Primary care providers, or PCPs, have long been the hallmark of a successful public health strategy.
Patients who know and have a trusting relationship with their provider are more likely to catch issues early and to follow up with treatment.
When there are more PCPs per capita, patient outcomes improve, with less visits to urgent care clinics and emergency departments. This translates into lower mortality rates and health care costs.
Unfortunately, the use of PCPs in the U.S. has been in decline since the 1990s.
In February, a study published in the Annals of Internal Medicine revealed that PCP visits for patients under 65 years of age dropped by 24% from 2008 to 2016 and the number of adults who went a year without seeing a PCP increased to 46% from 38%.
The decline in PCP visits can be attributed to two factors, both of which are economic.
The first is simple numbers. We do not have enough PCPs for every American.
U.S. Health Resources and Services Administration has predicted that we will face a PCP shortfall of more than 23,000 by 2025. The Association of American Medical Colleges predicts that this shortfall could reach 50,000 by 2030.
The federal agency predicts that midwestern and southern states will be hardest hit with the physician shortage. These are the same states with the highest levels of chronic diseases.
Empowering nurse practitioners and physician assistants to fill the gap can help, but this is still not enough. Our medical education pipelines simply are not producing enough general practitioners to meet demand.
This is an economic problem related to how we pay providers. The system weighs heavily upon specialists whose services cost more.
The U.S. spent $3.7 trillion on health care in 2019. With all the talk about the cost of prescription drugs, one would think that was where most of the money is spent.
Yet, American Medical Association data reveals that 31.4% was actually spent on hospitalizations. Only 15% of the total spending went to physicians, with only a third of all physician-spending going to PCPs. The rest went to specialists.
Decades of research have shown that PCPs reduce hospitalizations and expensive interventions provided by specialists, thus lowering costs. The failure to focus more on PCPs is linked to the excessive amount spent on hospitalizations and more expensive therapies.
In addition to funding priorities, our current reimbursement system forces PCPs to see a lot of patients in order to keep their practices afloat.
On average, private physicians see over 22 patients a day. As a result, it is estimated that physicians only spend 16 minutes of face-to-face time with each patient.
This is barely enough time to review the patient’s chart, make new notes, write orders and answer questions.
While 16 minutes seems low, that number has remained steady for decades. For example, in the 1990s, physicians reported spending an average of 17 minutes with each patient.
Also, these numbers might be inflated because staff, physicians and even chaplains tend to overestimate the length of patient visits by about four minutes.
Part of the problem is that it is difficult to estimate how much time is spent with a patient because Medicare and Medicaid reimbursement rules require physicians to complete specific reports and tasks in the patient electronic health record.
A recent study published in the Annals of Internal Medicine revealed the average clinic physician spends 27% of their time on face-to-face patient care but almost 50% of their time dealing with the patient’s electronic health record and other administrative tasks.
Electronic health records are beneficial as they help providers review a patient’s history, labs and other studies quickly, but the era of excess patient charting can take away from face-to-face time with patients.
All of this has created long wait times, with 60% of patients forced to wait an average of two weeks to see their PCP for nonurgent needs. Only 10% can get an appointment on the day they need it.
The other factor contributing to the low rate of PCP visits is the cost to the patient.
The ACA made wellness and annual physicals affordable, so more people started getting comprehensive physicals and addressing chronic health issues.
At the same time, there was a 30% decline in symptom-based visits, like sinus infections and the flu. This can be attributed to an increase in fees from an average of $20 to $40 in recent years.
That may not sound like a lot, but it is cost prohibitive for a family of four who might need to make multiple visits during a typical cold and flu session.
In addition, many families are selecting high deductible insurance plans due to the lower cost in premiums. While helping with the monthly costs, these plans can result in significant costs to see a physician until the annual deductible is met.
In short, the U.S. public is making less PCP visits because of availability and cost.
Because these visits are linked to any successful public health strategy, it is time that we seriously restructure our fee-for-service healthcare system.
We need a system that is affordable for the average American and one that encourages new physicians to become general practitioners who are able to spend more than a few minutes with each patient.
We need a return to a system that rebuilds the physician-patient relationship. It is these relationships that will ultimately address chronic illnesses and bring down the cost of health care.
Senior Staff Chaplain and Clinical Ethicist at the Baptist Health Medical Center in Little Rock, Arkansas.
