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February 18, 2020

Why 50% of adults with private insurance skip primary care

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    The number of privately insured U.S. adults who visited a primary care provider for an annual checkup decreased by almost a quarter between 2008 and 2016, according to a recent study published in the Annals of Internal Medicine—and researchers are questioning whether rising costs are driving the decline.

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    Fewer privately insured adults are using primary care, study finds

    Primary care providers are viewed as "key" to improving health outcomes across the country, Reuters reports. However, recent studies have found that the percentage of Americans using primary care is declining.

    For the latest study, researchers analyzed deidentified claims data from a private insurer that covers about 20 million members annually across all 50 states. The analysis included insurance claims from 2008 to 2016 for members ages 18 to 64.

    The researchers found that the overall rate of primary care visits declined by about 24%, falling from 169.5 visits per 100 member-years in 2008 to 134.3 visits per 100 member-years in 2016. Further, the percentage of adults who didn't visit a primary care provider at all in a given year increased from about 38% in 2008 to about 46% in 2016. The researchers "defined member-years as the number of months … members were enrolled divided by 12."

    According to the study, the percentage of adults who didn't visit a primary care provider rose among all age groups, but the increase was highest among adults ages 18 to 34. From 2008 to 2016, the proportion of adults ages 18 to 34 with no primary care visits increased from about 48% to about 57%, the researchers found.

    The researchers also found that the rate of "problem-based" visits, or sick visits, among adults decreased by 30.5%, falling from 154.5 visits per 100 member-years in 2008 to 112.8 visits per 100 member-years in 2016.

    However, the researchers found that the rate of preventive primary care visits increased by about 41%, from about 15 visits per 100 member-years in 2008 to about 21.5 visits per 100 member-years in 2016.

    Why are more privately adults shirking primary care?

    While the research did not assess why the rate of most primary care visits declined among the study population, the researchers pointed to some findings that suggest rising out-of-pocket costs might have played a role.

    For instance, the researchers found that patients' average out-of-pocket fees for preventive primary care visits declined by 76% from 2008 to 2016. According to NPR's "Shots," the researchers speculated that those costs decreased because the Affordable Care Act mandates that insurers cover annual preventive care visits with no cost-sharing requirements. As such, more Americans likely could access preventive primary care visits with no or reduced out-of-pocket costs.

    In contrast, the researchers found that out-of-pocket costs for problem-based visits increased by 32%, from about $30 in 2008 to about $39 in 2016. In addition, the percentage of primary care visits that were subject to insurance deductibles grew from less than 10% in 2008 to more than 25% in 2016, NPR's "Shots" reports.

    Ishani Ganguli, lead author of the study and a physician for Harvard Medical School and Brigham and Women's Hospital, said the researchers found that the decline in the rate of primary care visits "was larger in poorer areas, just as out-of-pocket costs for most primary care provider visits went up."

    The researchers also found that visits to alternative care settings, such as urgent care centers and retail clinics, increased by about 47% from 2008 to 2016, suggesting patients could be using alternative care settings instead of primary care providers.

    "Americans are using urgent care centers, retail clinics, and emergency departments more," Ganguli said. However, she noted, "[T]hese rates are still very low relative to primary care visits."


    Kimberly Rask, chief data officer at Alliant Health Solutions, said the study's findings raise concerns about Americans' ability to afford needed health care services. "There is a lot of data showing that when you raise health care costs, people will receive less care," Rask said, adding, "But it doesn't mean that they only stop unnecessary care. They will reduce both necessary and unnecessary care."

    Perhaps even more concerning is that the findings also suggest people are unaware of the importance of primary care, Rask said. "There is very strong evidence that primary care can improve health outcomes through timely screening for preventable diseases and effective management of chronic conditions like high blood pressure and diabetes. If people are avoiding 'well-care' or disease management visits because of the co-pays, then they may be at risk of poor health outcomes and higher costs for both them and the health care system in the future."

    Ganguli said, "[I]t's still really important to have a primary care provider if you can get one—someone you trust, who knows you as a whole person, is the first call (or email) you make when you have a medical issue, and helps you coordinate your care with specialists." She added, "It's the foundation of the health care system" (Rapaport, Reuters, 2/3; Renken, "Shots," NPR, 2/3; Owens, "Vitals," Axios, 2/4; Ganguli et al., Annals of Internal Medicine, 2/4).

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