Access to US primary care through extended weekday or weekend clinic hours fell during the COVID-19 pandemic, although hospital/health systems, practices with more integrated ownership, and participants in an accountable care organization (ACO) tended to adapt better than their counterparts, according to a Dartmouth-led study.
The researchers surveyed 710 primary care practices across the country twice (2017 to 2018 and 2022 to 2023) about access to care, implementation of evidence-based care-delivery capabilities (eg, integration of screening for clinical conditions), practice ownership and structure, and participation in an ACO. ACOs are healthcare organizations that link reimbursements to quality metrics and lower costs of care.
"Recognizing the importance of timely access to care, many primary care practices have used advanced access models, which prioritize same-day visits, and offered extended weekday or weekend clinic hours, which can reduce wait times and decrease urgent and emergency care use," the researchers noted.
The findings were published late last week in JAMA Health Forum.
Limited weekend hours, advanced-access appointments
Of the 710 practices, 234 were independently owned, 105 were owned by a physician group, and 321 were hospital/health–system owned in 2017 to 2018, and 68 reported no ACO participation, 107 joined an ACO between surveys, and 486 otherwise participated in ACOs. On average, ACO participation rose from 1.2 to 1.6 contracts of different payer types per practice, but 43% of practices reported contracts with one or no payer types in 2022 to 2023.
Independent ownership decreased from 37% to 31%, hospital/system ownership grew from 40% to 49%, and physician-group ownership fell from 13% to 10%.
Overall, accessibility declined over time, as shown by a substantial reduction in practices offering weekend hours (from 44% to 26% [−18 percentage points]) and a decline in advanced-access scheduling (26% of practices routinely used this approach in 2022 to 2023 vs 60% in 2017 to 2018 [−34 percentage points]).
Average capability scores improved from 51 to 54 on a 100-point scale (increase of 4 points). The biggest improvement in capabilities (from 46 to 61, a 15-point difference) was in the care of patients with complex/high needs.
Meaningful improvement was also noted in electronic health-record integration and depression-care processes (from 59 to 67 and 67 to 72, respectively), with fewer improvements in the use of patient-reported outcome measures and screening for social needs (from 63 to 70 and from 37 to 43, respectively). No other significant changes were noted except for a decline in the use of physician- and clinic-improvement processes (from 44 to 41).
Payment reforms, ACO participation
While overall accessibility declined, ACO participants had higher rates of extended hours than nonparticipants in 2022 to 2023 (55% vs 34% [difference, 22 percentage points]), as did hospital/health system–owned practices relative to independent practices (54% vs 38% [16 percentage points]).
Integrated practice ownership and ACO participation were both associated with better access and capability scores, suggesting that value-based payment and integrated care delivery support the development of higher-quality primary care.
Stratification by ACO participation revealed that capability scores in both periods were highest for participants, lowest for nonparticipants, and intermediate for those who joined between surveys.
ACO nonparticipants were the only group seeing a considerable drop in behavioral-health integration scores, while those who joined ACOs made substantial improvements in chronic disease–management processes (14 points) and depression-care processes (13 points).
On average, capability scores were higher for practices owned by physician groups and hospitals/health systems than for independent practices (for physician groups, difference of 12 points in both surveys).
"Over the time period including the COVID-19 pandemic, primary care practices reported a decline in access to care, while average practice capabilities improved," the study authors wrote. "Integrated practice ownership and ACO participation were both associated with better access and capability scores, suggesting that value-based payment and integrated care delivery support the development of higher-quality primary care."
Overall, variations by practice suggest big opportunities for improvement and highlight the importance of incentives and structures to improve primary care delivery, they said: "The findings suggest that payment reform and primary care ownership are highly relevant to enhancing the capabilities essential to deliver high-quality, accessible primary care."
