A few weeks ago, a headline in the Chicago Tribune grabbed my attention: “Millennials are trading primary care doctors for faster, cheaper alternatives.” This headline fits the rather unfortunate stereotype of millennials as impatient, job-hopping, financially-struggling, digital natives.
But if this is true, then millennials are bound to “swipe left” to health care delivered in a way that demands patience, commitment, and still relies heavily on the fax machine. Primary care often comes with a wait, usually requires insurance, emphasizes a relationship between the patient and provider and, well, still rarely comes with an app.
Citing Kaiser Family Foundation polling conducted specifically for the news article, the Tribune reports that millennials are less likely than other ages groups to report having a primary care physician (some 28% of 18-to-29-year-olds report going without, compared to 18% of adults ages 50 to 64).
And this made me wonder whether such choices by millennials—born in the 1980s through the early 2000s, who will next year become the largest demographic in the U.S. population—will begin to shape the way health care is delivered. And it made me wonder whether primary care, which has for years struggled for new recruits, will eventually go the way of the dinosaur. Will the surviving primary care practices evolve into birds: smaller, lighter, and much more mobile?
The value of primary care
Currently, primary care is designed to be the point of first contact in the medical system. Other key elements of primary care practice are an emphasis on continuity of care, comprehensiveness (an emphasis on treating common conditions in the community), and coordinating more specialized care when needed. Decades of research [PDF] have shown that countries that emphasize primary care do better on a range of health and health care system performance measures. Even among lower and middle-income countries, primary care uniquely contributes to better population health.
But the ability of primary care to improve population health will be limited in the U.S. if the most recent estimate [PDF] of primary care provider shortages by the American Association of Medical Colleges (up to 55,000 doctors by 2032) holds true. Today, only one-third (33%) of physicians in the US are practicing primary care (compared to about 70% in most other developed countries and in the United States fifty years ago). Physician assistants (PAs) help fill some gaps, but only about one-quarter [PDF] practice primary care. Over three-quarters (78%) of nurse practitioners (NPs) practice primary care, but the majority of states restrict the ability of NPs (and PAs) to practice independently.
Reshaping how primary care is delivered
In addition to provider supply issues, there are other forces shaping the field of primary care.
The pressure for solo primary care practitioners to join larger practices echoes the trends that we have seen among bookstores, grocery stores, and restaurants. Smaller shops lose out to the competitive advantages and efficiencies of larger ones. And in health care, provider consolidation seems especially aggressive in areas dominated by just a few health insurers (possibly because consolidation strengthens negotiating power).
Beyond that, retail clinics in pharmacies and “big box” stores are increasingly common. Today there are estimated to be more than 2,000 of these instant clinics [PDF], and most have somewhat extended hours beyond a typical primary care practice, including weekends. Their prices are usually listed on a “menu”, and they are nearly always staffed by NPs.
With many health insurers now including coverage for these clinics and, more ominously, with major mergers between retail clinics, pharmacies, and insurers (such as CVS Health and Aetna), there is likely to be even more emphasis on the use of these clinics. The chief medical officer for CVS, interviewed by the New York Times, envisions retail clinics playing a much bigger role in monitoring and managing patients’ health, becoming more like full primary care.
The greatest speculation, of course, is whether Amazon jumps in. They appear poised.
Adjusting to a new normal
These rapid changes in primary care would seem to speak to the needs of many millennials. However, I’m hesitant to believe that these forces will replace the primary care system as we know it. The days of solo primary care practitioners may be numbered, and retail clinics may absorb some of the routine functions of primary care offices. But there is a lot of space between such acute, short-term delivery and complex specialty care.
For those who develop anything beyond a urinary tract or upper respiratory infection, primary care fills that space. Ongoing conditions like asthma, high blood pressure, or diabetes allow the skills of a primary care provider acting as a personal health care “coach” to shine. I’ve argued before that care coordination may, in fact, be the most powerful ingredient in the delivery of primary care.
Lastly, millennials are a socially conscious bunch. Getting the majority of their primary care from Walmart or Amazon is at least somewhat at odds with their reported preference for authentic experiences, their skepticism of large corporations, and their support for brands that embrace social causes. Rather than dismantling primary care, it may turn out that this generation swipes right on primary care — with a focus on social good.
Gregory Stevens