From 2008 to 2016, a sharp decrease in primary care visits among pediatric patients with commercial insurance was observed, according to study results published in JAMA Pediatrics. This decrease was seen across all demographic groups, geographic regions, and patient groups with the exception of children with behavioral and psychiatric diagnoses, noted the researchers.  

Despite policy interventions, including the Affordable Care Act, to improve access to preventative primary care, the authors found several factors that may account for the drop in primary care visits. “Potential explanations for these trends could include replacement of primary care visits with other sites of care [urgent care, retail clinics, specialty care]; increased out-of-pocket costs creating a disincentive to primary care; rise in other nonfinancial barriers to primary care; or decreased need for primary care,” the authors noted.

To study trends in pediatric visits to primary car clinicians, the investigators used claims data from 2008 to 2016 among commercially insured children aged 17 and younger. The researchers also measured out-of-pocket costs, patterns in patient and visit characteristics, and changes in alternative care options.

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Using data from more than 71 million pediatric primary care visits across 29 million pediatric child-years, the unadjusted rate of primary care visits dropped from 259.6 to 227.2 per 100 child-years (regression-estimated change of -14.4% from 2008 to 2016; absolute change: -32.4 visits per 100 child-years). The regression-estimated change in primary care visit rates was -12.9% after adjusting for changes in demographics.

Children in the youngest measured age groups (aged 0-1 years) had the smallest regression-estimated change in primary care visit rates (-6.0%), while children who lived in ZIP codes with the lowest median incomes and in the South were reported to have the greatest changes (-16.9% and -19.8%, respectively).

In the studied timeframe, the rate of preventive primary care visits increased from 74.9 to 83.2 visits per 100 child-years (9.9%), whereas problem-based primary care visits dropped from 184.7 to 144.1 per 100 child-years (-24.1%). Of note, psychiatric and behavioral health visits were the only problem-based diagnosis groups to increase (42.0%) during the duration of the study.

From 2008 to 2016, 75th percentile out-of-pocket costs for problem-based visits increased from $31 to $50 but decreased for preventive visits from $26 to $0. The number of visits to alternative facilities such as emergency departments, urgent care, retail-based clinics, and telemedicine increased from 21.3 to 27.6 visits per 100 child-years. Specialist visit rates also increased from 45.2 to 53.5 per 100 child-years. However, the overall rate of visits across primary care, acute venues, and specialists decreased by -0.9%.

“Limitations of our study include that, as an analysis based on claims data, we lack clinical records and data on severity of illness of follow-up recommendations,” added the investigators. “Because of lack of data, we also could not assess other potentially relevant variables such as health literacy, proximity to care, transportation availability, language barriers, and experiences of marginalization within the health care system.”

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The researchers concluded that “the decrease occurred specifically among problem-based visits, and the decrease was partially offset by an increase in preventive visits and visits to other settings.”


Ray KN, Shi Z, Ganguli I, Rao A, Orav EJ, Mehrotra A. Trends in pediatric primary care visits among commercially insured US children, 2008-2016 [published online January 21, 2020]. JAMA Pediatr. doi: 10.1001/jamapediatrics.2019.5509

This article originally appeared on Clinical Advisor