Building Research Capacity in Primary Care Practices That Serve Predominantly Racial and Ethnic Minority Populations

ABSTRACT

Primary care research represents only 1% of all federally funded projects. However, innovation in primary care is central to advancing health care delivery. Indeed, leaders in health care innovation recently called for primary care payment reform proposals to be tested in accountable care organizations (ACOs) consisting of independent practices (ie, practices not owned by hospitals). Yet these same practices may have less experience with the kind of systematic innovation that leads to generalizable insights, because what little funding is available for primary care research is mostly awarded to large academic medical centers. In this commentary, we report on lessons learned over 2 years (2020-2022) from conducting primary care research through a novel alliance of an ACO consisting of independent practices, a health plan, and several academic researchers, with the support of a private foundation. This collaboration is also notable because it was specifically assembled to address racial and ethnic inequities in the midst of the COVID-19 pandemic.

Am J Manag Care. 2023;29(6):280-282. https://doi.org/10.37765/ajmc.2023.89368

Takeaway Points

The process of collaborating on research was mutually beneficial for a network of independent practices and a group of academic researchers.

• The process benefited the practices by facilitating more precise thinking about quality improvement, motivating the staff, and enabling readiness for health system change.
• The process benefited the researchers by illuminating nuances of clinical and organizational workflow and revealing the practices’ in-depth understanding of the communities they serve.
• If practices have more federally funded opportunities to consistently participate in research, it could help speed greater adoption of payment reform models to promote health equity at the state and national levels.

A 2021 National Academies of Sciences, Engineering, and Medicine report, Implementing High-Quality Primary Care, has called out the persistent “neglect of basic primary care research” in the United States.¹ A 2020 study by the RAND Corporation found that primary care research represents only 1% of all federally funded projects (including projects funded by the National Institutes of Health, the Agency for Healthcare Research and Quality [AHRQ], and the Veterans Health Administration).²

However, innovation in primary care is central to advancing health care delivery. Leaders in health care innovation recently called for CMS to test a proposal for primary care payment reform in accountable care organizations (ACOs) composed of independent practices (ie, practices not owned by hospitals).³ By innovating in independent practices, these leaders argued that CMS would provide incentives for those practices to stay independent, thereby potentially decreasing the vertical market consolidation that contributes to rising health care costs.³ Yet these same practices may have less experience with the kind of systematic innovation that leads to generalizable insights, because what little funding is available for primary care research is mostly awarded to large academic medical centers.¹ AHRQ’s practice-based research networks have not fully addressed this gap, as they have struggled to find infrastructure and maintain funding.¹

In this commentary, we report on the lessons we learned over 2 years (2020-2022) from conducting primary care research through a novel alliance of an ACO consisting of independent practices, a health plan, and several academic researchers, with the support of a private foundation. This collaboration is also notable because it was specifically assembled to address racial and ethnic inequities in the midst of the COVID-19 pandemic.⁴

Context

AdvantageCare Physicians (ACPNY) is a large, community-based, multispecialty network of practices that cares for nearly 500,000 patients in the New York metropolitan area.⁵ The majority (60%) of ACPNY’s more than 350 providers are primary care physicians. ACPNY participates as an ACO with Medicare.⁶ More than half of ACPNY’s patients are Black or Latinx. The 2 most common languages spoken among patients are English and Spanish. ACPNY has 37 sites across New York City and Long Island, which all use the same Epic electronic health record (EHR). ACPNY is also part of a larger organization called EmblemHealth. Approximately half of ACPNY’s patients have EmblemHealth commercial, Medicare, or Medicaid insurance.

Methods

The research team included 3 people from ACPNY: a physician-leader, who serves as president and chief medical officer of ACPNY and as an officer of EmblemHealth (N.V.R.); a strategic planning specialist, who had previous training in quality measurement (A.J.); and the chief strategy officer (T.K.). The research team also included 3 people from Weill Cornell Medicine: a physician-scientist with experience in community-based health information technology research (L.M.K.), a data analyst (J.B.R.), and a research assistant (J.E.A.). The research team met weekly and received periodic input from 2 external advisers (an expert in electronic patient portals in underserved communities [J.S.A.] and an expert in health communication [M.J.S.]). In addition, the research team worked with ACPNY staff members (who had expertise in Epic and patient outreach) and providers to invite feedback on the initiative and facilitate buy-in.

Projects Completed

The team completed 2 projects over the span of 2 years. First, we conducted a qualitative study of patients’ perspectives on COVID-19 vaccines and whom they would trust to deliver information about the vaccine (July-December 2021). The data, which were collected in English and in Spanish, showed that patients trusted primary care providers, including the primary care providers at ACPNY, more than any other source of information, including the government.⁷ The implications are that efforts to address COVID-19 vaccine hesitancy should leverage the existing relationships that patients have with their primary care physicians, which has largely not been done.⁷

The second project was to test the feasibility of building and deploying an intervention to leverage trust in primary care physicians to address COVID-19 vaccine hesitancy (December 2021-April 2022). Based on the results of the first study, we developed an outreach message to patients expressing openness to hearing questions about COVID-19 vaccines, and then we worked with the Epic team to customize the messages so that they came from each patient’s individual primary care provider. We sent the customized messages through the patient portal, through text messages, and through landline phone calls to a total of 46,795 patients; they comprised a 50% random sample of those eligible (adult patients who had a primary care physician at ACPNY, had EmblemHealth capitated insurance, and spoke English or Spanish). We captured rates at which patients opened messages in the patient portal (46.1%), and we captured the percentage of patients who contacted ACPNY to schedule a follow-up appointment within 30 days after receiving the message (37.1%). This was a feasibility study, so we did not have a concurrent control group that received alternative (noncustomized) messages. This feasibility study was also conducted more than 1 year after COVID-19 vaccines became available, at a time when most ACPNY patients were already vaccinated. Nevertheless, pursuing this work yielded valuable lessons.

