Staff Engagement in the Implementation of a Primary Care Value-Based Payment Program Increases Outpatient Care Utilization: A Mixed Methods Study

This convergent parallel mixed-methods study examined how a primary care value-based payment (VBP) model affected patient health care use and captured implementation experiences from select clinics. Focusing on outpatient care as a key step to improving outcomes, we used a difference-in-differences model to compare outpatient utilization between PCPM (the VBP model) and non-PCPM clinics, and semi-structured interviews with a subset of participating clinics to explore implementation efforts on the ground. We identified our quantitative study population (cases N = 68 807; control N = 71 695) and outcomes from Oregon’s All Payer All Claims (APAC) data system and, qualitatively, we conducted 12 interviews with operational/administrative staff at 7 PCPM clinics. Our findings indicated that PCPM patients experienced greater connection to primary and specialty care—both the proportion who used care and the average amount of care used per member—relative to the control group. Primary care use rose by 4.2 percentage points (95% CI: 3.3%, 5.1%; P < .001), and specialty care by 1.1 points (95% CI: 0.4%, 1.8%; P = .002). Among users, primary care visits increased by 136.9 per 1000 member months (95% CI: 107.2, 166.6; P < .001), and specialty care by 32.1 (95% CI: 10.5, 53.7; P = .004). Qualitative findings added further context: (1) staff communication about PCPM efforts connects directly to improvements in care delivery and patient outcomes; (2) success depends on care team staff being involved in the creation of new workflows and processes; and (3) access to program data helps to identify care gaps and improve patient care delivery. We concluded that care team staff engagement in VBP models is strengthened by making the connection between VBP and direct improvements to patient care. Models that motivate staff can lead to increased connection to primary and specialty care among the clinic’s patient population.