Commercially insured populations now engage more with behavioral health than they do with primary care.

Since 2018, behavioral health utilization across the U.S. has increased by 44%, while primary care use has decreased by 7%. In 2024, the total number of behavioral health visits totaled 66.4 million, while the number of primary care visits dipped to 62.8 million, according to a new report by Trilliant Health.

This development reflects the heightened relevance of behavioral health in the American health care economy. It also reflects changes in how, if at all, Americans engage with primary care.

“We think it’s remarkable and something that we need to know about and should be paying close attention to,” Allison Oakes, Trilliant Health’s chief research officer, told Behavioral Health Business.

The figure comes with a few caveats and disclaimers. On the primary care side, the Trilliant report limits the number of visits examined to physicians of varying specialties and excludes nurse practitioners and physician assistants. However, Oakes stated that including these other provider types would not alter the overall conclusion of the data, even if primary care utilization declined overall.

“We’ve seen over more recent years this declining use of primary care, which we think is a combination of issues,” Oakes said. “One stems from issues related to affordability, but also related to issues of trust and distrust in the healthcare system. Increasingly, it seems like people are disengaging with traditional forms of healthcare utilization.”

To a degree, part of the increased utilization is driven by the nature of behavioral health care itself. Often, courses of treatment require many touchpoints in a given span of time.

“If people are using primary care somewhat intermittently but behavioral health more frequently, that’s where you start to see the pattern that we see here, where these lines are actually crossing one another as of 2024,” Oakes said.

The trend also demonstrates that more and more people lack connection to the health care system overall and that care is becoming more fragmented in America.

The report also reflects a notable shift in the rate of telehealth utilization among commercially insured patients.

Since the pandemic, behavioral health has accounted for the vast majority of all telehealth visits. While behavioral health made up 67% of telehealth visits in 2024, the number of these visits dropped steeply in 2024, falling to under 40 million compared to nearly 50 million in 2023. All other health care specialties accounted for just under 20 million telehealth visits.

Since 2020, telehealth volume across all specialties has dipped 32% compared to 2024.

This reflects the increase in the rate at which specific demographics engage with health care solely in-person. Across age and gender groups, regardless of care type, more people got in-person only care, while the rate of people getting a hybrid of in-person and telehealth has remained relatively flat or declined.

“It’s become clear that behavioral health is really the primary area where telehealth is a good substitute for in-person care,” Oakes said. “That said, it’s a good substitute. It’s not a perfect substitute.”

These data reflect the durability of telehealth utilization across behavioral health, especially in outpatient mental health. About 70% of the visits at LifeStance Health Group (Nasdaq: LFST), one of the nation’s largest outpatient mental health companies, are conducted via telehealth. The company operates over 550 locations in 33 states.

Oakes noted there has been a bit of a migration back to in-person care in 2024 as that year has seen the largest decrease in telehealth behavioral health visits since the onset of COVID.

The report also makes note of the wide retreat of retail giants from the health care space. While most of these offerings centered on primary and urgent care, mental health offerings were often included as part of holistic services offerings.

“Whether it’s one year, two years, or three years down the road, they come to this conclusion that healthcare is hard, and they’re actually going to pivot away from it,” Oakes said. “We think that was a noble effort. … We need to figure out how to do it better within our health care system. But unfortunately, the reality is that we don’t reimburse very well for primary care. While these retailers were able to logistically and operationally figure out how to stand up primary care services, at the end of the day, it wasn’t that profitable, and it wasn’t the best strategy for them moving forward.”

Walmart Inc. (NYSE: WMT) announced last year that it would shutter 51 Walmart Health locations after a roughly five-year run at getting clinics in its stores. The company pointed to low reimbursement rates for services. On top of that, behavioral health insiders said that on-demand, walk-in and similar retail-esque models fail to maximize the lifetime value of traditional provider-patient relationships.