Trends in Primary Care Utilization

Non-physician healthcare visits increased from 39.2% to 52.3% between 2010 and 2019. More data trends below.

Despite a decrease in various types of primary care visits between 2010 and 2019, primary care physicians saw a higher volume of complex visits, including more medically and socially vulnerable patient populations during that time, according to a recent study out of the Robert Graham Center. Acute visits decreased the most, likely due to the shortage of available physicians.

“Essentially, we looked at a large publicly available data to see the trends in primary care visits over the last decade,” said Yalda Jabbarpour, MD, director of the American Academy of Family Physicians (AAFP) Robert Graham Center. She was a co-author of the study, led by Anuradha Jetty, MPH, a senior epidemiologist at the Robert Graham Center. Their work was published in the Annals of Family Medicine in November.

The team wanted to find out, “Who are patients seeing in the primary care team, why are they seeing them, and who are the patients more likely to see?” said Dr. Jabbarpour. “We found that visits to PCPs are decreasing overall, with the most being a decline in acute type visit. People are having a hard time accessing primary care.”

With an explosion in advanced practitioners and other healthcare professionals offering primary care, the team aimed to put those areas of data together and see where people are accessing their primary care, added Dr. Jabbarpour.

Where Care Visits are Declining and Rising

Primary and Subspecialty Visits Dove, Non-Physician Visits Rose

The team analyzed a nationally representative sample of US adults from the Medical Expenditure Panel Survey (MEPS) from 2010 to 2019. The research objectives were to examine trends in outpatient visits over the decade, assess the number of diagnoses over visits by clinician type, and investigate sociodemographic factors associated with primary care visits versus subspecialist visits.

They specifically looked at ambulatory care, preventive care, acute care, chronic care, and diagnosis by five types of clinicians: primary care physicians, internal medicine-subspecialists (IM-subspec), OBGYNs, psychiatrists, and advanced practitioners [namely, nurse practitioners or physician assistants (NP/PAs)].

Using summary statistics and regression analyses, the authors found that:

• Both primary care (26.8% in 2010 to 19.2% in 2019) and subspecialist visits (34.1% to 28.5%) decreased in general; however, preventive care visits to primary care physicians and advanced practitioners rose during the same period.

• Acute care visits were reduced for all clinicians except advanced practitioners, who saw an increase, while chronic care visits decreased for all clinician types.

• Non-physician visits increased from 39.2% to 52.3%, including an increase in visits to advanced practitioners, from 6.4% in 2010 to 9.0% in 2019.

• Outpatient visits to primary care (internal medicine specialty) and OBGYNs declined but remained stable with psychiatrist visits.

• Primary care physicians experienced a greater proportion of visits with patients who had two or more diagnosed conditions per visit (69% in 2019 vs 58% in 2010).

Overall, there were higher odds of visits to primary care physicians compared to subspecialists among a few patient groups: those 40 years of age or older; those without high school diplomas; white and Hispanic adults; and those with poor health status and multiple chronic conditions.

Advanced Practitioner Care

Dr. Jabbarpour noted that the rise in non-physician visits seemed to be driven by many factors, but mainly the availability of physicians. The number of nurse practitioners and non-physicians who provide primary care has increased in recent years, and thus their percentage of visits was expected to increase. “So, it made sense to us that their number of visits increased from 39.2 to 52.3%,” she said. “We also expected the finding that PCPs were more likely to see complex visits and more medically and socially vulnerable patients. Patients are becoming sicker, and they are more socially complex than they were a few years ago,’’ she added.

Complex Visits

The team’s findings align with other recent research that links visit declines to the shrinking of the primary care workforce, noted Dr. Jabbarpour.

“What we found surprising was an overall decrease in most visits and the type of visits increasing and decreasing for PCPs….. The job is more difficult when straightforward complaints like UTI and cold are replaced by complex, acute conditions…. patients are becoming sicker, and they are more socially complex than they were a few years ago,” she explained, adding, “Knowing that, it makes sense why primary care physicians are burning out at high rates.”

Healthcare Workforce Needs Expansion, Investment

Simply put, said Dr. Jabbarpour, “We do not have the workforce we need to meet the medical needs of the patients…. When a patient calls and wants to see their primary care physician within the week, they won’t be able to do that. So, patients are going to urgent care health centers or they are going straight to specialists or emergency rooms,” she said.

Increasing the primary care workforce collaborations may help this problem. “This workforce should be team-based because physicians can’t do it all alone and everyone should work to the top of their license. The workforce should be made of physicians, practice providers like nurses, physician assistants, social workers, behavioralists, and others who could help in patient care,” she added. “I also think physicians should remember that there is more than enough to go around…. Nurse practitioners and physician assistants are helping with some cases, especially for acute care visits.”

Dr. Jabbarpour also suggested the need for the government to increase investment into primary care practices. Currently, the nation spends about 5% to 7% of all healthcare expenditures on primary care, she said. “That is small thinking about the fact that primary care is the backbone of healthcare. If that is doubled, for instance, it can cater for infrastructural changes that would allow for better access in the primary care office,” she said.

When a system invests in primary care, it can pay for team members that would take care of patients’ social needs or their paperwork, so that the physician is free to focus on medical care, she said. “You could also invest in technologies that streamline some of the administrative work that physicians have to do so that they can focus their time on taking care of patients,” she added.