FROM POLICY TO PRACTICE: PRIMARY CARE PHYSICIAN PERSPECTIVES ON VALUE AND ITS INFLUENCE ON MAKING CLINICAL DECISIONS

Purpose: Improving value (outcomes/cost) in healthcare is central to the US Patient Protection and Affordable Care Act, and primary care physicians (PCPs) are key to its delivery. This study examined PCPs’ understanding of value, its influence on their clinical practice, and their perceptions of how the healthcare systems in which they work support value-based decision-making.

Method: Twenty-four semi-structured interviews with PCPs as part of three qualitative parallel case studies. The cases were purposely selected to reflect different forms of US healthcare delivery system: a group model integrated delivery system; an independent practice association; and a public safety-net integrated delivery system.

Results: All PCPs recognized value as a priority for their systems and considered their role to be improving outcomes by implementing best practice and preventive care. Half the physicians consciously took cost into account. The concept of value was understood differently by PCPs working in the private systems where few felt cost-constrained. In the public system, value definitions were less likely to refer to cost, and it was more common to feel cost-constrained. In all three cases, patients’ sense of value had a growing and direct impact on clinical decision-making. As a system, the group model was described as “cost-conscious” but providing little direct challenge to PCP practice. For the IPA, focus on value was “subtle” and utilization management hurdles were “frustrating”. In the safety-net system, PCPs felt the system drove value by maximizing patient throughput, in both primary care and specialist care, resulting in long waits for the latter. Quality metrics were routine in all systems; no PCPs received information on the financial impact of their decisions although most would welcome it. More clinical resources (group model and safety-net system), greater patient education (group model and safety-net system), better links with specialists (the IPA), and better electronic medical records (IPA and safety-net system) were seen as potential ways to improve value.

Conclusion: PCPs appreciated the concept of value but felt more able to focus on quality than cost in their clinical decision-making, whether in public or private, integrated or independent systems. PCPs’ ability to increase value could be improved through greater use of cost information complemented by continued system-wide focus on value. This could improve overall value without decreasing physicians’ sense of autonomy.