Report: Percentage of Patients With Usual Source of Primary Care Declines
Americans with an ongoing primary care relationship dropped from 84 percent to 74 percent between 2000 and 2019, and ticked up only slightly in 2020, according to a new report published by the Primary Care Collaborative.
The “2022 Evidence Report: Relationships Matter. How Usual is Usual Primary Care?” was prepared by PCC and the Robert Graham Center. This report puts Usual Source of Care (USC) data from 2000-2020 in context and examines trends by age, demographic group, insurance product, and geography. These metrics matter, the report notes, because a usual source of care is associated with better population health, more equity, and lower costs.
The report provides recommendations for improving patient access to primary care providers, as well as actions for diversifying the workforce. Specifically, the report provides an in-depth analysis of the role of relationships and care from a consistent and familiar source, often primary, to patient care quality and satisfaction, while identifying a number of troubling trends that need to be addressed.
The report also found that:
• Hispanic individuals had a 66 percent higher rate of no usual source of care (USC) (34.3 percent) as compared to their White counterparts (20.7 percent) in 2019.
• Non-Hispanic Black individuals had a 38 percent higher rate of no USC (28.4 percent) as compared to their White counterparts (20.7 percent) in 2019.
• There was a 10 percent decline in USC for those with dual coverage (Medicare & Medicaid) between 2015 – 2020.
• 46 percent of 18–34-year-olds had no USC in 2019, up from 34 percent in 2014.
• In 2020, there was a spread of 27 percent points in USC across 50 states.
During a Nov. 16 panel session discussing the report, Asaf Bitton, M.D., M.P.H., executive director of Ariadne Labs at Harvard T.H. Chan School of Public Health and Brigham & Women's Hospital, said that we're nowhere near where we need to be in the U.S., in terms of having enough people having a usual source of care — in particular for those who might need it the most, including those who have high-complexity needs, those who are older or have comorbid conditions or who are younger and who have challenging life experiences, psychosocial conditions and physical conditions.
“When we see the incredible variation in uptake and access to usual source of care, that gives us concern. When we see that bifurcated by disparities, unfortunately, where those who are black, who are Hispanic, who are poor, who live in rural areas, have less access to resources, that's really concerning. And it's really hard to imagine how we reach our collective national state and local health goals without improving this,” Bitton said, “I think this is the challenge, honestly, that we have to state back to the policy community, to the payer community, to the provider community and to all stakeholders. It is high time to walk to the talk around improving primary care, and that's going to require different types of payment, different forms of payment, and a real focus on improving access to usual source of care. It's not enough for reports to be published or to say, oh, yeah, you're right, and then to spend 3 or 5 percent of total health spend on primary care. That's just not enough. If you're an ACO you cannot achieve your ACO goals without a more robust and more accessible primary care basis. If you are a health plan, you cannot achieve your goals without more and robust primary care. If you're a health system, if you're a health entity of your community, the pathway to the better health and better health equity that we know primary care provides goes through having a usual source of primary care and that usual source of primary care is not just any team or any person has to be a usual source of high-quality primary care with to really insert that quality mechanism.”
Adam Meyers, M.D., senior vice president and chief clinical transformation officer at Blue Cross Blue Shield Association, stressed that relationships matter. “We're at our core human beings and we are built for relationships, and care delivery systems really necessitate having relationship in order to be most effective,” he said. “The outcomes bear that out in that where there's a usual source of care that functions in that relational manner, outcomes, experience, and affordability are all enhanced.
Meyers said he thinks that there in their care relationships people want to feel heard and understood as a human being. They want to feel like they are part of a process of determining their own health outcomes, understanding the physiological issues that they face and are part of determining the care plan. They want shared decision-making.
They want to feel that they're being cared for by a team of people that is communicating with each other and on the same page. “I can think of no other sort of milieu in which all of those boxes are checked rather than through a usual source of care such as primary care,” Meyers said. “Now, we certainly have seen a decline, as the research here suggests, in that usual source of care uptake, and it's certainly multifactorial, but I think the fee for service nature of our payment paradigm certainly contributes to that through the transactional nature of it.”
Prior to joining the Association in September 2021, Meyers served as the Cleveland Clinic’s chief of population health and director of the Cleveland Clinic Community Care program, where he provided leadership to a wide variety of clinical and residency programs, as well as the center for value-based research.
He said alternative payment models offer opportunities to improve primary care.
In the fee for service model, Meyers e said, “what you found was the typical pattern of people seeing a patient every 15 minutes or so almost on a treadmill of sorts. Not much time for thought, not much time for proactive panel management. The economics didn't support team-based care. It made access difficult for people to get in when and how they wanted to,” he said. Cleveland Clinic began a transition toward upfront payment models. “By the time we finished that transition, more than half of all of the revenue for primary care there was from a guaranteed upfront payment model in the primary care space,” he explained. “That enabled us to invest in teams where we had behavioral health, social workers, pharmacists, and other types of team members embedded in the practices because we had the revenue. The teams actually had time periods where there are no patients scheduled in the office and they sat down and said not just who's on our schedule, but who's on our panel that needs our attention, so that we can reach out to them? Changing the payment paradigm led to a care model redesign process that led to better outcomes for the patients, better experience for the patients, greater affordability of the overall spend, and importantly, the practice of medicine turned back into what they desire to go into in the first place. There was that relationship continuity, and the rewards were present. I think it was really a tremendous shift. However, it required at first a payment paradigm shift.”