At the conclusion of these projects, the research team met to explicitly synthesize the lessons they had learned over the 2-year period of collaboration. Ideas were iteratively refined verbally and in writing.

Lessons Learned

This collaboration yielded 2 major lessons: the value to independent practices of conducting research and the value to academic researchers of engaging with independent practices, which are listed in the Table and described below.

Lesson 1: the value to independent practices of conducting research. All members of the research team from ACPNY reported that the experience of conducting research enabled them to think more precisely about quality improvement (lesson 1A). For example, when we were developing the feasibility study, we had to determine exactly what outcome we were trying to effect with the customized outreach messages (eg, message read rates, appointments made, vaccines delivered, or another outcome). Once an outcome was chosen, we had to make sure that that outcome could be measured, in reports that could be generated easily from the EHR. The processes of anticipating outcomes, building measurement into the process from the beginning, and analyzing results were critical activities.

ACPNY also found that participating in research motivated the staff of the organization (lesson 1B). For example, when the qualitative study found that patients trusted the providers at ACPNY and the ACPNY organization itself, staff could feel great pride in their work and motivation to continue. Those findings were particularly meaningful because they were generated in partnership with academic researchers, who brought rigor and objectivity to the process.

Finally, ACPNY found that experience with research facilitates innovation and readiness for health system change (lesson 1C). After learning how to generate random samples of patients, send customized messages through the patient portal, and measure the result, the team at ACPNY felt more comfortable with and more emboldened to make systematic changes to care delivery in order to improve quality and outcomes. They also felt more prepared to engage in the type of practice transformation and quality measurement that would be required of them in the context of payment reform.

Lesson 2: the value to academic researchers of engaging independent practices. It quickly became apparent to the academic researchers that the nuances of clinical and organizational workflows would be critical for success (lesson 2A). For example, researchers learned from their ACPNY partners that outreach through the patient portal could not be sent all at once but rather needed to be sent out in waves to ensure that the practice could handle the volume of responses it might receive.

In addition, ACPNY’s in-depth knowledge of local communities was essential (lesson 2B). Although we started the collaboration with a focus on racial and ethnic inequities, it became clear that misinformation about COVID-19 vaccines was clustered geographically and influenced by political affiliation, not necessarily by race or ethnicity. The independent practices’ knowledge of the communities they serve was critical for our work.

Conclusions

This 2-year collaboration between a network of independent practices and academic researchers was highly successful. The results of our research found that patients trust their primary care physicians for COVID-19 vaccine information more than they trust the government, which strongly suggests that the government would benefit from closer collaboration with primary care practices in the current pandemic and in future public health emergencies.⁷ The process of conducting research benefited the network of independent practices by facilitating more precise thinking about quality improvement, motivating the staff, and enabling readiness for health system change. The process of conducting research benefited the academic researchers by illuminating nuances of clinical and organizational workflow and revealing the practices’ in-depth understanding of the communities they serve.

The perspective of independent practices is urgently needed in national discussions about payment reform, and those practices will be much better equipped to participate if they have research experience. If practices have more federally funded opportunities to consistently participate in research, it could help speed greater adoption of payment reform models to promote health equity at state and national levels.

Author Affiliations: Weill Cornell Medicine (LMK, JEA, JBR), New York, NY; AdvantageCare Physicians (AJ, TK, NVR), New York, NY; EmblemHealth (AJ, NVR), New York, NY; Fred Hutchinson Cancer Center (MJS), Seattle, WA; Vanderbilt University Medical Center (JSA), Nashville, TN.

Source of Funding: This work was funded by a charitable contribution from the Royalty Pharma Foundation to Weill Cornell Medicine.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (LMK, AJ, TK, NVR); acquisition of data (LMK, JEA, AJ, NVR); analysis and interpretation of data (LMK, JEA, AJ, TK, JBR, MJS, JSA, NVR); drafting of the manuscript (LMK, JEA, TK, MJS, JSA, NVR); critical revision of the manuscript for important intellectual content (LMK, JEA, AJ, TK, JBR, MJS, JSA, NVR); statistical analysis (JBR); provision of patients or study materials (AJ, NVR); obtaining funding (LMK); administrative, technical, or logistic support (LMK, JEA, AJ, TK); and supervision (LMK, TK, NVR).

Address Correspondence to: Lisa M. Kern, MD, MPH, Weill Cornell Medicine, 420 E 70th St, Box 331, New York, NY 10021. Email: lmk2003@med.cornell.edu.

REFERENCES

1. National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. The National Academies Press; 2021.

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