Gains in Capability, Losses in Access to Primary Care After COVID-19

Researchers have found that access to care declined, while average practice capabilities improved following the COVID-19 pandemic. A new study published today in JAMA Health Forum highlights how the COVID-19 pandemic affected health care access and practice capabilities, revealing both challenges and areas for improvement.¹

Primary care for patients in the US is important, primarily in its use in managing chronic conditions, preventing diseases, promoting health, and diagnosing chronic or acute conditions.² These services can involve expertise in many areas to accomplish, including screening and behavioral health tools. The extent to which these tools and services changed after the COVID-19 pandemic is still being studied, and a clearer picture of postpandemic changes is still forming. This study aimed to compare surveys from a national sample of physician practices conducted in 2017 to 2018 and 2022 to 2023 that focused on care accessibility, practice ownership and participation in accountable care organizations (ACOs), and the implementation of care delivery processes to observe differences between the 2 time periods.

The National Survey of Healthcare Organizations and Systems was conducted from 2017 to 2018 with a follow-up in 2022 to 2023. All of the participating primary care practices were from the US. The surveys were created by engaging with national experts, developing new items, finding previously validated surveys, and reviewing literature. Sample frames for the survey were collected from the IQVIA OneKey database. Practices with at least 3 adult primary care clinicians were randomly sampled for the survey. All those who initially participated in the survey in 2017 to 2018 were invited to participate in the follow-up.

Practice capabilities improved in systems partnered with an ACO after the pandemic. | Image credit: Syda Productions - stock.adobe.com

The primary outcomes of the study were the reporting of adoption of care delivery capabilities and payment reforms and their association with better performance. The OneKey database was used to get counts for both clinicians and ownership in 2017 and 2022.

The researchers saw a decrease in independent ownership from 2017 (37%) to 2023 (31%), as well as physician group ownership (13% to 10%). An increase in practices owned by hospitals and health systems was found in response, from 40% to 49%. All practices that started as part of a hospital or health system remained as such after the pandemic. Participation in ACOs increased slightly, from 1.2 to 1.6 contracts of different payer types per practices; 43% of practices reported 1 or no types of payers in 2022 to 2023.

Forms of accessibility also declined overall after the pandemic. Practices offering weekend hours decreased from 44% to 26% and advanced access scheduling decreasing from 60% to 26%.

Capability scores, however, increased from 51 to 54 on a 100-point scale, with patients with complex or high needs having the largest improvement of 15 points. Depression care proceeses increased from 67 to 72 points, and electronic health record integration increased from 59 to 67 points. Screening for social needs saw a smaller increase of 37 to 43 points, and patient-reported outcome measures saw an increase from 63 to 70 points. No other capabilities saw a meaningful change.

Among those with lower scores, practices improved scores between surveys if they joined an ACO or were owned by a physican group and hospital/health systems. Higher rates of extended-hours access were reported in ACO participants compared with nonparticipants (55% vs 34%), even as accessibility declined overall. Practices in ACOs had the highest capability scores and nonparticipants had the lowest.

Practices that were owned by physician groups and hospitals/health systems had higher average capability scores compared with those that were independently owned, with a difference of 12 points at baseline and after the pandemic.

There were some limitations to this study. Favorability bias was possible due to the self-reported nature of the study and the lack of other comparbale data. The response rates were also lower after the pandemic compared with the response rates in 2017 to 2018, and comparisons across groups may not be possible due to unobserved differences in those who did and did not respond. Further, practices with 2 or fewer primary care physicians may not be generalizable to these data, clinician telephone calls or patient messaging were not captured in this data, and causal links could not be determined through this study.

“While this analysis cannot determine the extent to which the COVID-19 pandemic itself or other factors underlie these associations, the findings suggest that payment reform and primary care ownership are highly relevant to enhancing the capabilities essential to delivery high-quality, accessible primary care,” the researchers concluded.

References

1. Mackwood M, Fisher E, Schmidt RO, et al. Changes in US primary care access and capabilities during the COVID-19 pandemic. JAMA Health Forum. 2025;6(2):e245237. doi:10.1001/jamahealthforum.2024.5237

2. Savoy M, Hazlett-O’Brien C, Rapacciuolo J. The role of primary care physicians in managing chronic disease. Dela J Public Health. 2017;3(1):86-93. doi:10.32481/djph.2017.03.012