Does Ownership Make a Difference in Primary Care Practice?

Stephan Lindner, PhD; Leif I. Solberg, MD; William L. Miller, MD, MA; Bijal A. Balasubramanian, MBBS, PhD; Miguel Marino, PhD; K. John McConnell, PhD; Samuel T. Edwards, MD; Kurt C. Stange, MD, PhD; Rachel J. Springer, MS; Deborah J. Cohen, PhD


J Am Board Fam Med. 2019;32(3):398-407. 

In This Article

Abstract and Introduction


Purpose: We assessed differences in structural characteristics, quality improvement processes, and cardiovascular preventive care by ownership type among 989 small to medium primary care practices.

Methods: This cross-sectional analysis used electronic health record and survey data collected between September 2015 and April 2017 as part of an evaluation of the EvidenceNOW: Advancing Heart Health in Primary Care Initiative by the Agency for Health Care Research and Quality. We compared physician-owned practices, health system or medical group practices, and Federally Qualified Health Centers (FQHC) by using 15 survey-based practice characteristic measures, 9 survey-based quality improvement process measures, and 4 electronic health record-based cardiovascular disease prevention quality measures, namely, aspirin prescription, blood pressure control, cholesterol management, and smoking cessation support (ABCS).

Results: Physician-owned practices were more likely to be solo (45.0% compared with 8.1%, P < .001 for health system practices and 12.8%, P = .009 for FQHCs) and less likely to have experienced a major change (eg, moved to a new location) in the last year (43.1% vs 65.4%, P = .01 and 72.1%, P = .001, respectively). FQHCs reported the highest use of quality improvement processes, followed by health system practices. ABCS performance was similar across ownership type, with the exception of smoking cessation support (51.0% for physician-owned practices vs 67.3%, P = .004 for health system practices and 69.3%, P = .004 for FQHCs).

Conclusions: Primary care practice ownership was associated with differences in quality improvement process measures, with FQHCs reporting the highest use of such quality-improvement strategies. ABCS were mostly unrelated to ownership, suggesting a complex path between quality improvement strategies and outcomes.


The organizational structure of primary care practices is rapidly changing in the United States. Primary care can be categorized into 3 major ownership types: independent physician-owned practices, practices employed by hospitals (health system or medical group practices), and Federally Qualified Health Centers (FQHCs; ie, practices that provide comprehensive primary care to low-income people in underserved communities and that are governed by community boards). Among these, the proportion of US physicians employed by hospitals increased from 20% in 2002 to over 50% in 2008.[1] Simultaneously, the number of FQHCs has grown dramatically over the past 20 years in response to higher federal funding, and their role is likely to increase further in the future.[2–4] At the same time, independent physician-owned practices continue to provide care for millions of Americans.[5]

Despite these changes, we know little about how physician-owned practices, FQHCs, and health system or medical group practices differ in their structural characteristics; approach to quality improvement (QI), including both change management and quality-aligned care delivery processes; and patient outcomes. Health systems and medical groups (ie, practices owned by a hospital and practices owned by nonhospital organizations, respectively) have tended to perform well on process and care quality measures but not across all measures and studies.[6–15] These studies typically focus on a few measures, 1 or 2 ownership types, and larger practices. Studies on FQHCs have generally been favorable in terms of access, prevention, and quality of care,[2,16–18] but they too typically focus on a few measures and lack explicit comparisons by practice ownership type.

In 2015, the Agency for Health Care Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in Primary Care. This multiyear, multisite demonstration project tests the effectiveness of external support strategies (eg, practice facilitation) in helping small- to medium-sized primary care practices improve the delivery of preventive care for cardiovascular disease. AHRQ funded 7 regional cooperatives in 12 states that were responsible for recruiting practices and testing various forms of external support.[19–21] It also funded an independent national evaluation of the overall initiative called Evaluating System Change to Advance Learning and Take Evidence to Scale.[22] EvidenceNOW Cooperatives recruited 1719 small- to medium-sized primary care practices, defined by AHRQ as practices that provide "integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs".[23] Recruited practices typically had fewer than 10 clinicians, including physicians, physician assistants, or nurse practitioners.[22]

In this study, we comprehensively compared health system and medical group practices, FQHCs, and physician-owned practices along a rich set of practice characteristics, QI processes, and cardiovascular disease prevention quality outcomes by using a large sample of 923 small- to medium-sized primary care practices that participated in EvidenceNOW. Our goal was to identify differences in these 3 most prevalent primary care ownership types in the United States that might help practice leaders, researchers, and policy makers better understand these practice types to tailor their efforts to improve care where needed.