Changes in rates and content of primary care visits within an evolving health care system

It is no secret to patients and clinicians that the past decade has brought many changes to the organization, operations, and financing of health care in the United States. The Patient Protection and Affordable Care Act of 2010 (ACA) expanded the number of insured and otherwise reduced costs as a barrier to care, bolstered federal safety net programs, and promoted coverage of preventive services and wellness programs. The advent of the patient-centered medical home and primary care practice redesign has broadened services provided both during and between office visits through care teams that can include health coaches, panel managers, patient navigators, and care coordinators. Electronic medical records (EMRs) have become central to patient care, supporting chronic disease and preventive care management, promoting quality of care for set metrics, and providing new ways for patients, staff, and physicians to communicate. Institutional reorganization and new financing models now have most physicians working in practices that have contracted with accountable care organizations (ACOs) and other value-based payment arrangements, becoming responsible for the health and care of a growing 10% of the US population. Care previously received from standalone outpatient practices and siloed hospitals is now often received through regional integrated health care systems, with their centralized management, standardized protocols, and growing incentives for patients and clinicians. For the first time, fewer than one-half of physicians work in practices they own