Primary Care Spending in the US Population

Abstract

This survey study assesses the 2019 spending estimates on checkups, well-child visits, and diagnosis or treatment provided by primary care physicians, nurses, nurse practitioners, and physician's assistants.

Many recent health policy initiatives emphasize primary care. For example, the Affordable Care Act expanded primary care residency slots and implemented Medicare and Medicaid payment enhancements to primary care physicians. Previous work has described primary care spending in the Medicare fee-for-service population¹ and a sample of the commercially insured population.² In this survey study, we assessed primary care spending in the entire US community population regardless of insurance source.

Methods

We analyzed primary care spending estimates from the Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the US civilian, noninstitutionalized population, and their medical practitioners. All analyses were conducted under a protocol approved by Advarra Institutional Review Board. We followed the AAPOR reporting guideline.

Primary care visits were defined as visits to nurses, nurse practitioners, physician's assistants, or physicians in general or family practice, pediatrics, geriatrics, internal medicine, or obstetrics/gynecology (if not pregnancy-related) specialties. This definition is similar to the broad definitions provided in other studies.^1,2,3 We reported 2019 estimates of primary care spending, total medical spending, percentage of medical spending on primary care visits, and percentage with 0 spending on primary care visits. We analyzed race and ethnicity data to test whether primary care spending was greater in some groups compared with others. Estimates used sample weights and were compared by characteristic using unpaired, 2-tailed t tests, accounting for the MEPS complex design. A 5% level indicated statistical significance. Statistical analysis was performed from September 8, 2022, through April 3, 2023, using Stata 17.0 (StataCorp LLC).

Results

A total of 28 512 MEPS participants (mean [SE] age, 38.6 [0.3] years) were included in the sample. Weighted percentages for participants included 51.1% females, 49.1% males, 18.5% Hispanic, 12.3% non-Hispanic Black, 59.7% non-Hispanic White individuals, and 9.6% non-Hispanic individuals of other races and ethnicities (including Alaska Native, American Indian, Asian, Native Hawaiian, Pacific Islander, and multiple races). Primary care spending in 2019 totaled $439 per person (Table). Spending was highest for the Medicare population ($736) and lowest for the uninsured population ($78); spending was $461 for those with group private insurance.

Table. Use of Primary Care in 2019 According to the MEPS^a.

	Primary care spending, $b	Total medical spending, $c	Percentage of medical spending on primary care visitsb	Percentage with 0 spending on primary care visitsb
All MEPS participants	439	6252	7.0	40.5
Sex
Female	529d	6738d	7.8d	34.4d
Male [Reference]	345	5747	6.0	46.9
Health status
Good or better [Reference]	374	4878	7.7	41.8
Fair or poor	1020d	18 301d	5.6d	28.4d
Economic status
Income above the FPL [Reference]	441	6207	7.1	39.8
Income at or below the FPL	424	6588	6.4	46.2d
Residential area
Metropolitan area [Reference]	427	6150	6.9	41.0
Nonmetropolitan area	518	6929d	7.5	37.2d
Age, y
≤18 [Reference]	324	2846	11.4	36.1
19-44	322	3889d	8.3d	54.6d
45-64	570d	8435d	6.8d	37.9
≥65	651d	12 828d	5.1d	20.4d
Race and ethnicitye
Hispanic	291d	3878d	7.5	52.7d
Non-Hispanic Black	335d	5557d	6.0	49.0d
Non-Hispanic White [Reference]	514	7329	7.0	34.4
Non-Hispanic Otherf	386d	5003d	7.7	44.3d
Insurance type for full yearg
Private insurance [Reference]	457	5220	8.7	39.5
Group	461	4841	8.7	38.6
Nongroup	428	5272	8.8	46.7d
Medicaid	267d	3623d	7.4	42.1d
Medicare	736d	13 888d	5.3d	20.3d
Uninsured	78d	1103d	7.1	79.9d
Region
Northeast [Reference]	396	6622	6.0	38.1
Midwest	541d	7133	7.6d	35.1d
South	440	5565d	7.3d	41.2d
West	468	5991	7.3	44.8d

Abbreviations: FPL, federal poverty level; MEPS, Medical Expenditure Panel Survey.

^a Mean estimates were calculated using 2019 MEPS sample weights, and comparisons accounted for the complex design of the MEPS.

^b Primary care visits consist of those in a medical office or an outpatient facility for a general checkup, well-child examination, or diagnosis or treatment. For a visit to be considered a primary care visit, the specialty of the physician seen (if one was seen) must be general or family practice, pediatrics, geriatrics, or internal medicine. Visits where the clinician seen is a nurse, nurse practitioner, or physician's assistant are also included, as are visits to an obstetrician-gynecologist that are not pregnancy related.

^c The measure of spending includes spending on direct medical care; it does not include spending on long-term care, acute care expenditures for those institutionalized, public health activities, disproportionate share, direct graduate medical education, or other lump-sum payments to clinicians (eg, bonuses).

^d Indicates that the value is significantly different (5% level) from the value of the reference category.

^e Race and ethnicity were reported for each member of a household by 1 MEPS respondent in the household.

^f Non-Hispanic Other included Alaska Native, American Indian, Asian, Native Hawaiian, Pacific Islander, and multiple races.

^g Categorization by insurance type omits the approximately 14% of the sample who change their insurance type during the year.

The percentage of medical spending on primary care was 7.0% for the population and was lower for those 65 years or older (5.1%), those in worse health (5.6%), and those with Medicare (5.3%). Nearly 41% of the population had 0 primary care spending. This percentage was higher for Hispanic (52.7%), non-Hispanic Black (49.0%), and non-Hispanic other (44.3%) individuals and 79.9% for uninsured individuals (Table).

Discussion

Primary care spending varied significantly by insurance type and area. The estimated 5.3% spending on primary care for the Medicare population in 2019 was similar to the 4.9% estimate in 2015.¹ The estimated $461 spending for those with group private insurance in 2019 was in between the estimated amounts for a commercially insured sample using narrow ($291) and broad ($538) definitions of primary care.²

The study is limited by MEPS being subject to underreporting of medical visits, although MEPS produces nationally representative estimates of primary care spending for all insurance sources. The degree of underreporting varies little by population characteristics: age, sex, race and ethnicity, and insurance source,⁴ and MEPS data are used to derive official estimates of national health care spending.⁵ Imputation of some price data produces unbiased expenditure estimates, but MEPS variance estimates do not account for imputation.

Several states have established targets for insurers’ share of primary care spending under the assumption that higher shares are better.⁶ Because this share varies by characteristic, adjusting targets for some characteristics, such as age, may be needed, although having different targets for other characteristics, such as race and ethnicity, is problematic. Consensus on the ideal share of medical spending on primary care may be difficult to reach, but the large fraction of the population with no primary care spending, especially among uninsured individuals, seems likely to be suboptimal.

Supplement.

Data Sharing Statement