TITLE: Assessing the Impact of Health System Ownership on Fulfilling the Vision of High-Quality
Primary Care and Whole Health
PROJECT SUMMARY
The National Academies of Sciences, Engineering, and Medicine’s (NASEM) reports “Implementing High
Quality Primary Care'' and “Achieving Whole Health: A New Approach for Veterans and the Nation'' call for
coordinated systems level approaches to care.1,2 In response to these calls for action and stresses on primary
care from the COVID pandemic and other market forces, primary care practices are increasingly owned by
health systems. In Virginia we have documented that between 2018 and 2022 there was an increase from 25%
to 43% of practices being owned by a health system with a concurrent decline in clinician ownership.3 These
changes could both help (e.g., provide a systems level approach, expanded interprofessional teams, new
resources) and/or undermine (e.g., reduce local decision-making authority, replace ambulatory focus with
hospital interests, undermine organizational culture) the ability to achieve NASEM’s vision. We propose an
explanatory sequential mixed-methods study using multimedia elicitation surveys and focus group interviews to
assess the impact of ownership on high-quality primary care and whole health care and to describe contextual
factors that may impact care. Building on our ongoing, longitudinal assessment of primary care in Virginia
conducted in the Ambulatory Care Outcomes Research Network (ACORN), we will randomly sample 30
primary care practices throughout the state, stratified by practices that in the past 5 years (a) moved from
clinician to hospital ownership, (b) stayed clinician owned, or (c) stayed hospital owned. The survey will consist
of a brief multimedia presentation, developed in collaboration with the NASEM report authors, of the key
elements of high-quality primary care and whole health, immediately followed by Likert scale questions to
assess team members’ attitudes, current practice, and confidence in the ability to improve on these elements.
The survey will be digitally administered with REDCap software to representatives of each clinical team
member type. To develop the multimedia elicitation survey, we will work with the NASEM report authors and
committee members to distill and operationalize core elements articulated in the reports, including questions
on equity, accessibility, integration, interprofessional teamwork, professional satisfaction and team wellbeing,
and community engagement. A practice structural questionnaire will also collect information on practice
organization and staffing levels, patient volume and population demographics, payer mix, EHR capabilities,
enhanced access options, and participation in innovative payment models. Follow-up group interviews with
practice teams will reflect on team survey responses and assess the organizational, practice, and individual
level factors influencing high-quality primary care and whole health care. Study findings will be used to further
AHRQ’s mission of revitalizing the Nation’s primary care system, promote the NASEM vision of Whole Health
in primary care, and develop future interventions to help primary care deliver high-quality and whole health
care in diverse ownership settings.
