decreasing utilization of primary care

a recent letter-to-the-editor found that the proportion of adult Americans with an identified source of primary care decreased between 2002 and 2015 (see primary care dec utiliz jamaintmed2019 in dropbox, or doi:10.1001/jamainternmed.2019.6282).

Details:

--data from the Medical Expenditure Panel Survey: 21,915-26,509 individuals assessed annually from 2002 through 2015

--primary care was defined as the 4 C's: first contact; comprehensive, coordinated, and continuous care

--values from each year were adjusted for sociodemographic and clinical variables: age, sex, race/ethnicity, region of the US, partner status, education, health insurance coverage, perceived health status, employment, smoking status, need for ADL help, need for IADL help, number of chronic diseases (of the 20 conditions considered to be chronic by US Health and Human Services), income, BMI

--baseline: age (20% in their 20s/19% 30s/19% 40s/18% 50s/12% 60s/8% 70s/4% >80); 51% female; 67% white/14% Latinx/11% Black/5% Asian; region (19% Northeast, 22% Midwest, 36% South, 23% West); Partner status (55% married/partnered, 7% widowed, 13% divorced/26% never married); education (18% <high school, 55% high school/GED/some college, 17% bachelor degree, 10% more); health insurance (72% private, 17% public only, 11% uninsured); 71% employed; 17% smoker; 3% need help with ADLs; 5% need help with IADLs; chronic diseases (55% with none, 20% with 1, 11% with 2, 13% with >2); income (10% poor, 4% near poor, 13% low income, 30% middle income, 42% high income), BMI 28

Results:

--comparing 2002 to 2015:

    --the overall  proportion of adults with identified primary care decreased from 77% (76%-78%) to 75% (74%-76%)

        -- odds ratio 0.90 (0.82-0.98)

    --receipt of primary care decreased for every age decade, except for those in their 80s, with statistically significant decreases in those in their 30s, 40s and 50s

        --30s: having primary care decreased from 71% (69%-73%) to 64% (61%-67%), adjusted OR (aOR) 1.22 (1.17-1.28), p<0.001, compared with those in their 20s (reference)

        --40s: from 79% (77%-80%) to 75% (73%-77%), aOR 1.61 (1.53-1.69), p=0.003

        --50s: from 85% (84%-87%) to 82% (81%-84%), aOR 1.84 (1.73-1.94), p=0.009

    --the decrease in primary care was generally large and statistically significant for those in their 30s, 40s, 50s, and 60s with no comorbidities; overall decrease from 60% (59%-61%) to 51% (50%-52%) [the numbers below are my assessment from their bar graphs]

        --20s: decreased from 57% to 54%, p=0.08 (not quite statistically significant)

        --30s: decreased from 67% to 58%, p<0.001

        --40s: decreased from 72% to 66%, p<0.001

        --50s: decreased from 77% to 68%, p<0.001

        --60s: decreased from 82% to 73%, p=0.003

    --the decrease in primary care was small but statistically significant for those in their 40s and 70s with at least 3 comorbidities:

        --40s: decreased from 95% to 90%, p=0.04

        --70s: decreased from 98% to 95%, p=0.005

--multivariate modeling:

    --decrease in primary care for each calendar year, aOR 0.97 (0.97-0.98)

    --decreased for male sex, aOR 0.59 (0.57-0.60)

    --increased for Latinx race/ethnicity (vs white), aOR 0.80 (0.77-0.84) [there was an inconsistency in their calculations here]

    --decreased for black race/ethnicity (vs white), aOR 0.88 (0.84-0.93)

    --decreased for Asian race/ethnicity (vs white), aOR 0.67 (0.62-0.74)

    --decreased in those not having insurance, aOR 0.29 (0.27-0.30); ie those without insurance were 71% less likely to access primary care

    --decreased in those in Southern US Census Bureau region (vs Northeast), aOR 0.53 (0.48-0.58)

Commentary:

