Why aren’t Americans seeing primary care doctors?

Visits to primary care doctors have been falling for decades in the U.S., and rising out-of-pocket costs are the main, although not the only, reason why.

That is the conclusion of two recent studies of trends in visits to primary care physicians (PCPs), one looking at the period 2008 to 2016 and the other 1998 to 2017. It calls into question the widely -held assumption among healthcare policymakers that lack of insurance coverage is the main obstacle patients face in obtaining medical care, especially primary care.

One of the studies, published in Annals of Internal Medicine, focuses on trends in visits to PCPs among a cohort of people age 18 to 64 enrolled with a national commercial insurer between 2008 and 2016. The authors examined records of 142 million primary care visits among 94 million member-years (defined as the total number of months those in the study were enrolled divided by 12).

After adjusting for changes in age, income and location among enrollees, the study found a 24 percent decline in PCP visits. Moreover, by the end of the period, 46 percent of  the people in the study had no PCP visits in a given year, up from 38 percent at the start of the period.

The authors offer three possible explanations for the trend: first, that patients are becoming more comfortable with going online to get information for addressing non-acute needs, and communicating with their doctor electronically rather than in person for some acute medical needs.

Second, more adults are enrolled in commercial plans with deductibles and/or copays for primary care visits and the payment amounts required for both have been increasing, thus discouraging people from seeking care. As evidence, the authors note that the decline in PCP visits was largest among people with low incomes, a group that other studies have shown to respond the most to higher out-of-pocket costs. 

The third possibility, the authors say, is that patients are replacing PCP visits with visits to specialists, or obtaining primary care at urgent care centers, retail clinics, or via telemedicine. 

The other study, which appears in JAMA Internal Medicine, focuses more specifically on the link between the decline in patient visits and the rising cost of accessing primary care during the period 1998-2017. Using data from CDC and state health department surveys, it found the number of insured adults who said they couldn’t see a doctor because of cost grew by 3.6 percentage points. Among adults without insurance, the increase was 5.9 percentage points.

More disturbingly, the study finds more people with some common chronic conditions were unable to afford doctor visits. For patients with cardiovascular disease, the increase was 5.9 percent, for those with elevated cholesterol it was 3.5 percent, and for those with binge drinking it was 3.1 percent. The proportion of chronically ill patients receiving checkups did not change, however.

The authors note that these shifts took place despite increases in the number of insured Americans during the study period resulting from the Affordable Care Act, suggesting that “increasing copayments and deductibles have decreased the affordability of physician visits for this group [people with insurance].” They also cite a RAND Corporation estimate that total healthcare expenditures nearly doubled for consumers between 1999 and 2009, far outstripping the inflation rate.

In an editorial accompanying the Annals study, Kimberly Rask, MD, Ph.D., associate professor of public health at Emory University and chief data officer for Alliant Health, writes that insurance companies have used methods such as patient cost-sharing and high-deductible health plans to discourage unnecessary healthcare use. But given patients’ sensitivity to the costs of their care, she notes, “the steady decline in PCP visit rates…may be the unintended consequence of using cost sharing to reduce unnecessary care in an uncoordinated healthcare system.”