Urgent care entrance Millennialsprefer the convenience of retail clinics, free-standing urgent carecenters that tout evening and weekend hours, and onlinetelemedicine sites that offer virtual visits. (Photo:Shutterstock)

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Calvin Brown doesn't have a primary care doctor — and the peripatetic23-year-old doesn't want one.

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Since his graduation last year from the University of San Diego,Brown has held a series of jobs that have taken him to severalCalifornia cities. “As a young person in a nomadic state,” Brownsaid, he prefers finding a walk-in clinic on the rare occasions when he'ssick.

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“The whole 'going to the doctor' phenomenon is something that'sfading away from our generation,” said Brown, who now lives in DalyCity outside San Francisco. “It means getting in a car [and] goingto a waiting room.” In his view, urgent care, which costs him about $40 pervisit, is more convenient — “like speed dating. Services arerendered in a quick manner.”

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Expanding access to health care:Transparency,
technology and convenience:
any solution that does not address
these will not contribute to a truly accessible
health care system.

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Brown's views appear to be shared by many millennials, the 83million Americans born between 1981 and 1996 who constitute thenation's biggest generation. Their preferences — for convenience,fast service, connectivity and price transparency — are upendingthe time-honored model of office-based primary care.

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Many young adults are turning to a fast-growing constellation ofalternatives: retail clinics carved out of drugstores or big-boxretail outlets, free-standing urgent care centers that tout eveningand weekend hours, and online telemedicine sites that offer virtualvisits without having to leave home. Unlike doctors' offices, wherecharges are often opaque and disclosed only after services arerendered, many clinics and telemedicine sites post theirprices.

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A national poll of 1,200 randomly selected adults conducted inJuly by the Kaiser Family Foundation for this story found that 26percent said they did not have a primary care provider. There was apronounced difference among age groups: 45 percent of 18- to29-year-olds had no primary care provider, compared with 28 percentof those 30 to 49, 18 percent of those 50 to 64 and 12 percent age65 and older. (Kaiser Health News is an editorially independentprogram of the foundation.)

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A 2017 surveyby the Employee Benefit Research Institute, a Washington thinktank, and Greenwald and Associates yielded similar results: 33percent of millennials did not have a regular doctor, compared with15 percent of those age 50 to 64.

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“There is a generational shift,” said Dr. AteevMehrotra, an internist and associate professor in theDepartment of Health Care Policy at Harvard Medical School. “Thesetrends are more evident among millennials, but not unique to them.I think people's expectations have changed. Convenience [is prized]in almost every aspect of our lives,” from shopping to onlinebanking.

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So is speed. Younger patients, Mehrotra noted, are unwilling towait a few days to see a doctor for an acute problem, a situationthat used to be routine. “Now,” Mehrotra said, “people say, 'That'scrazy, why would I wait that long?'”

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Until recently, the after-hours alternative to a doctor's officefor treatment of a strep throat or other acute problem was ahospital emergency room, which usually meant a long wait and a bigbill.

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Luring millennials

For decades, primary care physicians have been the doctors withwhom patients had the closest relationship, a bond that can lastyears. An internist, family physician, geriatrician or generalpractitioner traditionally served as a trusted adviser whocoordinated care, ordered tests, helped sort out treatment optionsand made referrals to specialists.

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But some experts warn that moving away from a one-on-onerelationship may be drivingup costs and worsening the problem of fragmented or unnecessarycare, including the misuse of antibiotics.

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A recent report in JAMA Internal Medicine found that nearly halfof patients who sought treatment at an urgent care clinic for acold, the flu or a similar respiratory ailment left with anunnecessary and potentially harmful prescription for antibiotics,compared with 17 percent of those seen in a doctor's office.Antibiotics are useless against viruses and may expose patients tosevere side effects with just a single dose.

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“I've seen many people who go to five different places to betreated for a UTI [urinary tract infection] who don't have a UTI,”said Dr. Janis Orlowski, a nephrologist who is chief health careofficer at the Association of American Medical Colleges, or AAMC.“That's where I see the problem of not having some kind ofcontinuous care.”

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“We all need care that is coordinated and longitudinal,” saidDr. Michael Munger, president of the American Academy of FamilyPhysicians, who practices in Overland Park, Kan. “Regardless of howhealthy you are, you need someone who knows you.” The best time tofind that person, Munger and others say, is before a health crisis,not during one.

