Specialist Office Visits Outpaced Primary Care in 2013

May 07, 2014

Reformers from President Barack Obama on down speak of primary care as the proper foundation for the nation's healthcare system. The Affordable Care Act (ACA) and other initiatives public and private are attempting to make that a reality.

A study released last month by a branch of IMS Health, however, delivers a jolt to this vision of primary care pre-eminence. The firm reported that 51% of physician office visits in 2013 were with specialists, the first time this number had topped those with primary care physicians.

Underscoring that this is not a fluke finding, the percentage of office visits involving specialists had been swinging upward for some time. It rose from 48% in 2011 to 49% in 2012.

"We're not surprised to see this steady increase," said Murray Aitken, executive director of IMS Institute for Healthcare Informatics. Like others, Aitken attributes the trend in part to aging Baby Boomers, whose joints and organs have their own dedicated caretaker, and the sheer numerical superiority of specialists. A study commissioned by the federal Agency for Healthcare Research and Quality reported that only about 1 in 3 physicians in 2010 practiced in primary care, not counting hospitalists and primary care physicians who work in emergency departments (EDs).

Another contributing factor is the decline of health maintenance organizations — and their gatekeepers — and the growth of preferred provider organizations, which allow members to self-refer to anyone in their network, said Robert Berenson, MD, a senior fellow at the Urban Institute's Health Policy Center. At the same time, primary care physicians are abdicating their past role as a source of comprehensive care.

"It's not at all emphasized in the medical home," he said. "Referring to a specialist has become the standard." Because they bear financial risk, accountable care organizations promise to do a better job than medical homes at lessening reliance on specialists, he said, but these new provider groups are just getting started.

Dr. Berenson and other healthcare policy experts are trying to fathom what effect this tilt toward specialist office visits has on patient care and healthcare costs, and whether the ACA will counteract this trend.

Healthcare Costs Spiking Again

Reid Blackwelder, MD, the president of the American Academy of Family Physicians (AAFP), said the report of specialty visits topping primary care visits is both believable and clinically worrisome. As patients visit one physician for their heart and another for their kidney, "specialists are not likely to coordinate care," Dr. Blackwelder told Medscape Medical News.

More uncoordinated care also will drive up costs — dramatically — as specialists duplicate lab tests, diagnostic imaging, and other services, he said. A burgeoning Medicare population with multiple chronic illnesses will only exacerbate this trend.

The Urban Center's Dr. Berenson said that increased utilization of specialists already is contributing to a "new spike" in healthcare spending in 2014 as reported by the US Bureau of Economic Analysis in the US Commerce Department as well as the Altarum Institute. In an interview with Medscape Medical News, he emphasized that the main cost driver with specialists is not the office visit per se, but the tests and procedures they order.

However, more specialty office visits may be dampening costs by keeping people out of the hospital, said Jeffery Ward, MD, immediate past chair of the clinical practice committee of the American Society of Clinical Oncology (ASCO). The recent IMS Health study reported that hospital admissions in 2013, including those from EDs, rose just 2.6%, which was characterized as flat growth. Specialists appear to be reducing the most expensive form of medical care, Dr. Ward said.

Murray Aitken, one of the authors of the IMS Health report, said more data and analysis is needed before anyone can say how the increased use of specialists is affecting healthcare costs and outcomes. "We're not in a position to comment on that," he said.

ACA Wild Cards

IMS Health looked at physician office visits in 2013, one year ahead of the debut of state health insurance marketplaces, or exchanges, under the ACA, as well as expanded eligibility for Medicaid and the Children's Health Insurance Program (CHIP). The US Department of Health & Human Services reported last week that some 8 million Americans had signed up for private insurance coverage in the first enrollment period, while almost 5 million other Americans enrolled in Medicaid and CHIP through March 2014.

These newly insured people figure into an analysis of physician office visits. Like others, ASCO's Dr. Ward said their impact will depend on their age and their health status. Younger, healthier people who gain benefits will gravitate toward primary care physicians while older Americans with chronic illnesses will tend to book appointments with specialists. So far, 28% of Americans who signed up for an exchange plan were between the ages of 18 and 34 years.

Still, it's too early to assess enrollment demographics and healthcare utilization, noted Aitken. If anything, he said, increased insurance coverage under the ACA may only temporarily counter the shift to specialty visits, and the trend line may resume eventually.

The AAFP's Dr. Blackwelder sees another ACA wildcard in play — the potential impact of high deductibles in exchange plans on choice of physician. Many patients with high-deductible plans delay seeking needed medical care until they become so sick that they land in a hospital ED and an inpatient bed.

"And they often get shipped out to specialists," Dr. Blackwelder said.

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