Primary care was suffering before COVID-19

Oct. 7, 2020 / By Steve Delaronde

Primary care is the doorway to health care in the United States—at least in theory. The trust established between a patient and their primary care physician (PCP) allows the physician to understand and treat the whole patient. However, the popularity of primary care in the United States has been waning. COVID-19 has both accelerated and accentuated the decline of in-person primary care, but this trend was well underway before the pandemic. In our fee-for-service payment structure, patients are choosing other ways to address their health care needs, while incentives to maintain the patient-PCP relationship remain misappropriated.

A study published in February 2020 reported that PCP visits declined by 24 percent from 2008-2016 for commercially insured adults. Another study shows a shift to other types of primary care providers such as physician assistants and nurse practitioners. The shift to alternative health care venues continues unabated, as evidenced by a 46 percent increase in urgent care clinics over the same period.

Accessibility, affordability and convenience have improved with increased use of non-physician providers, urgent care centers and retail health clinics. However, this shift has had a negative impact on patient care continuity and coordination that traditional primary care offers. Millennials have become the new disruptors in health care. Forty-five percent of adults under 30 report that they do not have one person that they think of as their primary care doctor compared to 12 percent of those 65 and older.

While continuity and care coordination may not be a significant issue for managing acute conditions, it is extremely important for managing complex and chronic conditions such as diabetes, heart disease, and depression. Patients with multiple complex conditions are often not offered additional incentives to engage in the management of their health than those patients presenting with minor acute conditions. 

Employed individuals increasingly opt for high deductible health plans that may discourage regular health care management typically received through a primary care physician. Currently, 28 percent of workers report annual deductibles that exceed $2,000. While attempts have been made to shift the costs of managing chronic illness from the patient to the insurer, this is neither widespread nor sufficient.

The decline in primary care physician visits accelerated beginning in March 2020 due to fear of COVID-19. In person ambulatory care visits dropped by as much as 70 percent. Visit rates have rebounded for most primary care practices to between 85-95 percent of pre-COVID rates, but there has not been a full recovery. Telemedicine visits were practically nonexistent before the pandemic, but now make up roughly 7 percent of overall visits.

Increased availability of mobile solutions for patients to engage with their own health care is an eventual and positive development. However, in a recent survey only 11 percent of health care consumers indicated that their provider recommended digital tools to manage their health even though nearly a quarter thought that it would be helpful to them.

Finally, the fee-for-service approach to primary care does not align the PCP with the needs of their patients. Not only does a fee-for-service system discourage patients from seeking regular and necessary care, but it simultaneously encourages providers to deliver care that the patient may not need or want. Fee-for-service systems typically do not cover services that may be a higher priority than a lab test or diagnostic procedure. Until recently, there have been few financial incentives for primary care physicians to address non-medical issues that impact health such as diet, exercise, food insecurity, social isolation and other social determinants of health.

Primary care is in crisis, particularly for the 60 percent of adults with at least one chronic disease. Incentives must align across all areas of health care, but particularly between the PCP and the patient. Prospective payment along with risk-adjusted quality outcome measures better aligns the PCP with the needs of their patients. Mobile health care solutions, telemedicine and addressing social determinants of health need to be viewed as opportunities to enhance primary care, rather than non-reimbursable distractions.

Steve Delaronde is manager of products for Population and Payment Solutions at 3M Health Information Systems.

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