Explaining the drop off in primary care visits

Expanding primary care’s role in the healthcare system has long been viewed as key to reining in healthcare costs and improving outcomes. But patients themselves apparently haven’t gotten the message.

Medical Economics recently reported on a study of claims data at a large commercial health insurer that found a 25 percent decline in visits to primary care providers between 2008 and 2016. To gain more insight into the study’s background and findings. Medical Economics recently spoke with Ishani Ganguli, MD, MPH, one of the study’s authors. A transcript of the interview, edited for clarity and brevity, follows.

Medical Economics: What evidence had you seen of a decline in primary care visits that led you and your coauthors to undertake this study?

Ishani Ganguli: We first noticed it when we were studying a different but related topic, the Medicare Annual Wellness Visit, which began in 2011 as part of the Affordable Care Act. Myself and [co-author] Ateev Mehrotra had collaborated on that study and had noticed that primary care visit rates were going down in Medicare. So we started digging more and noticed this pattern was present across different populations.

So we published a paper last year in the Journal of General Internal Medicine demonstrating this decline in Medicare in two national surveys as well as employer data sets and this commercial population. This more recent paper was our opportunity to study in more depth what was happening among these commercially insured adults and to get more clues as to why it was happening.

ME: Annual checkups used to be routine, at least among people with insurance. Is that no longer the case, or would those now be considered preventative visits? And if it is no longer the case, why not?

IG: Let me unpack that a little. Annual Wellness Visits and preventative visits are two terms for what are essentially the same thing, and preventative visits are actually going up. So what we find is a couple of different threads. We know that having a primary care doctor is a good thing and that being in an area with lots of primary care doctors is good for your health.

But going in for an annual checkup is not that useful, particularly if you are a young or healthy person. In fact, when I have young healthy people come to my office I will do a new patient visit but tell them to come back every couple years because there’s no benefit to coming in every year if they don’t have any new medical needs. So hopefully we’re being more judicious about when to offer those routine checkups.

The other thing you’ll see in the data is a story about cost incentives. Thanks to the ACA, these preventative visits became much cheaper, or free to the patient. So part of why we might be seeing a rise in preventative visits as other types of visits in primary care go down is that exact fact.

Patients are savvy and know that [preventative] visit will be paid for and come in for that. If I, as a doctor know a patient is eligible for their next preventative visit they will have to pay less. Whereas the costs to patients for other types of primary care visits have been going up during this period we studied.

ME: Do you think that the way the insurance company whose data you used for the study structured its plans might have contributed to fewer primary care visits by its members?

 IG: No. A large national insurer such as this one works with hundreds, maybe thousands of employers and designs plans specifically for each of them, so it’s virtually impossible to try and categorize these plans in any meaningful way.

Also, it’s certainly not unique to this insurer. But it may reflect broader trends in, for example, increasing reliance on high-deductible health plans.

ME: What has been the response to the study?

IG: The ACP [American College of Physicians] has been interested because it speaks to the larger challenges of the disconnect in the way we think about healthcare. We increasingly think of primary care as being the solution to a lot of the challenges we face in healthcare. We think about it as a way of saving money and improving the quality of care. And the new primary care models, like accountable care organizations and patient-centered medical homes have primary care at their center. Yet if people aren’t seeing their primary care doctor as much, that gives you pause. So I think that’s why people have been interested, this sort of disconnect between what we want primary care to do for us and what this evidence suggests.

All that being said-and I think we make this point in the paper-some of the reasons for the decline are worrisome, like issues of access, such as when there’s no primary care doctor who has availability, or the cost barriers.

The good news story, though, is that I think primary care has gotten more efficient and tends to be better than specialist care at using other members of the team, and at doing virtual care through e-mails or telephone calls. So some of the decline might be an appropriate shift to other types of interactions between doctors and patients.

ME: Is it also possible that people just are healthier and thus have less reason to see a doctor?

IG: Yes, I think in certain ways that’s probably true. We have better vaccinations, for example. One of my colleagues led a study, using this same data, looking at children in the commercially-insured population and found that vaccines for preventing upper respiratory infections resulted in a huge decline in visits. We’ve seen a big drop in visits for more mild conditions like a cold or pink eye where you could go online and figure out what to do, or call your doctor but not come in. The paper we published last year goes into the whole universe of possible reasons [for the decline in primary care visits.]

ME: What are the implications of your findings for primary care doctors and the country’s healthcare system?

IG: To the extent that this is a worrisome story, whether it’s bigger drops in low-income areas that suggests shortage of primary care doctors and challenges paying for visits, we need to redesign areas of our healthcare system to try and make that better. That could be insurance companies making high-value visits like primary care visits free or low-cost for patients, or changes in our medical education policies to encourage more students to go into primary care, fostering our nurse practitioner and physician assistant colleagues--we included them in the study as primary care practitioners--all those changes are important.

I think there’s also education that needs to be done around how patients view primary care. We saw a decline not just among millennials, which is the group we often think of that doesn’t feel like they need to see a doctor, but even among folks in the 55-64 age group, the decline was present. To the extent that’s telling us either people aren’t seeing the value in primary care, or getting their needs met in another venue, like an urgent care setting, we need to think more about how we make primary care accessible and attractive to people because of all the current challenges in accessing care.

So I’d say, broadly speaking, it’s changing the way patients pay for primary care, there’s how we structure the payment and delivery of primary care to make it easier for primary care docs to meet patients where they need to be, and it’s educating patients on why it’s important to have a primary care doctor.