Characteristics of Americans With Primary Care and Changes Over Time, 2002-2015 | Health Care Delivery Models | JAMA Internal Medicine | JAMA Network
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Figure.  Nationally Representative Sample of Adult Americans With an Identified Source of Primary Care, 2002-2015
Nationally Representative Sample of Adult Americans With an Identified Source of Primary Care, 2002-2015

A, Americans with primary care, by age. B, Americans with primary care and no comorbidities, by age. C, Americans with primary care and 3 or more comorbidities, by age. Error bars are unadjusted 95% CIs.

Table.  Nationally Representative Sample of Adult Americans With and Without Primary Care, 2002-20151
Nationally Representative Sample of Adult Americans With and Without Primary Care, 2002-2015
1.
Levine  DM, Landon  BE, Linder  JA.  Quality and experience of outpatient care in the United States for adults with or without primary care.  JAMA Intern Med. 2019;179(3):363-372. doi:10.1001/jamainternmed.2018.6716PubMedGoogle ScholarCrossref
2.
Basu  S, Berkowitz  SA, Phillips  RL, Bitton  A, Landon  BE, Phillips  RS.  Association of primary care physician supply with population mortality in the United States, 2005-2015.  JAMA Intern Med. 2019;179(4):506-514. doi:10.1001/jamainternmed.2018.7624PubMedGoogle ScholarCrossref
3.
Mehrotra  A.  The convenience revolution for treatment of low-acuity conditions.  JAMA. 2013;310(1):35-36. doi:10.1001/jama.2013.6825PubMedGoogle ScholarCrossref
4.
Linder  JA, Levine  DM.  Health care communication technology and improved access, continuity, and relationships: the revolution will be Uberized.  JAMA Intern Med. 2016;176(5):643-644. doi:10.1001/jamainternmed.2016.0692PubMedGoogle ScholarCrossref
5.
Levine  DM, Linder  JA.  Retail clinics shine a harsh light on the failure of primary care access.  J Gen Intern Med. 2016;31(3):260-262. doi:10.1007/s11606-015-3555-4PubMedGoogle ScholarCrossref
6.
Miller  S, Wherry  LR.  Health and access to care during the first 2 years of the ACA Medicaid expansions.  N Engl J Med. 2017;376(10):947-956. doi:10.1056/NEJMsa1612890PubMedGoogle ScholarCrossref
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    1 Comment for this article
    EXPAND ALL
    It's our culture and the system, stupid!
    Jeoffry Gordon, MD, MPH | solo family doctor
    For at least 30 years the ratio of specialists to primary providers (docs, PAs, and RNPs) in the US has been around 2:1 (with the marked exception of the Kaiser system). In most other advanced, industrialized nations the ratio is the reverse with 2 primary care providers for every specialist. Many studies show this not only produces more satisfaction and continuity of care, with higher quality on many parameters, but also less 'excessive' care, all with less cost on the aggregate.
    Lower use of primary care is built into the system, by the types of docs we educate, to the
    debt burden of education (almost 50% of graduates have $200,000 in loans or more), to the reembursement system which has always paid procedures in medical care (specialists) disproportionately more than cognitive care, to the emphasis on high tech medicine which often produces only marginal benefit at high cost. All of this validly reflects the culture of America and the public policies it generates and supports.
    CONFLICT OF INTEREST: None Reported
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    Views 2,956
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    Research Letter
    Health Care Reform
    December 16, 2019

    Characteristics of Americans With Primary Care and Changes Over Time, 2002-2015

    Author Affiliations
    • 1Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Harvard Medical School, Harvard University, Boston, Massachusetts
    • 3Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
    • 4Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
    • 5Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    JAMA Intern Med. 2020;180(3):463-466. doi:10.1001/jamainternmed.2019.6282

    Receipt of primary care is associated with better health.1,2 Despite the benefits of primary care, Americans’ receipt of primary care, changes in receipt of primary care over time, and differences in receipt of primary care according to sociodemographic and clinical characteristics are not well known.

    Methods

    We analyzed data from the nationally representative Medical Expenditure Panel Survey (21 915-26 509 individuals yearly) from 2002 through 2015. We used a patient-centered definition of primary care that included the 4 C’s of primary care: first contact, comprehensive, coordinated, and continuous. To estimate factors associated with receiving primary care over time, we used multivariable logistic regression, adjusting for each year from 2002 through 2015;sociodemographic and clinical variables, presented in the Table; and the complex survey design. We examined having primary care over time by decade of age and stratified by comorbidity. We performed all analyses with SAS statistical software (version 9.4, SAS Institute). The Harvard Medical School Institutional Review Board approved this study and determined it not to be human subject research, so patient informed consent was waived.

