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Characteristics of Office-based Physician Visits, 2016

Key findings, do office-based physician visit rates vary by patient age and sex, what was the primary expected source of payment at office-based physician visits, and did it vary by age, what were the major reasons for office-based physician visits, what were the services ordered or provided at office-based physician visits, and did they vary by age, definitions, data source and methods, about the authors, suggested citation.

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Jill J. Ashman, Ph.D., Pinyao Rui, M.P.H., Titilayo Okeyode

Data from the National Ambulatory Medical Care Survey

• In 2016, there were an estimated 278 office-based physician visits per 100 persons.
• The visit rate among females exceeded the rate for males, and the rates for both infants and older adults exceeded the rates for those aged 1–64 years.
• Private insurance was the primary expected source of payment for the majority of visits by children under age 18 and adults aged 18–64, whereas Medicare was the primary expected source of payment for the majority of visits by adults aged 65 and over.
• Compared with adults, a larger percentage of visits by children were for either preventive care or a new problem.
• Compared with children, a larger percentage of visits by adults included an imaging service that was ordered or provided.

In 2016, most Americans had a usual place to receive health care (86% of adults and 96% of children) ( 1 , 2 ). The majority of children and adults listed a doctor’s office as the usual place they received care ( 1 , 2 ). In 2016, there were an estimated 883.7 million office-based physician visits in the United States ( 3 , 4 ). This report examines visit rates by age and sex. It also examines visit characteristics—including insurance status, reason for visit, and services—by age. Estimates use data from the 2016 National Ambulatory Medical Care Survey (NAMCS).

Keywords : ambulatory health care, insurance, NAMCS

• In 2016, there were 278 office-based physician visits per 100 persons ( Figure 1 ).
• The visit rate for both infants under 1 year of age (736 per 100 infants) and adults aged 65 and over (498 per 100 adults aged 65 and over) was higher than the rate for children aged 1–17 years (213 per 100 children aged 1–17 years), adults aged 18–44 (190 per 100 adults aged 18–44), and adults aged 45–64 (302 per 100 adults aged 45–64).
• The visit rate among females (315 visits per 100 females) was higher than the rate for males (239 visits per 100 males).

Figure 1. Visit rates, by selected demographics: United States, 2016

1 Significant difference in estimates among all age groups. 2 Significant difference in estimates between females and males. NOTES: Visit rates are based on the July 1, 2016, set of estimates of the civilian noninstitutionalized population of the United States, as developed by the Population Division, U.S. Census Bureau. Total visits includes all visits by patients of all ages. For more information, see the 2016 National Ambulatory Medical Care Survey Documentation , Access data table for Figure 1 . SOURCE: NCHS, National Ambulatory Medical Care Survey, 2016.

• Private insurance was the primary expected source of payment at over one-half (54%) of all office-based physician visits, followed by Medicare (26%), Medicaid (15%), and no insurance (3%) ( Figure 2 ).
• Private insurance was the primary expected source of payment for the majority of visits by children under age 18 years (63%) and adults aged 18–64 (71%), whereas Medicare was the primary expected source of payment for the majority of visits by adults aged 65 and over (82%).
• Medicaid as the primary expected source of payment decreased with increasing age, 32% among children, 15% among adults aged 18–64, and 2% among adults aged 65 and over.
• No insurance or self-pay as the primary expected source of payment varied by age (5% among adults aged 18–64, 3% among children under 18, and 1% among adults 65 and over).

Figure 2. Primary expected source of payment, by age: United States, 2016

1 Significant difference in estimates between those under age 65 and those aged 65 and over. 2 Significant difference in estimates among all age groups. NOTES: All sources of payment were combined into one mutually exclusive primary source of payment using the following hierarchy: Medicare, Medicaid or Children’s Health Insurance Program, or other state-based program; private insurance; and no insurance. Total visits includes all visits by patients of all ages. No insurance is defined as having only self-pay, no charge, or charity as payment sources. Other sources of payment and missing or blank data are not included in this figure and represent 6.9% (weighted) of visits. Figures exclude 5.3% (weighted) of visits for which data were missing or blank. For more information, see the 2016 National Ambulatory Medical Care Survey documentation , Access data table for Figure 2 . SOURCE: NCHS, National Ambulatory Medical Care Survey, 2016.

• A chronic condition was listed as the major reason for 37% of all office-based physician visits, followed by a new problem (27%), preventive care (23%), an injury (7%), and pre- or post-surgery care (6%) ( Figure 3 ).
• Both chronic conditions (17% among children under age 18 years, 37% among those aged 18–64, and 51% among those aged 65 and over) and pre- and post-surgery care (2% among children under age 18, 6% among those aged 18–64, and 8% among those aged 65 and over), as the major reason for visit, increased with increasing age.
• Both preventive care (32% among children under age 18 years, 24% among those aged 18–64, and 15% among those aged 65 and over) and new problem (41% among children under age 18 years, 24% among those aged 18–64, and 21% among those aged 65 and over), as the major reason for visit, decreased with increasing age.
• Injury was listed as the major reason for visit at a higher percentage of visits by children (8%) and adults aged 18–64 (8%) than adults aged 65 and over (5%).

Figure 3. Major reason for office-based physician visit, by age: United States, 2016

1 Significant difference in estimates between those aged 65 and over and both those aged under 18 and those aged 18–64. 2 Significant difference in estimates among all age groups. NOTES: Provider-assessed major reason for visit was combined with injury to create a combined mutually exclusive reason for visit, with an injury visit having precedence over all other reasons. In 2016, the definition of injury changed due to the switch from using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD–9–CM) to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD–10–CM) to code injury and poisoning diagnoses. Therefore, estimates for injury should not be considered comparable with previous years of injury estimates. Total visits includes all visits by patients of all ages. Numbers may not add to 100% due to rounding. Figures exclude 2.3% (weighted) of visits for which data were missing either injury or reason for visit. For more information, please see the 2016 NAMCS documentation , Access data table for Figure 3 . SOURCE: NCHS, National Ambulatory Medical Care Survey, 2016.

• An examination or screening was ordered or provided at almost one-half (48%) of all office-based physician visits, followed by laboratory tests (29%), health education and counseling (22%), imaging (14%), and procedures (14%) ( Figure 4 ).
• A higher percentage of examinations and screenings were ordered or provided at visits by children under age 18 years than adults aged 18–64, but a higher percentage of laboratory visits occurred among adults aged 18–64 compared with children.
• A higher percentage of health education and counseling services were ordered or provided at visits by children than adults, but there was a higher percentage of visits with imaging services among adults compared with children.
• A higher percentage of procedures were ordered or provided at visits by adults aged 65 and over than younger adults and children.

Figure 4. Selected services ordered or provided at office-based physician visits, by age: United States, 2016

*Estimate does not meet NCHS standards of reliability. 1 Significant difference in estimates between those under age 18 and those aged 18–64. 2 Significant difference in estimates between those under age 18 and those aged 18–64 and 65 and over. For imaging services, estimate for those under age 18 is significantly lower than estimates for those aged 18–64 and 65 and over. 3 Estimate for those aged 65 and over is significantly higher than estimates for those aged under 18 and aged 18–64. NOTES: More than one service may be reported per visit. Total visits includes all visits by patients of all ages. Note that due to the switch to ICD–10–CM in 2016, the method used to derive examinations or screenings is different from that used in prior years. Therefore, estimates for examinations and screenings should not be considered comparable to previous years of examinations and screenings estimates. See the definitions section for the specific services included in each category. For the complete list of services, see the 2016 National Ambulatory Medical Care Survey summary documentation , Access data table for Figure 4 . SOURCE: NCHS, National Ambulatory Medical Care Survey, 2016.

During 2016, the overall rate of office-based physician visits was 278 visits per 100 persons. The visit rate for infants and older adults was higher than the rate for other age groups. The visit rate for females was higher than the rate for males.

The majority of visits by children (63%) and adults aged 18–64 (71%) listed private insurance as the primary expected source of payment, whereas the majority of visits by older adults listed Medicare as the primary expected source of payment (82%). Approximately 3% of office-based physician visits were made by those with no insurance. A higher percentage of visits by adults 18–64 (5%) had no insurance compared with adults aged 65 and over (1%) and children (3%).

A chronic condition was the major reason for 37% of all office-based physician visits, and visits for chronic conditions were higher among adults than children. A higher percentage of visits by children than adults were for a new problem or preventive care, whereas the reverse was true for visits related to pre- or post-surgery care.

Almost one-half (48%) of all office-based physician visits included an examination or screening that was ordered or provided. Compared with adults, a higher percentage of visits by children included health education and counseling. Compared with children, a higher percentage of visits by adults included imaging services.

Major reason for this visit : A variable was created by merging the “INJURY” variable with the provider-assessed major reason for this visit ( 5 ). Injury was given preference over all other reasons. The five categories for major reason for this visit include:

• Injury: A visit defined as injury or poisoning related, based on any listed reason for visit and diagnosis ( 5 ). In 2016, the definition of injury changed due to the switch from using using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD–9–CM) to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD–10–CM) to code injury and poisoning diagnoses. Therefore, estimates for injury in this report should not be considered comparable with previous years of injury estimates.
• New problem: A visit for a condition or illness having a relatively sudden or recent onset (within 3 months of this visit).
• Chronic condition: A visit primarily to receive care or examination for a preexisting chronic condition or illness (onset of condition was 3 months or more before this visit). This includes both routine visits and flare-ups; a visit primarily due to a sudden exacerbation of a preexisting chronic condition.
• Pre- and post-surgery: A visit scheduled primarily for care required prior to or following surgery (e.g., presurgery tests or removing sutures).
• Preventive care: General medical examinations and routine periodic examinations. Includes prenatal care, annual physicals, well-child exams, screening, and insurance examinations.

Selected services : Included are services that were ordered or provided during the sampled visit for the purpose of screening (i.e., early detection of health problems in asymptomatic individuals) or diagnosis (i.e., identification of health problems causing individuals to be symptomatic) ( 5 ). Each selected service item was grouped into five categories as follows

• Examinations or screenings: Alcohol misuse, breast, depression, domestic violence, foot, neurologic, pelvic, rectal, retinal or eye, skin, and substance abuse. Note that due to the switch to ICD–10–CM in 2016, the method used to derive examinations and screenings in this report is different from that used in prior years. Therefore, estimates for examinations and screenings in this report should not be considered comparable with previous years of examinations and screenings estimates.
• Health education or counseling: Alcohol abuse counseling, asthma, asthma action plan given to patient, diabetes education, diet or nutrition, exercise, family planning or contraception, genetic counseling, growth or development, injury prevention, sexually transmitted disease prevention, stress management, substance abuse counseling, tobacco use or exposure, and weight reduction.
• Imaging services: Includes bone mineral density, CT scan, echocardiogram, ultrasound, mammography, MRI, and X-ray.
• Laboratory tests: Includes basic metabolic panel, complete blood count, chlamydia test, comprehensive metabolic panel, creatinine or renal function panel, culture (blood, throat, urine, or other), glucose, gonorrhea test, HbA1c, hepatitis testing, HIV test, human papillomavirus DNA test, lipid profile, liver enzymes or hepatic function panel, pap test, pregnancy or HCG test, prostate-specific antigen, rapid strep test, thyroid-stimulating hormone or thyroid panel, urinalysis, and vitamin D test.
• Procedures: Includes audiometry, biopsy, cardiac stress test, colonoscopy, cryosurgery or destruction of tissue, EKG or ECG, electroencephalogram, electromyogram, excision of tissue, fetal monitoring, peak flow, sigmoidoscopy, spirometry, tonometry, tuberculosis skin testing, and upper gastrointestinal endoscopy.

Data for this report are from the National Ambulatory Medical Care Survey (NAMCS), which is conducted by the National Center for Health Statistics. NAMCS is an annual, nationally representative survey of office-based physicians and visits to their practices ( 3 , 5 ). The target universe of NAMCS is physicians classified as providing direct patient care in office-based practices. Radiologists, anesthesiologists, and pathologists are excluded, as are physicians in community health centers. The 2016 sample consists of 3,699 physicians. Participating physicians provided 13,165 visit records. The participation rate—the percentage of in-scope physicians for whom at least one visit record was completed—was 39.3%. The response rate—the percentage of in-scope physicians for whom at least one-half of their expected number of visit records was completed—was 32.7%.

Data analyses were performed using the statistical packages SAS version 9.4 (SAS Institute, Cary, N.C.) and SAS-callable SUDAAN version 11.0 (RTI International, Research Triangle Park, N.C.). Differences in the distribution of selected characteristics of office-based physician visits are based on chi-square tests ( p < 0.05). If a difference was found to be statistically significant, additional pairwise tests were performed. Statements of difference in paired estimates are based on two-tailed t tests with statistical significance at the p < 0.05 level. Terms such as “higher” or “lower” indicate that the differences are statistically significant.

Jill J. Ashman, Pinyao Rui, and Titilayo Okeyode are with the National Center for Health Statistics, Division of Health Care Statistics.

• Black LI, Benson, V. Tables of summary health statistics for U.S. children: 2016 National Health Interview Survey . 2018. Available from:
• Blackwell DL, Villarroel MA. Tables of summary health statistics for U.S. adults: 2016 National Health Interview Survey . National Center for Health Statistics. 2018.
• National Center for Health Statistics. 2016 NAMCS micro-data file. Hyattsville, MD. 2019.
• Rui P, Okeyode T. National Ambulatory Medical Care Survey: 2016 national summary tables . 2019.
• National Center for Health Statistics. 2016 NAMCS micro-data file documentation. Hyattsville, MD. 2019.

Ashman JJ, Rui P, Okeyode T. Characteristics of office-based physician visits, 2016. NCHS Data Brief, no 331. Hyattsville, MD: National Center for Health Statistics. 2019.

Copyright information

All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

National Center for Health Statistics

Charles J. Rothwell, M.S., M.B.A., Director Jennifer H. Madans, Ph.D., Associate Director for Science

Division of Health Care Statistics

Denys T. Lau, Ph.D., Director Alexander Strashny, Ph.D., Associate Director for Science

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National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015

Affiliations.

