Commonwealth Fund Finds Mixed Views of PCPs Towards New Payment Models

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.”

Melinda Abrams

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.)

A similar scenario played out with regard to primary care perceptions of accountable care organizations (ACOs). Among all primary care physicians, only 14 percent of those surveyed xpressed positive perceptions of ACOs’ ability to promote higher-quality, more-efficient care, while 26 percent expressed negative perceptions. But among those participating in ACO arrangements, 30 percent had positive perceptions, while only 24 perception had negative ones.

What do such survey results mean? “My view on a lot of this is that physicians are facing a variety of challenges in a rapidly changing healthcare system,” Abrams says. Some of these changes stem from how busy providers are. They do not see that the increased numbers of patients are compromising the quality of care they provide. And they are not closing their practices to new patients. And the share of physicians accepting Medicaid remains unchanged from before the expansion went into effect. With the expansions in insurance—Medicaid expansion, plus the exchanges, were we going to see lack of appointment access for patients, or physicians closing practices to new patients? And we’re not seeing any of that,” she says.

“So,” Abrams says, “ we are also seeing from this survey that they are experiencing this shift towards the pay-for-value movement. And significant minorities, about one-third, are participating in medical homes and ACOs.”

Will the favorability numbers go up as more providers join ACOs and PCMHs? “Yes, I would agree,” Abrams says. “As more primary care providers experience these new models of care, their views and attitudes will improve, and their ability to provide high-quality care will improve.”

In addition, primary care physicians’ perceptions of reliance on nurse practitioners and physician assistance and the impact of that reliance on quality of care differed considerably based on whether they in fact employed nurse practitioners and physician assistants in their practices. Overall, 41 percent viewed such impact as negative, 29 percent as positive, 18 percent saw no impact, and 12 percent were not sure. Among those with no mid-level practitioners in their practice, 50 percent saw the impact as negative, 16 percent as positive, 20 percent saw no impact, and 14 percent were unsure. But among those with mid-level practitioners in their practices, 40 percent saw the impact as positive, only 35 percent saw it as negative, 16 percent saw no impact, and 10 percent were unsure. Not surprisingly, the mid-level practitioners working in physician practices had a very different set of views: zero percent saw their presence as negative, 88 percent saw it as positive, 8 percent said it had no impact on quality of care, and 3 percent were unsure.

PCPs like the idea of IT as a facilitator

Overall, perceptions of primary care physicians of new payment models, are mixed, according to survey respondents; but healthcare IT is largely viewed positively, the Commonwealth Fund found. As the brief notes, “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.⁸ 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.”

“Our results show that 50 percent of primary care providers say that healthcare IT is improving the quality of care they provide,” Abrams notes. “And what we’ve learned from other studies is this: other studies have found that providers generally accept the promise of HIT as a concept, even as they dislike the process of transitioning to electronic from paper. Our specific question was on the impact of their ability to provide high-quality care to their patients. It’s a more general question than about the transition. We weren’t asking about the transition. So half of physicians and two-thirds of mid-level providers see the advance of health IT as having a positive impact,” she says. “That means 50 percent of physicians, and 64 percent of nurse practitioners and physician assistants.”

Does Abrams expect that level of support for healthcare IT to go up over time? “It may,” she says. “My other theory is that they’ve had more experience and exposure to this. Pretty substantial resources and momentum have encouraged PCPs to adopt information technology with the stimulus package. My theory is that the results around HIT and around the medical home—they’ve had more exposure to those two delivery system efforts; and with more exposure and more time, they are a little more positive about them than say, accountable care organizations, which is a newer model and may be one led by a hospital and not as closely tied to the primary care practice.”

Will successful implementation of IT improve physicians’ favorability of new payment models? “There’s nothing in the survey findings that would indicate that increased success with IT would improve their views of ACOs and medical homes; our findings don’t show that,” Abrams says. “But I would suspect that, to fulfill the promise of ACOs and PCMHs requires ease of use of IT and the data from that technology, the more they learn to use technology effectively to optimize patient care, yes, I believe they will become more positive about ACOs and patient-centered medical homes, yes. And more pieces will help them embrace ACOs and PCMHs, including payment that allows them to provide more accessible, high-quality, efficient care, allows them to work in teams and be more proactive and contact patients remotely. There are other pieces, but I do think the IT is a foundational element, and with greater exposure and time with IT, there will be increased acceptance of these models.”

Yet she adds a caveat. “The IT itself also needs to continue to evolve and make it easier for providers to pull out the information they need to provide the proactive patient-centered care,” she emphasizes. “It needs to be easier to build those registries, query those registries, pull out those quality metrics, use those quality metrics, and compare their performance to that of peers across the country. The easier we make it for physicians and patients to see that data, the better these models will fare and be successful.”

Going back to the broader picture, Abrams says, “There are two or three other main points that are worth saying. In the midst of all this change in healthcare, our survey shows that satisfaction levels remain reasonably high, and relatively unchanged from historical levels. Around 83 percent of PCPs are satisfied or very satisfied with their practices; and with all the change, their satisfaction levels remain relatively high. And another important takeaway is, through changing circumstances, many physicians remain unaware about trends in their environment. For example, 40 percent could not correctly say whether their state had expanded Medicaid; 50 percent were unaware of increases in Medicare payments. They’re providing clinical care, they’re seeing patients. But some of these changes might affect their well-being, their bottom line, to know there are more people with insurance; or that there’s an opportunity for enhanced or increased payments under Medicare.”

Meanwhile, Abrams says, “The other important finding, and this was more from the last brief, but we did ask primary care providers about their opinions towards the Affordable Care Act; and party affiliation seemed to be the decisive factor. Primary care physicians who identified as Democrats had a much more favorable view—87 percent had a favorable or somewhat favorable view of the ACA, compared to only 13 percent who identified themselves as Republicans. What it means is that their judgment about the Affordable Care Act is often through a lens just as the public has and is often rooted in their political party affiliation, just like everyone else.”