Lucia Agajanian, 25, a freelance film producer in Chicago, doesn’t have a primary care doctor, preferring the convenience of visiting a clinic for flu shots or going online for video visits.
“You say what you need, and there’s a 15-minute wait time,” Agajanian said, describing how her appointments usually work. “I really liked that.”
Olga Lucia Torres, 52, who teaches narrative medicine classes at Columbia University in New York, had a longtime primary care doctor who for two decades kept tabs on her conditions, including lupus and rheumatoid arthritis, and made sure she was up to date on vaccines and screening tests. Two years ago, Torres got a letter telling her he was changing to a “boutique practice” and would charge a retainer fee of $10,000 for her to stay on as a patient.
“I felt really sad and abandoned,” Torres said. “This was my PCP. I was, like, ‘Dude, I thought we were in this together!’”
In different ways, Agajanian’s and Torres’ situations point to how the primary care landscape is changing in ways that could shape access and quality of care.
An enduring relationship with a primary care doctor has long been regarded as the bedrock of a quality health system. But investment in primary care in the United States lags behind other high-income countries. The United States has a smaller share of primary care physicians than most of its European counterparts.
An estimated one-third of all physicians nationwide are primary care doctors — including family medicine physicians, general internists and pediatricians — according to the Robert Graham Center, a research and analysis organization that studies primary care. Other researchers say the numbers are even lower. The Peterson-KFF Health System Tracker reports only 12% of U.S. doctors are generalists, compared with 23% in Germany and as many as 45% in the Netherlands.
That means it’s often hard to find a doctor and to get an appointment without having to wait weeks or months.
“This is a problem that has been simmering and now beginning to erupt in some communities at a boil,” said Ann Greiner, president and chief executive officer of the Primary Care Collaborative, a nonprofit membership organization. “It’s hard to find that front door of the health system.”
A smaller percentage of physicians are entering the field than are practicing, suggesting that shortages will worsen over time.
Interest has waned partly because primary care yields lower salaries than other medical and surgical specialties.
Some doctors say they are burned out, facing cumbersome electronic health record systems and limits on appointment times, making it harder to get to know a patient and establish a relationship.
Others are retiring or selling their practices. Hospitals, insurers like Aetna-CVS Health and other corporate entities like Amazon are on a buying spree, snapping up primary care practices, furthering a move away from the “Marcus Welby, M.D.”-style neighborhood doctor. About 48% of primary care physicians work in practices they do not own. Two-thirds of those doctors are employed by private equity investors or other corporate entities, according to data in the “Primary Care Chartbook,” collected and published by the Graham Center.
People who seek care at these offices might not be seen by the same doctor at every visit. They might not be seen by a doctor at all but instead by a paraprofessional — a nurse practitioner or physician assistant, for instance — generally working under the supervision of a licensed physician. That trend has been accelerated by new laws — as well as changes in Medicare policy — that loosen the requirements for physician supervisors and billing. These are expected to be among the decade’s fastest-growing health jobs.
Demand for primary care is up, spurred partly by record enrollment in Affordable Care Act plans. Those new patients combined with the low supply of doctors are contributing to a yearslong downward trend in the number of people reporting they have a usual source of care, be it an individual doctor or a specific clinic or practice.
“Is it poor access or problems with the supply of providers? Does it reflect a societal disconnection, a go-it-alone phenomenon?” asked Christopher Koller, president of the Milbank Memorial Fund, a foundation whose nonpartisan analyses focus on state health policy.
Frustrating wait times are one result. A recent survey by a physician staffing firm found that it now takes an average of 21 days to get in to see a doctor of family medicine, defined as a subgroup of primary care, which includes general internists and pediatricians. Those physicians are many patients’ first stop for health care.
That runs counter to the trend in other countries, where patients complain of months- or yearslong waits for elective procedures like hip replacements but generally have short waits for primary care visits.
All of these factors are adding urgency to concerns about attracting new doctors to primary care.
Dr. Natalie A. Cameron, a Northwestern University internist, chose primary care in part because “I’m specifically interested in prevention and women’s health, and you do a lot of that in primary care.”
Provided
When she was in medical school, Dr. Natalie A. Cameron, who’s now a Northwestern University internist, chose primary care because she enjoyed forming relationships with patients and because “I’m specifically interested in prevention and women’s health, and you do a lot of that in primary care.”
Still, Cameron, 33, an instructor of medicine at Northwestern who sees patients at a primary care practice, says she understands why many of her colleagues chose something else. For some, it’s the pay. For others, it’s because of primary care’s reputation for involving “a lot of care and paperwork and coordinating a lot of issues that may not just be medical,” Cameron said.
How much does having a usual source of care influence medical outcomes and cost? And for which kinds of patients is having a close relationship with a doctor important?
Studies show that many young people value the convenience of visiting urgent care — especially when it takes so long to see a primary care doctor. But will their long-term health suffer because of that strategy?
Many people — particularly those who are young and generally healthy — shrug at the new normal, embracing alternatives that require less waiting. These options are particularly attractive to millennials, who tell focus groups the convenience of a one-off video call or visit to a big-box store clinic trumps a long-standing relationship with a doctor, especially if they have to wait days, weeks or longer for a traditional appointment.
“The doctor I have is a family friend, but definitely I would take access and ease over a relationship,” said Matt Degn, 24, who lives in Salt Lake City and says it can take two to three months to book a routine appointment.
People increasingly are turning to “retail clinics” such as CVS’ Minute Clinics, which tout “in-person and virtual care 7 days a week.” CVS Health’s more than 1,000 clinics inside stores across the United States treated more than five million people last year, according to Dr. Creagh Milford, a physician who is the company’s senior vice president of retail health. He cited a recent study by a data products firm showing the use of retail clinics has grown 200% over the past five years.
Health policy experts say increased access to alternatives can be good but that forgoing an ongoing relationship to a regular provider is not, especially as people get older and are more likely to develop chronic conditions or other medical problems.
“There’s a lot of data that show communities with a lot of primary care have better health,” Koller said.
People with a regular primary care doctor or practice are more likely to get preventive care such as cancer screenings or flu shots, studies show, and are less likely to die if they haver a heart attack.
Physicians who see patients regularly are better able to spot patterns of seemingly minor concerns that could add up to a serious health issue.
“What happens when you go to four different providers on four platforms for urinary tract infections because, well, they are just UTIs?” said Dr. Yalda Jabbarpour, a family physician in Washington, D.C., and director of the Robert Graham Center for Policy Studies. “But actually you have a large kidney stone that’s causing your UTI or have some sort of immune deficiency like diabetes that’s causing frequent UTIs. But no one tested you.”
Most experts say figuring out how to coordinate care amid the changing landscape and make it more accessible without undermining quality — even when different doctors, locations, health systems and electronic health records are involved — will be as complex as the pressures already causing long waits and less interest from doctors in doing primary care.
There’s something to be said for establishing a primary care relationship, Agajanian said. After an injury at work last year that necessitated shoulder surgery, she said she was rethinking her decision to cobble together care rather than have a primary care doctor or clinic.
“As I’m getting older, even though I’m still young, I have all these problems with my body,” she said. “And it would be nice to have a consistent person who knows all my problems to talk with.”
Contributing: Colleen DeGuzman
KFF Health News is a national newsroom that produces in-depth journalism on health issues.
