For six years during her 20s, Tara Carter didn’t have a primary care doctor.
To her, it wasn’t an efficient use of her time.
First, she had to take time off work and sit in a doctor’s office, where she’d shell out her copay and answer a ton of questions.
And often she’d be referred to a specialist, where she’d repeat the process over again.
For minor health problems, such as sinus infections, she used retail walk-in or urgent care clinics instead.
Carter, who lives in the Washington, D.C. area, told Healthline that these are “sufficient to get the help I need and get out the door and back in bed — without waiting days for an appointment that didn’t fit my schedule.”
Plus, at $ 50 to $ 75 per visit and offering middle-of-the night appointments and often prescriptions on the spot, Carter finds this kind of on-demand healthcare “convenient and solution-driven.”
Carter’s approach to healthcare isn’t unique.
Many other millennials — Americans born between 1981 and 1996 — are passing up visits to primary care offices in search of shorter wait times, virtual healthcare, and clearer pricing models.
A survey by the Kaiser Family Foundation found that 45 percent of 18- to 29-year-olds and 28 percent of 30- to 40-year-olds didn’t have a primary care provider.
Compare this to 18 percent among Americans ages 50 to 64 and 12 percent among those ages 65 and older who don’t have a primary care physician.
This “generational shift” in how younger Americans access health is so drastic that some people are blaming millennials for killing primary care — in the same way they’ve supposedly killed car ownership, vacations, and marriage.
Millennials, however, aren’t the only ones avoiding the doctor’s office.
A 2016 report by the Health Care Cost Institute found that office visits to primary care physicians dropped 18 percent overall between 2012 and 2016.
“What we don’t know is how much people are getting their care in other settings, such as in retail clinics, through telemedicine, or going on the internet and deciding to self-treat,” Ann Greiner, president and CEO of the Patient-Centered Primary Care Collaborative, told Healthline.
Also, young people have long used healthcare at lower rates than older age groups — whether it’s because they’re healthier, lack health insurance, or just have a low tolerance for inconvenience.
A number of trends
Millennials may just be the most vocal champions of several trends that are also affecting other age groups.
One of these is the rise in the availability of urgent care centers and retail health clinics.
The RAND Corporation estimates there are more than 2,700 retail clinics in the United States, including ones at pharmacies and big-box stores.
“Millennials rightfully want more flexible ways to get care, and they want more transparency about price and quality,” Greiner.
Retail clinics are “pushing the envelope here,” she added, but primary care needs to do a better job.
There’s also a shortage of primary care physicians in the United States, which makes it harder to find a doctor and longer to get in to see one.
This makes other options more attractive.
And then there’s technology.
Electronic medical records, email, texting, and virtual doctor’s appointments are reshaping health services — with millennials at the forefront of this wave and post-millennials riding not far behind.
But are these trends enough to kill office-based primary care?
Convenient care that counts
Young adults may feel invincible, but they’re not immune to health problems.
Dr. Jeffrey Gold, a primary care doctor in Marblehead, Massachusetts, saw an 18-year-old man earlier this year at his office for a routine checkup.
During the exam he found an abnormal mass on one of the man’s testicles. It turned out to be testicular cancer.
Without early detection, the outcome could’ve been much worse. This kind of proactive care is where primary care shines.
“We know that if you get the right preventive care or you are managing a chronic condition well, you can stave off a decline in your health and also more costly treatment,” Greiner said. “So the decline in primary care visits is not a good sign.”
Young adults face other health problems that can benefit from regular visits to the doctor, including high rates of substance use disorders, sexually transmitted diseases, suicide, smoking, and binge drinking.
Also, more than one-third of 20- to 39-year-olds are obese, according to the Centers for Disease Control and Prevention (CDC).
This increases the risk of other health problems, including diabetes, heart disease, and some types of cancer.
The big question is whether you need to go to an office to prevent and treat these conditions.
Gold had another patient, a 28-year-old man from Queens, New York, who texted him through a secure app to say he had had unprotected sex with someone he didn’t know and thought he now had herpes.
Gold was able to handle this even without a face-to-face visit, asking the man to send a picture of the rash.
“Herpes is really a clinical diagnosis. You look at it and you say it’s herpes,” Gold said. “Within 10 minutes of receiving the picture, I had sent a prescription for antiviral medicine to his pharmacy in New York and he was done.”
This is the kind of convenient care that millennials are craving. It’s also a model that’s hard to find in the United States.
Gold’s practice isn’t your usual primary care office. It’s based on the direct primary care model, in which patients pay a monthly or annual fee that covers all office visits.
Gold offers monthly pricing tiers based on age, with the lowest rates for people under 30. Patients also get a discount on lab work, medication, imaging, and other medical services.
For the man from Queens, the convenience, clear pricing, and virtual consultations overcame any downsides of being so far away.
“He told me that for the one time of year that he needed to come to my office, it would cost him less to take the Acela train, get a Zipcar, and stay one night than it would to buy health insurance for the year,” Gold said.
Many healthcare systems are getting on board with telemedicine, offering virtual visits alongside traditional face-to-face ones.
Stanford’s ClickWell Care program is trying to move beyond “click when you’re sick” telemedicine and encourage patients to build relationships with a doctor.
In a recent study, they found that many patients choose a face-to-face for their first visit with a doctor, then opt for video or phone call follow-ups.
Young men, though, seemed to prefer to receive all of their care virtually, while young women wanted a mix of virtual and in-person or only in-person care.
Building a relationship with a doctor virtually isn’t easy. But experts say this still matters, even with so many options available for online interactions.
“There’s all kinds of evidence that you get better outcomes when you have a relationship with a doctor who knows you over time and looks at your care in a more holistic way,” Greiner said.
When your doctor understands your personal and family medical history, they may be more likely to notice that you’re struggling with depression, or they may ask you why you’ve stopped exercising recently. It’s also easier to bring up uncomfortable topics.
“My patient from Queens didn’t feel embarrassed to pick up the phone and text me about his herpes rash,” Gold said. “He’s getting treated. I also sent him a handout through text with some education on herpes virus.”
Insurance, though, may not always pay primary care doctors for responding to patients by email or text, which can discourage them from fully embracing technology in their practice.
Greiner says this is partly due to the way much of medical care is paid for in the United States, where doctors receive payment for each service they provide rather than for the patient’s overall health.
“We need to move away from that kind of payment model toward a more holistic approach,” Greiner said. “That might include sending texts to your doctor or having a consult over email and getting an issue taken care of.”
This shift is already happening in direct primary care. Because patients pay Gold a set fee for the year, his practice benefits if he keeps his patients well. And he can use whatever technologies help him do that.
Gold points out, though, that virtual communication doesn’t work equally well for all health issues. But if the relationship is there, patients will keep coming back — like a friend you haven’t seen for years but still connect with.
Finding a good fit
Some would say, though, that millennials prefer virtual and superficial interactions to “real” relationships. But that’s not always the case.
When Carter turned 30, she was ready to find a primary care physician again. But she did it in true millennial fashion — with lots of research.
Over four months, she went to three different doctors to “interview” them, asking questions like why she has to wait two hours to see them or why she has to come to the office to get her results instead of online or over the phone.
The research paid off. She eventually found a doctor who was a good fit — an older millennial who didn’t waste Carter’s time and was available through email and virtual appointments.
“I feel like I finally have a team member with her,” Carter said. “And even though I have left the city she is in and she is no longer easily accessible, I still go back to her when I visit home, since she is under my insurance and remotely accessible.”