In recent years, the U.S. government has invested substantially in Federally Qualified Health Centers (FQHCs), which have become synonymous in policy discussions with primary care for the socially vulnerable. Conversely, no such investment has been made in independent practices serving socially vulnerable patients. As independent practices become less financially viable, this disparity could severely limit primary care options for socially vulnerable patients. This mixed-methods study considers the extent to which independent family physicians in urban communities serve socially vulnerable patients and aims to better understand their practices, challenges, and the structural supports that could better facilitate their patient care.
Quantitative analysis of data from the 2017-2020 American Board of Family Medicine's (ABFM) Family Medicine Certification Examination questionnaire, a mandatory component of family medicine recertification, showed that 19.3% of family physicians in urban areas, down from 22.6% in 2017, served in independent practices with one to five clinicians. Nearly half of them reported that more than 10% of their patients were socially vulnerable. For the qualitative portion of the study, researchers conducted one-hour semi-structured virtual interviews with 22 physicians who, per their ABFM questionnaires, met the following inclusion criteria: (1) their principal practice site is independently owned; (2) they are its sole or partial owner; (3) their practice has one to five providers; (4) their practice is in an urban area; and (5) more than 50% of their patients are socially vulnerable. The results of the interviews revealed five themes: (1) substantial time is spent addressing access issues and social determinants of health; (2) these practices receive minimal support from health care entities such as independent practice associations and health plans and have insufficient connections with community-based organizations; (3) they face myriad financial challenges; (4) they have serious concerns about their future; and (5) their physicians hold a deep personal commitment to serving socially vulnerable patients in independent practice. The researchers conclude that health equity–focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients will continue to have options when seeking primary care.
What We Know: Historically, primary care for socially vulnerable populations has depended on a fragmented "safety net" of public hospitals, health centers, and other health care organizations that provide care regardless of whether patients can pay. In recent years, the federal government has provided substantial funding to large FQHCs to care for the socially vulnerable, though no equivalent investment has been made in independent practices. Consequently, such practices are at risk of closure, even though many physicians and patients still prefer smaller, independent practice settings.
What This Study Adds: This study provides rich insights from independent primary care physicians serving socially vulnerable patients, a perspective that is underrepresented in the literature. While the multidisciplinary research team focused on urban communities, their findings might also be relevant to small independent rural practices. They propose that public policy focused on health equity, new primary care payment models that increase payments to independent practices, and new workforce policies that encourage recruitment and retention of small practice primary care teams could help these practices stay afloat.
Small Independent Primary Care Practices Serving Socially Vulnerable Urban Populations
Diane R. Rittenhouse, MD, MPH, et al
Mathematica, Oakland, California
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