Physicians positive about negative effects of payment, delivery models

Although it may be too early to determine the quality or cost effects of new primary care payment and delivery models that have emerged under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), according to a Commonwealth Fund survey of over 1,600 primary care physicians and 520 midlevel clinicians (nurse practitioners and physician assistants), the providers have less favorable views of the efforts associated with these new models to improve patient outcomes and lower health care costs. Many of the primary care providers expressed uncertainty about the impact of accountable care organizations (ACO) on quality of care; physicians with an opinion were more likely to say ACOs were a having a negative rather than a positive impact on quality of care. Providers were also more negative about the use of quality metrics to assess their performance, even those providers who received incentive payments based on quality. Nearly half of physicians and about a quarter of nurse practitioners and physician assistants said recent trends in health care are causing them to consider early retirement. However, a large majority of providers report satisfaction with their medical practice overall.

New models of delivery

Whether established or accelerated by the ACA’s enactment, there are several newer models of delivering care specifically created to improve the way care is organized, paid for, and delivered. This includes: (1) the patient-centered medical home (PCMH), a model of care that emphasizes comprehensive care coordination, care teams, patient engagement, and population care management; and (2) the ACO, a model in which several types of health care providers collectively take responsibility for the quality and costs of care for a population of patients.

Twenty-nine percent of all primary care physicians said they participate in an ACO arrangement with Medicare or private insurers; 34 percent of those who accept Medicare also participate in ACOs.

Mixed views of care

Overall, 33 percent of physicians and 40 percent of practitioners and physician assistants said they believe medical homes were having a positive impact on quality of care, while roughly 10 percent said the impact has been negative. About 25 percent of each group said there has been no impact or they are not sure. Among those in practices currently receiving incentives or payments for qualifying as a PCMH, larger percentages expressed positive views of the impact of medical homes—43 percent of the physicians and 63 percent of the nurse practitioners and physician assistants.

Likewise, ACO impact was unsettled. Primary care clinicians’ views were negative regarding financial penalties and the increased use of quality metrics in judging their performance. Physicians were more likely to view the increased prevalence of ACOs as having a negative (26 percent) rather than positive (14 percent) impact on quality of care. Nearly 40 percent of physicians over 50 percent of the nurse practitioners and physician assistants were not sure of ACOs’ effect on the quality of care provided to the nearly 24 million patients enrolled.

Quality care concerns

The survey found that performance assessments and financial penalties tied to patients’ outcomes were unfavorable among providers, with 50 percent of physicians and 40 percent of nurse practitioners and physician assistants believing that quality metrics affected quality of care. Primary care providers also rejected the idea that programs with financial penalties for unnecessary admissions or readmissions contributed to improved quality of care.

Views on insurers

In terms of reimbursement rates and administrative burdens, overall, fewer than half of physicians gave positive ratings to any type of insurer on measures related to reimbursement, though ratings were higher for private insurers and lowest for Medicaid, with Medicare falling in the middle. Nearly 46 percent of physicians accepting private insurance considered these insurers’ payment rates to be good or excellent, with only 11 percent rating Medicaid as highly. Medicare ranked in the middle, with 21 percent of physicians who accept it for payment stating that payment rates are good or excellent.


Health information technology (HIT) received positive views from 50 percent of physicians and 64 percent of midlevel clinicians. Primary care providers generally accept the promise of HIT to improve quality of care even if there is dislike of the process of transitioning from paper-based records. The report authors noted that the survey results also may reflect clinicians’ earlier exposure to certain models and tools, e.g., 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 ACA.