Report shows decline in usual care among Americans

November 16, 2022

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Disclosures:
Greiner is president and CEO of the Primary Care Collaborative. Healio was unable to confirm other relevant financial information at the time of publication.


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The percentage of Americans with routine care is falling, and the solution will require new investments in health care to improve access and strengthen patient-physician relationships, experts say.

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


The report examines the role of connections from familiar, consistent sources such as primary care physicians, describes trends that may be considered worrisome, and offers recommendations for reversing them.

Policy in care

Previous studies have shown that access to health care increases life expectancy for the community—a direct effect on life expectancy that is unique among medical specialties.

“An ongoing relationship – often considered the ‘secret sauce of health care’ – can enable doctors to better know and understand their patients’ needs and preferences, build trust and rapport, and can lead to greater patient satisfaction.” Yalda Jabbarpour, MD, medical director of the Robert Graham Center for Policy Studies in Washington, DC, an assistant professor of family medicine at Georgetown University and a practicing family physician, and colleagues wrote the evidence report.

Based on data from the Institute for Healthcare Research and Quality’s 2000-2020 Study Committee on Physician Expenditure, the 2019 Behavioral Health Risk Factor Surveillance System, and the 2019 National Health Interview Survey, researchers determined that the percentage of Americans who have an ongoing relationship with a primary care provider dropped from 84% in 2000 to 74% in 2019. There was a “slight increase” in 2020, up to 75%, but the authors cautioned that this may be due to the COVID-19 pandemic, and it is not clear whether this is a “one-off increase or a trend change”.

“There are many reasons why usual care continues to decline – affecting population health and equity,” Ann Greiner, MCP, president and CEO of PCC, Healio said. “Physicians need to join with other stakeholders to enact policy and market changes to reverse declines so we can help improve the health of all Americans.”

The percentage of people with an ongoing health care relationship varies by 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 states with lower rates — up to 57% — are concentrated in the Southeast and Southwest, especially non-Medicaid expansion states, and include Alaska, Nevada, and Wyoming,” the researchers wrote in the report.

There have been declining rates in all demographics, but blacks and Hispanics started at a lower rate than whites. The researchers wrote that in 2019, Hispanics had a 66% higher rate of no regular caregivers compared to whites — 34.3%. 20.7%. In addition, black people saw a 37% higher rate of no regular caregivers or 28.4% compared to white people.

Notably, the location where people receive care also varies, with black and Hispanic individuals more often receiving care in an emergency room or “in a facility than from an individual,” the researchers wrote.

“Holding all other demographic variables constant – including age, insurance type, poverty, region and income – the odds of having [usual source of care] is even lower for non-Hispanic blacks and Hispanics,” they wrote. “Collectively, these racial/ethnic disparities are worrisome and may contribute to persistent and persistent health disparities, disparities that worsened during the pandemic.”

Solutions

To improve access to health care and strengthen the patient-physician relationship, health care has begun to “leverage technology and teams,” Jabbarpour and colleagues wrote. For example, building teams to provide more contacts, offering telehealth visits and implementing patient portals that improve two-way communication.

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

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

The first solution the researchers highlighted was “changing how and how much we pay for basic services.”

They wrote that “both public and commercial payers should invest more in health care and pay with a hybrid payment model — mostly with some fee-for-service.” The dominant way basic care is paid for is still fee-for-service, they added, and “investment, calculated as a percentage of health care spending as a percentage of the total cost of care, is a dismal 5 to 7 cents on the dollar.”

“Paying more and differently can support primary care in building teams to provide more accessible and comprehensive services, supporting longer visits for patients who need more attention, introducing creative ways to deliver care beyond the visit and attract and retain undergraduate physicians. caring,” they wrote. “Primary care teams, with all members working to bring their skills and expertise, could potentially provide care that is more timely, individualized and able to meet a variety of patient needs.”

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

“Basically, we’re rushing forward with the status quo because it’s easy for health systems and payers … in a fee-for-service system.” But that’s not how you build relationships, especially in the digital world,” he said. “So the payment in form, function and level has to change.”

The second solution identified in the report was to “encourage choice and remove financial barriers to healthcare”.

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

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

Finally, the researchers proposed a “workforce strategy to attract, retain, and diversify essential services.”

“In addition to policies that support team-based care, more effective strategies are needed to diversify the workforce to better match patient race/ethnicity and to attract more students to select primary care specialties and practice in underserved areas,” they wrote. .

For roughly 4 decades, the United States has made “virtually no progress” in the representation of black and Hispanic medical students. While many experts agree that pathway programs focused on recruiting people from underrepresented populations into health care professions earlier in education “should be the focus,” the researchers wrote that “federal and state loan forgiveness programs focus on primary care physicians who practice rural jobs and distress. could be more generous.”

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