Ask our primary care clinicians how well reform is working

Primary Care Providers' Views of Recent Trends in Health Care Delivery and Payment

By Jamie Ryan, Michelle M. Doty, Liz Hamel, Mira Norton, Melinda K. Abrams, Mollyann Brodie
The Commonwealth Fund and The Kaiser Family Foundation, August 5, 2015

In recent years, the U.S. primary care delivery system has experienced many changes in the way health care is organized, delivered, and financed. Some of these changes have been strengthened or accelerated by the Affordable Care Act (ACA). For instance, there has been an increased use of health information technology, a move toward team-based care and using nonphysician clinicians, an effort to better coordinate care through medical homes and accountable care organizations, and the introduction of financial incentives and quality metrics to determine how providers are paid.

Using data from the Commonwealth Fund/Kaiser Family Foundation 2015 National Survey of Primary Care Providers, this brief examines providers’ opinions about the changes in primary care payment and health care delivery. Between January 5 and March 30, 2015, a nationally representative sample of 1,624 primary care physicians and a separate sample of 525 midlevel clinicians (i.e., nurse practitioners and physician assistants) working in primary care practices were surveyed online and by mail.


New primary care payment and delivery models have emerged in recent years as part of efforts to improve patient outcomes and lower health care costs, with the Affordable Care Act accelerating many of these changes. It may be too early to reach a conclusion on the quality or cost effects of these primary care reforms, but assessing the perspective and experience of those on the front lines is critical to understanding the implementation of these reforms, including any challenges that could potentially undermine the process.

The survey results indicate that primary care providers’ views of many of these new models are more negative than positive. There are exceptions: health information technology gets mostly positive views and medical homes receive mixed opinions with a positive tilt. With regard to HIT, our study indicates that primary care providers generally accept the promise of HIT to improve quality of care even if previous research shows they dislike the process of transitioning from paper-based records. Our survey results also may reflect clinicians’ earlier exposure to certain models and tools National adoption of electronic health records received a boost from the Health Information Technology for Economic and Clinical Health (HITECH) Act of the federal stimulus package of 2009, while the four primary care specialty societies announced a joint statement regarding medical homes in February 2007, several years before passage of the Affordable Care Act.

Though many providers are unsure of the impact of ACOs on quality of care, those physicians who do have an opinion are more likely to say ACOs are having a negative rather than a positive impact on quality of care. ACO implementation is a somewhat more recent development, and primary care providers are not as involved in the day-to-day management of organizational change. Primary care clinicians’ views are also decidedly negative when it comes to financial penalties and the increased use of quality metrics in judging their performance. It may be some time before they can become comfortable with these new payment models.

More primary care providers may be participating in ACOs and relying on quality metrics for performance assessment in the near future. In early 2015, the Centers for Medicare and Medicaid Services announced that 85 percent of Medicare fee-for-service payments should be tied to quality or value by 2016. And, by the end of 2018, 50 percent of all Medicare payments should be tied to quality or value through specific alternative payment models, like ACOs and bundled payments. Dissatisfaction with new models may not be solely attributable to a difficult transformation process; larger culture change within the practice of medicine may be a necessary first step before delivery system reforms such as ACOs and medical homes are fully accepted on the ground.

As primary care transformation efforts mature and spread, it will remain important to judge their effects on patients in terms of access, quality, and costs of care. However, it is also important to assess their effect on primary care clinicians. Of concern, nearly half of primary care physicians say that recent trends in health care are causing them to consider retiring earlier than planned. Market trends in health care have been affecting physicians’ satisfaction for more than 20 years. It will be important to monitor providers’ satisfaction with delivery reform efforts.



By Don McCanne, MD

The intent of health care reform, reinforced through the Affordable Care Act, was not only to improve the financing of health care by increasing the numbers insured and providing more government support through insurance subsidies and Medicaid, but it was also to improve the health care delivery system through structural changes that theoretically would improve quality while controlling costs.

Some of the structural reforms included increased use of health information technology (HIT), establishment of accountable care organizations (ACOs), reinforcing primary care through medical homes, use of alternative payment models with financial incentives, and quality metrics to determine how health care professionals are paid.

So far, evaluation of these efforts have provided us with mostly weak and inconclusive data, with initial results suggesting that the effectiveness in improving quality and controlling spending has been very unimpressive, with little positive impact.

Although the public and private bureaucracies are not providing us with enough impressive data to move forward aggressively with these programs, the physician and non-physician clinicians on the front lines can give us a better perspective of just what is happening. This report provides us with their insight.

A few conclusions:

  • The transition from paper to electronic records has been difficult, especially because of the amount of time required to interact with the HIT system, but clinicians believe that electronic records may improve quality through error reduction, though recent data has cast doubts on this as well.
  • Medical homes have increased administrative activities with mixed opinions as to their value, with “a positive tilt” in their views.
  • Many clinicians have not formed opinions on ACOs, but those who have are “more likely to say ACOs are having a negative rather than a positive impact on quality of care.”
  • Dissatisfaction with the new models do not seem to be limited to transition issues but challenge the very culture of the practice of medicine. Efforts to change the culture could further entrench dissatisfaction and have adverse consequences on the patient experience.
  • “Primary care clinicians’ views are also decidedly negative when it comes to financial penalties and the increased use of quality metrics in judging their performance.” With little evidence that these metrics improve quality, it seems that creating clinician animosity would be a reason to abandon this experiment.
  • Medicare’s requirement that payments be tied to quality or value through alternative payment models is an unwise policy decision of the CMS bureaucrats considering the lack of studies that support this move and the increased clinician animosity that will ensue.
  • “Of concern, nearly half of primary care physicians say that recent trends in health care are causing them to consider retiring earlier than planned.”

The Affordable Care Act and the various measures leading up to it did not adequately address the financing issues in that it left it place our expensive, dysfunctional, fragmented financing system and left far too many people uninsured and even more with under-insurance. Nevertheless, the legislators and bureaucrats have demonstrated even greater incompetence in putting into effect these changes supposedly designed to improve the health care delivery system, when the evidence does not support these particular transformational changes.

These screwball ideas simply thought up by non-clinician policy academics are wasting valuable resources while having negligible or negative impact on health care delivery. What is worse is that they have diverted us from proceeding with reform that would have a very positive impact on health care for all of us.

The greatest driver of quality is to have a system that delivers the right care to the right people at the right time. This is exactly what a single payer national health program is designed to do. Let’s do that instead of wasting our time and resources with measures that do not do much more than to alienate our clinicians.