What happens when your own primary care doctor goes on vacation? This simple question is at the heart of the new CSS Institute working paper, “Access to Whom? Relational Frictions and Healthcare Demand” by Linn Hjalmarsson and Nicolas Schreiner.
In our analysis of 1.8 million insured individuals between 2014 and 2024, we find that when a person’s own primary care doctor is temporarily absent:
- The probability of a primary care visit falls by about two thirds.
- Total weekly healthcare costs drop by 19 percent.
Patients hardly switch to other doctors—neither to other primary care physicians, nor to specialists, nor to emergency departments. Instead, they simply forgo the doctor visit altogether—even though other doctors in the region remain available and nothing changes in terms of insurance coverage or cost sharing.
How much does this effect depend on local physician density? Not at all. Whether 2 or 20 alternative primary care doctors practice nearby, the decline is virtually identical. The insurance model also plays little role: patients with free choice of doctor refrain from visiting just as much as those in models with a formal referral requirement—the voluntary attachment to one’s own primary care doctor is at least as strong as contractual gatekeeping.
The personal relationship with the doctor thus turns out to be one of the strongest drivers of healthcare demand—stronger than the number of available doctors, stronger than differences across insurance models, and, judging by its magnitude, stronger than cost sharing.
A more detailed summary is available here on our website, and the full working paper is also available for download.