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Background: Payers are increasingly interested in quality improvement for opioid use disorder (OUD) treatment, including incorporating patient experiences. Medicaid is the largest payer for OUD treatment, yet we know little about the treatment benefits Medicaid members report, how these vary across members, or changed with the COVID-19 pandemic. Objective: To examine Medicaid members' report of outpatient treatment benefits, employment, and housing outcomes before and during the pandemic. Methods: A representative sample of 1,032 Virginia Medicaid members (52% women) receiving OUD treatment completed a survey of treatment benefits, health status and social needs. A reported treatment benefit index was created based on seven self-reported items. Multivariable linear regression models, pooled and stratified by time (pre-COVID-19/COVID-19), assessed member characteristics associated with reported treatment benefit, employment and housing outcomes. Results: Members reported strong treatment benefit (mean: 21.8 [SD: 5.9] out of 28 points) and improvements in employment (2.4 [1.3] out of 5) and housing (2.8 [1.2] out of 5). After adjustment, mental distress (regression coefficient: −3.00 [95% CI:-3.97;-2.03]), polysubstance use (−1.25 [−1.99;-0.51]), and food insecurity (−1.00 [−1.71;-0.29]), were associated with decreased benefits from treatment. During COVID-19, justice-involved individuals reported decreased benefits (−2.17 [−3.54; −0.80]) compared to before the pandemic (−0.09 [−1.4-;1.24] p <.05). Conclusions: Medicaid members receiving outpatient OUD treatment reported positive treatment benefits, and housing and employment outcomes. However, those with comorbid health and social conditions often benefited the least. As payers move toward quality improvement and value-based purchasing initiatives, collecting and integrating patient reported outcomes into quality metrics is critical. [ABSTRACT FROM AUTHOR]

Context: The US healthcare system suffers from high healthcare costs, suboptimal health outcomes, and a fragmented primary care system, at least in part due to a fee-for-service payment model. The National Academies of Sciences, Engineering, and Medicine recommend a transition to alternative payment models (APMs) as a pathway to implementing high-quality primary care. Many suggest that practices need at least 25% APM-attributable revenue (AAR) in order to see change. Objective: We sought to assess the adoption of APMs among primary care practices in Virginia. Study Design: Mixed-methods evaluation of practice surveys and semi-structured interviews. Population studied: All primary care practices in Virginia were surveyed. 40 clinicians from responding practices were interviewed, representing the spectrum of rurality, ownership, and APM penetrance. Dataset: Surveys were emailed and mailed to practices up to six times between 9/1/21 and 4/22/22. Non-responding practices were called. Surveys followed up a 2018 primary care survey with an emphasis on APM. Interviews further explored findings. Outcome measures: Practice characteristics, current APM participation, AAR, and interest in future APM. Results: 418 of 2119 practices completed the survey (19.7%). Nearly half (49%) of practices have no AAR, 30% have 1-10% AAR, 9% have 11-24% AAR, and 12% practices have 25% or more AAR. For practices with no (0% AAR), medium (11-24% AAR) and high (=25% AAR), there were only minor differences in: ownership (clinician owned: 59% vs 39% vs 46% / health system owned: 29% vs 50% vs 39%), care of vulnerable populations (81% vs 89% vs 85%), quality measurement (51% vs 67% vs 68%), and social needs screening (29% vs 28% vs 32%). However, for practices with no, medium, and high AAR, practices with medium payment seemed different from the others in terms of APM perspective including: interest in Medicaid APM (29% vs 65% vs 28%), would make changes if more APM (24% vs 41% vs 17%), reduce turnover with more APM (19% vs 41% vs 35%), and improve access with more APM (35% vs 59% vs 31%). Many clinicians felt APMs would allow them to hire additional support staff and care for more patients, yet there was skepticism on whether APMs would represent a true increase in primary care investment. Conclusions: While uptake of APM is low, there is general interest in more APM and a belief it can improve care. Practices with a medium amount of AAR may be most open and amenable to change. [ABSTRACT FROM AUTHOR]

