic primary care practice in New York in 2017. Participants were asked “Why do you think some patients receive care from many different providers and others do not?” and “What do you think happens as a result of patients receiving care from many different providers?” The study was funded by the Weill Cornell Institute for Primary Care Innovation, which seeks to inspire the next generation of primary care physicians who can develop new innovations in the field.

The 40+ causes of fragmentation that participants identified came from all levels of the healthcare system: patients, providers, healthcare organizations and healthcare environments. For example, patient-level causes included preference for the convenience of particular locations, the availability of appointments, and the need for second opinions. Provider-level reasons included the amount of time needed to educate a patient versus referring them to a specialist and increasing sub-specializations. Causes at the healthcare organization level included policies set by the provider such as discharge processes that encourage follow-up with various specialists and insurers’ decisions regarding which providers are “in network.” At the environment level, the rise of urgent care clinics was cited as a factor.   

Focus group participants also identified 24 consequences of healthcare fragmentation, of which three were desirable, including appropriate consultation with a specialist, higher patient satisfaction in cases where care is well coordinated and stronger relationships with primary care physicians when consulting physicians agree with the primary care physician’s assessment. The focus group also identified 21 undesirable consequences, including medication errors, unnecessary testing, misdiagnosis and provider burnout.

“This study suggests that fragmentation is modifiable,” Dr. Kern said. “Future interventions could change healthcare delivery to minimize unnecessary fragmentation. Our study provides a granular roadmap for those future interventions.”

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