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Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline.To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits.Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008-2016. A 5% claims sample was used for Poisson regression models to quantify visit trends.National, population-based.Adult health plan members aged 18 to 64 years.PCP visit rates per 100 member-years.In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, -48.1% to -47.3%). The decline was largest among the youngest adults (-27.6% [CI, -28.2% to -27.1%]), those without chronic conditions (-26.4% [CI, -26.7% to -26.1%]), and those living in the lowest-income areas (-31.4% [CI, -31.8% to -30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (-0.08% [CI, -0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%).Data were limited to a single commercial insurer and did not capture nonbilled clinician-patient interactions.Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care.None.

Under new U.S. Department of Health and Human Services rules, hospitals must post prices for all of their services as of 1 January 2019. This commentary discusses the current implementation of this...

Telehealth can often be provided at a lower cost than other types of care, but it may increase the total amount of care delivered. The effect on spending depends on how much telehealth substitutes ...

Payment trends are producing powerful financial incentives that influence how physicians provide patient care. To be effective, these incentives must target the physician responsible for care. The ...

Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood.To systematically review evidence of the association between health care quality and cost.Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012.Title, abstract, and full-text review to identify relevant studies.Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders.Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise or indeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings.Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies.Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste.Robert Wood Johnson Foundation.

The current medical billing system is a common source of patient frustration with health care. Many are inundated with bills and insurance statements that are sometimes confusing or inaccurate and ...

Physicians and patients have come to expect that periodic health examinations (PHEs) are a standard part of comprehensive ongoing medical care. However, considerable research has not demonstrated a substantial benefit of the PHE. Given this lack of benefit and the high total cost of PHE to the health care system, the American Board of Internal Medicine (ABIM) Foundation and the Society of General Internal Medicine (SGIM) have identified "routine health checks in asymptomatic patients" as something of low value that physicians and patients should question, as a part of the Choosing Wisely campaign. Two discussants review the debate about PHE and consider the value of PHE for a healthy 70-year-old woman who appreciates seeing her physician annually.

Retail clinics are an increasingly popular source for medical care. Concerns have been raised about the effect of these clinics on the cost, quality, and delivery of preventive care.To compare the care received at retail clinics for 3 acute conditions with that received at other care settings.Claims data from 2005 and 2006 from the health plan were aggregated into care episodes (units that included initial and follow-up visits, pharmaceuticals, and ancillary tests). After 2100 episodes (700 each) were identified in which otitis media, pharyngitis, and urinary tract infection (UTI) were treated first in retail clinics, these episodes were matched with other episodes in which these illnesses were treated first in physician offices, urgent care centers, or emergency departments.Enrollees of a large Minnesota health plan.Enrollees who received care for otitis media, pharyngitis, or UTI.Costs per episode, performance on 14 quality indicators, and receipt of 7 preventive care services at the initial appointment or subsequent 3 months.Overall costs of care for episodes initiated at retail clinics were substantially lower than those of matched episodes initiated at physician offices, urgent care centers, and emergency departments ($110 vs. $166, $156, and $570, respectively; P0.001 for each comparison). Prescription costs were similar in retail clinics, physician offices, and urgent care centers ($21, $21, and $22), as were aggregate quality scores (63.6%, 61.0%, and 62.6%) and patient's receipt of preventive care (14.5%, 14.2%, and 13.7%) (P0.05 vs. retail clinics). In emergency departments, average prescription costs were higher and aggregate quality scores were significantly lower than in other settings.A limited number of quality measures and preventive care services were studied. Despite matching, patients at different care sites might differ in their severity of illness.Retail clinics provide less costly treatment than physician offices or urgent care centers for 3 common illnesses, with no apparent adverse effect on quality of care or delivery of preventive care.California HealthCare Foundation.

In 1961, an article with a similar title changed our understanding about who receives medical care. This article updates our understanding since then, describes the trends changing the ecology of c...

