Impacts of patient-centered medical home environment, financial incentive, and restrictions on physicians' ability to provide quality primary care

Background: The Affordable Care Act (ACA) relies heavily on high quality primary care to maximize overall healthcare quality, access and equity. The patient-centered medical home (PCMH) model of primary care is a promising strategy. To accelerate such a transformation we need empirical evidence showing that PCMH environments increase primary care physicians' (PCP) ability to provide high quality primary care. Second, empirical evidence is needed on what motivates PCPs to provide high quality primary care. Financial incentives are known to reinforce the specific practice behavior targeted, but whether financial incentives reinforce globally high quality care remains undocumented. Such documentation may accelerate the adoption of suitably designed financial incentives to reinforce the current efforts to transform primary care settings into PCMHs to accelerate the quality gains from PCMH transformation of primary care settings.

Objective. To examine the association of financial incentives and patient-centeredness of the practice setting with PCPs' self-reported ability to provide high quality care controlling for extraneous structural and clinical resource constraints.

Data Sources. Cross-sectional, pooled data on 1,733 salaried PCPs in group practices surveyed in the 2004 and 2005 Community Tracking Study (CTS) Physician Surveys from 60 randomly selected U.S. communities were subjected to logistic regression modeling using composite scores of financial incentives and PCMH-practice climate generated by exploratory factor analyses. We modeled PCPs' self-reported ability to provide quality care (ordinal scale, 3 categories) controlling for clinical resource constraints, prescribing constraints, patient financial burden, and practice type. Findings: PCMH-orientation of the practice was positively associated with self assessed ability to provide high quality care, as was financial incentive linked to care quality/content. Odds ratio for ability to provide high quality care was 8.63 for high PCMH practices, and 2.88 for modestly PCMH-oriented practices, relative to low PCMH practices. Dominance of quality-driven financial incentives in PCPs' compensation package is positively associated with high quality care (OR=1.30 for high dominance of these incentives and OR=1.22 for modest presence of quality-driven incentives). Constraints in obtaining clinical resources (specialist referrals, inpatient, laboratory or emergency services) were negatively associated with ability to provide high quality care. Drug-prescribing restraints and patients' out-of-pocket financial burden were not significant.

Conclusion. Our findings support the ongoing efforts to expand PCMH in primary care and indicate that well-designed financial incentives can reinforce PCPs' focus on global care quality.