NP, PA Office Visits Grow 129%, But Healthcare Costs Still Rising

November 16, 2018 - Office visits to primary care physicians dropped 18 percent from 2012 to 2016 among non-elderly adults with employer-sponsored healthcare coverage, the Health Care Cost Institute (HCCI) recently reported.

“The decline in primary care visits comes at a time when awareness has grown of the role of primary care in prevention and in containing overall medical spending,” Niall Brennan, President and CEO of HCCI, stated in a press release. “We saw these trends in our annual report and wanted to explore them more fully to shed light on this aspect of rising healthcare costs.”

Healthcare leaders and policymakers are putting primary care at the center of healthcare to reduce costs and improve the value of care delivery. Primary care is key to managing costly chronic conditions, preventing rising risk patients from developing the conditions, and steering patients to the appropriate, low-cost care setting.

Value-based care models are prime examples of primary care becoming the quarterback of patient care. Accountable care organizations (ACOs), patient-centered medical homes, and other value-based care arrangements oftentimes attribute patients to primary care providers and hold those providers accountable for the outcomes and costs of that patient’s care.

However, HCCI found that patients are not seeing their primary care physicians as often as they used to. Office visits to primary care physicians decreased from 1,510 visits per 1,000 members in 2012 to just 1,237 visits by 2016.

READ MORE: Aligning Incentives for Providers, Payers Improves Primary Care

The independent, non-profit research institute used claims data from 2012 to 2016 for adults under 65 years old with employer-sponsored insurance offered by Aetna, Humana, Kaiser Permanente, and UnitedHealthcare.

Even the number of established patient office visits (EPOVs) declined during the period, HCCI emphasized. EPOVs to primary care physicians fell every year, from 1,582 fewer visits per 1,000 members in 2009 to 1,140 fewer visits in 2016.

“EPOVs are the most common type of office visit, and their utilization trends may be less sensitive to changes in insurance coverage and plan design,” HCCI explained in the report. “EPOVs are also important in the context of primary care for patients with chronic conditions that require regular evaluation and management.”

While the number of office visits to primary care physicians steadily declined, HCCI pointed out that office visits for primary care services with other providers significantly increased at the same time. From 2012 to 2016, primary care office visits with all other providers increased 14 percent.

Notably, visits with nurse practitioners (NPs) and physician assistants (PAs) increased 129 percent.

READ MORE: How CMS Improves Primary Care Payments Through Codes, APMs

However, office visits with NPs and PAs did not offset the overall decline in primary care visits during the period, HCCI noted. The boost in NP and PA visits accounted for 42 percent of the total decline in primary care visits. And some of those visits may not have been for primary care, so that value may be the upper bound.

Despite patients seeing NPs and PAs more for primary care, healthcare costs still rose from 2012 to 2016.

Advanced practice clinicians earn significantly less than physicians, and payers typically reimburse at a lower rate for services delivered by NPs and PAs. Healthcare stakeholders argue that allowing NPs and PAs to practice at the scope of their licensure should bring down healthcare costs.

One study showed that higher ratios of physician assistants to physicians can produce thousands in savings for hospitals, while a more recent MGMA survey revealed that practices ending 2016 with greater revenue used higher ratios of non-physician providers and support staff to physicians.

Advocates of relaxing or expanding scope of practice laws for advanced practice clinicians also argue that permitting NPs and PAs to handle more healthcare responsibilities will lower costs for the healthcare system.

READ MORE: Six Characteristics of High-Value Primary Care Practices

But physician offices charged almost as much for an office visit with a NP or PA. HCCI reported that the average cost of an office visit with a primary care physician averaged $106 in 2016, while the same visit with a NP or a PA cost $103 on average.

“Any substitution of providers did not result in cost savings,” HCCI stressed in the report.

Overall, the decline in primary care visits spells trouble for the healthcare system. Healthcare is slated to account for almost 20 percent of the economy by 2026, growing at an average annual rate of 5.5 percent over the next either years.

The decline in primary care visits does not suggest that patients are better managing their conditions or health in general. Costs are still rising, and they will continue to grow as the population ages.

Value-based care and purchasing models may be the key to emphasizing the value of primary care. Value-based arrangements like the Comprehensive Primary Care Plus model from Medicare deliver incentives to boost primary care utilization with the goal of reducing costs and improving care quality.

Physicians, however, need to get on board with value-based care models. A recent survey uncovered that 61 percent of doctors think value-based arrangements will financially damage their practice.

Creating value-based care and purchasing models that deliver the right incentives for primary care providers could help to boost support and participation, placing primary care back in the center of patient care.