Primary Care Appointment Numbers Dropping, Despite ACA

Marcia Frellick

November 18, 2019

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

But experts disagree on whether this trend is good or bad for the health system.

In one study, Aarti Rao, BA, Icahn School of Medicine at Mount Sinai, New York City, and colleagues found that from 2008 to 2015 the average number of primary care physician (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.

The researchers found in data obtained from the National Ambulatory Medical Care Survey that drops came across all racial/ethnic groups and insurance types and in urban and rural areas. They published their findings online November 12 in Annals of Family Medicine.

The authors suggest the decline may come from several developments during the time of the study.

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.

Additionally, appointments were less likely to have scheduled follow-up for certain patients and conditions.

And physicians offered much more non face-to-face care, such as secure messaging and virtual care. For instance, it's no longer necessary in most cases for patients to come in to obtain lab 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; additionally, other factors could play a role, such as more patients seeking care in retail and urgent care centers or appointments with nurse practitioners or physician assistants, factors the investigators were not able to measure.

Specialist 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, with Grant Medical Center, OhioHealth in Columbus, and Caroline R. Richardson, MD, with the the University of Michigan in Ann Arbor, write in a second study published in the journal.

In fact, the likelihood of visiting a specialist decreased for all patients younger than age 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.

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

In that study, ED 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.

Pathman told Medscape Medical News that both studies represent good news. Even though the intent of the ACA was to have a heavier primary care focus, what may be happening is that we're getting 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," Pathman explained.

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

"It may be that the decrease in number of visits is probably what we should have expected and it's a good thing," he said.

Concerning Trends

Johansen told Medscape Medical News that this study continues a long-term trend of less contact with primary care and, "as a primary care physician I see that as a bad thing."

He said he's not convinced that the care is necessarily more efficient or that more is getting done in a single appointment.

Johansen said more issues may be addressed in the short visit but disagrees that a short visit translates to efficient healthcare.

"Patients aren't economic beings that do what we want them to do or tell them to do. They are humans that can only take so much change at one time. If I deal with five problems at a visit, the likelihood that that patient is actually going to be able to comprehend all five things is highly unlikely," he said.

He notes that their study looks at primary care contacts monthly, including phone calls, rather than number of primary care visits — and those numbers are going down as well.

Johansen and Richardson used the 2002–2016 Medical Expenditure Panel Survey to determine rates of visit or contacts per 1000 individuals per month for physicians, emergency departments, inpatient hospitalizations, dental visits, and home health visits.

They were surprised to find that the groups having disproportionately fewer primary care visits included those "at high risk of symptoms and disease" particularly those at least 65 years old and those in fair or poor health.

It is possible those groups were accessing medical care in other ways, such as nurse practitioner visits or by email, they acknowledge.

"Primary care's biggest value to the system is dealing with complexity of patients. Having people in poor health, for instance, go to primary care less, that decline is problematic," Johansen said.

He said 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, Johansen explained, noting that who is not accessing primary care, where they are going instead, and how the trend affects outcomes are still unknown.

No funding was used in this research. Study author Ishani Ganguli reports compensation as a consultant from Haven. Johansen receives funding from the Government Resource Center working on the Group VIII evaluation of Ohio's Medicaid expansion. The remaining authors and editorialist Pathman have disclosed no relevant financial relationships.

Ann Fam Med. Published online November 12, 2019.
Rao et al study, Johansen/Richardson study, Editorial

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