The Health Care Cost Institute has gathered information from several large commercial payers and uses that data to identify trends in spending and utilization, particularly for those in private health plans. The most recent report assesses trends in visits to primary care physicians. (HCCI Report) Primary care use is particularly important given the renewed emphasis on its ability to effectively prevent exacerbations of disease and coordinate utilization and care for chronic diseases. You might expect that visits would be up, but the report suggests otherwise. The researchers looked at visits per 1000 people for adults under age 65 with employer-sponsored insurance. They found an 18% drop in primary care visits to doctors between 2012 and 2016, but there was a 14% increase in visits to other clinicians, including specialist physicians, nurse practitioners, and physician assistants. In total this resulted in a 2% reduction in office visits of all types. From 2012 to 2016 the percent of all office visits that were to a primary care doctor dropped from 51% to 43%. Office visits to nurse practitioners and PAs rose by 129% in this time and visits to specialists were basically flat. During the same time the cost of an average office visit rose by 15%. That is a little surprising because generally you would think NP and PA visits cost less than a visit to a physician, but in fact the average for a physician visit was $106 in 2016 compared to $103 for an NP or PA. Since those clinicians aren’t compensated as highly as physicians, this suggests greater profits for the institutions employing NPs and PAs. While primary care physician visits declined in every state, there was a wide geographic variation, which may reflect scope of practice laws, and there was an increase in NP and PA visits in every state. The decline in primary care physician visits ranged from 6% in Washington, DC, to 31% in North Dakota and the increase in NP and PA use varied from 37% in New Mexico to 285% in Massachusetts. Looking only at established patient visits revealed a similar trend, suggesting a generalized substitution of use of nurse practitioners and physician assistants instead of primary care doctors.