• 1 Icahn School of Medicine at Mount Sinai, New York City, New York.
• 2 Harvard Medical School, Boston, Massachusetts.
• 3 Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
• 4 Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
• 5 Harvard Medical School, Boston, Massachusetts [email protected].
• 6 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
• PMID: 31712292
• PMCID: PMC6846275
• DOI: 10.1370/afm.2474

Purpose: Recent evidence shows a national decline in primary care visit rates over the last decade. It is unclear how changes in practice-including the use and content of primary care visits-may have contributed.

Methods: We analyzed nationally representative data of adult visits to primary care physicians (PCPs) and physician practice characteristics from 2007-2016 (National Ambulatory Medical Care Survey). United States census estimates were used to calculate visits per capita. Measures included visit rates per person year; visit duration; number of medications, diagnoses, and preventive services per visit; percentage of visits with scheduled follow-up; and percentage of physicians with practice capabilities including an electronic medical record (EMR).

Results: Our weighted sample represented 3.2 billion visits (83,368 visits, unweighted). Visits per capita declined by 20% (-0.25 visits per person, 95% CI, -0.32 to -0.19) during this time, while visit duration increased by 2.4 minutes per visit (95% CI, 1.1-3.8). Per visit, PCPs addressed 0.30 more diagnoses (95% CI, 0.16-0.43) and 0.82 more medications (95% CI, 0.59-1.1), and provided 0.24 more preventive services (95% CI, 0.12-0.36). Visits with scheduled PCP followup declined by 6.0% (95% CI, -12.4 to 0.46), while PCPs reporting use of EMR increased by 44.3% (95% CI, 39.1-49.5) and those reporting use of secure messaging increased by 60.9% (95% CI, 27.5-94.3).

Conclusion: From 2008 to 2015, primary care visits were longer, addressed more issues per visit, and were less likely to have scheduled follow-up for certain patients and conditions. Meanwhile, more PCPs offered non-face-to-face care. The decline in primary care visit rates may be explained in part by PCPs offering more comprehensive in-person visits and using more non-face-to-face care.

Keywords: National Ambulatory Medical Care Survey; preventive services; primary care visits.

© 2019 Annals of Family Medicine, Inc.

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Trends In Primary Care Visits

Office visits to primary care physicians (PCPs) declined 18 percent from 2012 to 2016 for adults under 65 years old with employer-sponsored health insurance, while office visits to nurse practitioners (NPs) and physician assistants (PAs) increased 129 percent.

Comparing 2012 to 2016, there were 273 fewer office visits per 1,000 insured individuals to primary care physicians over that span, while visits to nurse practitioners and physician assistants rose from 88 visits per 1,000 insured members to 201. The rate of office visits to specialists and other non-physician providers remained relatively unchanged over the period.

While the utilization of office visits to NPs and PAs increased dramatically over the study period, the substitution did not result in cost savings. Since 2012, the average cost of an office visit to a primary care physician remained closely aligned with the cost of a NP and PA visit. In 2016, the average cost per visit to a primary care physician was $106 compared to $103 for an office visit to a NP or PA.

Full Resource/Source: Health Care Cost Institute

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Americans' Primary Care Experiences and Preferences: 2024 Survey Report

U.S. News & World Report surveyed 2,000 U.S. adults about health care issues, including why and how often they go to the doctor, how they choose their doctors and why they choose to (or don't) follow the advice of their doctors.

Americans' Primary Care Experiences

People don’t typically think about their health until they get sick. At that point, they might visit an urgent care center or emergency room rather than seeing a primary care provider , or PCP. However, a trip to the ER for a common ailment is, on average, 12 times more expensive than getting care at a physician’s office, according to an analysis from UnitedHealth Group.

In addition to vast cost savings, having a consistent primary care provider for health ailments and regular screenings can improve a patient's experience and help prevent medical issues from becoming critical emergencies. Most health insurance companies and Medicare plans will cover an annual preventative wellness visit to a PCP.

Health care costs have been on the rise for years; and for many Americans, it’s an obstacle to getting timely and dependable health care. According to the Kaiser Family Foundation, one in four American adults say they have skipped or postponed getting medical care because of costs, and 41% of adults report having medical or dental care debt.

To better understand Americans’ health care preferences and attitudes, U.S. News & World Report surveyed 2,000 U.S. adults about a number of health care issues, including why and how often they go to the doctor, how they choose their doctors and why they choose to follow the advice of their doctors – or not.

Here are the top insights from that survey.

How Often Americans Go to the Doctor

Nearly three in four (73%) of respondents had their last annual physical in either 2023 or 2024.

It seems the COVID pandemic has shifted many Americans’ attitudes on wellness and preventative health. Of the respondents who had gone in recently for an annual physical, 29% said that since the COVID pandemic, they now visit their PCP more regularly. And more than two in three (68%) surveyed adults said they plan to have an annual physical this year.

Why Some Americans Won’t Go to the Doctor

While a majority of adults surveyed have recently seen a primary care provider, many people aren’t getting the preventative health screenings and checkups they need. In fact, 12% of the surveyed adults said they were unsure of when they would go in for their next annual physical.

Of those who haven’t had an annual physical recently, people had different reasons for not visiting a doctor or other health care provider:

• 32% said they can’t fit an appointment into their schedule or keep forgetting to make an appointment. 
• 25% said they don’t like going to the doctor. 
• 12% said they just haven’t found a PCP they like. 
• 10% said they have felt shamed or judged by doctors in the past. 
• 10% said they’re afraid of getting sick from others during a PCP visit.

Scheduling issues and poor experiences can be difficult obstacles to overcome. The relationship with a primary care physician is an important one, and some patients might be seeing a PCP who simply isn’t a good fit for them.

Finding the right primary care provider is the first step a patient can take. And it’s easier than ever to find a doctor by using U.S. News & World Report’s doctor finder tool , which allows patients to search for a doctor by specialty and areas of expertise, location, insurance accepted and many more details to ensure patients choose a doctor that will be a good fit for them. The doctor finder tool also shows patient ratings of individual doctors.

How Americans Choose Their Primary Care Providers

Establishing care with a PCP seems to make people more likely to have regular visits: 81% of people who had a recent annual physical visited a PCP that they’d seen previously. Seeing the same PCP year after year and creating that continuity of care (vs. a one-off urgent care visit) can improve the quality of care a patient receives because that PCP will be more familiar with them and their medical history.

How people find their PCPs varies. About one quarter (24%) found their PCP through their insurance provider’s directory of providers that are in-network.

Types of Doctors

Adults in the U.S. can choose to see different types of doctors :

• Family medicine specialists treat people from childhood through adulthood.
• Internal medicine doctors , or internists, only treat adults. 
• Children may see pediatricians through the age of 18 to 21, depending on the practice.
• Older adults may choose to see a geriatrician .
• Doctors for women, including OB/GYNs, provide important additional preventative care, including mammograms and PAP smears.
• Gastroenterologists also provide important preventative screenings, like colonoscopies .
• Some men may see a urologist for conditions such as an enlarged prostrate or prostate cancer.

What to Look For in a Doctor

Aside from the type of doctor, people surveyed considered the following characteristics when choosing a doctor:

• Nearly 30% (28%) of U.S. adults are looking for their doctor to have experience and expertise in a specific area of care, possibly one related to a health condition they have. 
• 24% are looking for providers with positive patient reviews.
• 13% look for a PCP who is the same sex, gender or race as them. 
• 13% look for a PCP who is associated with a highly-rated hospital . 
• Only 9% look for whether the PCP went to a top medical school or residency program. 

COVID precautions

It's been four years since the beginning of the COVID pandemic, and most Americans still value providers who follow COVID-related precautions: 66% are more likely to make an appointment if masks are required, and three quarters of those surveyed (75%) would be more likely to make an appointment if the office offers COVID vaccines and boosters.

What Americans Think Makes a Great Doctor

People may want to consider certain c haracteristics when looking for a doctor that is a good fit for them. For example, they may think about whether the doctor communicates with an open and empathetic dialogue, shows compassion and fosters trust.

The good news is that of the respondents who had their last annual physical in 2023 or 2024, an overwhelming majority feel comfortable with and trust their doctor, at 96% and 95%, respectively.

Additionally, of the 2,000 survey respondents:

• 35% felt heard and understood by their PCP during their last annual physical exam.
• 26% said their PCP eased their nerves during their last annual physical exam. 

Of those who felt heard and understood by their PCP:

• 56% said their PCP asked questions in a nonjudgmental way. 
• 38% reported that their PCP said they would follow up with next steps or answers to their questions . 

Of those who felt that their PCP eased their nerves:

• 50% said their PCP was compassionate.
• 48% said their PCP asked questions in a nonjudgmental way.
• 22% said their PCP clearly explained next steps in their care. 

Online Patient Portals

Respondents were also asked to select up to three choices from a set of options about what features they’d like to be able to use with an online patient portal for their PCP.

The most popular options chosen:

• Ability to review test results within the online portal. More than half (57%) of adults want this option.
• Request medication refills. 47% would prioritize being able to request medication refills.
• Schedule an appointment. 47% of respondents chose this option. 
• Message with their PCP or staff. 42% want the ability to communicate with their PCP via an online portal.

What Americans Do – And Don’t – Want to Know About Their Doctor

When people visit their doctor, they aren’t just looking for answers about their health. There are things that they do - and don’t - want to know about their doctor.

For this question, respondents were able to select up to three options that they’d like to know about their doctor. These were the most common things patients want to know about their doctor:

• Beliefs about alternative medicine. 46% of respondents said they would like to know their provider’s beliefs about alternative medicine.
• Stance on vaccination. 42% of respondents wanted to know their provider’s stance on COVID vaccines, and 22% wanted to know their PCP’s stance on vaccinations for infants and children.
• Opinion on cannabis. 20% of respondents said they would like to know their PCP’s opinion on cannabis. 
• Perspective on ethnic disparities in healthcare. 20% of respondents said they’d like to know more about their PCP’s perspective on ethnic disparities in healthcare. 

What patients are less interested in knowing about their doctor:

• Stance on abortion. Only 13% of U.S. adults surveyed want to know their PCP’s stance on abortion.
• Political affiliation. Additionally, most respondents (73%) said they would prefer not to know their PCP’s political affiliation. 

When Americans Don’t Follow Their Doctor’s Advice – and Why

When Americans visit their PCP, they generally follow the advice that the PCP gives them. Four in five (81%) say they usually or always follow their PCP’s health advice.

When people don’t follow their PCP’s advice, they say it’s because:

• The advice is difficult to implement in daily life (43% of the time).
• They cannot afford what their PCP recommends (34% of the time). 

While treatments are often covered by a person’s medical insurance, doctors may sometimes recommend things like vitamins and supplements, over-the-counter medications , ongoing physical therapy or new medical equipment that insurers don’t always cover.

Bottom Line

PCPs can be a valuable part of a person’s medical journey – both to prevent health emergencies as well as to effectively manage ongoing health conditions. These health professionals can see and treat a person throughout their life, tracking medical issues over the course of years or decades, and puzzling together pieces of medical information to understand a full picture of a patient’s health.

While many Americans have a PCP whom they see regularly and report positive experiences with, there are still millions of people who do not see a PCP on a regular basis for a variety of reasons, from time constraints to trust issues and poor prior experiences.

Methodology

In February of 2024, 2,000 U.S. adults were surveyed about their experiences with primary care. 44% identified as male and 56% identified as female at the time of the survey. After collecting responses through a third-party survey platform, responses were weighted to reflect the current U.S. population by achieving equal distribution with known population characteristics. According to Census.gov , as of July 2023, the population of those 18 years of age and older in the United States was 262,083,034 and thus the margin of error for this survey is 3% at a 95% confidence level.

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Should you reference any data from this report elsewhere, please include a source link to https://health.usnews.com/health-care/top-doctors/articles/primary-care-experiences-survey-report .

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The U.S. Physician Workforce Data Dashboard provides the most current data available about the physician workforce across specialties in a series of interactive dashboards. The U.S. Physician Workforce Data Dashboard combines data previously published in two separate AAMC workforce studies reports, Physician Specialty Data Report and State Physician Workforce Data Report .

This dashboard provides detailed statistics about active physicians in the largest practice specialties (i.e., specialties with > 2,500 active physicians) in the United States and its territories. Data include the number of physicians by specialty, the number of people per direct patient care physician by specialty, age, sex, race/ethnicity, major professional activity, medical school location, and type of U.S. medical degree by specialty. The dashboard's next iteration will provide data for physicians in Accreditation Council for Graduate Medical Education (ACGME) residencies and fellowship programs. Please check back periodically for the next dashboard iteration.

Primary Data Sources

• The 2023 American Medical Association (AMA) Physician Professional Data (as of Dec. 31, 2022) provided data for active physicians. The AMA Physician Professional Data is updated annually from various sources, including a survey of physicians.
• Race and ethnicity are obtained from a variety of AAMC sources (e.g., Electronic Residency Application Service, American Medical College Application Service, Medical College Admission Test) with priority given to the most recent, self-reported source.
• U.S. Census Bureau population estimates were used to calculate the number of people per physician.

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Is there really a primary care shortage?

The United States seems to be on the brink of a severe physician shortage. Demand for primary care will far outpace physician supply as the population continues to grow and age, but the rate of physicians entering the workforce stays roughly the same. It seems inevitable that physician shortages will worsen access to care and burden practicing physicians for years to come.

But a true shortage is not inevitable. Our analysis shows that primary care leaders can avoid a shortage in care supply by adopting proven productivity improvement strategies.

The United States faces an inevitable primary care physician (PCP) shortage. Patient volumes, administrative burdens, and limited workforce growth have led to a shortage in PCPs. Furthermore, new demand from a growing, aging, and increasingly complex population will far outpace new workforce entries from physicians and advanced practice providers (APPs).

This shortage will worsen access to care and burden practicing physicians for years to come.

Administrative burdens and operational efficiency keep the current physician workforce from practicing to its full clinical capacity. By addressing those challenges, health care leaders can prevent a physician shortage.

We crunched the numbers and found that there would, in fact, be a small shortage of primary care providers if nothing changes. However, we then evaluated how interventions in four categories would affect primary care visit supply (workflow optimization, care team redesign, telemedicine, and enabling technology). Even in our most conservative estimates, these interventions increase physician capacity to far exceed demand: a physician surplus rather than a shortage. Getting as tactical as possible, we found implementing just one intervention from each of the four categories would yield a 40% increase in PCP capacity and eliminate the shortage.

