Primary Care Visits Fell Nearly One Quarter in Less Than 10 Years

Primary care visits among commercially insured adults decreased 24.2% over 9 years, while specialist visits remained largely unchanged, according to a new report published this week in the Annals of Internal Medicine.
The large study, based on insurance claims from January 2008 through December 2016, also showed that the number of adults with no primary care visits in an entire year grew from 38.1% to 46.4% over the study period.
“The reason alarm bells ring is that we  know that primary care is associated, at a population level, with lower mortality and has been associated with better health outcomes, less need for emergency care, lower costs of care and better patient satisfaction,” lead author Ishani Ganguli, MD, MPH, an assistant professor at  Harvard Medical School in Boston, Massachusetts, told Medscape Medical News.
Healthcare reform efforts in the United States rely on primary care as a foundation, added Ganguli, who is also an internist at Brigham and Women’s Hospital.

For the current study, the researchers looked at 142 million primary care visits over 94 million person-years with a single insurer. They defined PCPs as physicians, nurse practitioners (NPs), and physician assistants (PAs) whose National Provider Identifier included general practice, medicine, family practice, pediatrics, or geriatric, internal, or adolescent medicine.

Possible Reasons for the Decline

The researchers suggest three main reasons for the decline in visits.
One is that more are seeking care online. Decreases in use were found across all age groups, but were largest among the young and healthy who may be more comfortable with online consults and Internet searches for minor needs.

“[V]isit rates decreased sharply for low-acuity conditions, such as conjunctivitis, that might be addressed more easily by calling a nurse or searching the Internet,” the authors note.
Another reason may be the rising deductibles and out-of-pocket costs for care. The study found, as others have, that the decline in PCP visits was largest in low-income communities, though the drop in visits was evident across all income levels.
“[W]e estimate that the 32% increase in out-of-pocket costs for problem-based visits we observed may explain approximately 3 to 6 percentage points of the 24-percentage point decline (that is, 12.5% to 25% of the decline),” they write.
The study pointed out that the average out-of-pocket cost for a primary care visit related to a health problem rose from about $30 to $40 during the study period. Additionally, the percentage of visits that involved a deductible jumped from less than 10% in 2008 to more than 25% in 2016.

Meanwhile, preventive care visits, which are largely free under provisions of the Affordable Care Act, went up 40.6% in that time.

Some Seeking Care Elsewhere

The authors also note that visits to urgent care centers, retail clinics, and emergency departments, as well as telemedicine visits, were up by 9 visits per 100 member-years, “offsetting about one quarter of the PCP visit decline (35 visits per 100 member-years).”
However, Ganguli emphasized these visits are a small percentage of total visits.
While such alternative visits can be very useful for some transactional needs, such as testing for strep throat, she said, “They don’t replace a relationship with a primary care clinician who knows you well. That’s the big distinction.”

Some Positives in the Data

The positive news from the research, Ganguli says, is that PCPs are finding other, more convenient ways to interact with patients besides office visits.
She gave an example in her own practice: Ganguli said she might see a patient for high blood pressure in the office and then, instead of scheduling a follow-up visit in a month, she’ll give information on buying a home blood pressure cuff with instructions to email her with results.
PCP visits may also be getting more efficient, and physicians may be getting more done at each appointment — so fewer are necessary. Ganguli said their previous research supports this idea, with evidence of longer visits and more objectives accomplished during the visits.

The downward trend may also reflect the move away from needing to have a PCP referral for specialist services, said John Hargraves, MPP, senior researcher with the Health Care Cost Institute, based in Washington, DC.
“For many specialists, patients have enough knowledge to choose the appropriate provider and don’t need the referral,” said Hargraves, who analyzes trends in primary care visits.
Hargraves told Medscape Medical News the Ganguli study helps confirm previous reports of declines in the numbers of PCP visits.

He said the concern is not necessarily with people who are healthy and perhaps can skip some annual primary care checkups. “But if you’ve been diagnosed with asthma or are diabetic and are not going to the doctor, that could lead to serious complications down the line — and is much more costly to the system and the patient.”
What the study was not able to show — and what remains a gray area in medicine — is where the line is between necessary and unnecessary care.
“We don’t know that we’re looking at a decline in necessary care,” he said.

Coverage Does Not Equal Access

In an accompanying editorial, Kimberly Rask, MD, PhD, with Emory University and Alliant Health Group in Atlanta, Georgia, notes that the strengths of the study are that it used a large database and it showed that even people with commercial insurance are using PCP care less.
But coverage does not equate to access, Rask notes. And this study shows that applies to those who are commercially insured just as previous studies have shown that to be the case among publicly-insured patients.
She draws her own conclusions of the problem, writing: “The steady decline in PCP visit rates across age, health status, and income may be the unintended consequence of using cost sharing to reduce unnecessary care in an uncoordinated health care system.”
While cost-sharing and high-deductibles have been designed to decrease use of unneeded care and require patient investment, research suggests that needed care is being decreased along with unnecessary care, she pointed out.
Ganguli, who reports receiving compensation as a consultant from Haven (a nonprofit healthcare venture), said that studies over the long term that evaluate whether the decline in PCP visits is related to poorer outcomes will  help to clarify that question and aid in effecting change.
The study had no primary funding source. Apart from Ganguli’s consultancy with Haven, the other study authors and the editorialist have disclosed no relevant financial relationships.
Ann Intern Med. Published online February 3, 2020. Abstract, Editorial
https://www.medscape.com/viewarticle/924951#vp_1