Decreasing Use of Primary Care: A Repeated Cross-Sectional Study of MEPS 2007-2017

Drs Johansen and Niforatos are commended for their detailed analysis of MEPS identifying decreasing primary care visits. This is important information and critical to policy planning. Also, such technical work is an example of what can be done with MEPS.

I offer some comments in reflection of this work.

(1) The 10-year MGMA data through 2019 also documents declining trends primary care productivity - but in annual encounters and wRVUs. Not quite the same but perhaps trending down productivity is a contributing reason.

(2) The absence of PA and NP in delivering primary care makes the findings a bit cautious. As of 2020 there are 140,000 PAs and 210,000 NPs clinically active in the US (BLS 2021). One third of PAs and 2/3 of NPs work in "primary care." PAs & NPs are the elephant in the room and to ignore their contributions to meeting primary care needs and service is to ignore a 50-year trend in American medicine. Nor is their productivity anything less than physicians' in the same setting.

(3) Hedden et al. (2017) showed that family medicine was declining in annual productivity, the main reason being changing attitudes about work vs leisure and the growing feminization of the family medicine workweek. The AAMC has validated the declining workweek for physicians.

(4) Predictions about primary care being replaced by non-primary care was made in 2011 by by the late RA 'Buz' Cooper and colleagues (Sargen et al. 2011). His argument was that Americans want direct access to speciality care - already a trend underway at the time. This prediction may have been prescient. Such direct access has been implemented in many health plans.

(5) The NAMCS trend analysis identifies that the number of visits per capita is increasing (20-year trend). If we match this data with MEPS it seems more annual visits are occuring but perhaps not to primary care.