Abstract
This study uses Health Care Cost Institute data to assess the share of total health care spending on primary care among individuals younger than 65 years covered by employer-sponsored insurance from 2013 to 2017.
Efforts to increase the value of health care by allocating more resources to primary care have used the share of total health care spending attributed to primary care as a measure of success. A 2019 study found that primary care represented 2% to 5% of total spending among Medicare fee-for-service beneficiaries in 2015.1 We assessed the share among individuals younger than 65 years covered by employer-sponsored insurance from 2013 to 2017.
Methods
Using Health Care Cost Institute data from 3 national payers, representing 26% of US individuals covered by employer-sponsored insurance, 3 annual measures were calculated. First, the share of total spending on services rendered by primary care clinicians (PCCs) was calculated (broad definition). Similar to previous studies,1,2 PCCs included family practice, geriatric medicine, gynecology, internal medicine, or pediatric physicians; physician assistants; or nurse practitioners on more than 50% of professional claims. Hospitalists were excluded. Second, the share of spending on primary care services rendered by PCCs, defined by Current Procedural Terminology codes, including evaluation and management visits, vaccinations, care planning, and other related services, was calculated (narrow definition). Third, utilization was calculated as the share of individuals who received at least 1 service from a PCC. The measures were assessed in the overall sample and in subgroups by age. Spending was defined as the total amount paid by the insurer and individual. Individuals with 12 months of medical and prescription drug coverage and positive total spending, including medical care and prescription drugs, in a calendar year were included. Spending was inflation-adjusted to 2017 US dollars using the Consumer Price Index.
To determine differences between 2013 and 2017, Wilcoxon signed-rank tests and logistic regressions were calculated for the share of PCC spending and utilization, respectively. Statistical significance was defined as a 2-sided P < .05. Analyses were conducted using SAS, version 9.4 (SAS Institute).
Results
Under the broad definition, mean primary care spending increased from $511 among 11 406 520 individuals in 2013 to $538 among 11 608 038 individuals in 2017 (Table 1), but declined as a share of total spending from 8.97% to 8.04% (difference, −0.93% [95% CI, −0.95% to −0.91%]; P < .001) (Table 2). Mean total spending increased from $5701 to $6688. Children had the highest primary care spending as a share of their total health care spending, with 20.33% in 2013 and 19.54% in 2017 (P < .001), and individuals aged 55 to 64 years had the lowest, with 7.25% in 2013 and 6.33% in 2017 (P < .001).
Table 1. Mean Health Care and Primary Care Spending by Age.
| Individuals by Age Group, y | No. of Individuals | Mean Spending in 2017, US $ | ||||||
|---|---|---|---|---|---|---|---|---|
| Total (Medical and Drug)a | Primary Care Clinician | |||||||
| Broad Definition | Narrow Definition | |||||||
| 2013 | 2017 | 2013 | 2017 | 2013 | 2017 | 2013 | 2017 | |
| Total | 11 406 520 | 11 608 038 | 5701 | 6688 | 511 | 538 | 262 | 291 |
| 0-17 (Children) | 2 778 902 | 2 656 739 | 2600 | 3007 | 529 | 588 | 356 | 376 |
| 18-24 | 991 142 | 979 503 | 3669 | 4144 | 319 | 351 | 167 | 187 |
| 25-34 | 1 411 538 | 1 491 395 | 4582 | 5113 | 351 | 362 | 173 | 191 |
| 35-44 | 1 858 028 | 1 847 887 | 5381 | 6192 | 421 | 435 | 212 | 237 |
| 45-54 | 2 256 798 | 2 216 787 | 7271 | 8366 | 544 | 553 | 249 | 284 |
| 55-64 | 2 110 112 | 2 415 727 | 10 087 | 11 575 | 731 | 733 | 303 | 348 |
To facilitate comparisons with previous work, prescription drug spending was included in the denominator. Because data on drug rebates are not available, the calculations reflect gross spending. If rebates increased faster than gross spending, the findings overstate the decline in primary care share.