Shortage models assume static productivity

Physician workforce growth is too slow to prevent a shortage

If we assume workforce growth is the only driver for increased capacity, a primary care shortage seems inevitable. The average PCP currently sees an estimated 2,360 visits per year. At that rate, we would need to add tens of thousands of PCPs to meet present demand.

Even fast-growing, fully autonomous APP workforce would not meet demand

APPs are projected to be one of the fastest growing health care roles across the next 10 years. More practices are elevating the role of APPs to manage patients autonomously, and more states are allowing APPs to see their own panels. If we assumed that APPs could see the same number of patients as PCPs without any physician support, we would expect an additional supply of 322 million visits.

Despite that additional capacity, projected demand still far exceeds the number of visits a combined physician and APP workforce could manage.

There is not a primary care shortage

By focusing on workforce growth as the only lever to increase visits, most primary care supply models make a shortage appear inevitable. What these models overlook is the misapplication of physician time and capacity.

Staff and workflow innovations increase clinical capacity

Workflow changes can increase primary care visit capacity by 40%

By focusing on reallocating provider time instead of growing the workforce, physician leaders can prevent a shortage. We analyzed four different types of primary care workflow interventions. In total, we looked at 11 specific tactics that leading organizations have implemented to increase physician capacity and allow them to spend more time on clinical care and less time on administrative work:

Holistic care team redesign

• Increased MA staffing
• Codifying roles across the care team

Workflow optimization

• Efficiency-oriented physical design
• Continuous EMR training
• Pharmacists focused on high-risk patients
• Dedicated staff for referral management
• Medication refill protocols
• Filtering patient communication across the care team

Enabling technologies

• Documentation technology
• Assistive clinical technology

Telemedicine

• Asynchronous virtual visits for basic care

Then we tested what impact those improvements could have on PCP supply.

Even our most conservative estimates for added visit supply completely negated the shortage. Instead, we saw a visit surplus that was three times larger than the shortage. This stark difference reflects just how much time is lost to non-patient-facing tasks in primary care, time that can be given back through implementing already proven workflow changes.

Put in numbers, currently PCPs only spend a third of their time on direct patient care. This means that they’re only able to see about 10 patients per day. We estimate that these interventions increase provider direct clinical time by upwards of 40%, or an additional 10 to 15 visits per day.

A bigger care team has the biggest impact on capacity, but automation may be more feasible

The good news is physician leaders don’t have to implement all 11 strategies to see major improvement.

We analyzed the most impactful intervention in each category and identified them in the chart below. These are the interventions with the biggest bang for their buck and the ones physician practice leaders should prioritize for implementation. Just these four yield less administrative burden, greater physician capacity, and no PCP shortage.

Leaders should weigh their organization’s circumstances when evaluating what interventions are most feasible. But even if an organization can’t do all four of the most impactful tactics, doing one or two still makes a difference—small improvements that can help practices win market share, improve access and patient experience, reduce turnover and recruitment costs, and negate the physician shortage.

Physician leaders have the ability to prevent a physician shortage. But workflow improvement could not only impending access and quality challenges driven by a shortage—they can also improve the working life for physicians.

Take models seriously, but not literally

If the Covid-19 pandemic teaches us anything, it’s how quickly things change in health care. The future supply of physicians is impossible to accurately quantify no matter how perfect the data or calculations.

Be aware of the strain of high provider working hours

On average, PCPs around the nation work more than 50 hours per week. Much of their work happens after clinic hours. More than mitigating a long-term physician shortage, implementing these interventions makes current physician practice more sustainable. For practicing physicians, spending upwards of 75% of their time on patient care instead of desktop medicine will get them back to why most of them wanted to go into medicine in the first place: to care for patients. For physician leaders, a better work-life balance gives an organization an advantage when recruiting new physicians and retaining existing ones.

You have more agency than you might think

Our analysis shows there is a lot within a provider organization’s control to increase their primary care visit supply. Organizations can and should make these care model and technology changes now—not just to offset a future shortage but to ease the burden on their current workforce.

Provider supply

We considered both PCPs and advanced practice providers (APPs) in supply, accounting for departures and entrants over the next decade. Then, we converted the number of providers into clinical hours and visits per year to get projected supply of visit capacity.

Provider demand

We estimated current annual demand by applying the average annual visit number per primary care provider from our Integrated Medical Group Benchmark Generator to the entire U.S. adult population. We then applied population growth projection to estimate future demand. Those estimates are in line with external analyses, such as from the AAMC .

Impact of workflow interventions

After segmenting current provider time worked into administrative or clinical, we identified several primary care workflow interventions with vetted data that reduce provider administrative burden or increase their visit capacity. Then, we determined how many visits (or fractions of a visit) each intervention could produce per provider. We calculated how much each intervention could increase visit supply at conservative, moderate, and aggressive levels.

This analysis was based on the principle that physicians can’t work more hours, but their time can be redistributed from administrative tasks to more clinical time. We also projected all three estimates forward to 2030 based on simple assumptions on population growth and estimates of provider supply from external sources. We then compared these measures to capture presence of a shortage.

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Posted on November 03, 2022

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Publication

The Duration of Office Visits in the United States, 1993 to 2010

Nationally representative data show that outpatient office visits to both primary care physicians and specialists grew longer over the period from 1993 to 2010.

ABSTRACT Objectives

Since many physicians feel that they are not allotted enough time to adequately evaluate and effectively provide care for patients, we sought to analyze the average duration of office visits with physicians from 1993 through 2010.

Study Design

Retrospective analysis of data from the National Ambulatory Medical Care Survey of the National Center for Health Statistics.

Data were analyzed to examine the duration of office visits with physicians from 1993 through 2010. The trends for patients visiting primary care physicians and specialists, for a range of patient ages, for visits with and without physician’s assistants or nurse practitioners, and for different numbers of diagnoses were all analyzed.

From 1993 through 2010, reported visit duration increased over time from 17.9 minutes to 20.3 minutes for primary care visits ( P <.001) and from 19.0 minutes to 21.0 minutes for specialized visits ( P <.001). The increase in visit duration was consistent across different age ranges, for different numbers of diagnoses, and for patients who did and did not have a procedure performed during the visit.

Conclusions

Contrary to expectations and beliefs, from 1993 to 2010 a trend of a reduction in the average duration of office visits with physicians has not been observed. Visit duration has increased for both primary care physicians and specialists, across all age ranges, and for different numbers of diagnoses.

Am J Manag Care. 2014;20(10):820-826

This study supports the conclusion that outpatient office visits have continued to get longer over time.

• The increase in the length of visits remains present after controlling for factors such as increasing patient age or complexity, an increased number of procedures, or adoption of electronic medical records.
• Increasing length of visits should be expected to exacerbate the anticipated physician shortage in coming years, and may increase problems with access to care.

Since the expansion of managed care in the 1990s, physicians frequently report a high level of concern about the effects of time constraints on medical practice. 1 Many report feeling more and more rushed to see an increasing number of patients. Guidelines recommend that physicians should be providing preventive services, helping to minimize the need for expensive emergency care. However, patient loads for primary care physicians generally contain patient visits that are a response to illness or injury, as opposed to visits that cover preventive care. 1,2 Time constraints are one of the most cited reasons by physicians for not providing preventive care as often as guidelines would dictate. 1-3 Spending less time with patients makes it more difficult for physicians to obtain a full history, potentially making treatment choices less efficient, and preventing patients from receiving the entirety of the care they need. 4 Adult patients in the United States receive a little over half of the healthcare that is recommended to them as outlined by the US Preventive Services Task Force. 3,5

The perception that office visits are getting shorter has been common for many years. Responding to the growth in managed care, in 2001 Mechanic, McAlpine, and Rosenthal tested the hypothesis that office visits were becoming shorter, using data from the annual National Ambulatory Medical Care Surveys (NAMCS) from 1989 to 1998. 6 They found that contrary to the perception, the average duration of office visits continued to increase. The effect was consistent across both prepaid and non-prepaid visits, suggesting managed care did not cause the longer average visit time. 6 The data also did not support the idea that increased patient age or complexity of patient issues caused longer visits. 6 Although managed care has now become a less hotly contested issue, time constraints on physicians continue to be a widespread concern. We sought to determine whether the average duration of physician visits has continued to rise, using the most recent available data from NAMCS up to 2010.

Data from annual surveys from the NAMCS from 1993 through 2010 were analyzed. These surveys obtained a representative sample of visit lengths to nonfederally employed outpatient physicians in all specialties except anesthesiology, pathology, and radiology. The duration of the visit was recorded to be only the amount of time the physician spent in face-to-face contact with the patient, and did not include time spent with physician extenders or nurses. For each visit selected, the physician or a member of the physician’s staff is expected to provide information about the characteristics of the patient, the duration of the visit, the reason for the visit, any diagnoses made, and any tests and procedures performed. Standard errors were adjusted for in the sampling design through the NAMCS survey and through SAS statements “CLUSTER cpsum, and STRATA cstratm.” Populationbased estimates were calculated by dividing the number of NAMCS visits in each year by the US population according to US Census data. This study was approved by the Wake Forest Baptist Hospital Institutional Review Board and under the rules of the Health Insurance Portability and Accountability Act of 1996, which permits physicians to make disclosures of protected health information with patient authorization for public health purposes or for approved research. 7

During the declared data recording week, physicians, members of the physicians’ staff, or Census field reporters used an arrival log to keep a daily catalogue of all patient visits.8 Visits included both scheduled and non-scheduled patients, while excluding cancellations and no-shows. 8 The CDC website describes that visits from which data were collected were selected “from the list using a random start and a predetermined sampling interval based on the physician’s estimated visits for the week and the number of days the physician was expected to see patients that week.” 8 Through this process, the NAMCS was able to produce a systematic random sample of visits from that physician.

The rate of response to the survey varied from 58.3% in 2010 to 73.0% in 1995 and 1993 over the 18-year period, with an average response rate of 65.6%. A systematic random sample of visits to each physician was selected during 1 randomly chosen 1-week period. The number of visits sampled per year ranged from 20,992 visits in 1999 to 36,875 visits in 1995. The estimates presented were calculated with the weighting used by the NAMCS to adjust for nonresponse and to produce nationally representative estimates. All data analysis was performed using SAS 9.1.3 (SAS Institute, Cary, North Carolina).

The data included information about the visit duration for visits to all physicians, including primary care physicians and specialists. In bivariate analyses, duration was also examined separately for those of different age ranges, for individuals who did and did not have a procedure performed, for visits in which patients only saw a physician (without a nurse practitioner or a physician’s assistant present), and for patients who had different numbers of diagnoses. A regression was performed to analyze visits that occurred without the use of the electronic medical record (EMR). A multivariate linear regression was performed to assess simultaneously the impact of age, year, specialty, insurance type, new versus return patient status, procedure status, employment status (owner versus employee or contractor), use of the EMR, and number of diagnoses on visit length. The multivariate analysis was run 3 different times beginning in the years 1993, 1997, and 2003 to allow for the inclusion of variables relating to payment type and employment status (first included in the survey in 1997), and the use of the EMR (first included in 2003).

From 1993 to 2010, the total number of physician visits increased from approximately 717 million to 994 million, resulting in an approximate 39% increase in total visits. During this time, there was a 19% increase in the total population of the United States. 9,10 The number of visits per physician eligible for NAMCS showed little change, fluctuating from 1993.8 visits per physician in 1993 to 1943.2 visits per physician in 2010. Additionally, the number of annual visits per United States resident increased from 2.7 visits per resident in 1993 to 3.2 visits per resident in 2010. One would assume that in order to compensate for the increase in the number of possible patients and the increase in the number of visits per US resident, the duration of each such visit would need to decrease.

However, based on the data, the average visit duration increased for both primary care physicians and specialists, with an annual increase of 0.17 minutes per visit from 1993 to 2010 for primary care physicians, to give an approximately 3-minute total increase over the 17-year span for general practitioners, family practitioners, internal medicine physicians, and pediatricians ( P <.001, Figure 1 ). The annual increase was 0.12 minutes for specialists, to total a 2.1-minute increase per visit from 1993 to 2010 ( P <.001, Figure 1). The increasing duration of office visits was observed across each age group (children, adults, and the elderly, eAppendix , available at www.ajmc.com ) and for both primary care physicians and specialists. The increase in visit duration remained when patients who saw physician extenders were excluded, and when no procedures were performed ( Figure 2 ).

Multivariate Regression

In the multivariate regression for 1993-2010, of the 13 specialties compared with general and family practice, 9 specialties averaged longer visits, with only pediatrics, orthopedic surgery, dermatology, and otolaryngology averaging the same or shorter visits ( ). Additionally, the positive values demonstrate that higher age, later year, and a greater number of diagnoses are all associated with longer visits (Table). Through these data, we were able to identify a number of factors associated with an increased duration of visits, but after controlling for all of these variables, it was seen that later year has a large effect upon visit duration (0.17 minutes longer per year) (Table). In the 1997-2010 analysis, visits paid by insurance from Medicare ( P = .02, beta= —1.71 minutes) or Medicaid ( P = .006, beta = —1.61 minutes) were associated with shorter visits compared with payers other than Medicare or Medicaid. Visits paid with private insurance were not significantly different from those visits that were paid out of pocket ( P = .09; beta = —1.03). Employment status did not have a significant effect ( P = .26), and the effect of later year was still similar (β = 0.21; P <.0001).

Bivariate Analysis

To control for the possibility that increased patient complexity caused the rise in visit duration, we analyzed patients with only 1 diagnosis separately from those with multiple diagnoses. While there were longer visits associated with more diagnoses, the average visit duration increased in all groups for primary care physicians and specialists ( and ). Also, visits without EMRs showed the same increasing trend ( P <.001), suggesting that the increase in visit length was not caused primarily by EMR use.

The data were also stratified by whether an outpatient procedure was performed, to control for the possibility that procedures being performed were the cause of the rise in visit duration. Visit duration increased with patients who did and did not receive a procedure by primary care physicians and with patients who did not receive a procedure by specialists (Figure 2). Those patients who did receive a procedure by specialists actually experienced a decrease in duration of visit (Figure 2). However, this result is likely an anomaly resulting from a greatly increased number of procedures recorded in the last 2 years. The number of recorded procedures jumped from 99 million in 2008 to 400 million in 2009 and 395 million in 2010, including large increases in the number of nonoperative measurements and examinations, general physical examinations, and eye examinations not otherwise specified. When stratified by specialty area, 11 of 15 specialty areas showed an increase in visit duration, with only cardiology, psychiatry, neurology, and ophthalmology showing a decrease in visit duration.

