Why Some Hospitals Send Surgical Patients Back to Their Family Doctor and Others Don’t

When a patient survives a major operation, the surgery is only half the story. What happens in the weeks after discharge, particularly whether the patient reconnects with a primary care physician, can shape recovery, medication management, and the risk of a costly readmission. A new study published in the Journal of General Internal Medicine reveals just how wildly this basic step varies from one US hospital to another, and it raises pointed questions about whether the nation’s flagship surgical payment reform is measuring hospitals on something they may not fully control.

The research team, led by Dr. Jamila K. Picart of the University of Michigan Medical School along with colleagues at the Center for Healthcare Outcomes and Policy and the Institute for Healthcare Policy and Innovation, examined postoperative primary care follow-up after major surgery using national Medicare data obtained from the Centers for Medicare & Medicaid Services under a data use agreement. Their central finding is deceptively simple: the likelihood that a Medicare beneficiary sees a primary care clinician after a major operation depends substantially on which hospital performed the surgery, even after accounting for patient differences.

Why does this matter? Because the federal government increasingly pays for surgical care through episode-based accountability models, most prominently the Bundled Payments for Care Improvement Advanced initiative and its successor frameworks, in which hospitals and their clinical partners share financial responsibility for costs incurred during a defined window around an operation, typically spanning the hospitalization plus 30 or 90 days afterward. The Transforming Episode Accountability Model referenced in the study’s title represents the latest evolution of this approach, and it holds hospitals accountable for outcomes and costs that extend well beyond the operating room walls.

The technical problem the researchers confronted is a classic one in health services research: attribution. Episode-based payment models assign responsibility to a triggering hospital, but much of the care that determines whether the episode succeeds or fails is delivered by clinicians who have no formal relationship with that hospital. A patient who undergoes a colectomy at a high-performing academic medical center may return home fifty miles away, where follow-up depends on the local supply of primary care clinicians, the density of post-acute care facilities, and longstanding referral patterns that the hospital cannot easily influence. Prior work cited in the study, including analyses in JAMA Surgery, has linked care fragmentation after discharge to higher mortality, and other research has connected the local supply of postdischarge care options to hospital readmission rates.

The University of Michigan team quantified the scale of the variation by measuring the proportion of patients at each hospital who obtained primary care follow-up in the postoperative period. The distribution was wide. Some hospitals managed to connect a large majority of their surgical patients with primary care after discharge, while others serving demographically similar patients achieved far lower rates. Because the study used CMS data, the analysis could adjust for patient comorbidities, procedure type, and other observable characteristics, making the residual hospital-level differences a meaningful signal of structural variation rather than mere case mix.

Several mechanisms could plausibly drive this variation, and the authors’ framing draws on the broader literature on pay-for-performance, including a well-known review by Markovitz and Ryan questioning whether disappointing pay-for-performance results reflect genuine failure or masked heterogeneity in the environments that different providers face. Hospitals embedded in integrated health systems, for example, may find it operationally easier to schedule follow-up visits because the primary care physicians are colleagues within the same electronic health record and scheduling infrastructure. Hospitals in primary care shortage areas face a fundamentally different challenge: their patients may want follow-up but be unable to secure an appointment. Prior work by Anderson and colleagues has documented differences in primary care follow-up after acute care discharge both within and across health systems, suggesting that the pattern is systemic rather than idiosyncratic.

The clinical stakes are well documented. Studies of high-risk surgery have shown that early primary care provider follow-up is associated with lower readmission rates, and research on emergency general surgery found that primary care physician follow-up relates to 30-day readmission outcomes. Fragmented postdischarge care, in which patients bounce between specialists, emergency departments, and unfamiliar clinicians, has been repeatedly associated with worse surgical outcomes. In other words, the quiet office visit two weeks after discharge is not a formality; it is a checkpoint where medications get reconciled, wounds get inspected, and creeping complications get caught before they become admissions.

The policy implication is where the study becomes genuinely provocative. If the Transforming Episode Accountability Model penalizes or rewards hospitals partly based on outcomes that are downstream of postdischarge primary care engagement, then some hospitals will be judged on terrain they cannot readily reshape. A hospital in a rural county with a shrinking physician workforce cannot conjure primary care capacity, no matter how excellent its surgeons are. Conversely, a hospital affiliated with a large primary care network enjoys a structural advantage that has little to do with surgical quality. Under such conditions, performance scores risk measuring local health system architecture as much as hospital skill, an issue the authors argue deserves explicit attention as the model is refined.

There are potential remedies embedded in this diagnosis. Episode models could adjust for local primary care supply when calculating accountability metrics, similar to how risk adjustment accounts for patient sickness. Alternatively, models could directly reward hospitals that close the follow-up gap, giving them resources and incentives to build discharge-to-primary-care pathways: automated appointment scheduling before discharge, telehealth bridges for patients far from clinics, and data-sharing agreements with community practices. The study, funded in part through the National Clinician Scholars Program, stops short of prescribing a single fix, but its framing makes clear that the design choices embedded in the next generation of episode-based payment will determine whether the model drives genuine improvement or merely rewards geography.

For patients, the takeaway is more immediate. Anyone heading into major surgery should ask, before the operation, how follow-up with their regular doctor will be arranged and who is responsible for making it happen. The study’s hospital-to-hospital variation suggests that the answer depends heavily on where the surgery happens, and that the difference between a well-coordinated recovery and a fragmented one may lie in systems most patients never see. As Medicare continues its march toward accountability models that span the entire care episode, this research delivers a clear message: the surgery may end at discharge, but the accounting has only just begun, and it will be fair only if it recognizes that not every hospital starts from the same place.

Subject of Research: Hospital-level variation in postoperative primary care follow-up after major surgery and its implications for Medicare episode-based payment models

Article Title: Hospital Variation in Postoperative Primary Care Follow-up After Major Surgery: Implications for the Transforming Episode Accountability Model

Article References: Picart, J. K., Mullens, C. L., Harbaugh, C. M., Ibrahim, A. M., & Markovitz, A. A. (2026). Hospital Variation in Postoperative Primary Care Follow-up After Major Surgery: Implications for the Transforming Episode Accountability Model. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10748-1

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10748-1

Keywords: primary care follow-up, major surgery, hospital variation, episode-based payment, Medicare, Transforming Episode Accountability Model, care fragmentation, readmission, health policy, bundled payments, postdischarge care, health services research