Why Do Some Primary Care Practices Engage in Practice Improvement Efforts Whereas Others Do Not

Why do some primary care practices manage to transform themselves into new models of health care delivery whereas others do not? This is the central question of our research because the quality of care received by many Americans is often suboptimal (Schoen et al. 2007; Anderson and Marcovich 2010). Quality issues plaguing primary care include patients' lack of access to services (Huynh et al. 2006), inconsistencies in providing evidence-based medicine (Grol and Grimshaw 2003; McGynn et al. 2003), poor coordination of care across health system components (MacKinney, Ullrich, and Mueller 2011), and complexity involved in caring for individuals with chronic illnesses (Von Korff et al. 1997). Recognizing this problem, the Affordable Care Act emphasizes patient-centered care that is reliable, accessible, and safe; improves the health of the population; and reduces costs to deliver care. Primary care transformation is seen as a key element in meeting these goals. Knowing which practices have adopted new primary care approaches, like the patient-centered medical home (PCMH) model, and contrasting them with those that have not is an important step toward knowing which policies to select to remedy the overall capabilities of primary care delivery. Thus, in this study we differentiate between primary care practices that are and are not transforming to deliver evidence-based medicine, implementing new models of care delivery such as the PCMH, improving transparency through performance measurement and reporting, and creating strategic alliances for advanced integrated care models like accountable care organizations (ACOs). Pressures external to the organization that favor these transformations come via pay-for-performance (P4P) compensation methods, public reporting of performance, government requirements for adoption and meaningful use of electronic health records (EHRs), board recertification processes, and increased expectations from patients and other stakeholder groups. However, primary care practices also experience pressures not to change. For example, payment systems encourage high volume and episodic care, which runs counter to key features of the PCMH and ACO models. Primary care practices are therefore caught in a cross fire of contradictory forces. Recent literature has identified various internal and external factors that may influence practices' ability to transform (Milstein and Gilbertson 2009). Adoption of PCMH components was greatest for large medical groups and for those owned by large health systems—all more likely to have greater resources (Rittenhouse et al. 2008; Goldberg and Mick 2010). The National Demonstration Project identified access to resources as a facilitator of practice transformation, as well as having a supportive infrastructure and management model, facilitative leadership, and an empowering and responsive culture (Nutting et al. 2010). Wise et al. (2011) found that transformation to PCMHs correlated with perceived value of the change, understanding PCMH requirements, leadership and staff commitment, and financial incentives. Reid et al. (2011) reported lack of financial incentives as the primary reason why residency practices discontinued transformation efforts. Fernald et al. (2011) found that embedded culture from historical events, such as previous failed attempts at transformation, a lack of meeting structure, and lack of participation by key practice members influenced practices' ability to transform. They also identified barriers to practice transformation, including a lack of support by leadership and affiliated organizations, and nonsupportive organizational structures and processes. Although these studies present various influences on practice transformation, they do not provide an exploration of both pressures and internal practice characteristics affecting change. The present study begins to fill this gap. There are three critical aspects of current practice transformation efforts (Hoff 2010). First, is added payment for care coordination or case management to break the cycle of “15-minute medicine” caused by volume-driven fee-for-service reimbursement. Second is a “minimum level” of health information technology (HIT) capacity in every practice. And, third, is the transformation of existing patient care and administrative work into team-based care models, in which physicians become team leaders and nurses have increased roles and responsibilities for patient care. The problem is that: It cannot nor should it be expected that after a decade or more of forcing PCPs [primary care physicians] to practice in an assembly-line-like manner provides an immediately favorable environment for practices to innovate…. PCP mindsets are attuned to the demands of high-volume medicine. (Hoff 2010, p. 181) Given forces arrayed against practice transformation efforts, our basic question was what enables a practice to transform itself. Building on previous research was another goal of our study. Our aim was to gain additional knowledge from in-depth case studies to develop a framework explaining the mechanisms of influence and contextual modifiers on performance improvement in physician practices. We studied physician practices in their natural environment to understand performance improvement efforts or their lack and real-life complications, issues, and solutions.