Are Primary Care Visits on the Decline?

Primary care is essential for a high-performing healthcare system, as patients with a regular primary care physician (PCP) have higher rates of recommended screenings and lower rates of preventable hospital admissions and mortality. Although recent studies suggest declining rates of primary care visits during the last decade in the United States, the contribution of practice changes, such as the use and content of such visits, to this decline is still undetermined. To address this question, researchers used nationally representative data from the National Ambulatory Medical Care Survey to analyze adult visits to PCPs and physician practice characteristics from 2007 to 2016.

The goal of a second study was to examine changes in individuals' contact with the medical system during the implementation of the Patient Protection and Affordable Care Act (ACA) within longer-term trends.

This study used data from the 2002 to 2016 Medical Expenditure Panel Survey to determine rates of contact per 1000 individuals per month for physicians, PCPs, specialty physicians, and emergency departments; inpatient hospitalizations; dental visits; and home health visits for the overall population and by age, financial status, health status, and race/ethnicity.

The number of primary care visits in the United States is unexpectedly decreasing at a time when the ACA has reduced financial barriers to care and ushered in a new era of prevention and wellness, 2 studies have found.

Experts disagree on whether this trend is good or bad for the health system. The passage of the Affordable Care Act should have increased the frequency of visits, while the use of telehealth would decrease face to face visits.  The availability of online laboratory test results obviates a clinic visit.

Other factors also changed. The length of a patient visit increased with the addition of education, coaching,  and more comprehensive visits.

In 1 study, Aarti Rao, BA, from the Icahn School of Medicine at Mount Sinai, New York City, and colleagues found that from 2008 to 2015, the average number of PCP visits per person dropped by 20% in a sample of 3.2 billion visits (−0.25 visits per person; 95% confidence interval [CI], −0.32 to −0.19). Visits dropped particularly for acute and chronic diseases, but not for general medical exams and mental illness.

Appointment Length Increased

The time of each appointment lengthened, on average, by 2.4 minutes, and each appointment addressed more concerns, enabled in part by electronic health records, and provided more preventive services and procedures, such as vaccines and wound care. In addition, appointments were less likely to have scheduled a follow-up for certain patients and conditions.

Physicians also offered much more non-face-to-face care, such as secure messaging and virtual care. For instance, it is no longer necessary in most cases for patients to come in to obtain laboratory results.

The researchers say that fewer visits can be explained partially by more comprehensive appointments and more out-of-office care.

They acknowledge, however, that the rise of high-deductible health plans may also be keeping some people from coming in at all; in addition, other factors could play a role, such as more patients seeking care at retail and urgent centers or appointments with nurse practitioners or physician assistants, which the investigators were not able to measure.

Specialist Care and Emergency Department Care Have Not Increased

The decrease in the numbers of primary care visits has not, for the most part, resulted in an increase of visits to specialists and emergency departments, Michael Johansen, MD, from Grant Medical Center, OhioHealth in Columbus, and Caroline R. Richardson, MD, from the University of Michigan, Ann Arbor, write in a second study published in the journal.[2]

In fact, the likelihood of visiting a specialist decreased for all patients younger than 65 years, Donald Pathman, MD, MPH, director of the Program on Primary Care at the University of North Carolina at Chapel Hill, explains in an accompanying editorial.[3]

That is a welcome finding, he writes, considering some "balloon" theorists have suggested when primary care visits go down, the use of more expensive care goes up.

Some changes were specific to age groups.

In this second study, emergency department visits did not change for individuals aged 18 to 40 years and those aged 65 years and older but increased for those aged 41 to 65 years.

Even though the intent of the ACA was to have a heavier primary care focus, what may be happening is that we are receiving more efficient primary care, albeit, in fewer visits, he said.

The intent of models such as accountable care organizations, he notes, is that care will be delivered and received where it is most appropriate, "and that oftentimes means you don't need an office visit," he explained.

Patients are getting more questions answered electronically, and more follow-up telephone calls are taking the place of in-office visits.

It seems the changes in the system are working in unplanned ways and most of it is good.  Perhaps we are getting more bang for ours. expensive health system.

Providers are becoming more proficient at using all the resources that have developed in IT and administrative matters.

He added that the studies show a surprising lack of response to the ACA, in that it appears the ACA did not increase the numbers of contacts with primary care or influence where people were seeking care.

In the end, neither of these studies gives a clear answer on whether less contact with primary care is a good or bad thing, Dr. Johansen explained, noting that who is not accessing primary care, where they are going instead, and how the trend affects outcomes are still unknown.









Are Primary Care Visits on the Decline?: US primary care visits are unexpectedly declining, despite the

Affordable Care Act implementation, which was intended to lower financial barriers to care and improve access to prevention and wellness.