Primary care visits declining while urgent care use is on the rise, study finds

Early evidence indicates a decline in per capita primary care visits, with possible explanations including the rise of urgent care, telemedicine, and high-deductible health insurance plans, study authors said.

Commercially insured adults have been visiting primary care clinicians less often in recent years, and nearly one half had no primary care visits in any given year, according to a new study.

Researchers quantified visit trends using data from a national, population-based, private insurance health plan for adults ages 18 to 64 years, comprising 142 million primary care visits among 94 million member-years from 2008 to 2016. Results were published Feb. 4 by Annals of Internal Medicine.

Visits to primary care clinicians declined by 24.2% over the studied time period, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no primary care visits in a given year rose from 38.1% to 46.4%. All age groups had a similar increase over the study period. Among patients ages 18 to 34 years, 48.2% had no primary care visits in 2008 compared with 56.7% in 2016; among those ages 55 to 64 years, 26.6% had no primary care visits in 2008 compared with 33.9% in 2016.

Visits for low-acuity conditions decreased by 47.7% (95% CI, −48.1% to −47.3%). The decline was largest among the youngest adults (−27.6%; 95% CI, −28.2% to −27.1%), those without chronic conditions (−26.4%; 95% CI, −26.7% to−26.1%), and those living in the lowest-income areas (−31.4%; 95% CI, −31.8% to −30.9%). Out-of-pocket cost per problem-based visit rose by $9.40 (31.5%). Visits to specialists remained stable at −0.08% (95% CI, −0.56% to 0.40%), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (95% CI, 45.8% to 48.1%).

This decline may be explained by decreased real or perceived need for primary care, financial deterrents, and use of alternative sources of care, the study authors wrote. Larger declines may have been seen in younger, healthier adults because they have fewer routine care needs and may be increasingly comfortable with online self-care or a secure message with their clinician when acute needs arise. Patients may also face greater financial barriers to seeking primary care, as deductibles rise and a larger proportion of adults enroll in plans that involve a high deductible. Patients could also be replacing primary care visits with visits to specialists, as those visit rates remained steady.

Meanwhile, visits to alternative venues, such as urgent care clinics, retail clinics, EDs, and telemedicine, increased by 9 visits per 100 member-years, offsetting about one-quarter of the primary care visit decline (35 visits per 100 member-years). The convenience of these alternatives may be particularly attractive compared with inefficient or inflexible scheduling practices in traditional primary care settings, the authors noted. The study didn't capture non-billed interactions between patients and their primary care offices, such as telephone calls and secure messages, despite their growing use, the authors acknowledged.

An editorial stated that private health insurers have focused heavily on encouraging consumers to be cost-conscious through first-dollar cost-sharing efforts, such as high-deductible plans. However, when patients face cost barriers, they are just as likely to decrease use of medically necessary care as medically unnecessary care.

“The steady decline in primary care provider visit rates across age, health status, and income may be the unintended consequence of using cost sharing to reduce unnecessary care in an uncoordinated health care system,” the editorial concluded.