Earlier this year, our team surveyed hundreds of Millennials (men and women aged between 20 and 40) in three major East Coast cities to determine their attitudes toward primary care. We wanted to know if these young adults had primary care doctors, whether they saw value in a primary care relationship, where they received healthcare services and how they felt about their health.
What we found surprised us: only 42% of Millennials we surveyed had engaged with a PCP in the past year, which was worse than the 50% (nationally) that we had seen quoted in the media. We also found, paradoxically, that most Millennials we surveyed saw great value in coordinated and regular care and 80% worried that they had been neglecting their health.
This discordance between Millennial’s self-professed interest in wellness and health and their engagement with primary care was striking: after all, the most enthusiastic buyers of wellness trackers, apps, specialty meals and behavioral health gadgets are also the ones avoiding preventive, holistic and longitudinal PCP care.
What explains this disengagement from primary care and why does it matter? In this piece I’ll review this emerging trend, discuss some contributing factors, and explain why this pivot away from primary care by young adults has significant implications for US healthcare.
Somewhere around half of Millennials nationally don’t identify as having have a PCP, and many of those are cobbling together care using online services, urgent care clinics and retail clinics. This disengagement, it seems, is driven by three factors inherent to most traditional primary care:
- High costs and lack of transparency about pricing
- Timeliness / access to care
Let’s talk about these in turn-
First- issues with costs are probably secondary to those of access and convenience, but are important. It’s widely recognized that Millennials are poorer and more price-conscious than earlier generations. 96% of Millennials in a 2017 focus group agreed with the following statement: “With costs rising out of control and the quality of coverage declining, the healthcare system in our country is broken, and we need to make fundamental change”. Doctors polled by physician networking site Sermo identified millennials’ cost-consciousness as the biggest differentiator between them and other generations: 54% of the physicians in that poll reported their millennial patients were more up-front about asking for lower-cost alternatives than other patients.
Millennials are certainly carrying more debt and make less money than their parents did. But an important difference is that more Millennials are in high deductible plans (where consumers are on the hook for the first several thousand dollars of healthcare expenses) than their parents when they were younger. (As a sidenote, many preventive services are, under law, fully covered but the insurance company– but this is often a nuance lost on consumers).
This financial exposure makes price transparency important at a time when most physicians offices are unable to tell consumers what a visit will cost until after claims adjudication occurs. Millennials, trying to avoid the risk of a surprise bill, will preferentially pick online, retail and urgent care clinics where cash prices are fully transparent at the time of service.
A second factor is poor access to care.
Even if young adults wanted to get care from a traditional PCP there wouldn’t be enough to meet demand. Managed care, and aging Boomers are driving up demand for scarce PCPs. Without changing something, the US is projected to have a shortage of 14,000 to 49,000 physician PCPs by 2030 according to the most recent AAMC workforce report. This lack of capacity means in many cities panels are closed and wait times are long- in many cities weeks to months.
These access issues run directly into the third factor, which is the rapid consumer-ization of patient expectations. At a time when consumer expectations around service and waits are in greater daily, given the rapidly improving retail experiences that consumers get from Amazon and other digitally enabled stores, the analog consumer experience offered by most traditional PCPs seems archaic.
This Millennial migration away from primary care isn’t without consequences. One often hears the old canard that moat young adults are healthy and don’t need anything besides episodic care. Most obviously, at least for the young adult, a cobbled-together care experience (which I termed “virtual interlining” and wrote about a couple of years ago) makes it very easy for preventive services to be missed, early presentations of illness to be missed and for care to be disconnected.
As proof, we’re seeing a rise of chronic and preventable diseases in the under-40 population. Many young adults are not receiving preventive screenings or early diagnosis/ management of their chronic diseases. In the US, there has been a significant increase in “diseases of the elderly” in the young and much of this is heavily concentrated in ethnic minorities. Half of young patients with diabetes are unaware of their diagnosis. Other chronic illnesses show a similar trend: earlier onset, with worse long-term outcomes. For example, researchers in JAMA found acute ischemic stroke hospitalization rates almost doubled for men aged 18 to 44 years since 1995-1996. These outcomes were correlated to increased risk factors in these patients: high cholesterol, high blood pressure, diabetes, obesity and tobacco use.
Retail and urgent care clinics today are identifying thousands of patients with new diabetes and hypertension annually, and many are ill-equipped to provide follow-up or ongoing care. Episodic care has been referred to as a garage that fixes broken brakes but doesn’t do oil changes.
Impact on the system
Healthcare executives should ignore this Millennial pivot away from primary care at their own peril. Though primary care in a fee-for-service environment has never been especially lucrative, Millennial alienation is creating huge opportunity for disruptors (both payers and providers) to enter markets where well-established incumbents rule the roost.
There are three strategic and economic implications to this Millennial migration:
The first, I suspect (and as a caveat I have no proof, and would love somebody with an actuarial background to push back on this assumption) that the cumulative cost of missed preventive and early-detection visits will end up costing the system, over time, far more than the cumulative cost of preventive visits. For example, factor the effect of missed PAP exams, testicular masses, secondary hypertension, etc. This would seem to be a demographic time bomb at least on a population level.
More strategically, from a health system perspective, the Millennial is a proverbial canary in the goldmine. Older generations– perhaps those who have longer relationships with their doctors, more money (and better ability to compartmentalize their consumer experiences)– may be willing to put up with the Byzantine journey that is primary care today. But how long will it be before the cognitive dissonance of an Amazon-enabled retail experience versus a standard consumer healthcare experience becomes too great for even the middle-aged consumer? When the primary care relationship (which is, after all, typically the glue that keeps patients in a healthcare system) erodes, the door is open for consumers of all ages to virtual interline their own care experiences, shopping outside the system for the best specialists, etc. Health system loyalty can’t be taken for granted anymore. (Read more about my thoughts on medical segmentation here here and here.)
Last, the pivot from primary care throws open the doors to new entrant providers, who find themselves well-positioned in between payers and specialist/hospital/lucrative procedure (“downstream”) providers. There has been a (welcome) explosion of new-entrant primary care companies in recent years and most seem to be doing reasonably well, even in a fee-for-service environment. The work (and consumer experience delivered by) One Medical, VillageMD and others are doing is terrific. As the system pivots to risk, the opportunity for new entrants to create unique and tailored “primary care” experiences for segments of the population will only increase. I put the term “primary care” in brackets since these new entrants may not share much at all, design-wise, with legacy primary care, perhaps sharing only the fact they are the first point of contact with the healthcare system for many patients, and in a risk environment are the nidus where all the spending decisions are made.
No integrated system wants to be dis-intermediated. But to avoid this fate, legacy systems are going to need to cough up some real innovation and consumer-friendly, segmented, care solutions, especially those that address the needs of 92 million cranky, poor and inherently disloyal young consumers.
In the next post, probably in a week or two, we’ll talk more about what innovation needs to look like to be successful, and some thoughts on how to respond to the clear desire many Millennials have for holistic, integrated yet accessible and consumer-centric care.
Marc-David Munk, MD, MHCM is the founder of Creemore Advisors, a specialty healthcare advisory firm based in Boston. He has helped lead some of the nation’s most forward-looking healthcare delivery companies.