High Quality Primary Care, Stress, and Major Practice Changes

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.