In a STAT article published last week, Jeffrey Millstein, an internist, clinical assistant professor at the Perelman School of Medicine at the University of Pennsylvania, and regional medical director for Penn Primary Care, noted that the most common complaint heard from the patients at his practice is that it has become difficult to schedule an urgent or time-sensitive appointment. While Millstein outlined several factors impacting access to primary care, he pointed to value-based payments as "one of the most profound influences on access to care."
We think there's more to the national primary care access issues than just value-based care (VBC). Let's unpack five factors that are influencing access to primary care.
1. Access issues predate most VBC efforts
It's true healthcare has an access problem, especially in primary care. But this problem has existed for far longer than the last 10 years, which we can generally consider the timeframe for growth of value-based payment models.
Because of these long-standing challenges, we've seen explosive growth in urgent care centers, retail clinics, and virtual-first access models. Whether it's dedicated urgent care companies like Legacy ER and Urgent Care, CVS's MinuteClinic and HealthHub, or virtual platforms like DoctoronDemand or Teladoc, these organizations would not exist or have grown at such an incredible rate if we had sufficient primary care availability.
2. Holding slots for last-minute appointments is risky for providers
In primary care, patients usually want to be seen on one of three timeframes: today or tomorrow (short-term), this week, or long-term (such as for a follow-up appointment in three months).
Ensuring short-term access means providers need to hold unscheduled time to account for these visits — and that's where it gets tricky.
One medical group ran an analysis to identify the right number of same and next day visits they should be holding open in their primary care physicians' calendars. The answer they found: six per day. The idea of having six "open" or unscheduled slots on a physician's calendar is concerning on a number of levels.
For example, what if those visits don't get used? What if the patient shows up but it's a much more complicated visit? What if the patient should have gone to an urgent care center or the ED instead of primary care? What if all the people who take those short-term slots are new patients and therefore more labor-intensive for the physician and their practice? These concerns lead many organizations to prioritize longer-term, more predictable appointments over short-term access.
3. Primary care as we know it is changing
Even before the pandemic, we were seeing a shift in primary care. Organizations realized that primary care needs to look different for different patient populations. As a result, we've seen a segmentation of primary care, whether through different care models with smaller panels for some patients or entirely new "specialties" within primary care.
These changes were an acknowledgement that with all the "new" work primary care has absorbed in recent years, we don't have enough primary care capacity. And we want to be clear: our research suggests that we lack the capacity — not the bodies. Our analysis indicates we have enough primary care providers. But as an industry we don't have enough access to their time, and this is what causes the feeling of a primary care shortage.
No matter how you look at it, primary care is different now than it was a decade ago. Having absorbed so many of the changes in the industry recently, today's "primary care" is not sustainable. That's why start-ups, health plans, health systems, physician groups, and more are all innovating in primary care.
4. The data suggest that access is improving
So far, the innovation in primary care seems to be working. The 2022 survey of physician appointment wait times and Medicare and Medicaid acceptance rates found that the average wait time for a family medicine appointment decreased between 2017 and 2022 in 11 of the 15 markets analyzed.
We're not saying the problem is solved. What we need is continued innovation and focus on how to best serve different populations in primary care.
5. VBC isn't to blame — but there is still room for improvement
Without a doubt, successful VBC requires some change to physician practice — but we'd argue that those changes aren't limiting short-term access to primary care.
We think there are other forces at play, including the rise of patient consumerism, regulatory requirements, and the effects of the Affordable Care Act. Fair or not, most of the burdens of these forces fall squarely on the primary care provider. In short, primary care has become a catch all that's not really working for anyone with high physician burnout, decreased quality post-pandemic, and long wait times.
We know primary care is critical for success in VBC models. But there is room for improvement. New VBC models should consider what metrics and incentives make the most sense in the changing primary care landscape. Alternatively, they should encourage the use of reliable technology and predictive analytics to help better segment the population.
The answer isn't to back away from VBC because of access challenges. Instead, stakeholders should consider how to better support primary care providers as they balance incentives across fee-for-service and VBC models.
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