In 2001, Mechanic et al determined that between 1989 and 1998 the number of visits to physicians’ offices increased significantly. 6 Mechanic et al also determined that the average duration of visits increased between 1 and 2 minutes between 1989 and 1998.6 NAMCS data through 2010 permit an analysis of subsequent changes that may have occurred after 1998. The analysis performed on the data from 1993 to 2010 provided results consistent with those of Mechanic et al, demonstrating the continued increase in visit duration over the entire time period from 1989 to 2010.

Visit duration increased in all types of visits tested, except for those during which a procedure was performed. While duration of visits increased in all primary care specialties, duration of visits for 6 types of specialists increased, while the duration of visits for 2 specialties (psychiatry and ophthalmology) showed significant decreases, and the visit duration for 2 others (cardiology and neurology) showed nonsignificant decreases. The multivariate linear regression of the data confirmed our initial analysis that visit durations were increasing; we saw that later year has a large effect upon visit duration, even after controlling for all other variables. The increase in visit duration over time appears independent from greater patient complexity, changes in specialties seen, or any other factors analyzed. The multivariate regression provided new analysis in comparison to what Mechanic et al had analyzed, and allowed us to conclude that once these external variables were taken into account, the increase in the duration of visits to general physicians and specialists was consistent with the original analysis.

One possible explanation for the increase in visit duration could be an increase in discussions between patients and their physicians. According to a National Research Corporation Survey, patients listed “willingness to explain things” as the most important factor in selecting a physician. 11 Recent surveys estimate that about 86% of the adults who have access to the Internet use it to seek health information. 12,13 With patients’ expanded access to Internet resources, they are able now, more than ever, to research any problems they may be experiencing and the multitude of treatment options available to them 14 —options they may be discussing with their physicians. Visit duration may be increasing due to these more thorough discussions.

The use of care managers, or other nonphysician extender personnel, might allow for physicians to spend more time with their patients, as these personnel are able to oversee other work that would have been previously performed by physicians and limited the amount of time for physicians to interact with their patients. Additionally, as the use of the EMR increases, physicians may be spending an increasing portion of the time spent with their patients documenting their assessments of patient health. 15 However, the regression analysis of visits without the use of the EMR are also increasing in duration, so the use of the EMR cannot be the sole reason for the increase.

One limitation of this study is the cross-sectional nature of the NAMCS; we could not follow visit durations of individual patients over time. Although the NAMCS provides considerable detail on characteristics of office visits, it does not provide information on how much time was devoted to examination versus discussion and patient education, which might further explain the increase in visit duration if patients have increased the amount of time they spend talking to their physicians. Additionally, the NAMCS does not provide information about Work Relative Value Units, so it is difficult to quantify specifically if more is being done during individual visits than in the past. The control of the number of diagnoses per visits was an attempt to monitor this; however, it is possible that patient complexity is increasing, and as a result more is being done in each visit without accruing extra diagnoses. The study was not able to directly assess the amount of useful time spent by physicians, and future research may be able to provide insight on how much is spent on tasks that might be more efficiently assigned to other healthcare workers.

A potential bias for the data collected by the NAMCS would be the type of physicians who agreed to participate in the survey. Those physicians who agree to the NAMCS survey often have to fill out a significant amount of paperwork associated with it; therefore, one could assume that those physicians who truly feel pressed for time with their patients would not agree to participate in the survey. However, with the NAMCS covering such a significant number of physicians over the entire country, we feel that the data presented should still be an excellent representation of the average time physicians are spending with their patients.

By 2020, the Association of American Medical Colleges projects that there will be a shortage of 91,500 doctors in the United States. 16,17 This shortage is in part attributed to the severely limited number of residency positions available, and in part to the dramatic increase in the number of insured Americans under the Patient Protection and Affordable Care Act. 16-18 During the span of the survey, the total number of physicians eligible for NAMCS increased from 359,598 in 1993 to 511,517 in 2010, resulting in a 42% increase in the number of doctors over the span of the survey. Thus, while the number of physicians is growing, the number of visits to physicians is growing at an even greater rate and could overwhelm the number of physicians available. Consequently, it would be prudent to continue to monitor the durations of visits as a measure of determining if physicians are able to continue to provide the high standard of quality care that we have come to expect in the United States.

Acknowledgments

The authors would like to gratefully acknowledge Karen E. Huang, MS, for statistical assistance. Author Affiliations: Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC (MKS, SAD, ABF, SRF).

Funding Source: The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, LP. However, the funding source had no role in the study.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MKS, SAD, ABF, SRF); acquisition of data (SAD); analysis and interpretation of data (MKS, SAD, ABF, SRF); drafting of the manuscript (MKS); critical revision of the manuscript for important intellectual content (MKS, SAD, ABF, SRF); statistical analysis (SAD); administrative, technical, or logistic support (ABF, SRF); and supervision (SAD, ABF, SRF).

Address correspondence to: Scott A. Davis, MA, Department of Dermatology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: [email protected] . REFERENCES

1. Kottke TE, Brekke ML, Solberg LI. Making "time" for preventive services. Mayo Clin Proc . 1993;68(8):785-791.

2. French MT, Homer JF, Klevay S, Goldman E, Ullmann SG, Kahn BE. Is the United States ready to embrace concierge medicine? Popul Health Manag . 2010;13(4):177-182.

3. Linz AJ, Haas PF, Fallon LF Jr, Metz RJ. Impact of concierge care on healthcare and clinical practice. J Am Osteopath Assoc . 2005;105(11):515-520.

4. Dorr Goold S, Lipkin M Jr. The doctor-patient relationship: challenges, opportunities, and strategies. J Gen Intern Med . 1999;(14, suppl 1):S26-S33.

5. McGlynn EA, Asch SM, Adams J et al. The quality of health care delivered to adults in the United States. N Engl J Med . 2003;348(26):2635-2645.

6. Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians getting shorter? N Engl J Med . 2001;344(3):198-204.

7. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey Participants Homepage. http://www.cdc.gov/nchs/ahcd/namcs_participant.htm . Published June 28, 2013. Accessed July 25, 2013.

8. National Ambulatory Medical Care Survey Data Collection and Processing. CDC website. http://www.cdc.gov/nchs/ahcd/ahcd_data_collection.htm#namcs_collection . Published August 15, 2011. Accessed February 28, 2013.

9. Paul Mackun, Steven Wilson. Population distribution and change: 2000 to 2010. http://www.census.gov/prod/cen2010/briefs/c2010br-01.pdf. Published March 2011. Accessed January 31, 2013.

10. Population Estimates Program, Population Division, US Census Bureau. Monthly estimates of the United States population: April 1, 1980 to July 1, 1999, with short-term projections to November 1, 2000. http://www.census.gov/population/estimates/nation/intfile1-1.txt . Published January 2, 2001. Accessed January 31, 2013.

11. Prakash B. Patient satisfaction. J Cutan Aesthet Surg . 2010;3(3):151-155.

12. Mallappa Saroja CS, Hanji Chandrashekar S. Polycystic ovaries: review of medical information on the Internet for patients. Arch Gynecol Obstet . 2010;281(5):839-843.

13. Fox S. (2011). Health Topics. Pew Internet and American Life Project. http://pewinternet.org/Reports/2011/HealthTopics.aspx . Accessed September 29, 2014.

14. Danquah G, Mittal V, Solh M, Kolachalam RB. Effect of Internet use on patients’ surgical outcomes. Int Surg . 2007;92(6):339-343.

15. Hing E, Hsiao CJ. Electronic medical record use by office-based physicians and their practices: United States, 2007. Natl Health Stat Report . 2010;(23):1-11.

16. Arvantes J. Increasing primary care residency positions critical to alleviating physician shortages, says AAMC. AAFP News. http://www.aafp.org/news/education-professional-development/20121030aamcworkforcepaper.html . Published October 30, 2012. Accessed January 31, 2013.

17. AAMC physician workforce policy recommendations. Association of American Medical Colleges website. https://www.aamc.org/download/304026/data/2012aamcworkforcepolicyrecommendations.pdf . Published September 2012. Accessed January 31, 2013.

18. National Resident Matching Program. Results and data: specialties matching service 2012 appointment year. http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddatasms2012.pdf . Published February 2012. Accessed January 31, 2013.

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This figure represents the difference between the median number of visits to the community pharmacy and encounters with primary care physicians by state (A) and by county (B). Pharmacy visits were defined using a 13-day window between claims, as explained in the Methods section. Insufficient data denotes that there were less than 11 beneficiaries in each county, which is the minimum cell size requirement for reporting from the Centers for Medicare and Medicaid Services. Only 9 counties had primary care physician encounters that equaled or outnumbered pharmacy visits. These counties are in Florida, Georgia, Indiana, Kentucky, North Carolina, and Texas.

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Berenbrok LA , Gabriel N , Coley KC , Hernandez I. Evaluation of Frequency of Encounters With Primary Care Physicians vs Visits to Community Pharmacies Among Medicare Beneficiaries. JAMA Netw Open. 2020;3(7):e209132. doi:10.1001/jamanetworkopen.2020.9132

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Evaluation of Frequency of Encounters With Primary Care Physicians vs Visits to Community Pharmacies Among Medicare Beneficiaries

• 1 Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania

Question   How often do Medicare beneficiaries who actively access health care services visit community pharmacies compared with primary care physicians?

Findings   Among the 681 456 active Medicare beneficiaries included in this nationwide cross-sectional study, the median number of visits to community pharmacies was significantly higher than encounters with primary care physicians (13 vs 7).

Meaning   These findings suggest that community pharmacists are accessible health care professionals with frequent opportunities to deliver preventive care and chronic disease management services in collaboration with primary care physicians.

Importance   The shift toward value-based care has placed emphasis on preventive care and chronic disease management services delivered by multidisciplinary health care teams. Community pharmacists are particularly well positioned to deliver these services due to their accessibility.

Objective   To compare the number of patient visits to community pharmacies and the number of encounters with primary care physicians among Medicare beneficiaries who actively access health care services.

Design, Setting, and Participants   This cross-sectional study analyzed a 5% random sample of 2016 Medicare beneficiaries from January 1, 2016, to December 31, 2016 (N = 2 794 078). Data were analyzed from October 23, 2019, to December 20, 2019. Medicare Part D beneficiaries who were continuously enrolled and had at least 1 pharmacy claim and 1 encounter with a primary care physician were included in the final analysis (n = 681 456). Those excluded from the study were patients who were not continuously enrolled in Part D until death, those with Part B skilled nursing claims, and those with Part D mail-order pharmacy claims.

Exposures   We conducted analyses for the overall sample and for subgroups defined by demographics, region of residence, and clinical characteristics.

Main Outcomes and Measures   Outcomes included the number of visits to community pharmacies and encounters with primary care physicians. Unique visits to the community pharmacy were defined using a 13-day window between individual prescription drug claims. Kruskal-Wallis tests were used to compare the medians for the 2 outcomes.

Results   A total of 681 456 patients (mean [SD] age, 72.0 [12.5] years; 418 685 [61.4%] women and 262 771 [38.6%] men) were included in the analysis; 82.2% were white, 9.6% were black, 2.4% were Hispanic, and 5.7% were other races/ethnicities. Visits to the community pharmacy outnumbered encounters with primary care physicians (median [interquartile range (IQR)], 13 [9-17] vs 7 [4-14]; P  < .001). The number of pharmacy visits was significantly larger than the number of primary care physician encounters for all subgroups evaluated except for those with acute myocardial infarction (median [IQR], 15 [12-19] vs 14 [7-26]; P  = .60 using a 13-day window). The difference in the number of pharmacy and primary care physician encounters was larger in rural areas (median [IQR], 14 [10-17] vs 5 [2-11]; P  < .001) than in metropolitan areas (median [IQR], 13 [8-17] vs 8 [4-14]; P  < .001). In all 50 states and in all but 9 counties, the number of community pharmacy visits was larger than the number of encounters with primary care physicians.

Conclusions and Relevance   This cross-sectional study suggests that community pharmacists are accessible health care professionals with frequent opportunities to interact with community-dwelling patients. Primary care physicians should work collaboratively with community pharmacists, who can assist in the delivery of preventive care and chronic disease management.

The shift toward value-based care has placed emphasis on preventive care and chronic disease management services delivered by multidisciplinary health care teams. However, some patients continue to have difficulty accessing affordable quality care. Pharmacists are accessible and trusted members of the health care team and routinely encounter patients at their community pharmacies. Patient-pharmacist encounters have traditionally focused on the provision of medications. More recently, community pharmacists have transformed and optimized their roles from product-centered services (ie, medication dispensing and sale of over-the-counter medications) to patient-centered services (ie, medication therapy management). The goal of medication therapy management is to optimize medication use, reduce the risk of adverse events, and improve medication adherence. 1

Beyond the provision of medication therapy management services, pharmacists actively contribute to affordable quality care by offering preventive care services, such as administering vaccinations and identifying patients at high risk for certain diseases. 2 Pharmacists have also shown positive effects on patient and medication outcomes when contributing to the management of chronic diseases, including diabetes (type 1 and type 2), hypertension, hyperlipidemia, asthma, and depression. 3 - 7

To understand the potential for pharmacist-delivered preventive services and chronic care management, it is important to quantify how many times patients are likely to encounter community pharmacists and how this frequency compares with the number of patient encounters with primary care physicians. Previously, Tsuyuki et al 8 performed a nonsystematic review and found that patients encountered pharmacists between 1.5 and 10 times more frequently than they encountered primary care physicians. However, this nonsystematic review included only 1 study from the United States, and it was not peer reviewed. 8 To our knowledge, there is no peer-reviewed literature to date comparing the frequency of patient visits to community pharmacies with the number of patient encounters with primary care physicians in the United States. To address this evidence gap, we used 2016 data from a nationally representative sample of Medicare beneficiaries who actively access health care services.

