We studied 2,359,400 beneficiaries who sought care from 13,926 physicians. Every 0.1 increase in physician continuity score was associated with a $151 reduction in expenditure per beneficiary per year (p < 0.01), and every 0.1 increase in practice continuity score was associated with $282 decrease (p < 0.01) per beneficiary per year. Both physician- and practice-level continuity were associated with lower Medicare expenditures among small, medium, and large practices. Both physician- and practice-level continuity were associated with lower probabilities of hospitalization, ED visit, admissions for ACSC, and readmission.

Primary care continuity of care could serve as a potent value-based care quality metric. Physician-level continuity is a unique value center that cannot be supplanted by practice-level continuity.

As of 2020, annual federal and state support for graduate medical education (GME) had grown to nearly $19 billion, which funds 139,848 physician training positions in 1,657 teaching hospitals across the United States. These public subsidies are provided with the understanding that the training institutions will use this governmental funding to meet the health care needs of society, both now and in the future. Decisions about how that funding is further allocated are deferred to individual training sites. This arrangement represents an implicit social contract between teaching hospitals and the American public with the reciprocal responsibilities being sustained government funding that enables GME training programs to produce a workforce that can meet communities’ and the broader society’s needs. ^6,7 Surprisingly, this social contract contains little accountability for how that public funding is used.