Changes in US Primary Care Access and Capabilities During the COVID-19 Pandemic

Importance Many of the capabilities needed to deliver accessible, high-quality primary care have been defined, but little is known about how their implementation has changed in US practices over the course of the COVID-19 pandemic or about the factors associated with greater capabilities. Objective To describe US primary care practices’ accessibility and capabilities and examine recent changes. Design, Setting, and Participants This was a retrospective cohort study across 2 surveys, in 2017 to 2018 and 2022 to 2023, among a national sample of primary care practice leaders in the US. Data were analyzed from January 2023 to September 2024. Exposures Degree of integrated practice ownership and accountable care organization (ACO) participation. Main Outcomes and Measures Differences by practice ownership and ACO participation, and changes over time in access to care and care delivery capabilities. These were measured by composite scores of responses standardized to a scale of 0 to 100. Results This analysis included 710 practices, of which 234 were independently owned, 105 were physician group owned, and 321 were hospital/health system owned in 2017 to 2018, and 68 practices reported no ACO participation, 107 joined between surveys, and 486 otherwise participated in ACOs. Access to care (measured as extended weekday or weekend hours) was reported to decline from the first survey in 2017 to 2018 to the second in 2022 to 2023. Hospital/health system practices and ACO participants had higher rates of extended weekday hours than their comparators in 2022 to 2023. Average capability scores increased from 51 to 54 (increase of 4 points [95% CI, 1-6 points]). There was wide variation in scores within all ownership and ACO participant or nonparticipant groups. Capability scores were higher on average for more integrated practices (for physician groups compared to independent practices, 12 points [95% CI, 5-19 points] in 2017-2018 and 12 points [95% CI, 7-16 points] in 2022-2023) and for ACO participants compared to nonparticipants (13-point difference [6 to 20] in 2017-2018 and 12-point difference [6 to 18] in 2022-2023). Conclusions and Relevance In this cohort study, over the time period including the COVID-19 pandemic, primary care practices reported a decline in access to care, while average practice capabilities improved. Integrated practice ownership and ACO participation were both associated with better access and capability scores, suggesting that value-based payment and integrated care delivery support the development of higher-quality primary care. Variations across practices point to large opportunities for improvement overall and underscore the importance of incentives and structures as levers to improve primary care delivery.