Report shows decline in usual source of care among Americans

The percentage of Americans with a usual source of care is declining, and the solution will require new investments in primary care to improve access and strengthen patient-clinician relationships, according to experts.

This was recently discussed during a webinar hosted by the Primary Care Collaborative (PCC) and published in its 2022 evidence report.

The report examines the role of relationships from a familiar, consistent source like primary care physicians, describes trends that could be seen as troubling and offers recommendations to reverse them.

Trends in care

Previous research has shown that access to primary care increases life expectancy for the community — a direct impact on life expectancy that is unique among medical specialties.

“An ongoing relationship — often considered the ‘secret sauce of primary care’ — can enable clinicians to better know and understand their patients’ needs and preferences, to build trust and rapport, and may result in higher patient satisfaction,” Yalda Jabbarpour, MD, medical director of the Robert Graham Center for Policy Studies in Washington, D.C., assistant professor of family medicine at Georgetown University and a practicing family physician, and colleagues wrote in the evidence report.

Based on data from the Agency for Healthcare Research and Quality’s 2000-2020 Medical Expenditure Panel Survey, the 2019 Behavioral Health Risk Factor Surveillance System and the 2019 National Health Interview Survey, the researchers determined that the percentage of Americans who have an ongoing relationship with primary care dropped from 84% in 2000 to 74% in 2019. There was a “slight uptick” in 2020, up to 75%, but the authors offered the caveat that this could be because of the COVID-19 pandemic, and it is not clear if this is “a one-time increase or a change in trend.”

“There are a constellation of reasons why the usual source of care continues to decline — which has an impact on population health and equity,” Ann Greiner, MCP, president and CEO of the PCC, told Healio. “Primary care clinicians need to join with other stakeholders to enact policies and market changes to reverse declines so that we can help improve the health of all Americans.”

The percentage of people with an ongoing primary care relationship varies from state to state, with data showing a 27% spread, according to Jabbarpour and colleagues.

“The states with high rates — up to 84% — are in the upper Northeast and pockets of the Midwest. The lower rate states — as low as 57% — are concentrated in the Southeast and Southwest, particularly non-Medicaid expansion states, and include Alaska, Nevada, and Wyoming,” the researchers wrote in the report.

There have been declining rates across all demographics, but Black and Hispanic people started at lower levels than white people. The researchers wrote that, in 2019, Hispanic people had a 66% higher rate of no usual sources of care compared with white people —34.3% vs. 20.7%. Additionally, Black people saw a 37% higher rate of no usual sources of care at 28.4% compared with white people.

Notably, the location of where people receive care also varies, with Black and Hispanic people more often receiving care in the ED or “in a facility than from a person,” the researchers wrote.

“When holding all other demographic variables constant — including age, insurance type, poverty, region, and income — the odds of having a [usual source of care] is still lower for Non-Hispanic Black and Hispanic populations,” they wrote. “Taken together, these differences across racial/ethnic groups are concerning and may be contributing to ongoing and persistent health inequities, inequities that were made worse during the pandemic.”

Solutions

To improve access to primary care and strengthen patient-clinician relationships, primary care has begun “leveraging technology and teams,” Jabbarpour and colleagues wrote. For example, building out teams to provide more points of contact, offering telehealth visits and implementing patient portals that improve bi-directional communication.

However, the researchers wrote that, “to date, these innovations to enhance the value proposition for primary care have not been sufficient to overcome structural barriers.” So, they included three solutions that “could make a difference.”

“The heart of primary care — the patient-clinician relationship — is stressed,” Greiner told Healio. “Innovators are working to fill gaps and strengthen relationships, but we need policies to scale innovation so that individuals in every region of the country and across all demographic groups have access to the front door of the health system.”

The first solution the researchers highlighted was “change how and how much we pay primary care.”

They wrote that “both public and commercial payers should be investing more in primary care and paying through a hybrid payment model — predominantly capitated with some fee-for-service.” The dominant way that primary care is paid is still fee for service, they added, and “investment, calculated as the percentage of primary care spend as a percentage of total cost of care, is a dismal 5 to 7 cents on the dollar.”

“Paying more and differently can support primary care building out teams to provide more access and more comprehensive services, support longer visits for patients who need more attention, promulgate creative ways of delivering care not tied to a visit, and attract and retain clinicians in primary care,” they wrote. “Primary care teams, where all members are working to bring their talents and expertise, may be able to provide care that is more timely, individualized, and able to meet an array of patient needs.”

Asaf Bitton, MD, MPH, executive director of Ariadne Labs at Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital, said in the webinar that “at the core of so much of this Gordian knot is a broken payment system that’s not fit for purpose, that’s more around transactions than it is around relationships.”

“Basically, we're hurtling forward in a status quo because it's easy for health systems and payers ... in fee for service mechanisms. But that’s not the way that you create relationships, especially in a digital world,” he said. “So, the payment in form, function and level needs to change.”

The second solution noted in the report was “incentivize selection and remove financial barriers to primary care.”

About 46% of people with commercial insurance are in PPO plans — meaning they can skip primary care and go straight to specialist services.

In response, Jabbarpour and colleagues wrote that “employers need to take steps to make it easy and worthwhile” for employees to have a usual source of care.

Finally, the researchers suggested “workforce policies to attract, retain and diversify primary care.”

“In addition to policies that support team-based care, there needs to be more effective approaches to diversifying the workforce so that it better matches patient race/ethnicity and to attract more students to select the specialty of primary care and practice in underserved areas,” they wrote.

In about 4 decades, the U.S. “has made almost no progress” in the representation of Black and Hispanic medical students. Since many experts agree that pathway programs focusing on recruiting people from underrepresented populations into the health professions earlier in education “should be the focus,” the researchers wrote that “federal and state loan forgiveness programs focused on primary care clinicians practicing in rural and underserved areas could be made more generous.”

Reference:

• Relationships matter: How usual is usual source of (primary) care? 2022 PCC Evidence Report. https://www.pcpcc.org/resource/evidence2022?utm_source=link&utm_medium=link&utm_campaign=2022-evidence. Published Nov. 16, 2022. Accessed Nov. 16, 2022.