Continuity of care: health benefits and compensation

Continuity of care—a trusting relationship with a personal physician based on recurring interactions over time—is an essential ingredient of the secret sauce of family medicine. Numerous studies have demonstrated that higher care continuity is associated with more appropriate care and lower costs. Data also support positive effects on health outcomes. A retrospective analysis from Alberta, Canada, reported that physician and clinic continuity (seeing a clinical partner when one’s primary physician was unavailable) correlated with fewer emergency department visits across all levels of patient complexity and fewer hospitalizations for highly complex patients. A similar US cohort study of Medicare fee-for-service claims from a nationally representative sample of 4,940 medical practices found that patients with higher primary care physician continuity were 5.5% to 6.8% less likely to be hospitalized and 4.9% to 6.3% less likely to visit the emergency department.

In 2023, the Accreditation Council for Graduate Medical Education changed the emphasis of family medicine resident training requirements from volume of encounters to continuity of care. In a special article published in Family Medicine, Dr. Gregory Garrison and colleagues described five domains of care continuity. In addition to traditional clinician-patient or “relational” continuity, they discussed benefits of informational (medical record), managerial (interdisciplinary care), family (caring for multiple family members), and geographical (care in multiple locations or environments, such as home, office, and hospital) continuity.

Unfortunately, the percentage of the US population who experience continuity of care has been decreasing since the turn of the century. A 2015 Graham Center Policy One-Pager found that fewer adults reported a personal physician (as opposed to a practice or facility) as their usual source of health care. From 2000 to 2019, the percentage of US patients who reported having a usual source of care declined from 84% to 74%.

To support continuity and compensate primary care clinicians for the additional complexity and cognitive load involved in these longitudinal relationships, the Centers for Medicare and Medicaid Services (CMS) introduced the add-on G2211 code in January 2024 and refined its use in 2025. Some private health insurers also recognize and pay for this code. A 2024 Graham Center analysis projected that applying the G2211 code to all eligible Medicare evaluation and management (E/M) visits would increase annual reimbursement by an average of $2,667 per physician. Attaching the G2211 code to E/M visits with 25 modifiers (approved by CMS in 2025) resulted in another $990 per physician. This year, G2211 codes also can be applied to home-based primary care visits. Relative to the established benefits of care continuity, the added compensation seems modest at best. In addition, a research letter published this week in JAMA found that in 2024, the largest share of G2211 codes (43%) was billed by specialist physicians, not primary care physicians (40%), many for diagnoses "that may not qualify as serious or complex" as CMS originally intended.

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This post first appeared on the AFP Community Blog.

RFK Jr. is making measles great again: why it matters to everyone

2025 was a banner year for the measles. 2026 is already looking like it will be much worse.

Last year, there were more than 2,200 confirmed measles cases in the U.S., the highest number since 1991. More than 1 in 10 infected persons became sick enough to be hospitalized, and 3 people died.

This year, an ongoing measles outbreak in northwest South Carolina is up to 876 cases, more than 500 of which occurred after January 1. The first 5 cases of measles in Pennsylvania were just diagnosed here in Lancaster County. Measles spreads like wildfire. Vaccination denies it fuel. But county-level measles, mumps, and rubella (MMR) vaccination coverage has been falling for the past 5 years, creating pockets of vulnerability due to low immunity - perfect tinder for a highly contagious virus.

Now, you may wonder why this worsening epidemic should matter to you personally. If some people, for whatever reason, fear the MMR vaccine more than the measles (and mumps, and rubella), or want their "health freedom" so badly that they are willing to risk their well-being or that of their children, to each his own. You got your MMR vaccine as a child and made sure that your children did, too. You may sympathize with doctors and public health workers who have to clean up the mess that antivaxxers like Andrew Wakefield and Robert F. Kennedy, Jr. have made, but your good choices mean than you are protected, right?

Yes and no. Setting aside the issue that infants can't be vaccinated against the measles until they are 6 months old (and don't routinely receive their first dose of MMR vaccine until they turn one), those who have received two doses of measles vaccine are 97% protected against developing the measles from an exposure. On the individual level, 97% is about as good as it gets. That's much better protection than vaccines against Covid-19 or influenza or practically every other vaccine. But on a population level, because measles is so incredibly contagious, a kid with measles could attend school where every one of other the 500 students had received 2 doses of MMR, and 15 kids could still catch the virus. Someone with the measles could go to Disneyland, expose thousands of fully vaccinated people, and spread it to dozens.

An article in last week's Morbidity and Mortality Weekly Report described a measles outbreak investigation associated with an unvaccinated traveler who caught the measles in Colorado, then went to the airport in Denver and boarded an international flight. Epidemiologists painstakingly identified at least 17 measles cases that could be traced back to this traveler. Of the 9 cases in Colorado residents, 5 caught it at the airport and 4 on the flight. What I found striking was that 4 of the 9 had received two doses of MMR vaccine. Someone who doesn't understand statistics might look at that figure and say, well, the vaccine must not be very effective. Wrong: it's 97% effective. What almost certainly happened is that the index patient exposed at least 100 people at the airport and on the plane, most of whom were vaccinated. The unvaccinated people all caught the measles, while a few of the vaccinated did too.

Measles was once a common childhood illness. Thankfully, most of the time it resolves without any need for medical intervention. (That doesn't mean that patients don't experience significant suffering - take it from someone who caught chickenpox at age 16 and missed two full weeks of school, a few years before the varicella vaccine was approved.) But most of the time isn't all of the time. Per the MMWR article: "Complications occur in approximately 10% of patients with measles, including ear infections and diarrhea; serious complications including pneumonia (5%), encephalitis (0.1%), and death (0.1%–0.3%) also occur." Though rare, being unable to breathe, becoming comatose due to brain swelling, or dying are all real consequences of the measles. As a family physician who provides hospital care, I've seen plenty of patients with these complications as a result of other conditions that I can't prevent with two shots. I don't want to see them from an infection that is almost completely preventable. But as the measles wildfire burns on, and more communities become tinder, it's only a matter of time until I do.