Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016

Ann Intern Med. 2020 Feb 18;172(4):240-247. doi: 10.7326/M19-1834. Epub 2020 Feb 4.


Background: Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline.

Objective: To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits.

Design: Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008-2016. A 5% claims sample was used for Poisson regression models to quantify visit trends.

Setting: National, population-based.

Participants: Adult health plan members aged 18 to 64 years.

Measurements: PCP visit rates per 100 member-years.

Results: In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, -48.1% to -47.3%). The decline was largest among the youngest adults (-27.6% [CI, -28.2% to -27.1%]), those without chronic conditions (-26.4% [CI, -26.7% to -26.1%]), and those living in the lowest-income areas (-31.4% [CI, -31.8% to -30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (-0.08% [CI, -0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%).

Limitation: Data were limited to a single commercial insurer and did not capture nonbilled clinician-patient interactions.

Conclusion: Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care.

Primary funding source: None.

MeSH terms

  • Adolescent
  • Adult
  • Age Factors
  • Cross-Sectional Studies
  • Female
  • Humans
  • Insurance, Health / statistics & numerical data*
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Poisson Distribution
  • Primary Health Care / statistics & numerical data*
  • Sex Factors
  • United States
  • Young Adult