Background: Practice ownership has an impact on quality improvement, provision of low value care, and burnout. As hospital ownership expands and clinician owned practices become less common, it is necessary to quantify the differences in practice and patient characteristics that are associated with ownership. Objective: This study aims to identify patient characteristics, practice characteristics, stressors, and access for primary care practices by ownership. Study design, Setting: A cross-sectional survey was fielded to all primary care practices between 9/1/2021-4/22/2022. Results: 424 practices responded to the survey. 181 practices were health system owned, 178 clinicianowned, and 60 government, private or academic center owned (other). Health-system owned practices were more likely to see historically underserved patients (ie: low income (88.8% vs 73.0%, p<0.001), Medicaid recipients (23.0% vs 15.1%, p<0.001), non-English speakers (69.3% vs 50.9%, p<0.0003)) as compared to clinician-owned practices. Health-system were more likely to have patient strategies to improve care (ie: provide care coordination (64.9% vs 46.2%, p<0.001), patient advise line (25.3% vs 15.6% p<0.001), follow up after specialist (43.7% vs 37% p<0.001)). Hospital-system and clinician-owned practices had similar stressors in the past year (moved offices, changed EMR, changed billing system) but hospital-owned practices were less likely to experience COVID-19 related stressors (financial recovery (27.8% vs 46.0%, p<0.001), reduced pay (32.7% vs 38.7%, p<.001), staff layoffs (5.6% vs 13.3%, p=<.05)). Yet hospital-system practices are more likely to report struggling from burnout than clinicianowned practices (77.2 vs. 54.0, p<.001). Discussion: These results demonstrate that hospital ownership may be protective against major stressors and offer more ancillary services than clinician owned practices. This may be due to financial stability and larger institutional support but may also be due to the needs of the patients seen as hospital system owned practices are shown here to see more patients that receive Medicaid, Medicare and are uninsured. However, hospital-system practices struggle more from burnout. These results are particularly valuable to practices considering ownership changes, however, are limited as physician autonomy and wellness were not measured here. [ABSTRACT FROM AUTHOR]

Context: High quality primary care results in longer lives and more equity. Despite its high value, primary care is under-resourced and under perpetual stress. Clearly the COVID pandemic was a major stress, and the long-term impacts are still being felt by practices. Objective: We sought to assess the current state of stress in primary care and how it has impacted the provision of high-quality care. Study Design: Mixed methods evaluation of practice surveys and semi-structured interviews. Population studied: Every primary care practice in Virginia was surveyed. From respondents, 40 clinicians from practices representing the spectrum of rurality, ownership, and reported stress were interviewed. Dataset: In partnership with local primary care professional societies, surveys were emailed and then mailed to every practice in Virginia up to six times between 9/1/21 and 4/22/22. Non-responding practices were called. Surveys followed up a 2018 primary care survey. Interviews further explored findings. Outcome measures: Practice characteristics, scope of practice, and stresses experienced. Results: 418 of 2119 practices completed the survey (19.7%). 49.1% of practices reported a major stress in 2022, increased from 32% in 2018. Major stresses included losing one or more clinician (36.9%), office renovations (9.5%), changing EMRs (8.3%), changing billing systems (7.4%), and changing ownership (6.8%). 63.3% reported clinicians got COVID, 1.4% had clinicians or staff die from COVID, 34.0% had to reduce pay, 28.8% are still struggling financially, and 59.5% had clinicians struggling from burnout. Concurrently, practices still continue to deliver high quality primary care - 91.1% care for vulnerable populations, 68.9% accept new Medicaid patients, 64.6% measure and try to improve quality of care, 51.2% provide mental health care coordination, and 36.0% screen for social needs. Clinicians expressed frustration that healthcare is driven by business and corporate profit, and not caring for people and communities, while sharing fear that burnout is at an all-time high. Conclusions: Primary care practice continue to care for people and communities, offer comprehensive services, use tools and measures to improve quality, and provide access to underserved and vulnerable people. Concurrently, practice stress and change are at an all-time high, primarily driven by a loss of clinicians, which could jeopardize future access and quality to primary care. [ABSTRACT FROM AUTHOR]

Background: Primary care is the foundation of health care, resulting in longer lives and improved equity. Primary care was the frontline of the COVID-19 pandemic public response and essential for access to care. Yet primary care faces substantial structural and systemic challenges. As part of a longitudinal analysis to track the capacity and health of primary care, we surveyed every primary care practice in Virginia in 2018 and again in 2022., Methods: Surveys were emailed or mailed up to 6 times and nonresponders received a phone call. Questions assessed organizational characteristics, scope of care, capacity, and organizational stress in the prior year. From respondents, 39 clinicians, nurses, staff, administrators, and practice managers were interviewed., Results: 526 out of 2296 primary care practices (23% response rate) completed the survey, with broad representation across geography, ownership, and payer mix. Compared with 2018, in 2022 there were increases in practices owned by health systems (25% vs 43%, P < .0001 ) and average percent of patients with Medicaid per practice (12% vs 22%, P < .0001 ). The percent of practices reporting any major stressor increased from 34% to 53% ( P < .0001 ). The main increased stress was losing a clinician, with 13% of practices in 2018 versus 42% in 2022 reporting losing a clinician ( P < .0001 )., Conclusions: Primary care practices are resilient and continue to serve their communities, including a broad scope of services and care for underserved people. However, the COVID-19 pandemic caused significant stress. With an increase in clinicians leaving clinical practice, we anticipate worsening access to primary care., Competing Interests: Conflict of interest: Dr. Britz is a JABFM Fellow., (© Copyright by the American Board of Family Medicine.)