--these data reveal a decrease in Americans receiving primary care overall, but esp in those who were younger, male, less medically complex, of Black race, or living in the South; also, there were several percentage point decreases from 2002 to 2015 in primary care for all of the health insurance categories. this raises several issues:

    --those who are young and less medically complex are really important to involve in primary care, focusing on efforts to reinforce healthful behaviors and prevent morbidity (one of our most important goals in primary care)

    --those who are in racial/ethnic groups that are overall more marginalized from the health care system (esp Latinx and Black) had even less access over time

    --those who are poor or have low income had less primary care at both time intervals

    --and those without insurance (an increasing number in the Trump era) are at particularly high risk of lack of primary care

--a few studies have linked lower primary care rates to higher adverse clinical outcomes. eg, see http://gmodestmedblogs.blogspot.com/2019/02/primary-care-physiciansproviders.html, which reviewed a recent article finding that there was a significant relationship between the primary care physician supply and important health outcomes, noting that the mean density of primary care physicians decreased in 2015, and that adding 10 additional primary care physicians per 100,000 population would likely reduce cardiovascular, cancer, and respiratory mortality between 0.9%-1.4%.

--probably the most impressive outcome of this survey was that there were significant deteriorations of primary care in most of their different subgroup analyses, and there were not many improvements [as a point of reference the ACA (Affordable Care Act/Obamacare)  added 8 million people in 2014 to the "insured" category, and another 3.7 million in 2015;  under Trump, 1.9 million lost care as of 2018, and likely worse now (and way worse if he were to be re-elected!!!!]

--as a related issue regarding the outlandish and in fact counterproductive aspects of our health care system, a recent report found that 1 in 8 patients with atherosclerotic cardiovasc disease do not take their meds because of their cost (see http://gmodestmedblogs.blogspot.com/2020/01/medication-nonadherence-due-to-cost.html )

    --and, of course, there is the pretty inhumane aspect of not treating treatable conditions and decreasing morbidity/mortality/improving quality of life. the current system does not consistently promote primary care as its center and main access point to care, and even punishes people with skimpy insurance policies (see http://gmodestmedblogs.blogspot.com/2019/05/health-insurance-deductibles.html , noting that many people with these insurance policies, often the only ones offered by their employers or only affordable ones, are functionally uninsured ). And the current system  incurs greatly increased costs since patients then often go to the ED, are admitted, likely have very expensive tests and procedures, and then return to a situation where they may not be able to get followup primary care or again be able to afford their meds....  (and, this is especially true for those without insurance, who in many cases are only able to access care through emergency rooms, the most expensive and least appropriate access point)

so, again a study highlighting a huge deficiency in our health care system. Clearly, as noted above, there is much less access to primary care, and likely increased adverse health outcomes, and the situation now is getting worse. and this is a very expensive approach to health care on an overall systems basis. the really hard part now is that the chickens are really coming home to roost (ie, this was predictable, and predicted years ago):

    --it is increasingly hard to convince residents to go into primary care. it is one of the lowest paying fields (and new residents often have very huge loans to pay back, let alone living expenses/mortgages/etc/etc)

    --primary care is often denigrated in the academic medical centers (the derogatory "LMD" moniker, for local medical doctor)

    --there is definitely more competition by hospitalist programs for those interested in general medicine, since the pay is much higher, it is an easier transition (sort of just continuing their residency, which is much easier than shifting to the really pretty different outpatient medicine), and the hours are overall better (more clearly defined time off on the order of 1 week on/1 week off, with not much followup in the interim or the typically hours of followup necessary in primary care after coming back from a vacation), and there is much less paperwork and more clinical support

   --and, we in community health are having much more trouble attracting primary care physicians!!!

--but, but, but: (personal statement), there really is nothing as great as primary care, with the potential development of really profound long-term relationships with patients and their families; the constant intellectual challenge of diagnosis and treatment (involving understanding and addressing the complex interplay of clinical and  psychosocial factors); and working closely with the array of others to optimize patients' lives (behavioral health, community health advocates, nutrition, nursing staff, medical assistants -- all aligned to treat individual patients in the context of their families and social situations)

geoff​

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