We've spent the last few years writing about changes to the health care system due to the ACA and other reforms. But most of those pieces have focused on how those changes have affected spending or care. Few have discussed how physicians feel about reform. A recent survey by The Commonwealth Fund and The Kaiser Family Foundation will change that:
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.
In recent years, both patient-centered medical homes and accountable care organizations have sought to reorganize the way that care is delivered so that it's more coordinated and, perhaps, more efficient. Twenty-nine percent of physician respondents said that they participate in an ACO. About 30% reported receiving payments or incentives for qualifying as a patient-centered medical home under the Advanced Primary Care Practice medical home demonstration provision of the ACA. Many, however, (28%) did not know whether they were part of an ACO. An additional 17% of physicians reported that their practices were bought out by a larger organization, leading to consolidation.
Changes to practice or payment were not uncommon. Feelings about these changes were mixed. About a third of physicians viewed the impact of medical homes as positive, and another quarter or so thought they had no impact. More physicians who were in medical homes (43%) thought they had a positive impact than those not in medical home settings (28%). This relationship was also seen in midlevel practitioners, 63% of whom viewed them positively if they were in one, versus 31% of those who were not.
Respondents did not like the increased use of quality metrics. Half of all physician respondents were negative about them, regardless of whether they were receiving incentive payments based on their use. Of those physicians who did receive incentive payments, 28% viewed the quality metrics positively, versus 17% of those who didn't. Regardless, many more physicians viewed them negatively than did positively.
Physicians were also negative about the increased reliance on mid-level practitioners (41% negative versus 29% positive). Although those who had any nurse practitioners or physician assistants in their practice were more positive (25% negative versus 40% positive), they were dwarfed by the negativity of those practicing with none of them (50% negative versus 16% positive).
Physicians seemed most satisfied with payments from private insurance than with Medicare, and most unsatisfied with payments from Medicaid. When asked about the ease of administration related to reimbursements, the differences were not as striking. They were not positive on balance, though.
And, in what will likely get the most attention, almost half of primary care physicians reported that the trends discussed above are causing them to consider retiring earlier than they thought they would. As readers of my writing know, I usually take such pronouncements with a grain of salt.
But there was one finding that surprised me above all others. I've written many times about physicians' dismal view of health information technology. The survey asked primary care providers about the impact of HIT on quality of care for patients, and half of them responded that they thought it had a positive impact, versus 28% who said it had a negative impact. This is one of the most pro-HIT responses that I've seen in any surveys of physicians, and I look forward to seeing if that trend holds.
Although I encourage you to review the full report, the gist is this: primary care providers' views of many changes to the ways we organize and reimburse care are more negative than positive, with the exception of health information technology. It may be that these changes lead to improved outcomes or reduced national health care spending. In that care, they may be worth it, even if they don't make physicians happy. But if they don't, then it will be hard to justify their continued use.
–Aaron