On August 5, The Commonwealth Fund, the New York-based not-for-profit “private foundation that aims to promote a high performing healthcare system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. “ released a new issue brief, entitled “Primary Care Providers’ Views of Recent Trends in Health Care Delivery and Payment.” The brief was based on the results of a survey conducted earlier this year of 1,624 primary care physicians and 525 mid-level practitioners (nurse practitioners and physician assistants).
As the abstract to the issue brief notes, “A new survey from The Commonwealth Fund and The Kaiser Family Foundation asked primary care providers—physicians, nurse practitioners, and physician assistants—about their experiences with and reactions to recent changes in health care delivery and payment. Providers’ views are generally positive regarding the impact of health information technology on quality of care, but they are more divided on the increased use of medical homes and accountable care organizations. Overall, providers are more negative about the increased reliance on quality metrics to assess their performance and about financial penalties. Many physicians expressed frustration with the speed and administrative burden of Medicaid and Medicare payments. An earlier brief focused on providers’ experiences under the ACA’s coverage expansions and their opinions about the law.”
At a very high level, primary care physicians are more skeptical than are allied health professionals (nurse practitioners and physician assistants) regarding the value of value-based reimbursement in promoting improved care quality and efficiency in healthcare; but among those PCPs who are under some level of value-based payment, perceptions are more positive.
As the brief noted, “About two-thirds of primary care physicians (64 percent) reported they are paid either by capitation (i.e., prepayments for a set of services for a defined number of patients) or salary (i.e., predetermined income for an entire panel of patients) or through a combination of capitation, salary, and fee-for-service. Nearly nine of 10 nurse practitioners and physician assistants (87 percent) reported receiving payment through mechanisms that are not exclusively fee-for-service. Nevertheless, about a third of primary care physicians (34 percent) are still paid exclusively on a fee-for-service basis. More than half (55 percent) of physicians and about a third (34 percent) of nurse practitioners and physician assistants said their practice receives incentives or payments based on measures of quality of care, patients’ experiences, or efficiency of providing care. About one-third of nurse practitioners and physician assistants were unsure whether they had received such incentives.”
And what of clinicians’ attitudes? As the brief noted, “The survey asked primary care providers what effect, if any, they think these new models are having on providers’ ability to provide high-quality care to patients. Health information technology received the most positive ratings, with half (50%) of physicians and nearly two-thirds (64%) of nurse practitioners and physician assistants saying it has made a positive impact.”
Melinda Abrams, vice president, delivery system reform, at The Commonwealth Fund, says, “Our results show that primary care providers are experiencing the pay-for-value movement, which began before the passage of the Affordable Care Act, but was certainly accelerated by it. Our results show that only a third are still paid fee-for-service (34 percent), while 55 percent are experiencing some incentives related to quality or efficiently.”
As to why a strong plurality of primary care physicians have negative perceptions of value-based outcomes measures’ potential to improve care quality and efficiency, Abrams says, “To be honest, we don’t know why they don’t like the quality measures; we only know there’s a fair bit of dissatisfaction with the quality measures. When we asked physicians whether they thought the increased use of quality measures was impacting their ability to provide high-quality care, 50 percent were negative on that, and only 22 percent were positive. We also asked, are you receive quality incentive-based payments? That reflected the entire group, but even among those receiving incentive payments based on quality, 50 percent felt it was negative, and only 28 percent felt it was positive.”
Still, Abrams agrees that it is interesting that those primary care physicians actually involved in new delivery and payment models were indeed more positive on quality measures. For example, while only 33 percent of primary care physicians surveyed declared themselves positive on the patient-centered medical home (PCMH) model, among those working in PCMHs, 43 percent said the model was indeed having a positive effect on their ability to deliver higher-quality, more-efficient care. (Meanwhile, 63 percent of mid-level practitioners agreed that the PCMH model was enhancing their ability to deliver higher-quality care.)