Table 2. Utilization and Share of Total Health Care Spending Attributed to Primary Care.
| Individuals by Age Group, y | Share of Total Health Care Spending in 2017, US $ | Individuals With Primary Care Clinician Utilization | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Broad Definition | Narrow Definition | |||||||||||
| 2013, % | 2017, % | Difference, % (95% CI) | P Value | 2013, % | 2017, % | Difference, % (95% CI) | P Value | 2013, % | 2017, % | Difference, % (95% CI) | P Value | |
| Total | 8.97 | 8.04 | –0.93 (–0.95 to –0.91) | <.001 | 4.60 | 4.35 | –0.25 (–0.27 to –0.23) | <.001 | 78.35 | 79.65 | 1.30 (1.27-1.34) | <.001 |
| 0-17 (Children) | 20.33 | 19.54 | –0.79 (–0.82 to –0.76) | <.001 | 13.68 | 12.51 | –1.17 (–1.20 to –1.14) | <.001 | 89.99 | 90.71 | 0.72 (0.70-0.74) | <.001 |
| 18-24 | 8.69 | 8.48 | –0.21 (–0.23 to –0.19) | <.001 | 4.55 | 4.52 | –0.03 (–0.05 to –0.01) | .03 | 66.77 | 69.23 | 2.46 (2.42-2.50) | <.001 |
| 25-34 | 7.66 | 7.07 | –0.59 (–0.61 to –0.19) | <.001 | 3.77 | 3.74 | –0.03 (–0.05 to –0.01) | .001 | 65.82 | 67.27 | 1.45 (1.41-1.49) | <.001 |
| 35-44 | 7.82 | 7.02 | –0.80 (–0.82 to –0.78) | <.001 | 3.94 | 3.82 | –0.12 (–0.14 to –0.10) | <.001 | 72.89 | 73.95 | 1.06 (1.02-1.10) | <.001 |
| 45-54 | 7.47 | 6.61 | –0.86 (–0.88 to –0.84) | <.001 | 3.43 | 3.40 | –0.03 (–0.04 to –0.02) | <.001 | 77.48 | 79.11 | 1.63 (1.60-1.66) | <.001 |
| 55-64 | 7.25 | 6.33 | –0.92 (–0.94 to –0.90) | <.001 | 3.00 | 3.01 | 0.01 (0.00 to 0.02) | .26 | 82.59 | 84.23 | 1.64 (1.61-1.67) | <.001 |
Under the narrow definition, the primary care spending share declined from 4.60% to 4.35% (difference, −0.25% [95% CI, −0.27% to −0.23%]; P < .001). This decline was accounted for by children, for whom the share decreased from 13.68% to 12.51% (P < .001). The primary care spending share under this definition did not change substantially for any other age group. The share of individuals utilizing a PCC increased from 78.35% in 2013 to 79.65% in 2017 (difference, 1.30% [95% CI, 1.27%-1.34%]; P < .001) and varied across age groups (Table 2).
Discussion
From 2013 to 2017, the share of total spending attributed to primary care declined among individuals covered by employer-sponsored insurance despite an increase in PCC utilization and spending on primary care because total spending grew more quickly. Primary care may be both a substitute for and complement to non–primary care services.3 As a substitute, primary care may decrease spending for specialty and inpatient care, where services are more expensive.4 As a complement, it may increase utilization of more expensive care because patients are referred to a broader network of clinicians.5 A better understanding of the relationship between primary care and specialty utilization and spending is needed.
The estimates of primary care spending share are higher than estimates among Medicare fee-for-service beneficiaries,1 and fall between other estimates of individuals covered by employer-sponsored insurance using a convenience sample of insurers2 and Medical Expenditure Panel data.6
Factors affecting primary care spending, such as patient and PCC demographics and insurance plan benefit design, were not studied. The data may not be representative of the entire employer-sponsored insurance population.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
- 1.Reid R, Damberg C, Friedberg MW. Primary care spending in the fee-for-service Medicare population. JAMA Intern Med. 2019;179(7):977-980. doi: 10.1001/jamainternmed.2018.8747 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Bailit MH, Friedberg MW, Houy ML. Standardizing the Measurement of Commercial Health Plan Primary Care Spending. New York, NY: Milbank Memorial Fund; 2017. https://www.milbank.org/wp-content/uploads/2017/07/MMF-Primary-Care-Spending-Report.pdf. Accessed November 14, 2019.
- 3.Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. doi: 10.1111/j.1468-0009.2005.00409.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Fortney JC, Steffick DE, Burgess JF Jr, Maciejewski ML, Petersen LA. Are primary care services a substitute or complement for specialty and inpatient services? Health Serv Res. 2005;40(5 Pt 1):1422-1442. doi: 10.1111/j.1475-6773.2005.00424.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Aff (Millwood). 2013;32(4):686-694. doi: 10.1377/hlthaff.2012.1242 [DOI] [PubMed] [Google Scholar]
- 6.Jabbarpour Y, Greiner A, Jetty A, et al. . Investing in Primary Care: A State-Level Analysis New York, NY: Patient-Centered Primary Care Collaborative; 2019. https://www.pcpcc.org/sites/default/files/resources/pcmh_evidence_report_2019.pdf. Accessed November 14, 2019.