For this cross-sectional study, we obtained 2016 claims data from a 5% random sample of Medicare Part D beneficiaries from the Centers for Medicare and Medicaid Services from January 1, 2016, to December 31, 2016 (N = 2 794 078). Figure 1 provides an overview of the sample selection. We selected beneficiaries continuously enrolled in Medicare Part D in 2016 or until death. Beneficiaries with Medicare Part B skilled nursing claims or at least 1 Part D prescription drug claim from a mail-order pharmacy were excluded, because these patients have markedly fewer opportunities to visit a community pharmacy. For the sample to be representative of patients who actively access health care professionals, we only included beneficiaries who had at least 1 Part D prescription drug claim and at least 1 encounter with a primary care physician in 2016. Encounters with primary care physicians were identified using health care provider claims. The final sample included 681 456 Medicare beneficiaries. This study was approved by the University of Pittsburgh institutional review board as exempt from obtaining patient consent because deidentified data were used in the analyses. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

Outcomes included the number of encounters with primary care physicians and with community pharmacies and were expressed per person-year. Primary care physician encounters included encounters with physicians whose specialty was identified as family practice, general practice, geriatric medicine, internal medicine, or preventive medicine from Part B health care provider claims. Visits to the community pharmacy were estimated using Part D pharmacy claims. We defined unique visits to the community pharmacy using a 13-day window between individual prescription drug claims. In other words, prescription drug claims less than 13 days apart were considered the same pharmacy visit. A 13-day window was used because most pharmacy benefit managers require pharmacies to reverse claims for medications not picked up by the patient within 14 days of initial claim submission. This means that individual prescriptions with paid claims separated by 14 days or more would require 2 unique visits to the pharmacy. A 13-day window also allowed us to group multiple prescription drug claims synchronized around the same pickup date into 1 pharmacy visit. In sensitivity analyses, we used a 10-day window because 1 national community pharmacy chain reverses claims for medications not picked up by the patient within 10 days of initial claim submission.

Independent variables of interest included demographics, region of residence, and clinical characteristics. Demographic characteristics included age, sex, and race/ethnicity. Region of residence variables included degree of urbanization, an indicator variable for medically underserved area designation, state, and county and were all defined using the Federal Information Processing System code for each beneficiary. We used the 2013 Rural-Urban Continuum Codes from the US Department of Agriculture Economic Research Service to categorize Federal Information Processing System codes into 3 levels of urbanization, including metropolitan areas (codes 1-3), nonmetropolitan urban areas (codes 4-7), and nonmetropolitan rural areas (codes 8-9). 9 To identify medically underserved areas, we used data from the Health Resources & Services Administration. 10 Clinical characteristics included a history of acute myocardial infarction, asthma, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease, depression, diabetes (type 1 and type 2), heart failure, hyperlipidemia, hypertension, osteoporosis, rheumatoid arthritis or osteoarthritis, and stroke or transient ischemic attack. Clinical characteristics were defined using the Centers for Medicare and Medicaid Services Chronic Condition Data Warehouse definitions. 11

We compared the median number and interquartile ranges (IQRs) of encounters with primary care physicians and visits to the community pharmacy using Kruskal-Wallis tests. We conducted analyses for the overall sample and for subgroups defined by the independent variables listed previously. To explore whether there was geographic variation in the frequency of encounters with primary care physicians and visits to community pharmacies, we reported the differences in the median number of encounters by state and by county. Data were analyzed from October 23, 2019, to December 20, 2019. Analyses were conducted using SAS, version 9.4 (SAS Institute Inc) and R, version 3.6.1 (R Project for Statistical Computing). Two-sided P values were used. Statistical significance was set at P < .05.

Table 1 shows baseline demographic and clinical characteristics of the study sample. A total of 681 456 patients (mean [SD] age, 72.0 [12.5] years; 418 685 women [61.4%] and 262 771 men [38.6%]) were included in the analysis; 82.2% were white, 9.6% were black, 2.4% were Hispanic, and 5.7% were other races/ethnicities. Of the total number of patients, 289 482 patients (42.5%) were 75 years or older, 271 546 (39.9%) were aged 65 to 74 years, and 120 428 (17.7%) were younger than 65 years. Less than one-quarter of the study beneficiaries (160 591 [23.6%]) lived in medically underserved areas.

Overall visits to the community pharmacy significantly outnumbered encounters with primary care physicians (median [IQR], 13 [9-17] vs 7 [4-14]; P  < .001) using the conservative 13-day prescription drug claim window ( Table 2 ). The difference between community pharmacy visits and primary care physician encounters increased (median [IQR], 14 [9-19] vs 7 [4-14]; P  < .001) when the less conservative 10-day prescription drug claim window was applied.

Using 13-day windows to define pharmacy visits, the difference between community pharmacy visits and primary care physician encounters was greater for beneficiaries living in rural areas (median [IQR], 14 [10-17] vs 5 [2-11]; P  < .001) than for beneficiaries living in metropolitan areas (median [IQR], 13 [8-17] vs 8 [4-14]; P  < .001) ( Table 2 ). The number of community pharmacy visits was statistically larger than the number of primary care physician encounters for all clinical characteristic subgroups evaluated except for beneficiaries with acute myocardial infarction (median [IQR], 15 [12-19] vs 14 [7-26]; P  = .60). When the less conservative 10-day window was applied, community pharmacy visits were also significantly greater than primary care physician encounters for beneficiaries with a history of acute myocardial infarction (median [IQR], 17 [12-21] vs 14 [7-26]; P  < .001). Using 13-day windows to define pharmacy visits, differences between community pharmacy visits and primary care physician encounters were greatest for beneficiaries with depression (median [IQR], 16 [12-19] vs 10 [5-18]; P  < .001). Beneficiaries with chronic disease states related to metabolic syndrome, including diabetes (type 1 and type 2), hyperlipidemia, and hypertension, visited the pharmacy 5 occasions more than the primary care physician: diabetes (median [IQR], 15 [11-18] vs 10 [5-17]; P  < .001), heart failure (median [IQR], 15 [11-18] vs 10 [5-19]; P  < .001), hyperlipidemia (median [IQR], 14 [10-17] vs 9 [5-16]; P  < .001), and hypertension (median [IQR], 14 [10-18] vs 9 [5-16]; P  < .001).

In all 50 states, the number of community pharmacy visits was larger than the number of encounters with primary care physicians ( Figure 2 A). The difference between community pharmacy visits and primary care physician encounters was largest in Iowa (13 vs 5; P  < .001), Kentucky (14 vs 7; P  < .001), Louisiana (15 vs 6; P  < .001), Mississippi (15 vs 6; P  < .001), Montana (12 vs 4; P  < .001), North Dakota (12 vs 4; P  < .001), and Wyoming (12 vs 4; P  < .001) and lowest in Arizona (11 vs 8; P  < .001), Delaware (12 vs 8; P  < .001), Florida (13 vs 9; P  < .001), Hawaii (11 vs 8; P  < .001), Maryland (12 vs 8; P  < .001), Massachusetts (13 vs 9; P  < .001), and New Jersey (12 vs 9; P  < .001). The number of community pharmacy visits was larger than the number of encounters with primary care physicians in all but 9 US counties where primary care physician encounters equaled or outnumbered pharmacy visits, including Charlotte County, Florida (median pharmacy visits, 11 vs median primary care physician encounters, 11); Sumter County, Florida (11 vs 12); Marion County, Georgia (10 vs 10); Parke County, Indiana (13 vs 13); Bracken County, Kentucky (14 vs 14); Carlisle County, Kentucky (6 vs 12); Pamlico County, North Carolina (13 vs 14); Hidalgo County, Texas (14 vs 14); and Willacy County, Texas (14 vs 14) ( Figure 2 B).

In this cross-sectional study using a nationally representative sample of Medicare beneficiaries who actively access health care services, we found that patients visited community pharmacies approximately twice as frequently as they visited primary care physicians. The difference in frequency of visits and encounters was largest in nonmetropolitan rural areas.

Our study is an important contribution to the literature because it is the first, to our knowledge, to quantify and compare frequency of visits with community pharmacies and primary care physicians in a nationally representative sample. Although most patients visit community pharmacies for product-centered services, including prescription medication procurement and self-care with nonprescription medications, the frequency of visits estimated by our analysis suggests that community pharmacists have frequent opportunities to deliver patient-centered services in community-based locations. As value-based health care increasingly places emphasis on preventive care and chronic disease management, the community pharmacist is a highly accessible clinician who can provide many of these services.

The greatest difference between community pharmacy visits and primary care physician encounters was observed in nonmetropolitan rural areas, which underscores the importance of accessible health care professionals in small or isolated communities. As the need for primary care physicians continues to rise across the United States and particularly in rural areas, pharmacists are well placed to contribute to a multidisciplinary primary care team with direct and frequent follow-up. Frequent follow-up is often needed in the context of chronic disease and preventive medicine.

It is also important to note that pharmacists cannot capitalize on accessible and frequent encounters at community pharmacies without further practice change and transformation. The need to recognize pharmacists as providers of billable services, integrate pharmacists in emerging delivery and payment models, and enhance collaborative relationships between pharmacists and other members of the health care team have been well described in the literature. 12 To further capitalize on the uniqueness on the pharmacist as an accessible health care professional, pharmacy and health care organizations must consider how community pharmacy practice will adapt to transformed pharmacist roles, including changes to business models, workflows, and staffing.

The findings of our study should be interpreted in the context of its limitations. First, Medicare Part B claims data do not expressly identify the patient’s primary care physician. To minimize this limitation, we included all Part B claims billed to primary care specialties. Our attempt to be comprehensive may have overestimated the number of times patients encountered the primary care physician responsible for comprehensive care for the individual.

Second, we may have underestimated the number of visits to the community pharmacy in the absence of point-of-sale data from community pharmacies. To proceed without point-of-sale data confirming physical presence at the community pharmacy, we defined pharmacy visits using days between individual Part D prescription drug claims with conservative 10- and 13-day windows informed by industry standards. It was not possible to differentiate the number of days used to reverse unclaimed prescriptions at each pharmacy location because of the lack of reversed claims in the data set.

Third, cognitive services provided by pharmacists at the community pharmacy were not captured in our analysis. Pharmacists provide billable services outside of medication dispensing that include immunizations and medication therapy management. Nonbillable services are also routinely offered by community pharmacists at no charge. These include patient education and counseling for prescription medications, recommendations for self-care and nonprescription medications, point-of-care testing for acute and chronic illness, and screening and brief intervention for substance use disorders.

Lastly, our data do not capture the nature of each primary care physician encounter and pharmacy visit. Therefore, inferences as to what preventive service and disease state management were addressed at each primary care encounter or pharmacy visit cannot be made. Likewise, it was not possible to differentiate between health care professional–initiated and patient-initiated visits. Although most pharmacy visits are probably patient initiated, health care professional encounters most likely include a mix of visits initiated by both patients and health care professionals as follow-up care.

The findings of this cross-sectional study suggest that community pharmacists are accessible health care professionals who have frequent opportunities to interact with patients in the community. Given these findings, we believe community pharmacists and primary care physicians should collaborate as multidisciplinary primary care teams to prevent and manage chronic disease.

Accepted for Publication: April 21, 2020.

Published: July 15, 2020. doi:10.1001/jamanetworkopen.2020.9132

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2020 Berenbrok LA et al. JAMA Network Open .

Corresponding Author: Inmaculada Hernandez, PharmD, PhD, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3609 Forbes Ave, Room 103, Pittsburgh, PA 15213 ( [email protected] ).

Author Contributions: Mr Gabriel had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Berenbrok, Hernandez.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Berenbrok, Hernandez.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Gabriel, Hernandez.

Obtained funding: Hernandez.

Administrative, technical, or material support: Coley, Hernandez.

Supervision: Berenbrok, Hernandez.

Conflict of Interest Disclosures: Dr Berenbrok reported receiving grants from the National Association of Chain Drug Stores outside the submitted work. Dr Hernandez reported receiving grants from the National Association of Chain Drug Stores outside the submitted work. Dr. Coley reported receiving grants from the National Association of Chain Drug Stores outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by grant K01HL142847 from the National Heart, Lung, and Blood Institute (Dr Hernandez).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Study Charts Downturn in Primary Care Office Visits

Aafp cited report in recent response to state of the union speech.

February 26, 2020 10:29 am News Staff -- A recent study tracking a downward trend in primary care visits cited several contributing factors, including the high cost of care that the AAFP has been working to address.

Authors of "Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016"  said the drop -- 24.2% over nine years -- appears to be related to several factors.

The Numbers

Researchers examined claims data from 2008 through 2016 for patients ages 18 to 64 enrolled with a nationwide commercial health insurer, looking at utilization patterns, visit types (i.e., problem-based vs. preventive), differences among patients and geographic areas, out-of-pocket costs, and visits to specialists and alternative care venues.

They found that the number of primary care visits per 100 member-years dropped from 169.5 to 134.3 during the study period, and the proportion of adults with no primary care visits in a given year rose from 38.1% to 46.4%.

This decrease was greatest among those

• living in areas where the median household income is no higher than twice the federal poverty level (down 31.4%),
• ages 18 to 34 (down 27.6%),
• living in metropolitan areas (down 26.8%) and
• with no chronic conditions (down 26.4%).

The authors also found that during the study period, out-of-pocket cost per problem-based visit rose by 31.5%, and visits to nonprimary care venues increased by 46.9%.

The Reasons

According to the authors, an understanding of how adults with commercial insurance receive health care may help shape health care policy and changes in how health care is delivered "to sustain the benefits of primary care."

"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," they wrote.

Specifically, they suggested that the way patients receive care appears to be influenced by increasing financial and geographic barriers to primary care access, as well as by the availability of telemedicine, online medical information and venues such as urgent care clinics.

The Academy emphasized those financial barriers -- and the harms to which they lead -- when citing the report in its response to President Donald Trump's State of the Union address earlier this month.

"We continue to see the devastating effects of delaying or declining prescribed medications and needed treatments because patients can't afford them," said the statement by AAFP President Gary LeRoy, M.D., of Dayton, Ohio.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

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A new marker of primary care utilization - annual accumulated duration of time of visits

Talya a. nathan.

1 The Department of Family Medicine, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Arnon D. Cohen

2 Clalit Health Services, Tel Aviv; 3) Medical Division, Leumit Health Services, Tel Aviv, Israel

Shlomo Vinker

Associated data.

