Continuity in Gatekeepers: Quantifying the Impact of Care Fragmentation
38 Pages Posted: 8 Jan 2018 Last revised: 1 May 2018
Date Written: April 30, 2018
Operational systems increasingly rely upon specialized experts who can provide high-quality service. However, these experts, by definition, only address one part of an overall problem and so individuals are needed to coordinate the overall service provision. In many services, this coordination responsibility may be shared across multiple parties serving in the role of a gatekeeper. In this paper, we explore the operational consequences of continuity or fragmentation in the role of a gatekeeper. We use a unique and comprehensive dataset from the Veterans Health Administration, the largest integrated healthcare delivery system in the United States, to analyze over 300,000 patients over eleven years that suffer from diabetes, a chronic disease whose successful management requires care continuity, as well as kidney diseases, a major complication of diabetes. We examine how the continuity of care with their primary care physicians (PCPs), the gatekeeper in this environment, affects patients' health outcomes. Using a detailed dataset that permits us to control for potential sources of heterogeneity, we find that continuity of care is related to improvements in three important health outcomes: inpatient visits, length of stay, and readmission rate. Moreover, we find that the gains are not linearly improving in continuity, but rather, the relationship is U-shaped whereby there may be value in having multiple providers. In addition, we find that care continuity is even more important for patients suffering from more complex conditions. Finally, we find that continuity of care leads to a more efficient provision of resources, as measured by diagnostic tests ordered. We conduct extensive robustness checks and sensitivity analysis, including use of instrumental variables method to validate our findings. Our results have important implications for both the theory and practice of operations management, in general, and healthcare, in particular.
Keywords: Gatekeepers, Coordination, Continuity of Care, Healthcare Operations, Empirical Operations
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