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