The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.

Most of the research on primary care workload has focused on the number of visits or the average duration of visits to a primary care physician (PCP) and their effect on the quality of medical care. However, the accumulated annual visit duration has yet to be examined. This measure could also have implications for the allocation of resources among health plans and across regions. In this study we aimed to define and characterize the concept of "Accumulated Annual Duration of Time" (AADT) spent with a PCP. 

A cross-sectional study based on a national random sample of 77,247 adults aged 20 and over. The study’s variables included annual number of visits and AADT with a PCP, demographic characteristics and chronic diseases. The time period was the entire year of 2012.

For patients older than 20 years, the average annual number of visits to a PCP was 8.8 ± 9.1, and the median 6 ± 10 IQR (Interquartile Range). The mean AADT was 65.8 ± 75.7 min, and the median AADT was 43 ± 75 IQR minutes. The main characteristics of patients with a higher annual number of visits and a higher AADT with a PCP were: female, older in age, a higher Charlson index and a low socio-economic status. Chronic diseases were also found to increase the number of annual visits to a PCP as well as the AADT, patients with chronic heart failure had highest AADT in comparison to others (23.1 ± 15.5 vs. 8.6 ± 8.9 visits; and 165.3 ± 128.8 vs. 64.5 ± 74 min). It was also found that the relationship between AADT and age was very similar to the relationship between visits and age.

While facing the ongoing increase in a PCP’s work load and shortening of visit length, the concept of AADT provides a new measure to compare between different healthcare systems that allocate different time frames for a single primary care visit. For Israel, the analysis of the AADT data provides support for continued use of the number of visits in the capitation formula, as a reliable and readily-accessible indicator of primary care usage.

Electronic supplementary material

The online version of this article (doi:10.1186/s13584-017-0159-y) contains supplementary material, which is available to authorized users.

How this fits in

Novel concept of "Accumulated Annual Duration of Time" spent with a primary care physician as a new measure to assess health services.

• We present a new measure "The accumulated annual visit duration" with primary care physicians that had not been evaluated in the literature.
• Our findings support cumulative duration as a parallel mean to the number of visits for health services assessment. This novel concept may serve as a new standardized comparative measure to evaluate and unify the characteristics of high quality primary care.
• New primary care guidelines should also refer to the optimal amount of time needed to be spent on health topics within the visit, rather than focusing on the number of visits.

Primary care visits

The primary care visit remains the principal opportunity for health care providers to address patient’s needs. The results of the Israel Central Bureau of Statistics (ICBS) for 2009 indicate that the annual average number of visits to the primary care physician (PCP) is 6.2 in the general population of Israel and 16.1 for ages 65 and over. Age and the number of visits of patients with chronic diseases were found to be factors that significantly increase the annual average number of visits [ 1 ]. The most recent data found by us suggests that the mean duration of a visit with an Israeli PCP is 10.4 min [ 2 ].

The annual average number of visits can vary substantially across countries. One study in the United States calculated a mean of 1.6 PCP (defined as visits to a general practitioner, family physician, pediatrician, geriatrician, or general internist) yearly visits per person as of 2008 [ 3 ]. In the WHO European Region, the average outpatient contacts per person per year in 2006 was 7.85, and country specific averages for 2006 or the latest available year were 7.0 in Germany, 9.5 in Spain, 5.4 in the United Kingdom, 5.7 in the Netherlands, 6.6 in Belgium and 11.0 in Switzerland [ 4 ].

There is also significant cross-country variation in visit duration. In the United States, 2006 data from the Centers for Disease Control and Prevention (CDC) found that the mean duration of face-to-face visits with PCPs (general or family practice) was 19.5 min [ 5 ]. In Europe, it was found that the mean length of a visit with a PCP (general practitioner) was 7.6 min in Germany, 7.8 min in Spain, 9.4 min in the United Kingdom, 10.2 min in the Netherlands, 15.0 min in Belgium and 15.6 min in Switzerland [ 6 ]. A study by Bindman et al. found in a 2001–2 cross-sectional analysis that the average duration of a face-to-face visit with a PCP in the US (general internists, general pediatricians, and family practitioners) was 16.5 min, about 10% longer than with general practitioners in Australia (14.9 min) and New Zealand (15 min). Visit lengths were longer in the US for all age and gender groups. Because the average number of primary care visits per capita was greater in New Zealand and Australia, however, the mean per capita annual exposure to primary care physicians in the US (29.7 min) was about half of that in New Zealand (55.5 min) and about a third of that in Australia (83.4 min) [ 7 ].

Studies from various countries have found that the length of an ambulatory visit with PCPs is influenced by increasing age, presence of psychosocial problems [ 8 ], gender (women) and greater number of new problems discussed in the visit [ 6 ].

Visit duration and patient outcomes

Research in the matter has shown that longer PCP visits were associated with a range of better patient outcomes [ 9 , 10 ], including more statements about health education and prevention [ 11 ], as well as higher rates of preventive medical measures such as vaccinations [ 12 , 13 ], and mammography referrals [ 14 ]. The duration of PCP care was also associated with lower costs of inpatient and outpatient care and with a lower risk of hospitalizations [ 15 ]. Wilson et al. first concluded that a PCP with a higher average visit length is more likely to provide visits that include important aspects of care, and that longer visit length can therefore be used as a quality indicator [ 16 ]. They later conducted a systemic review, which found that in interventional studies that had been performed by altering same physicians’ visit length the above mentioned effect had not been demonstrated. However, their findings were not sufficient to support or resist a policy of altering PCP visit length, and due to many limitations of the study, it was difficult for them to define length as a marker of quality of care [ 17 ].

When analyzing the primary care setting, one aspect of the visit is its content. A study by Tai-Seale et al. found that visit length was insensitive to the content of a visit - longer time spent on major topics seemed to have been compensated by limiting the time allocated to minor topics, therefore leaving the visit length more or less the same. Instead, organizational structure, physicians’ practice settings and payment incentives appeared to have more influence on visit length [ 18 ]. However, other research suggested that there was a positive association between the number of problems discussed and the mean length of visits. It was found that on average, PCPs spend 11.9 min dealing with 2.5 problems, and a linear relationship was seen at least up to six problems, with the length of visits increasing by an average of 2 min for each additional problem above a baseline of 9 min for the first problem [ 19 ]. Abbo et al. found that the number of clinical items addressed during a PCP visit increased from 5.4 in 1997 to 7.1 in 2005, resulting in a decrease in minutes spent per clinical item from 4.4 to 3.8 [ 20 ]. Approximately 8% of PCP visit duration was found to be attributable to eight-related conditions included diabetes, hypertension, hyperlipidemia, obesity, cardiovascular disease, osteoarthritis, and low back pain [ 21 ]. Chen et al.’s findings suggested that the relationship between quality of care and physician visit duration depends on the type of quality indicator being measured, namely, medication quality indicators vs counseling or screening quality indicators. In their research, they found a clear and consistent relationship between visit duration and provision of counseling and screening-based care [ 22 ].

Moreover, nearly one half of a primary care physician’s workday was found to be spent on activities outside the examination room, predominately focused on follow-up and documentation of care for patients not physically present. In the United States, Gottschalk et al. found that national estimates of visit duration overestimate the combination of face-to-face time and time spent on visit-specific work outside the examination room by 41% [ 23 ].

However, despite evidence that increasing visit length is more likely to improve primary care, and that longer visit length can therefore be used as a quality indicator, to our knowledge and according to the literature review, we did not find a study that defined the optimal annual accumulated time (complementary to the number of visits) that should be spent with a patient to achieve better quality of care.

The potential implications for resource allocation

In many countries, the allocation of financial resources among regions and/or among care providers is based on capitation formulae which try to reflect how the composition of populations served affect the need for health care services. For example, as older people tend to use more health care services, regions and providers serving populations with higher concentrations of the elderly are often given more financial resources per capita. This is done so that they will have enough resources to provide quality care and to eliminate any incentive to avoid caring for elderly persons.

In Israel, for example, when Israel distributes the National Health Insurance monies among health plans, it uses a capitation formula which includes mainly age, gender and other minor affecting parameters. In developing that formula, the government examines how age and gender are related to resource use for the key types of care consumed – hospital care, community services, and medications. As its measure of community service use, the government currently uses the number of physician visits. However, if visit duration varies significantly by age or gender, then the number of physician visits would not be a good indicator of resource use, and AADT would be a more appropriate measure to use. If visit duration does not vary significantly by age or gender then it would make sense to continue to base the capitation formula on the number of visits, as it is easier for the government to collect survey data on the number of visits than on the AADT. When the health plans distribute funds among their regions they also take into account various demographic characteristics (including location) and their relationship to service use. They too face a decision of whether to use the number of visits or AADT in resource allocation decisions, and hence they too have interest in knowing whether visit duration varies by demographic characteristics, as well as by location.

We conducted a cross-sectional study based on the electronic medical records of the largest Health Maintenance Organization (HMO) in Israel to investigate the characteristics of the concept of Accumulated Annual Duration of Time (AADT) that the PCP spends with a patient. This is an important first step towards using AADT in resource planning and allocation, and perhaps even determining the optimum level of AADT.

Population and data source

Data was retrieved from the Clalit Health Services (CHS) central computerized database. CHS is the largest HMO in Israel, covering 54% of the entire Israeli population (about 4,200,000 people in 7 districts). Every person insured by CHS is assigned to a PCP. All the visits to a PCP are fully computerized and the information from the electronic medical records is retrieved to a central repository. The central database includes demographics, information about physician visits, and a register of a selected number of chronic diseases (from the HMO’s registry, diagnosed previously to the visits in question).

The study period was the entire 2012 calendar year. The population of this study consisted of all adult members of the HMO aged 20 and over, from which we draw a national random sample of 83,707. The sampling method was a randomized computer based binary extraction of 2% of all patient data, based on the two last digits of the patients’ social security number.

Of the patients who were randomly selected from the HMO’s database, 1088 died during the study period and 2615 left the HMO. Patients older than age 100 years ( n  = 25), bed-ridden ( n  = 2059) or in a nursing home ( n  = 673) were excluded from the study; therefore, the current analysis included 77,247 patients.

Data accessed

The number and duration of visits of CHS members with a PCP were retrieved for the study period. Additional patient data included: demographic characteristics: age, gender, country of birth, year of immigration to Israel (Individuals who were born in Ethiopia and immigrated to Israel after 1984 were defined as “new immigrants”. Immigrants from other countries were defined as “new immigrants” if they immigrated after 1990. These represent the two major waves of immigration to Israel that took place in the past 30 years), residency (Large city ≥100,000 citizens, other city, collective settlement - also known as a Kibbutz, cooperative Israeli settlement, small town and non-Jewish settlement), socioeconomic status (SES; low SES was defined as exemption from social security payments); chronic diseases (malignancy, diabetes, hypertension, hyperlipidemia, ischemic heart disease (IHD), chronic heart failure (CHF), status post cerebrovascular accident (s/p CVA), asthma, chronic obstructive pulmonary disease (COPD), dementia, epilepsy, anxiety disorder and drug abuse); and a Charlson comorbidity index [ 24 , 25 ], which was calculated as well.

The study was approved by the CHS ethics committee at the Meir Medical Center, Kfar Saba, Israel.

Statistical analysis

Descriptive statistics was the primary method of analyzing the data. The annual number of visits and annual duration of visits (in minutes) were analyzed as continuous parameters. The Central Limit Theorem justifies the results despite the non-normal distribution of these variables.

Demographic characteristics were compared as well as medical characteristics for sub-groups according to number of visits and visit duration, using correlations (for differences between continuous parameters), T-tests (for differences between dichotomized parameters and averages of continuous parameters), chi-squared analysis and Fisher IS (for categorical parameters) and ANOVA (for differences between more than two categories in a parameter). If the ANOVA was found to be significant, a POST HOC analysis using Tukey’s test was performed to distinguish the different categories.

We used multivariate analysis to construct predictive models for comparison between annual number of visits and annual duration of visits.

A Multivariate Linear Regression model was applied to the data to study simultaneously the independent relationship between the demographic (age, gender, SES, residence area, and immigration status) and clinical background (chronic diseases, Charlson comorbidity index) and visit characteristics. The model predicts the probability of higher number of visits and longer annual duration of visits as a function of the explanatory variables. We addressed the non-normal distribution of these variables by using a square root transformation.

A p -value of 0.05 or less was considered statistically significant. All results were rounded to tenths (+1 decimal place). All analyses were carried out with the assistance of The Statistical Consulting Lab at The School of Mathematical Sciences at Tel Aviv University, using SPSS ver. 21 statistical software.

Table ​ Table1 1 shows the characteristics of the study population. 52.3% were female and 13.1% were new immigrants. The majority of the study population (81.3%) was between the ages 20–64 (children, up to 20 years old, were excluded from the study), with an average age of 46.5 ± 18.1 years; 41% resided in large cities and only 15.8% were considered to be of low SES. The average Charlson comorbidity index was 3.0 ± 1.1. The average annual number of visits with a PCP during 2012 was 8.8 ± 9.1 visits while the median was 6 ± 10 IQR visits. The average duration of a single visit was 7.6 ± 4.3 min while the median duration was 7 ± 4.5 IQR minutes. The mean annual duration of visits was 65.8 ± 75.8 min while the median annual duration was 43 ± 75 IQR minutes.

Characteristics of study population and visits with primary care physicians

PCP Primary Care Physician

AADT Accumulated Annual Duration of Time

SES Socioeconomic Status

IQR Interquartile Range

Table ​ Table2 2 presents the characteristics of the annual number of visits and the annual duration of visits with a PCP during 2012. A positive correlation between the annual number of visits as well as the annual duration of visits was found with both age (0.4) and the Charlson index (0.5). More visits, with a higher AADT were made by women (9.8 ± 9.2 vs. 7.7 ± 8.9 visits and 73.3 ± 76.7 vs. 57.5 ± 73.8 min); by the subgroup of low SES (14.7 ± 11.9 vs. 7.7 ± 8.0 visits and 104.5 ± 98.4 vs. 58.5 ± 68.3 min); and in kibbutzim (11.9 ± 11.9 vs. <8.9 visits and 100.3 ± 116.9 vs. <67.2 min) in comparison to large cities. Those who were new immigrants visited less frequently (7.7 ± 8.1 vs. 9.0 ± 9.2 visits) and had a lower AADT (57.1 ± 67.4 vs. 67.1 ± 76.8 min). Patients with one or more chronic diseases were also found to have made more visits and spent more time with their PCP throughout the year. The most substantial difference was seen among patients with chronic heart failure (CHF) compared to patient without the disease (23.1 ± 15.5 vs. 8.6 ± 8.9 visits, a 167.9% increase and 165.3 ± 128.8 vs. 64.5 ± 74 min, a 156.2% difference) followed by chronic obstructive pulmonary disease (COPD) (20.1 ± 15.1 vs. 8.6 ± 8.8 visits, a 135.3% difference and 143.9 ± 120.9 vs. 63.9 ± 73.4 min, a 125% difference) and hypertension (15.9 ± 11.5 vs. 6.8 ± 7.2 visits, a 133.1% difference and 115.9 ± 98.7 vs. 51.8 ± 61 min, a 123.8% difference).