Some health plans profile physicians on the basis of their relative costs and use these profiles to assign physicians to cost categories. Physician organizations have questioned whether the rules used to attribute costs to a physician affect the cost category to which that physician is assigned.To evaluate the effect of 12 different attribution rules on physician cost profiles.Under each of the 12 attribution rules, a cost profile was created for the physicians in the aggregated claims database and the physicians were assigned to a cost category (high cost, average cost, low cost, or low sample size). The attribution rules differed by unit of analysis, signal for responsibility, number of physicians who can be assigned responsibility, and threshold value for assigning responsibility.Four commercial health plans in Massachusetts.1.1 million adults continuously enrolled in 4 commercial health plans in 2004 and 2005.Percentage of all episodes assigned to any physician and percentage of costs billed by a physician that were included in his or her own profile were calculated under each rule. The cost category assignments from a commonly used default rule were compared with those from each of the other 11 attribution rules and the rate of disagreement was calculated.Percentage of episodes that could be assigned to a physician varied substantially across the 12 rules (range, 20% to 69%), as did the mean percentage of costs billed by a physician that were included in that physician's own cost profile (range, 13% to 60%). Depending on the alternate rule used, between 17% and 61% of physicians would be assigned to a different cost category than that assigned by using the default rule.Results might differ if data from another state or from Medicare were used.The choice of attribution rule affects how costs are assigned to a physician and can substantially affect the cost category to which a physician is assigned.U.S. Department of Labor.

Open-access scheduling (also known as advanced access or same-day access) is a popular tool for improving patient access to primary care appointments.To assess the effect of open-access scheduling and describe the barriers to implementing the open-access scheduling model in primary care.Case series.Boston, Massachusetts, metropolitan area.6 primary care practices studied from October 2003 through June 2006.Implementation of open-access scheduling.Time to third available appointments, no-show rates, and patient and staff satisfaction with appointment availability.5 of 6 practices were able to implement open-access scheduling. Within 4 months of implementation, these 5 practices substantially reduced their mean wait for third available appointments from 21 to 8 days for 15-minute visits and from 39 to 14 days for 30-minute visits. However, none of the 5 practices attained the goal of same-day access, and waits for third available appointments increased during 2 years of follow-up. No consistent changes in patient or staff satisfaction or patient no-show rates were found. Barriers to implementation included decreases in appointment supply from provider leaves of absence and departures and increases in appointment demand when practices reopened to new patients after initial implementation of open-access scheduling.The study lacked control practices. The small number of practices and providers precluded formal statistical comparisons.In 5 of 6 primary care practices, implementation of open-access scheduling improved appointment access in some practices. However, none was able to achieve same-day access and patient and staff satisfaction and patient no-show rates were unchanged. Broader evaluation of open-access scheduling in primary care is needed.

The association between the organizational structure of physician groups and health care quality has never been evaluated empirically.To examine whether integrated medical groups (IMGs) provide higher-quality primary care than individual practice associations (IPAs).Cross-sectional study.PacifiCare, a large health maintenance organization.Approximately 1.7 million enrollees of PacifiCare cared for by 119 California physician groups between July 1999 and June 2000.The percentage of eligible PacifiCare enrollees who received mammography, Papanicolaou smear screening, chlamydia screening, diabetic eye examination, an asthma controller medication, or a beta-blocker after acute myocardial infarction.Physician groups identified as IMGs, compared with those identified as IPAs, had higher rates of mammography (relative risk, 1.15 [95% CI, 1.01 to 1.33]), Papanicolaou smear screening (relative risk, 2.29 [CI, 1.53 to 3.42]), chlamydia screening (relative risk, 2.17 [CI, 1.04 to 4.55]), and diabetic eye screening (relative risk, 1.55 [CI, 1.28 to 1.88]). Leaders of IMGs were more likely to report using EMRs (37% vs. 2%; P0.001) and quality improvement strategies, but these characteristics explained little of the quality differences between IMGs and IPAs.Organizational characteristics, including group type, were reported by physician group leaders and not directly assessed. Patient characteristics that could have accounted for some of the observed differences also were not assessed.Patients cared for in IMGs generally received higher-quality primary care than those cared for in IPAs. Having an EMR and implementation of quality improvement strategies did not explain the differences in quality. These findings suggest that physician group type influences health care quality.