Primary care experiences of Medicare beneficiaries, 1998 to 2000

OBJECTIVE: To examine changes in the quality of primary care experienced and reported by Medicare beneficiaries from 1998 to 2000. DESIGN: Longitudinal observational study. SETTING: Thirteen states with large, mature Medicare HMO markets. PARTICIPANTS: Probability sample of noninstitutionalized Medicare beneficiaries aged 65 and older enrolled in traditional Medicare (FFS) or a Medicare HMO. MEASUREMENTS AND MAIN RESULTS: We examined 2-year changes in 9 measures derived from the Primary Care Assessment Survey (PCAS). The measures covered 2 broad areas of primary care performance: quality of physician-patient interactions (5 measures) and structural/organizational features of care (4 measures). For each measure, we computed the change in each beneficiary's score (1998 vs 2000) and standardized effect sizes (ES). Results revealed significant declines in 3 measures of physician-patient interaction quality (communication, interpersonal treatment, and thoroughness of physical exams; Pless than or equal to .0001). Physicians' knowledge of patients increased significantly over the 2-year period (Pless than or equal to .001). Patient trust did not change (P = .10). With regard to structural/organizational features of care, there were significant declines in financial access (P less than or equal to .001), visit-based continuity (P < .001), and integration of care (Pless than or equal to .05), while organizational access increased (P less than or equal to .05). With the exception of financial access, observed changes did not differ by system (FFS, HMO). CONCLUSIONS: Over a 2-year period, the quality of seniors' interactions with their primary physicians declined significantly, as did other hallmarks of primary care such as continuity, integration of care, and financial access. This decline is in sharp contrast to the marked improvements in technical quality that have been measured over this period. In an era marked by substantial national investment in quality monitoring, measures of these elements of care are notably absent from the nation's portfolio of quality indicators.