Vital Signs Blog

More patients chose specialists over primary-care docs in 2013

In 2013, office visits to specialty physicians outnumbered office visits to primary-care physicians
It was probably just a matter of time before it happened, but 2013 may have marked the first year that office visits to specialty physicians outnumbered office visits to primary-care doctors.

The development was buried in a report from the IMS Institute for Healthcare Informatics on how healthcare spending had risen after years of “self-rationing.” This included a 2.7% increase in visits to physician offices.

It was the first such increase in four years, and Murray Aitken, executive director of the Institute, said 51% of those visits were to specialists' offices, a slight increase from the 49% and 48% recorded in 2012 and 2011.

“It's the crossing of a threshold, but it's not a dramatic one-year change,” Aitken said. “Our expectation is that it will continue to grow.”

Dr. Atul Grover, chief public policy officer for the Association of American Medical Colleges, observed in a Twitter message in response to this news that “Demographics = destiny.” Aitken agreed with that assessment.

He added, however, that the first two to four years of implementation of the Patient Protection and Affordable Care Act may temporarily alter this course as previously uninsured people gain coverage and enter the healthcare system via a local primary-care office. “That's the only thing that will interrupt the trend,” he said.

The IMS finding comes from 2013 survey data from a representative panel of 3,500 office-based physicians.

The two largest medical societies representing primary-care doctors—the American College of Physicians and the American Academy of Family Physicians—did not have any recent data on the IMS Health finding.

The ACP cited the 2010 Centers for Disease Control and Prevention's National Ambulatory Medical Survey (PDF), which recorded that 55% of the more than 1 billion office visits to U.S. physician offices between Dec. 28, 2009, and Dec. 26, 2010, were to primary-care offices. Twenty-four percent of the visits were to other medical specialists and 21% were to surgical specialists.

The AAFP's Robert Graham Center for Policy Studies in Primary Care and Family Medicine published a report in the Journal of the American Board of Family Medicine's January-February issue that used CDC survey data from 2008. According to the report, the majority of patients sought treatment from a primary-care physician for 10 of 14 highest-cost chronic conditions tracked by the CDC.

This included 86% of office visits for asthma treatment, 84% of visits for chronic obstructive pulmonary disease and 78% of visits for hyperlipidemia. The only conditions for which the majority of visits were not at a primary-care office were ischemic heart disease (34%), arthritis (36%); atrial fibrillation (37%) and diabetes (50%).

Lead author of the AAFP report, Dr. Manisha Sharma, medical director of the Evergreen Health Cooperative in Baltimore, suggested that maybe there needs to be a redefinition of terms.

"Primary-care physicians should be referred to as complex-care physicians because the burden increasingly falls on them," Sharma said in a news release. "More and more, primary-care physicians must not only identify medical needs of patients with chronic conditions, but they also must identify, coordinate, facilitate and manage issues surrounding and shaping those chronic conditions such as lifestyle behaviors, food access, safety, and social, environmental, and economic conditions—also known as social determinants of health.”

The IMS numbers, however, suggested that patients are increasingly turning to specialists for some of these needs.

The 2.7% increase shown in physician office visits for 2013 reflected a 4.9% increase in visits to specialists and 0.7% decrease in primary-care visits. While primary-care office visits among senior citizens increased by 2.6% last year, according to IMS Health, they decreased by 2.1% among adults ages 26-64 and fell by 2.7% among adults ages 19-25.

Sharma said in an interview that the scales could be tipping toward specialists in areas where there are long waits for primary-care appointments or where the local culture leans toward specialists over primary care. It could also reflect a rise in specialties such as oncology, whose patients have conditions that are generally not treated by primary-care physicians.

“In places that have a primary-care dearth—and Maryland is surprisingly one of those—I imagine it's possible,” Sharma said, adding that she remains skeptical that specialist visits have in fact surpassed primary-care visits in volume. “It could be an access issue, but with the ACA, it's too soon to tell.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks


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