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And that may mean waiting weeks. A 2017 survey by physician search firm Merritt Hawkins found thatthe average wait time for a new-patient appointment with a primarycare doctor in 15 large metropolitan areas is 24 days, up from 18.5days in 2014.

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While wait times for new patients may reflect a shortageof primary care physicians — in the view of the AAMC — or amaldistribution of doctors, as other experts argue, there is nodispute that primary care alternatives have exploded. There are nowmore than 2,700retail clinics in the United States, most in the South andMidwest, according to Rand Corp. researchers.

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Connecting with care

To attract and retain patients, especially young adults, primarycare practices are embracing new ways of doing business.

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Many are hiring additional physicians and nurse practitioners tosee patients more quickly. They have rolled out patient portals andother digital tools that enable people to communicate with theirdoctors and make appointments via their smartphones. Some areexploring the use of video visits.

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Mott Blair, a family physician in Wallace, N.C., a ruralcommunity 35 miles north of Wilmington, said he and his partnershave made changes to accommodate millennials, who make up a thirdof their practice.

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“We do far more messaging and interaction through electronicinterface,” he said. “I think millennials expect that kind ofconnectivity.” Blair said his practice has also added same-dayappointments.

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Although walk-in clinics may be fine as an option for someillnesses, few are equipped to provide holistic care, offerknowledgeable referrals to specialists or help patients decidewhether they really need, say, knee surgery, he noted. Primary caredoctors “treat the whole patient. We're tracking things like: Didyou get your mammogram? Flu shot? Pap smear? Eye exam?”

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Dr. Nitin Damle, an internist and past president of the AmericanCollege of Physicians, said that young people develop diabetes,hypertension and other problems “that require more than onevisit.”

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“We know who the best and most appropriate specialists in thearea are,” said Damle, an associate clinical professor of medicineat Brown University in Providence, R.I. “We know who to go to forasthma, allergies, inflammatory bowel disease.”

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Marquenttha Purvis, 38, said her primary care doctor wasinstrumental in helping arrange treatment for her stage 2 breastcancer last year. “It was important because I wouldn't have beenable to get the care I needed” without him, said Purvis, who livesin Richmond, Va.

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Sometimes the fragmented care that can result from not having adoctor has serious consequences.

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Orlowski cites the case of a relative, a 40-year-old corporateexecutive with excellent medical insurance. The man had always beenhealthy and didn't think he needed a primary care physician.

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“Between treating himself and then going to outpatient clinics,”he spent nearly a year battling a sore throat that turned out to beadvanced throat cancer, she said.

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For patients without symptoms or a chronic condition such asasthma or high blood pressure, a yearly visit to a primary caredoctor may not be necessary. Experts no longer recommend theonce-sacrosanct annual physical for people of all ages.

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“Not all access has to be with you sitting on an exam table,”Munger said. “And I may not need to see you more than every threeyears. But I should be that first point of contact.”

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Convenience is paramount

Caitlin Jozefcyk, 30, a high school history teacher in Sparta,N.J., uses urgent care when she's sick. She dumped her primary caredoctor seven years ago because “getting an appointment was sodifficult” and he routinely ran 45 minutes behind schedule. Duringher recent pregnancy, she saw her obstetrician.

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Jozefcyk knows she's not building a relationship with aphysician — she sees different doctors at the center — but“really likes the convenience” and extended hours.

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Digital access is also important to her. “I can makeappointments directly through an app, and prescriptions are sentdirectly to the pharmacy,” she said.

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After years of going to an urgent care center or, whennecessary, an emergency room, Jessica Luoma, a 29-year-oldstay-at-home mother in San Francisco, recently decided to find aprimary care doctor.

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“I'm very healthy, very active,” said Luoma, who has beentreated for a kidney infection and a miscarriage.

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Luoma said her husband pushed her to find a doctor after theinsurance offered by his new employer kicked in.

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“He's a little more 'safety first' than me,” she said. “Ifigured, 'Why not?' — just in case.”

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Kaiser HealthNews (KHN) is a national health policy news service. It is aneditorially independent program of the Henry J. Kaiser Family Foundation whichis not affiliated with Kaiser Permanente.

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