Between 2012 and 2016, primary care office visits to a physician declined by 18% and a 129% increase was reported in office visits to nurse practitioners (NPs) and physician assistants (PAs) among adults younger than age 65 with employer-based health insurance, according to the 2016 Health Care Cost and Utilization Report, published by the Health Care Cost Institute.

The report compiled 2 analytic data samples to generate a national, multi-payer, commercial health care claims database using data from Aetna, Humana, Kaiser Permanente, and United Healthcare. The investigators analyzed visits per 1000 adults (aged <65 y) who were insured by employers and examined data from 2009 to 2016.

Compared with primary care physician office visits, a 14% increase was reported in non-primary care physician office visits, which included physician specialists, NPs and PAs, all other non-physician providers, and unknown providers. A 2% decline was seen in all office visits per 1000 people.

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Office visits to primary care physicians decreased from 1510 per 1000 members in 2012 to 1237 per 1000 members in 2016 (-18%). In the same timeframe, office visits to NP and PA providers increased from 88 per 1000 members to 201 per 1000 members (129%) and accounted for 42% of the total decline in primary care physician visits. No significant changes were noted for specialist and other nonphysician visits.

Average costs for a visit to a primary care physician in 2012 ($92) and 2016 ($106) did not dramatically differ from NP/PA visit costs during the same time periods ($93 vs $103, respectively).

In addition, during the same time period the investigators noted that although the number of office visits to a primary care physician decreased in every state, the number of visits to a PA or NP increased in every state. The cumulative decline in visits to a primary care physician varied from 6% in Washington, DC to 31% in North Dakota. For visits to an NP or PA, the cumulative increase ranged from 37% in New Mexico to 285% in Massachusetts. Some factors that possibly influenced these results include state policies, insurance benefit variations, and variations in accessibility of provider types.

“Having more NPs and PAs provide primary care may ease potential shortages in [primary care physicians] and allow [these physicians] to focus on more clinically complex primary care,” the authors of the report noted. “However, the laws governing scope of practice for these nonphysician providers vary widely by state,” with some states permitting full practice authority and others mandating oversight of a physician.

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“Our work demonstrates that there is geographic variation in office visit utilization, which is likely influenced by differences in these laws, but more research is needed on those relationships,” the authors concluded.



Frost A, Hargraves J. HCCI brief: trends in primary care visits. Health Care Costs Institute. Published October 2018. Accessed November 20, 2018.