As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:
The next time you have a minor injury or get sick, will you call your primary care doctor to get a same-day appointment, or will you go to the local urgent care? Now may seem like a strange time to even be asking the question, since many patients aren’t taking the chance on either one. Patient volumes in medicine are down 50% or more as people practice social distancing and hospitals and surgery centers cancel elective procedures. But eventually we all need care. And a recent study in the Annals of Internal Medicine (paywall) found that when we seek that care we’re increasingly likely to seek it from urgent care centers.
Multiple investigators from Harvard, Mount Sinai, and the University of Pittsburgh looked at deidentified claims data for adults aged 18-64 years from a single commercial insurer (they didn’t reveal which one) between January 1, 2008, and December 31, 2016 to determine the rate of primary care visits per 100 member-years. By cleverly using CMS place-of-service codes, National Provider IDs, tax identification numbers, and CPT codes, they were able to further categorize visits as having taken place in a purely outpatient office, the emergency department, an urgent care, a retail clinic, or a commercial telemedicine visit.
What they found was bad news for primary care doctors and, if you believe that primary care saves money and improves outcomes, as most policy makers do, bad news for the people paying for healthcare, like employers. Primary care visit rates declined 24.2% in the eight years of the study, from 169.5 visits per 100 member-years in 2008 to 134.3 in 2016. The proportion of insured patients with no medical visits at all in a given year went up, from 26.1% to 32.5%, as did the proportion with no visits to a PCP in a given year (from 38.1% to 46.4%). This trend held even when gynecologists were re-classified as PCPs, since some women get the bulk of their care from their gynecologist.
An optimist might venture that the population was just healthier in 2016 than it was in 2008. And in patients that had no chronic diagnoses the drop in PCP visits was higher. But overall the insured group did not get healthier or sicker over the time of the study.
So where did the care go? To “alternative settings.” Urgent care visit rates almost doubled, from 4.4 visits per 100 member-years in 2008 to 8.0 in 2016. Retail clinic visit rates more than tripled, from 0.83 visits per 100 member-years in 2008 to 3.0 in 2016. Commercial telemedicine visit rates rose a spectacular 500%, from 0.003 visits per 100 member-years in 2008 to 1.6 in 2016.
The authors posited three possible explanations for this: First, patients may be less likely to seek primary care if they are younger and healthier and comfortable with online self-care or a secure message with a nurse or other non-physician provider when a minor acute need, like conjunctivitis, arises.
Second, those increasing financial barriers such as increased deductibles and co-pays may influence care more than we have previously thought. The average out-of-pocket cost of a visit increased from $29.70 in 2008 to $39.10 per visit in 2016 for “problem-based” visits (that is, visits meant to address a specific complaint). And over the time of the study more PCP visits became subject to a deductible (from 9.2% of visits in 2008 to 25.2% of visits in 2016). The decline in PCP visits in this study was largest in low-income communities. Using some clever economic calculations the authors estimated that this may have explained about a quarter of the decline in PCP use.
But third, and most powerfully, patients appear to simply be replacing PCP visits with visits to specialists and alternative settings. Even though the proportion of patients visiting specialists did not change, many patients saw multiple specialists. And the increase of 9 visits per 100 member-years to alternative settings offset about a quarter of the PCP visit decline. This may well have been a matter of convenience. As we’ve discussed before in this blog, the average physician visit takes more than two hours. Traditional primary care settings are known for their inefficient or inflexible scheduling practices. One study found that patients are so frustrated by scheduling practices that they think nothing of blowing off visits, leading to high no-show rates in the clinic. Visits to alternative venues may simply be more convenient not only in getting a generic appointment, but in getting an appointment after-hours so that no work is missed.
If the convenience argument is correct, doctors may be able to get some of that patient population back by employing “open access” scheduling. In this system, same-day appointments are almost always available. The day’s schedule isn’t full of appointments made weeks or months ago. The doctors preferentially schedule follow-up appointments in the morning, but fill much of their afternoon schedule as the day goes on. Somewhat famously, this is how a Kaiser Permanente clinic in Sacramento reduced their wait for an appointment from 55 days to one day. But the system requires some sacrifice on the part of the doctor, which may be a tough sell in a system where PCPs are already losing market share. Open patient slots, after all, are potentially lost money. It also may require some sacrifice on the part of the system. Open-access scheduling is generally thought to require doctors to carry smaller “patient panels” than they traditionally do, which may in turn lead to a need to train more physicians.
For larger employers there may be other fixes, such as on-site clinics. And with the increased adoption of telemedicine into traditional practices, we may see more patients using that option instead of going to the ER or to urgent care.
If your business has found a way to incentivize increased use of primary care, rather than ever-expanding use of urgent cares and emergency rooms, let us know.