Research

JAMA Internal Medicine | Original Investigation | HEALTH CARE REFORM

Quality and Experience of Outpatient Care in the

United States for Adults With or Without Primary Care
David M. Levine, MD, MPH, MA; Bruce E. Landon, MD, MBA, MSc; Jeffrey A. Linder, MD, MPH

Invited Commentary
IMPORTANCE The US health care system is typically organized around hospitals and specialty Supplemental content
care. The value of primary care remains unclear and debated.

OBJECTIVE To determine whether an association exists between receipt of primary care and
high-value services, low-value services, and patient experience.

DESIGN, SETTING, AND PARTICIPANTS This is a nationally representative analysis of

noninstitutionalized US adults 18 years or older who participated in the Medical Expenditure
Panel Survey. Propensity score–weighted quality and experience of care were compared
between 49 286 US adults with and 21 133 adults without primary care from 2012 to 2014.
Temporal trends were also analyzed from 2002 to 2014.

EXPOSURES Patient-reported receipt of primary care, determined by the 4 “Cs” of primary

care: first-contact care that is comprehensive, continuous, and coordinated.

MAIN OUTCOMES AND MEASURES Thirty-nine clinical quality measures and 7 patient
experience measures aggregated into 10 clinical quality composites (6 high-value and 4
low-value services), an overall patient experience rating, and 2 experience composites.

RESULTS From 2002 to 2014, the mean annual survey response rate was 58% (range,
49%-65%). Between 2012 and 2014, compared with respondents without primary care
(before adjustment), those with primary care were older (50 [95% CI, 50-51] vs 38 [95% CI,
38-39] years old), more often female (55% [95% CI, 54%-55%] vs 42% [95% CI, 41%-43%]),
and predominately white individuals (50% [95% CI, 49%-52%] vs 43% [95% CI, 41%-45%]).
After propensity score weighting, US adults with or without primary care had the same mean
numbers of outpatient (6.7 vs 5.9; difference, 0.8 [95% CI, −0.2 to 1.8]; P = .11), emergency
department (0.2 for both; difference, 0.0 [95% CI, −0.1 to 0.0]; P = .17), and inpatient (0.1 for
both; difference, 0.0 [95% CI, 0.0-0.0]; P = .92) encounters annually, but those with primary
care filled more prescriptions (mean, 14.1 vs 10.7; difference, 3.4 [95% CI, 2.0-4.7]; P < .001)
and were more likely to have a routine preventive visit in the past year (mean, 72.2% vs Author Affiliations: Division of
57.5%; difference, 14.7% [95% CI, 12.3%-17.1%]; P < .001). From 2012 to 2014, Americans with General Internal Medicine and
primary care received more high-value care in 4 of 5 composites. For example, 78% of those Primary Care, Brigham and Women’s
Hospital, Boston, Massachusetts
with primary care received high-value cancer screening compared with 67% without primary (Levine); Harvard Medical School,
care (difference, 10.8% [95% CI, 8.5%-13.0%]; P < .001). Americans with or without primary Boston, Massachusetts (Levine,
care received low-value care with similar frequencies on 3 of 4 composites, although Landon); Department of Health Care
Policy, Harvard Medical School,
Americans with primary care received more low-value antibiotics (59% vs 48%; difference,
Boston, Massachusetts (Landon);
11.0% [95% CI, 2.8%-19.3%] P < .001). Respondents with primary care also reported Division of General Medicine and
significantly better health care access and experience. For example, physician communication Primary Care, Beth Israel Deaconess
was highly rated for a greater proportion of those with (64%) vs without (54%) primary care Medical Center, Boston,
Massachusetts (Landon); Division of
(difference, 10.2%; 95% CI, 7.2%-13.1%; P < .001). Differences in quality and experience General Internal Medicine and
between Americans with or without primary care were essentially stable between 2002 Geriatrics, Northwestern University
and 2014. Feinberg School of Medicine,
Chicago, Illinois (Linder).

CONCLUSIONS AND RELEVANCE Receipt of primary care was associated with significantly Corresponding Author: David M.
Levine, MD, MPH, MA, Division of
more high-value care, slightly more low-value care, and better health care experience. General Internal Medicine and
Policymakers and health system leaders seeking to improve value should consider increasing Primary Care, Harvard Medical
investments in primary care. School, Brigham and Women’s
Hospital, 1620 Tremont St,
JAMA Intern Med. doi:10.1001/jamainternmed.2018.6716 Third Floor, Boston, MA 02120
Published online January 28, 2019. (dmlevine@bwh.harvard.edu).