Characteristics of the annual number of visits and the Annual Accumulate Duration of Time spent with a primary care physician during 2012

IHD Ischemic Heart Disease

CHF Chronic Heart Failure

s/p CVA status post Cerebrovascular Accident

COPD Chronic Obstructive Pulmonary Disease

Table ​ Table3 3 presents data on the average visit duration varied by age and gender, calculated as AADT during 2012 No . of visits during 2012 for each age and gender group. The data indicate that visit duration was found to be very similar for both men and women and across age groups.

Average visit duration in 2012 AADT during 2012 No . of visits during 2012 , by age and gender

Table ​ Table4 4 presents a Multivariate Linear Regression analysis (in square root) for the number of visits (R-squared 0.39) and the AADT (R-squared 0.34) spent with a PCP during 2012. Increase in age was initially associated with a non-linear increase in the number of visits and in the amount of time spent with a PCP, however after age 80 subsequent increases in age showed a decline in the number and duration of visits (See Additional file 1 ). Women, patients of a low SES and with a higher Charlson index spent more time and paid more visits with their PCP. Being a new immigrant meant fewer and shorter visits, and compared to persons residing in large cities, kibbutz members had the highest visiting rate and spent the most time with their PCP.

Linear regression (in square root) - number of visits and Annual Accumulate Duration of Time spent with a primary care physician during 2012

During 2012, the average annual number of visits with a PCP was 8.8 ± 9.1 and the median was 6 ± 10 IQR. The mean AADT was 65.7 ± 75.8 min and the median AADT was 43 ± 75 IQR minutes. The average duration of a single visit was 7.6 ± 4.3 min and the median was 7 ± 4.5 IQR minutes, which is lower than the data known to us prior to this study [ 2 ]. This was to be expected following the rise in the PCP’s workload due to population growth and the increase in life expectancy.

The main characteristics of patients with a higher annual number of visits and a higher AADT with a PCP were: female, older in age, a higher Charlson index (all three of which coincide with previously known data [ 1 , 6 ]), of a low SES (which could be explained by Israel’s public health care system, providing highly available/no cost primary care), and residing in a kibbutz (possibly due to greater accessibility to PCP’s). New immigrants had a lower annual number of visits and a lower AADT with a PCP.

The study also found that average visit duration was very similar for both men and women and across the various age groups. This implies that the relationships of age and gender with the number of visits are similar to their relationships with AADT. Thus, while AADT does a better job of capturing resource use (i.e. the amount of time physicians invest in the care of various types of patients) than does the number of visits, it is reasonable to continue using the number of visits as a proxy for AADT in calculating capitation formulae. In the future, it will be important to examine whether visit duration is also consistent across geographic areas.

Strengths and limitations

One of the main strengths of the study is that it was based on a national sample from the largest HMO in Israel. Another is its use of thousands of electronic medical records (and not self-reports) from hundreds of general practices. This is in comparison to other studies, where the exposure to primary care was calculated from duration of visits recorded by the physician, and reports on rates of visits to primary care for each country [ 7 , 22 , 26 , 27 ]. However, international comparisons may be affected by differences in definitions and in the circumstances in which patients see primary care physicians in different countries. It is possible that some references to outpatient attendances include in part visits with specialists.

Another issue is that there are a substantial number of physician visits that are administrative in nature (repeat prescription, fill out laboratory tests forms, etc.) and do not entail a face-to-face meeting between patient and physician. Although the type of visit is specified in the electronic file, in our experience, this information is usually not accurate and therefore the type of visit is difficult to determine. Therefore, we could not separate between face-to-face and non face-to-face visits, but we believe that they are on the continuum of primary treatment and should be part of the calculated time load on the PCP. Furthermore, some other important limitations exist.

First, an underlying assumption of use of the AADT is that a higher number of annual visits with a shorter average duration are equivalent to a lower number of annual visits with a longer average duration. If the first 2 or 3 min of each visit are used by the physician to greet the patient and look at the electronic notes of past visits, this may not be the case. In addition, these actions may require a minimum time allocated for each visit even when only one problem is raised. These issues are directly related to health care policy planning. Assuming there is a more efficient utilization of physician time with fewer yet longer visits, this aspect requires future examination, which could result in an organizational paradigm shift within the health care system.

Second, we excluded patients that died during the study year. We know that at the end of life the utilization of health care resources can be abundant [ 28 – 30 ], influencing the utilization of primary care visits as well. Therefore, to evaluate this special group, we will need another focused study.

Third, the analysis was not limited to one designated physician per patient, as it was designed to find the importance of the AADT required from primary care as a whole for the treatment of patients. This is an important aspect to be examined in future research, to investigate whether time spent with a patient’s personal primary care physician is more effective.

Another limitation of the current study is a possible information bias - some of those classified as “new immigrants” (as well as others) may live outside Israel. The fact that in recent years new immigrants to Israel usually keep their original residency increases the probability of such events.

Comparison with existing literature

As expected, chronic diseases were found to increase the number of annual visits with a PCP as well as the AADT. This coincides with previous research, which found patients with multiple chronic diseases having more outpatient visits per year, more adverse events, higher health care costs including the prescription of multiple medications, and having a lower health-related quality of life [ 31 – 33 ], This can be partially attributed to the fact that the average age and Charlson index score in our study were higher amongst patients with chronic diseases. In accordance with this finding, Østbye et al. found that chronic illnesses require more time then physicians have available for patient care [ 34 ].

In an overworked primary care system, facing growing numbers of elderly and chronically ill patients as well as mounting guidelines and tests, providing the required preventive, chronic and acute medicine and maintaining high quality of care is becoming an extremely difficult task [ 35 ].

To deal with these rising challenges on current models of primary health care, other forms of care such as shared medical appointments have been suggested [ 36 ]. This model of non-physician clinicians was also suggested by Yarnall et al., who proposed another solution in the form of many more shorter visits per year [ 37 ]. Additional recommendations include comprehensive primary care guidelines that integrate highly correlated diseases together, as well as patient education [34].

Conclusion - implications for research and/or practice

In our review, we noticed the existence of a global variety of health organizations and operative units, accompanied by an increasing workload and a growing complexity of guideline-based primary care. The various international comparisons do not take into account the variability in PCP visit duration from one country to the next as well as the differences between health care systems. This in turn results in diverse guidelines as to how to organize the schedule of PCP visits duration. We suggest that this concept of AADT may serve as a new standardized comparative measure, by facilitating the standardization of PCP’s working hours to 1000 patients and accordingly the number of allocated PCP positions required. This makes it easier to evaluate and unify the characteristics of high quality primary care. However, further research is necessary to evaluate the potential of this novel concept. ‬

Another issue to address is that of chronically-ill patients’ follow-up. Due to current time constraints and limitations, it is clear that sufficient follow up and management cannot be conducted in a single visit. Our findings support cumulative duration as a parallel indicator (to the number of visits) for quality of care, and therefore there is room to evaluate whether new PCP guidelines should also refer to the optimal amount of time needed to be spent on health topics addressed within the PCP setting, rather than focusing on the number of visits.

In our study, we found that the AADT spent with a PCP is affected by the same variables as the number of visits. This finding should be evaluated by further research, which is required to assess the benefits of new practice models dealing with the allocation of time and how well they provide quality of care in the primary setting, by relating among others AADT to clinical outcomes and other relevant quality measures.

While facing the ongoing increase in a PCP’s work-load and continuous shortening of visit length, the novel concept of AADT gives a new measure to facilitate in health care policy design, compare between different healthcare systems that allocate different time frames for a single primary care visit, and plan time-consuming tasks (such as chronic disease follow up) as well as asses their contribution in terms of ‘physician time’ vs. number of visits.

Acknowledgements

All analyses were carried out with the assistance of Ms. Ilana Gelernter of The Statistical Consulting Lab at The School of Mathematical Sciences at Tel Aviv University.

Not applicable.

Availability of data and materials

Authors’ contributions.

Author’s contribution - TN carried out the literature review, participated in the statistical analysis, conducted the interpretation of the data and the drawing of conclusions, and drafted the manuscript. SV conceived of the study, participated in its design and coordination, supervised over the interpretation of the data and the drawing of conclusions, and helped to draft the manuscript. AC participated in the conception, design and coordination of the study. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Ethics approval and consent to participate.

The study was approved by the CHS ethics committee at the Meir Medical Center. Ref. No. 118/2010.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Abbreviations

Additional file.

Linear regression model of AADT (in minutes) spent with a PCP during 2012 according to age - B coeficient (Age group 20-29=1). (PDF 55 kb)

This work was performed in partial fulfillment of the M.D. thesis requirements of the Sackler School of Medicine, Tel Aviv University

Contributor Information

Talya A. Nathan, Phone: +972-524445206, Email: [email protected] .

Arnon D. Cohen, Email: li.gro.tilalc@nehocra .

Shlomo Vinker, Email: li.ten.vahaz@10rekniv .

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Controlling your panel: Are physician shortages creating more patients per doctor?

Measuring panel size

When it comes to patient panels for primary care practices, size absolutely matters. To maintain reasonable access for patients, a medical practice administrator should know the number of unique patients for which his or her care team is ultimately responsible. For primary care and cardiology practices that participate in the MGMA Cost and Revenue Survey each year, provider panel size is largely determined by the set of individual, unique patients seen by a provider within the practice over the past 18 months. The per-physician panel size is set using the following methodologies:

• If a patient has only seen one physician in the practice, assign the patient to that physician.
• If a patient has seen more than one physician in the practice, assign the patient to the physician seen most frequently.
• If a patient has seen more than one physician in the practice the same number of times, assign the patient to the physician who did the patient’s last physical.
• If a patient has not had a physical, assign him/her to the physician seen most recently.

The patient access challenge

Care models such as the patient-centered medical home (PCMH) shift the mentality of panel management away from episodic care to a proactive, relationship-focused model in which the full panel’s care is considered. [More information on panel management is available from the Agency for Healthcare Research and Quality (AHRQ) Practice Facilitation Handbook .] While the patient panel may not directly translate into a specific workload of patients in many medical groups, it does contribute to the challenge of managing patient access, which has increased in recent years. An Oct. 13 MGMA Stat poll found that consumerism is one of the biggest disruptors in healthcare in 2019, and ensuring short patient wait times for appointments is one piece of patient access that remains crucial for practice leaders to manage. As MGMA Chief Operating Officer Ron W. Holder Jr., MHA, FACMPE, FACHE, wrote: Patient access … used to boil down to having enough providers to meet patient demand. Now, due in part to the changing demographics of the patient population, access means providing telehealth, as well as offering evening and weekend appointments and more convenient hours. As with most elements of a practice’s operations management, the ability to appropriately staff for various models of care delivery is being impacted by a rising trend of physician shortages across the country in multiple specialties. The Association of American Medical Colleges (AAMC) projects a shortfall of between 46,900 and 121,900 physicians by 2032 for both primary and specialty care, driven largely by increased need for care and increased complexity of care as the population grows and ages. For the existing physician workforce, the number of patients from the panel who can be seen depends greatly on the number of hours worked and time dedicated to clinical work. Numerous reports on physician burnout point to non-clinical aspects of practice operations encroaching upon clinical time; the 2018 Survey of America’s Physicians: Practice Patterns & Perspectives by The Physicians Foundation finds that about one-quarter of a physician’s time is spent on non-clinical paperwork, resulting in fewer clinical hours worked and fewer patients seen. These factors can influence quality of care outcomes. A 2016 study of primary care physician (PCP) panel size and quality of care found that the likelihood of hospitalization related to ambulatory-care-sensitive conditions was higher for patients in larger panels. A separate study from 2016 of family medicine panel size found that patient diabetes control and a practice’s time-to-third (the average number of days from an appointment request to the third-next-available appointment per clinician) were negatively impacted with higher panel size.

Improving access and managing panels

To see patients as quickly and conveniently as possible, there are several initiatives that can help improve patient access without hiring more providers , according to Nate Moore, CPA, MBA, CMPE, president, Moore Solutions Inc. These include reducing no-shows to lower the number of unfilled appointment slots; implementing effective portals and online scheduling; and reducing errors in scheduling with specialists. The AHRQ recommends that practices monitor key metrics for empanelment, including but not limited to:

• Percentage of patient visits to designated clinicians
• Percentage of patient visits to non-designated clinicians
• Size of panel by clinician compared to the practice’s target panel size
• Number of overbooked appointments per week
• Time-to-third
• Patient satisfaction survey data pertaining to access.

 A 2017 report from the University of California Health’s Center for Health Quality and Innovation (CHQI) proposes three methods for determining the “right-sized” panel for a provider group:

• A visit-based method based solely on office visit supply, which calculates panel size by multiplying PCP scheduled visits per day by PCP work days per year, divided by average visits per patient per year. This method, however, does not account for time spent on non-face-to-face clinic activities, such as patient emails and other activities required for value-based payment arrangements.
• A time-based method can be used to establish a right-sized panel by examining how various types of care — preventive, chronic and acute — are delegated between physicians and nonphysician team members. Panel size varies based on time delegated to each set of the care team based on hours per patient per year in those three types of care.
• Using normative benchmarks of existing panel sizes in varying healthcare settings, since definitions of panel metrics are not standardized across specialties. This is particularly important for primary care practices with a greater share of geriatric patients in the panel, which likely leads to a more complex case mix in the patient population.

