Jeffrey Bendix

As part of its efforts to slow the spread of the novel coronavirus, COVID-19, the U.S. Centers for Disease Control and Prevention has developed recommendations for medical practices, aimed at reducing the chance of patients spreading the disease when they come to a medical office. They include steps practices should take before, during and after a patient visit.Below is a summary of the CDC’s recommendations. To see the full list, visit the CDC official website.Â Â Â 

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The Centers for Disease Control and Prevention has developed recommendations for medical practices concerning the COVID-19 outbreak. 

Minimizing COVID-19 exposures at medical practices: CDC recommendations

Expanding primary care’s role in the healthcare system has long been viewed as key to reining in healthcare costs and improving outcomes. But patients themselves apparently haven’t gotten the message.

 of claims data at a large commercial health insurer that found a 25 percent decline in visits to primary care providers between 2008 and 2016. To gain more insight into the study’s background and findings. 

 recently spoke with Ishani Ganguli, MD, MPH, one of the study’s authors. A transcript of the interview, edited for clarity and brevity, follows.

: What evidence had you seen of a decline in primary care visits that led you and your coauthors to undertake this study?

: We first noticed it when we were studying a different but related topic, the Medicare Annual Wellness Visit, which began in 2011 as part of the Affordable Care Act. Myself and [co-author] Ateev Mehrotra had collaborated on that study and had noticed that primary care visit rates were going down in Medicare. So we started digging more and noticed this pattern was present across different populations.

 demonstrating this decline in Medicare in two national surveys as well as employer data sets and this commercial population. This more recent paper was our opportunity to study in more depth what was happening among these commercially insured adults and to get more clues as to why it was happening.

: Annual checkups used to be routine, at least among people with insurance. Is that no longer the case, or would those now be considered preventative visits? And if it is no longer the case, why not?

 Let me unpack that a little. Annual Wellness Visits and preventative visits are two terms for what are essentially the same thing, and preventative visits are actually going up. So what we find is a couple of different threads. We know that having a primary care doctor is a good thing and that being in an area with lots of primary care doctors is good for your health.

But going in for an annual checkup is not that useful, particularly if you are a young or healthy person. In fact, when I have young healthy people come to my office I will do a new patient visit but tell them to come back every couple years because there’s no benefit to coming in every year if they don’t have any new medical needs. So hopefully we’re being more judicious about when to offer those routine checkups.

The other thing you’ll see in the data is a story about cost incentives. Thanks to the ACA, these preventative visits became much cheaper, or free to the patient. So part of why we might be seeing a rise in preventative visits as other types of visits in primary care go down is that exact fact.

Patients are savvy and know that [preventative] visit will be paid for and come in for that. If I, as a doctor know a patient is eligible for their next preventative visit they will have to pay less. Whereas the costs to patients for other types of primary care visits have been going up during this period we studied.

: Do you think that the way the insurance company whose data you used for the study structured its plans might have contributed to fewer primary care visits by its members?

: No. A large national insurer such as this one works with hundreds, maybe thousands of employers and designs plans specifically for each of them, so it’s virtually impossible to try and categorize these plans in any meaningful way.

Also, it’s certainly not unique to this insurer. But it may reflect broader trends in, for example, increasing reliance on high-deductible health plans.

: What has been the response to the study?

 The ACP [American College of Physicians] has been interested because it speaks to the larger challenges of the disconnect in the way we think about healthcare. We increasingly think of primary care as being the solution to a lot of the challenges we face in healthcare. We think about it as a way of saving money and improving the quality of care. And the new primary care models, like accountable care organizations and patient-centered medical homes have primary care at their center. Yet if people aren’t seeing their primary care doctor as much, that gives you pause. So I think that’s why people have been interested, this sort of disconnect between what we want primary care to do for us and what this evidence suggests.

All that being said-and I think we make this point in the paper-some of the reasons for the decline are worrisome, like issues of access, such as when there’s no primary care doctor who has availability, or the cost barriers.

The good news story, though, is that I think primary care has gotten more efficient and tends to be better than specialist care at using other members of the team, and at doing virtual care through e-mails or telephone calls. So some of the decline might be an appropriate shift to other types of interactions between doctors and patients.

: Is it also possible that people just are healthier and thus have less reason to see a doctor?

 Yes, I think in certain ways that’s probably true. We have better vaccinations, for example. One of my colleagues led a study, using this same data, looking at children in the commercially-insured population and found that vaccines for preventing upper respiratory infections resulted in a huge decline in visits. We’ve seen a big drop in visits for more mild conditions like a cold or pink eye where you could go online and figure out what to do, or call your doctor but not come in. The paper we published last year goes into the whole universe of possible reasons [for the decline in primary care visits.]