    Results

    The proportion of adult Americans with an identified source of primary care decreased from 77% (95% CI, 76%-78%) in 2002 to 75% (95% CI, 74%-76%) in 2015 (odds ratio, 0.90 [95% CI, 0.82-0.98]). During this period, receipt of primary care decreased for every decade of age except for Americans in their 80s, with statistically significant reductions for those in their 30s, 40s, and 50s (Figure, A). For example, 71% of Americans in their 30s had primary care in 2002 compared with 64% in 2015 (P < .001).

    Among Americans with no comorbidities (60% [95% CI, 59%-61%] in 2002 and 51% [95% CI, 50%-52%] in 2015), receipt of primary care decreased for every decade of age (Figure, B). For example, for Americans in their 60s with no comorbidities, having primary care fell from 82% in 2002 to 73% in 2015 (P = .003). Having primary care for Americans with at least 3 comorbidities was generally stable (Figure, C).

    In multivariable modeling, factors associated with a decreased likelihood of having primary care included calendar year (adjusted odds ratio [aOR], 0.97 for each year from 2002 through 2015 [95% CI, 0.97-0.98]), male sex (aOR vs female sex, 0.59 [95% CI, 0.57-0.60]), Latino race/ethnicity (aOR vs white, 0.80 [95% CI, 0.77-0.84]), black race/ethnicity (aOR vs white, 0.88 [95% CI, 0.84-0.93]), Asian race/ethnicity (aOR vs white, 0.67 [95% CI, 0.62-0.74]), not having insurance (aOR vs private insurance, 0.29 [95% CI, 0.27-0.30]), and Southern US Census Bureau region (aOR vs Northeast, 0.53 [95% CI, 0.48-0.58]) (Table).

    Discussion

    From 2002 through 2015, a decreasing proportion of Americans had an identified source of primary care, especially Americans who were younger, less medically complex, of minority background, or living in the South. To improve Americans’ health in an efficient and cost-effective manner, policy makers should prioritize increasing the proportion of Americans with primary care.

    The decrease in receipt of primary care, particularly among younger patients or patients with no chronic medical conditions, may be related to their choosing nonlongitudinal interactions over continuity, perhaps related to the convenience revolution3 and a perception that primary care has failed to adopt new modes of delivering treatment that might be more accessible to patients.4,5 Financial barriers, especially among uninsured Americans, may prevent some people from accessing primary care. Shortages in the availability of primary care may pose access barriers even to insured people, with the result that fewer younger and healthier patients have a regular source of care.6

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    Article Information

    Corresponding Author: David M. Levine, MD, MPH, MA, Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, 1620 Tremont St, 3rd Floor, Boston, MA 02120 (dmlevine@bwh.harvard.edu).

    Published Online: December 16, 2019. doi:10.1001/jamainternmed.2019.6282

    Author Contributions: Dr Levine 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. Drs Linder and Landon contributed equally to this article.

    Concept and design: All authors.

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

    Drafting of the manuscript: Levine, Linder.

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

    Statistical analysis: Levine, Linder.

    Administrative, technical, or material support: Levine, Linder.

    Supervision: Linder, Landon.

    Conflict of Interest Disclosures: Dr Levine reports funding through Biofourmis to perform a machine learning study of home-based acute care monitoring. No other disclosures were reported.

    References
    1.
    Levine  DM, Landon  BE, Linder  JA.  Quality and experience of outpatient care in the United States for adults with or without primary care.  JAMA Intern Med. 2019;179(3):363-372. doi:10.1001/jamainternmed.2018.6716PubMedGoogle ScholarCrossref
    2.
    Basu  S, Berkowitz  SA, Phillips  RL, Bitton  A, Landon  BE, Phillips  RS.  Association of primary care physician supply with population mortality in the United States, 2005-2015.  JAMA Intern Med. 2019;179(4):506-514. doi:10.1001/jamainternmed.2018.7624PubMedGoogle ScholarCrossref
    3.
    Mehrotra  A.  The convenience revolution for treatment of low-acuity conditions.  JAMA. 2013;310(1):35-36. doi:10.1001/jama.2013.6825PubMedGoogle ScholarCrossref
    4.
    Linder  JA, Levine  DM.  Health care communication technology and improved access, continuity, and relationships: the revolution will be Uberized.  JAMA Intern Med. 2016;176(5):643-644. doi:10.1001/jamainternmed.2016.0692PubMedGoogle ScholarCrossref
    5.
    Levine  DM, Linder  JA.  Retail clinics shine a harsh light on the failure of primary care access.  J Gen Intern Med. 2016;31(3):260-262. doi:10.1007/s11606-015-3555-4PubMedGoogle ScholarCrossref
    6.
    Miller  S, Wherry  LR.  Health and access to care during the first 2 years of the ACA Medicaid expansions.  N Engl J Med. 2017;376(10):947-956. doi:10.1056/NEJMsa1612890PubMedGoogle ScholarCrossref
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