Additional resources

• “Make room: Optimizing patient access and accelerating practice growth via a space utilization plan” ( MGMA Connection article)
• “How do you improve patient access for your organization?” (MGMA Stat data story)
• Patient Access: Tools and Strategies for the Medical Practice (Book)
• “Largest disruptors in healthcare from the past year” (MGMA Stat data story)
• “Maximizing Patient Access and Scheduling” (MGMA Research & Analysis report)
• “Manage panel size and scope of the practice” (Institute for Healthcare Improvement)
• “Panel size: How many patients can one doctor manage?” ( FPM )

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HHS Proposes Physician Payment Rule to Drive Whole-Person Care and Improve Health Quality for All Individuals with Medicare

Proposed policies would increase value-based care, strengthen primary care, and expand access to behavioral and oral health care

Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), proposed new policies in the calendar year (CY) 2025 Medicare Physician Fee Schedule (PFS) proposed rule to advance health equity and support whole-person care. The proposed rule would also strengthen primary care, expand access to behavioral health, oral health, and caregiver training services, maintain telehealth flexibilities, and expand access to screening for colorectal cancer and vaccinations for hepatitis B. The proposed rule reflects the Biden-Harris Administration’s vision for affordable, high-quality care for all Americans while driving innovation in the Medicare program.

“This proposed rule strengthens the care people with Medicare receive, advancing HHS’s goal of a health care system that not only treats those who are sick but also keeps people well,” said HHS Secretary Xavier Becerra. “The proposed rule continues our implementation of President Biden’s historic prescription drug law. The law lowers costs for seniors and people with disabilities and uses rebates from drug manufacturers to strengthen Medicare. It also increases access to behavioral and dental care, expands access to cancer screenings, and supports caregivers.”

“The Biden-Harris Administration is committed to protecting and expanding Americans’ access to quality, affordable health care,” said CMS Administrator Chiquita Brooks-LaSure. “The Calendar Year 2025 Physician Fee Schedule proposed rule supports physicians and other practitioners in delivering care that meets the needs of people with Medicare, including through telehealth flexibilities, strengthened primary, behavioral, and oral health care, and improved access to caregiver training services.”

Because of factors specified in law, average payment rates under the PFS are proposed to be reduced by 2.93% in CY 2025 compared to the average amount these services will be paid for most of CY 2024. The change to the PFS conversion factor incorporates the zero percent overall update required by statute, the expiration of the 2.93% increase in payment for CY 2024 required by statute, and a small adjustment necessary to account for changes in valuation for the work RVU portion of particular services. This amounts to a proposed estimated CY 2025 PFS conversion factor of $32.36, a decrease of $0.93 (or 2.80%) from the current CY 2024 conversion factor of $33.29.

“Whole-person care means moving towards a health-care system that recognizes each unique aspect of a person and their wellbeing, including physical health, behavioral health, oral health, social determinants of health, and caregiving supports, and it all starts first with a foundation of primary care that can integrate these components,” said Meena Seshamani, M.D. Ph.D., Deputy CMS Administrator and Director of the Center for Medicare. “We are taking lessons learned from numerous CMS Innovation Center models to strengthen primary care teams and accountable care organizations, allowing them to better meet the unique needs of every person with Medicare.”

Strengthening Primary Care while Driving Quality Improvement and Innovation

A person-centered approach to health care starts with a trusting relationship with a primary care team. Over the last decade, value-based primary care models tested by the CMS Innovation Center have demonstrated that comprehensive primary care can lead to reductions in emergency department and hospital visits while better meeting patient needs. CMS is proposing to use these lessons learned to establish a new, advanced primary care management bundle under the PFS. As an important first step as part of a multiyear effort, this proposed payment uses coding describing certain primary care services that would be provided by advanced primary care teams, with adjustments for patient medical and social complexity to promote health equity. These services would be tied to primary care quality measures to improve health outcomes for people with Medicare.

In addition, the Innovation Center’s Million Hearts® model demonstrated that payment for cardiovascular risk assessment and cardiovascular care management led to fewer deaths related to cardiovascular disease and important reductions in heart attacks and strokes. Based on these evaluation results, CMS is proposing new payment and coding for these services to better assess and manage heart health.

CMS continues to drive high-quality care through its Quality Payment Program and is continually strengthening the Merit-based Incentive Payment System (MIPS). This rule proposes six new MIPS Value Pathways (MVPs): ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care. CMS is also proposing updates to MIPS scoring methodologies and measure inventories to give all clinicians the opportunity to achieve positive scores and continued improvement. These updates will help ensure that all eligible clinician types can continue to meaningfully participate in MIPS as CMS transitions to MVPs.

To further leverage progress on MVP development, the RFI “Building Upon the MVP Framework to Improve Ambulatory Specialty Care ” solicits feedback on the design of a potential model to increase the engagement of specialists in value-based care . Under the potential model, participants would receive a payment adjustment based on their performance compared to other similar specialists on a set of clinically relevant MVP measures.

CMS is also proposing to strengthen the Medicare Shared Savings Program (Shared Savings Program) further, which is Medicare’s permanent Accountable Care Organization (ACO) program. For the first time, CMS is proposing to allow eligible ACOs with a history of success in the program access to an advance on their earned shared savings, known as prepaid shared savings, to encourage investment in staffing, health care infrastructure, and additional services for people with Medicare, such as nutrition support, transportation, dental, vision, hearing, and Part-B cost-sharing reductions. Additionally, CMS is proposing to further incentivize participation in the Shared Savings Program by ACOs that serve people with Medicare who are members of rural and underserved communities by adopting a health equity benchmark adjustment similar to that in the Innovation Center’s ACO REACH Model, which has been associated with increased safety net provider participation. CMS is also proposing to move the Shared Savings Program towards the Universal Foundation of quality measures, creating better quality measure alignment for providers and driving care transformation. Further, CMS is proposing a methodology to account for the impact of improper payments when reopening an ACO’s shared savings and shared losses calculations, which is complementary to the Anomalous Increases in Billing on Medicare Shared Savings Program Financial Calculations Proposed Rule issued on (June 28, 2024).  The proposed adjustments described in both rules would improve the accuracy, fairness, and integrity of Shared Savings Program financial calculations.

Expanding Access to Behavioral Health, Oral Health, and Caregiver Training Services

Addressing the country’s behavioral health crisis continues to be a key priority for CMS . In support of the President’s whole-of-government strategy to transform how we address behavioral health, CMS is proposing several additional, impactful changes in this year’s rule. CMS is proposing new payments for practitioners who are assisting people at high risk of suicide or overdose, including separate payment for safety planning interventions and post-discharge follow-up contacts. CMS is also proposing new payment and coding for use of digital tools that further support the delivery of specific behavioral health treatments, and also new coding and payment to make it easier for practitioners to consult behavioral health specialists. For Opioid Treatment Programs (OTPs), this rule also proposes new codes for FDA-approved medications for the treatment of Opioid Use Disorder (OUD) and known or suspected opioid overdose, increased telecommunication flexibilities for periodic assessments and methadone treatment initiation, and an increase in payment for intake activities to provide more comprehensive services for the treatment of OUD, including assessing for unmet health-related social needs, harm reduction intervention needs, and recovery support service needs.

In response to public feedback about Medicare coverage of dental services, CMS continues to explore payment policies for dental services critical to the success of certain medical care. CMS previously finalized that payment can be made for dental exams and certain necessary diagnostic and treatment services in connection with organ transplants (including stem cell and bone marrow transplants), cardiac valve replacements, valvuloplasty procedures, head and neck cancers, chemotherapy, chimeric antigen receptor T- (CAR-T) cell therapy and high-dose bone modifying agents (antiresorptive therapy). In this year’s rule, CMS proposes that payment can be made for certain dental services associated with dialysis treatments for end-stage renal disease and includes a request for comment about dental services related to diabetes care and covered services for individuals with autoimmune diseases receiving immunosuppressive therapies.

Finally, caregivers provide crucial, daily care to many people with Medicare, and CMS continues to prioritize caregiver training services consistent with the Biden Administration Executive Order on caregiving . In this year’s rule, CMS proposes new payment for caregiver training services related to direct care services and supports and would allow caregiver training services to be provided virtually, as clinically indicated.

Expanding Preventive Services: Hepatitis B Vaccinations, Drugs Covered as Additional Preventive Services, and Colorectal Cancer Screenings

CMS is proposing to expand coverage of the hepatitis B vaccine for people with Medicare who have not received the hepatitis B vaccine or whose vaccination status is unknown, with no cost to the individual. We are also proposing to allow people with Medicare to get the hepatitis B vaccine from pharmacies and to allow pharmacies and mass immunizers to roster bill Medicare consistent with current billing for flu, pneumococcal, and COVID-19 vaccines.

CMS is also proposing a fee schedule for drugs covered as additional preventive services since CMS has not yet covered or paid for any drugs under the benefit category of additional preventive services. On July 12, 2023, CMS released a Proposed NCD for Pre-Exposure Prophylaxis (PrEP) for Human Immunodeficiency Virus (HIV) Infection Prevention, which proposes to cover HIV PrEP drugs under Part B as additional preventive services.

CMS is also proposing to update and expand coverage of colorectal cancer screening to promote access and remove barriers for much needed cancer prevention and early detection, that may be especially important within rural communities and communities of color.

Maintaining Telehealth Flexibilities

During the COVID-19 public health emergency, CMS took action to expand access to telehealth services to ensure people could continue to access health care. Congress’ temporary extension of flexibilities related to payment for many telehealth services is scheduled, by statute, to expire at the end of 2024. In that context, CMS continues to examine telehealth and its impact on access and quality. Proposals in this year’s rule would allow CMS to maintain some important, but limited, flexibilities where possible and reflect CMS’ goal to maintain and expand the scope of and access to telehealth services where appropriate. For example, these proposals would continue to permit certain practitioners to provide virtual direct supervision to auxiliary personnel when required. CMS is also proposing temporary extensions of virtual supervision for a broader range of services when teaching physicians virtually supervise telehealth services provided by residents in teaching settings. However, absent Congressional action, beginning January 1, 2025, the statutory restrictions on geography, site of service, and practitioner type that existed prior to the COVID-19 PHE will go back into effect. After that date, people with Medicare will need to be in a rural area and a medical facility to receive non-behavioral health services via Medicare telehealth.

Inflation Reduction Act Implementation

The Inflation Reduction Act, President Biden’s prescription drug law, discourages runaway price increases by drug companies by requiring them to pay rebates to Medicare when prices increase faster than the rate of inflation for certain drugs under Part B and Part D. Additionally, Part B drugs that have raised prices faster than inflation in a given quarter will have a lower Part B coinsurance amount in a subsequent quarter. CMS will invoice drug companies for rebates owed to Medicare for Part B drugs for all calendar quarters in 2023 and 2024 no later than September 30, 2025, and for rebates owed to Medicare for Part D drugs for the 12-month applicable periods beginning October 1, 2022, and October 1, 2023, no later than December 31, 2025. The rebate amounts paid by drug companies will be deposited into the Federal Supplementary Medical Insurance Trust Fund, which will help ensure the long-term sustainability of the Medicare program for future generations. The CY 2025 PFS proposed rule codifies and builds on finalized guidance to continue implementation of the inflation rebates and proposes the next phase of implementation.

The 60-day comment period for the CY 2025 PFS proposed rule (CMS-1807-P) ends September 9, 2024.

For a fact sheet on the CY 2025 Physician Fee Schedule proposed rule, please visit: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-proposed-rule .

For a fact sheet on the CY 2025 Quality Payment Program proposed changes, please visit: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2876/2025-QPP-Proposed-Rule-Fact-Sheet-and-Policy-Comparison-Table.pdf .

For a fact sheet on the proposed Medicare Shared Savings Program changes in the CY 2025 PFS proposed rule, please visit: https://www.cms.gov/newsroom/fact-sheets/fact-sheet-calendar-year-cy-2025-medicare-physician-fee-schedule-proposed-rule-cms-1807-p-medicare .

For a fact sheet on the proposed Medicare Prescription Drug Inflation Rebate Program changes in the CY 2025 PFS proposed rule, please visit: https://www.cms.gov/files/document/medicare-prescription-drug-inflation-rebate-program-proposed-rule-fact-sheet.pdf .

To view the CY 2025 Physician Fee Schedule and Quality Payment Program proposed rule, please visit: https://www.federalregister.gov/public-inspection/current .

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How dangerous are Fourth of July fireworks? Here's a look at the numbers.

As Independence Day rolls around, bookended by days of bangs and pops from professional and store-bought fireworks, it's worth a reminder to play it safe before lighting off that fuse.

We're in the middle of the Consumer Product Safety Commission's annual window for studying the safety and injury impact of fireworks. The numbers, while down slightly, still signal a need for safety reminders.

“While it is a great American tradition to enjoy fireworks around the 4th of July, it is important to remember that all fireworks, even sparklers, pose dangers to consumers," Alex Hoehn-Saric, chairman of the CPSC, said in the agency's annual statement on fireworks safety . "The safest way to view fireworks is to watch professional displays.”

Fireworks present dangers of physical injury, particularly to the hands and face, and environmental concerns in drier areas of the country.

Last year, fireworks accounted for an estimated 9,700 injuries resulting in hospital emergency room visits.

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How many people were injured or killed by fireworks in 2023?

Roughly 9,700 people were injured by fireworks in the U.S. in 2023, according to the report. This represents a third straight year of declines in injury numbers after a record 15,600 injuries in 2020 at the height of the COVID-19 pandemic.

Of the eight deaths that occurred in 2023 – all male victims ranging in ages 15 to 51 – five deaths were determined to have resulted from misuse of fireworks.

What body parts are commonly injured by fireworks?

In the 2023 study period, which ran from June 16 to July 16, hand and finger injuries made up more than a third of the 6,400 fireworks injuries that resulted in emergency room visits. Injuries above the neck – eyes, ears, face and head – accounted for a combined 41% of those injuries.

Of all the injuries in the study period, 42% of them were burn-related.

Fireworks sales, 1998 to 2023

According to figures from the American Pyrotechnics Association, spending on consumer-grade fireworks dipped slightly last year, while spending on professional display fireworks continued growth from the 2020 low caused by the pandemic when public gatherings were limited.

SOURCES 2023 Fireworks Annual Report, Consumer Product Safety Commission