 What are the implications of your findings for primary care doctors and the country’s healthcare system?

 To the extent that this is a worrisome story, whether it’s bigger drops in low-income areas that suggests shortage of primary care doctors and challenges paying for visits, we need to redesign areas of our healthcare system to try and make that better. That could be insurance companies making high-value visits like primary care visits free or low-cost for patients, or changes in our medical education policies to encourage more students to go into primary care, fostering our nurse practitioner and physician assistant colleagues--we included them in the study as primary care practitioners--all those changes are important.

I think there’s also education that needs to be done around how patients view primary care. We saw a decline not just among millennials, which is the group we often think of that doesn’t feel like they need to see a doctor, but even among folks in the 55-64 age group, the decline was present. To the extent that’s telling us either people aren’t seeing the value in primary care, or getting their needs met in another venue, like an urgent care setting, we need to think more about how we make primary care accessible and attractive to people because of all the current challenges in accessing care.

So I’d say, broadly speaking, it’s changing the way patients pay for primary care, there’s how we structure the payment and delivery of primary care to make it easier for primary care docs to meet patients where they need to be, and it’s educating patients on why it’s important to have a primary care doctor.

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An author of a recent study on the subject unpacks the results.

 Explaining the drop off in primary care visits

Visits to primary care doctors have been falling for decades in the U.S., and rising out-of-pocket costs are the main, although not the only, reason why.

That is the conclusion of two recent studies of trends in visits to primary care physicians (PCPs), one looking at the period 2008 to 2016 and the other 1998 to 2017. It calls into question the widely -held assumption among healthcare policymakers that lack of insurance coverage is the main obstacle patients face in obtaining medical care, especially primary care.

, focuses on trends in visits to PCPs among a cohort of people age 18 to 64 enrolled with a national commercial insurer between 2008 and 2016. The authors examined records of 142 million primary care visits among 94 million member-years (defined as the total number of months those in the study were enrolled divided by 12).

After adjusting for changes in age, income and location among enrollees, the study found a 24 percent decline in PCP visits. Moreover, by the end of the period, 46 percent of  the people in the study had no PCP visits in a given year, up from 38 percent at the start of the period.

The authors offer three possible explanations for the trend: first, that patients are becoming more comfortable with going online to get information for addressing non-acute needs, and communicating with their doctor electronically rather than in person for some acute medical needs.

Second, more adults are enrolled in commercial plans with deductibles and/or copays for primary care visits and the payment amounts required for both have been increasing, thus discouraging people from seeking care. As evidence, the authors note that the decline in PCP visits was largest among people with low incomes, a group that other studies have shown to respond the most to higher out-of-pocket costs. 

The third possibility, the authors say, is that patients are replacing PCP visits with visits to specialists, or obtaining primary care at urgent care centers, retail clinics, or via telemedicine. 

, focuses more specifically on the link between the decline in patient visits and the rising cost of accessing primary care during the period 1998-2017. Using data from CDC and state health department surveys, it found the number of insured adults who said they couldn’t see a doctor because of cost grew by 3.6 percentage points. Among adults without insurance, the increase was 5.9 percentage points.

More disturbingly, the study finds more people with some common chronic conditions were unable to afford doctor visits. For patients with cardiovascular disease, the increase was 5.9 percent, for those with elevated cholesterol it was 3.5 percent, and for those with binge drinking it was 3.1 percent. The proportion of chronically ill patients receiving checkups did not change, however.

The authors note that these shifts took place despite increases in the number of insured Americans during the study period resulting from the Affordable Care Act, suggesting that “increasing copayments and deductibles have decreased the affordability of physician visits for this group [people with insurance].” They also cite a RAND Corporation estimate that total healthcare expenditures nearly doubled for consumers between 1999 and 2009, far outstripping the inflation rate.

study, Kimberly Rask, MD, Ph.D., associate professor of public health at Emory University and chief data officer for Alliant Health, writes that insurance companies have used methods such as patient cost-sharing and high-deductible health plans to discourage unnecessary healthcare use. But given patients’ sensitivity to the costs of their care, she notes, “the steady decline in PCP visit rates…may be the unintended consequence of using cost sharing to reduce unnecessary care in an uncoordinated healthcare system.”           

Americans have seen their primary care physicians less and less- here's why.

Author | Jeffrey Bendix

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Minimizing COVID-19 exposures at medical practices: CDC recommendations

Explaining the drop off in primary care visits

Why aren’t Americans seeing primary care doctors?