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US Approach to Primary Care Access Struggles Is Disjointed

Primary care access continues to dwindle, and the US is using a patchwork approach to filling in gaps with advanced practice providers and urgent care or retail health clinics.

A new report from FAIR Health indicates that the United States is taking a patchwork approach to patient access to care and primary care, with the data showing variable reliance on advanced practice providers and alternative care sites.

Taken together, this information is indicative of the primary care provider and physician shortage seen across the country. According to 2021 figures from the Association of American Medical Colleges (AAMC), the US could be short anywhere between 17,800 and 48,000 primary care doctors by 2034.

That physician shortage, plus a piecemeal approach to working around it, is playing out differently across the country, the FAIR Health report showed. Different states are able to offer different levels of primary care access based on their particular laws and policies, and it’s creating a disjointed picture of patient care access nationwide.

“Primary care is vital to the nation’s healthcare system,” Robin Gelburd, president of FAIR Health, said in a statement. “We hope this study of primary care provides actionable findings for all healthcare stakeholders, including patients, providers, payors, policy makers and researchers.”

Overall, patients aren’t really visiting primary care, the FAIR Health report showed. Between a quarter and a third (29 percent) of patients who received any kind of medical service between 2016 and 2022 did not get that care from a primary care provider. The report did not explore where patients did receive their care, but inpatient settings, outpatient surgical settings, and alternative care sites like retail health and urgent care clinics are all possibilities.

That number is representative of the overall primary care access problem the US has right now. There is a primary care provider shortage (plus patients experience convenient care access barriers and cost barriers), so it’s leaving folks to access urgent care or retail health clinics, or else see their conditions deteriorate until they need high-acuity treatment.

Further data in the FAIR Health report shows a jigsawed approach to filling in some of the primary care physician gaps. Perhaps most notably, patients who do access primary care are considering non-physician providers, such as advanced practice providers (APPs). While the majority of patients are still mostly seeing a primary care physician (54 percent), 44 percent are starting to loop in APPs.

Patients are mostly seeing nurse practitioners (NPs), but visiting with a physician assistant (PA) is also becoming common.

But seeing an APP in lieu of a primary care physician was variable across the country, with differences mostly lining up with scope of practice laws and a little bit with rurality. For example, in California, where scope of practice is restricted, 97.4 percent of patients are still mostly seeing a primary care physician. Only 1.7 percent of patients see an NP for primary care in California.

Meanwhile, in Mississippi, only 72.5 percent of patients see a primary care MD and 26.4 percent see an NP. Mississippi is the state with the largest share of patients seeing an NP for primary care.

“These lists of states correlate in large part with state laws and regulations regarding whether a nurse practitioner has full practice, reduced practice or restricted practice, as documented by the American Association of Nurse Practitioners,” the report authors wrote.

There could also be a slight link with rurality; Mississippi is far more rural than California and sees considerably lower primary care physician density than California. NPs are tapped to account for that lower physician density.

Rurality also aligned with likelihood to visit a family medicine provider. Family medicine physicians and providers usually see all members of a family, meaning they practice a more generalized form of primary care compared to, for example, a pediatrician.

This makes sense; with only one physician in a given area, it would behoove the physician and their patients that the physician practice family medicine so they could treat more patients.

The report also delved into the topic of mental health, a topic that has gained notoriety as more people express mental health needs.

Mental health is more commonly addressed in the primary care setting now, with the number of patients getting a mental health diagnosis from a primary care provider increasing by 7 percent between 2016 and 2022. When looking at patients with substance use disorder, that figure is 2.5 percent.

APPs and other non-physicians treated a greater proportion of patients with a mental health diagnosis than physicians did. During the 2016 to 2022 period, APPs saw increases in patients with mental health or substance use disorder diagnoses of more than 100 percent.

These findings outline the changing landscape of primary care, the report authors noted. Patients are contending with more care access options, plus new financial and social determinants of health challenges that affect their ability to access primary care. That, coupled with new care needs in mental and behavioral health, will reshape the specialty moving forward.

“Taken together, these findings are relevant to understanding, maintaining and improving primary care in the United States,” the researchers concluded. “Healthcare stakeholders, such as patients, providers, payors, policy makers and researchers, can use these data to bring clarity to the use of primary care across the country and to help determine where attention should be directed to improve primary care access and, ultimately, health outcomes.”

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