Primary care improves patient outcomes and lowers health care costs. That is why most countries emphasize primary care and why the United States is trying to expand primary care programs. This article finds that the United States may be losing ground and provides some clues about why we are not doing better.
Abstract
Background:
Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline.
Objective:
To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits.
Design:
Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008–2016. A 5% claims sample was used for Poisson regression models to quantify visit trends.
Setting:
National, population-based.
Participants:
Adult health plan members aged 18 to 64 years.
Measurements:
PCP visit rates per 100 member-years.
Results:
In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, −48.1% to −47.3%). The decline was largest among the youngest adults (−27.6% [CI, −28.2% to −27.1%]), those without chronic conditions (−26.4% [CI, −26.7% to −26.1%]), and those living in the lowest-income areas (−31.4% [CI, −31.8% to −30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (−0.08% [CI, −0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%).
Limitation:
Data were limited to a single commercial insurer and did not capture nonbilled clinician–patient interactions.
Conclusion:
Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care.
Primary Funding Source:
None.
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Author, Article, and Disclosure Information
Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
Icahn School of Medicine at Mount Sinai, New York City, New York (A.R.)
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (K.N.R.)
Disclosures: Dr. Ganguli reports receiving compensation as a consultant from Haven (a not-for-profit health care venture) and grant funding from International Business Machines Corporation. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1834.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Not applicable. Statistical code: Available from Dr. Ganguli (e-mail, [email protected]
Corresponding Author: Ishani Ganguli, MD, MPH, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02120; e-mail, [email protected]
Current Author Addresses: Drs. Ganguli and Orav and Ms. Rao: Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02120.
Ms. Shi and Dr. Mehrotra: Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115.
Dr. Ray: Children's Hospital Office Building, 3414 Fifth Avenue, Pittsburgh, PA 15213.
Author Contributions: Conception and design: I. Ganguli, K.N. Ray.
Analysis and interpretation of the data: I. Ganguli, Z. Shi, E.J. Orav, A. Rao, K.N. Ray, A. Mehrotra.
Drafting of the article: I. Ganguli, A. Rao.
Critical revision of the article for important intellectual content: I. Ganguli, Z. Shi, E.J. Orav, A. Rao, K.N. Ray, A. Mehrotra.
Final approval of the article: I. Ganguli, Z. Shi, E.J. Orav, A. Rao, K.N. Ray, A. Mehrotra.
Statistical expertise: E.J. Orav.
Administrative, technical, or logistic support: A. Mehrotra.
Collection and assembly of data: A. Mehrotra.
This article was published at Annals.org on 4 February 2020.
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