Recent efforts to improve the quality of primary care have encouraged a new practice model: the Patient-Centered Medical Home (PCMH).1,15
Formal standards defining the structural capabilities of the PCMH are still evolving, but they include capabilities in the 4 investigated domains: patient assistance and reminders, culture of quality, enhanced access, and electronic health records (EHRs).16,17,21
Where these capabilities are not already in place, their adoption may require substantial investment.
In a statewide cohort of primary care practices ranging in size from 2 to 74 physicians, we found wide variation in the presence of 13 pre-defined quality enhancing capabilities that we studied. Larger practices were significantly more likely than smaller practices to have 9 of 13 possible capabilities. Network-affiliated practices were more likely than non-affiliated practices to have 5 of the 13 capabilities. Larger practice size and network affiliation were both associated with higher prevalence of capabilities in 3 domains of improvement: feedback and improvement infrastructure, linguistic capabilities, and EHRs. However, the provision of weekend care was significantly lower among network-affiliated practices compared to non-affiliated practices, possibly reflecting the consolidation of these services to a limited number of locations. None of the findings were substantially altered by adjustment for other practice characteristics.
Primary care practices vary in many ways. Practice size and network affiliation, among other organizational characteristics, may affect practices’ ability to make PCMH investments. Prior studies of groups containing at least 20 physicians have found higher prevalence of structural capabilities among larger physician organizations and integrated groups than among smaller organizations and independent practice associations.29,37,38
However, smaller practices like those that we studied constitute the dominant organizational model for primary care in the United States.39
Our findings are consistent with other studies showing that even among these smaller practices, larger size is associated with higher rates of EHR adoption and physician participation in quality improvement.25,28,40,41
The lack of a consistent relationship between teaching status and structural capabilities may reflect competing organizational priorities within teaching practices.
The association between network affiliation and EHR adoption was more complex than for other capabilities. Overall, network affiliation was associated with frequently-used, highly-functional EHRs. However, their prevalence varied significantly between the 9 networks, and 4 networks had lower adjusted prevalence than the average among non-affiliated practices. This finding suggests that although some networks have fostered investment in EHRs, other factors (e.g., grants from health plans and quality improvement organizations) may also influence EHR adoption.
The study has limitations. First, the capabilities we studied do not encompass all of the potential attributes of the PCMH. Recent and evolving standards include attributes like having a personal physician-directed medical practice, providing access to care via telephone or email, and identifying health conditions important to the practice.15–17,21
Our intent was to evaluate, in a way suitable for research, capabilities common to PCMH proposals that were likely to be especially pertinent to measured quality, to require investment, and to be familiar to practicing physicians. Second, we chose to survey practicing physicians rather than managers. This constrained our ability to gather some types of practice information (e.g., detailed staff composition). Third, a cross-sectional study design limits inferences about causation. We cannot distinguish whether larger practice size makes investment in quality enhancing capabilities more likely, or if such capabilities lead to growth. Similarly, we cannot tell whether some networks invest in EHRs or whether some networks selectively affiliate with practices already having EHRs. Finally, the study took place in Massachusetts, a relatively small state with a high concentration of major medical teaching centers. Some of these centers have led the adoption of EHRs, and their graduates may practice locally. This may limit the generalizeability of some study findings.
Proposals to create PCMH standards and link payments to practices’ quality enhancing capabilities signal a renewed focus on structural measures of primary care quality—though whether possession of these structural capabilities for quality will translate to better processes or outcomes remains uncertain.2,42
Our analysis suggests that on many structural measures, larger practices have an advantage over smaller practices, with network affiliation conferring a narrower advantage. Small, non-affiliated practices may therefore require the largest investments in order to achieve PCMH designation. If strong financial or regulatory incentives are tied to PCMH designation, such practices may be encouraged to grow, merge, or affiliate with networks of other sites. Alternatively, if structural investment proves too difficult for small practices, these practices may not be able to count on PCMH-based payments in order to survive the “crisis” in primary care;14,43
structural improvements in primary care could come at the price of new access problems in areas predominantly served by small practices. As PCMH pilot programs go forward, policy makers should monitor their effects on both quality and access to primary care.