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 Research Original Investigation
P
rimary care—defined herein as first-contact, compre-
hensive, coordinated, and continuous care—is consid-
ered an essential component of well-functioning health
care systems.1,2 Beginning in the 1920s, following the Daw-
son Report, many countries made primary care the founda-
tion of their health systems.3,4 By contrast, the US health care
system is generally organized around hospitals and specialty
care despite landmark reports, such as the 1966 Millis Com-
mission Report, recommending that each person have a pri-
mary care physician.5,6 Moreover, Medicare only recently be-
gan supporting free coverage for preventive services and annual
wellness visits.7
Consequently, the value of primary care remains unclear
and debated in the United States.4 No definitive, large-scale
randomized controlled trial has evaluated the effect of pri-
mary care on quality and patient experience, nor will such a
trial likely occur. Moreover, observational analyses are chal-
lenged owing to selection effects compounded by poor iden-
tification of participants with or without primary care and poor
granularity of the quality and experience that primary care de-
livers. Some observational studies have examined the asso-
ciation of primary care with quality and experience of care, but
these studies generally have been ecological in nature.8 For in-
stance, Baicker and Chandra9 demonstrated that states with
more primary care clinicians had higher quality and lower costs.
Starfield and colleagues10 found that the regional supply of pri-
mary care physicians was associated with lower mortality,
higher birth weight, and better self-reported health. Other stud-
ies have tested the effect of health insurance on health out-
comes, although insurance may be a poor surrogate for
primary care.11-13
Ideally, well-functioning primary care should result in in-
creased high-value care, reduced low-value care, and better
patient experience and access to care.14,15 To date, however,
individual-level empirical data on the impact of primary care
are lacking. A more complete understanding of the associa-
tion between receipt of primary care and the quality and
experience of care, as well as how this has changed over time,
could inform investments in and use of primary care. Thus,
we examined whether receipt of primary care was associated
with high-value care, low-value care, or patient access and
experience.
Methods
Data Source
We analyzed data from the Medical Expenditure Panel Sur-
vey (MEPS) from 2002 to 2014 with particular focus on 2012
to 2014. The MEPS is a nationally representative annual sur-
vey of the noninstitutionalized United States civilian popula-
tion drawn from respondents to the National Health Inter-
view Survey.16 The MEPS employs a complex survey design
across 2 years that delivers English or Spanish language com-
puter-assisted personal interviews to collect detailed data on
demographic characteristics, health conditions, health sta-
tus, medical services use, medications, cost, source of pay-
ments, health insurance coverage, income, employment, ex-
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Quality and Experience of Outpatient Care for US Adults With or Without Primary Care
Key Points
Question How do the quality and experience of outpatient care
differ between adults with or without an endorsed source of
primary care?
Findings In this nationally representative survey study of 49 286
adults with and 21 133 adults without primary care, Americans with
primary care received significantly more high-value care (4 of 5
composites), received slightly more low-value care (3 of 4
composites), and reported significantly better health care access
and experience. These differences were stable from 2002 to 2014.
Meaning Policymakers and health system leaders seeking to
improve value should consider increasing investment in primary
care.
perience with care, and access to care. From 2002 to 2014, the
annual MEPS response rates ranged from 49% to 65% (mean
58%). The Harvard Medical School Institutional Review Board
determined this study not to be human subject research and
thus waived the need both for review and for obtaining in-
formed patient consent.
The MEPS supplements and validates self-reported infor-
mation by contacting respondents’ clinicians (mean re-
sponse rate, 86%), hospitals (mean response rate, 90%), phar-
macies (mean response rate, 77%), and employers (mean
response rate, 91%). Clinicians specify details regarding of-
fice visits (diagnosis, diagnostic test, cost, etc); hospitals specify
admissions; pharmacies specify individual medications; and
employers specify insurance plan particulars.
The MEPS also includes 2 additional mail-back surveys: the
adult self-administered questionnaire and the diabetes care
survey. The self-administered questionnaire includes items
from the Consumer Assessment of Healthcare Providers and
Systems survey, the 12-item Short Form Health Survey, and ad-
ditional items measuring respondents’ attitudes about health
care (annual response rate range, 89%-94%). The diabetes care
survey, administered to respondents with self-reported dia-
betes, includes items related to diabetes care (annual re-
sponse rate range, 88%-97%).
We restricted our analyses to the adult population aged 18
or older. Sample sizes ranged from 21 915 to 26 509 respon-
dents per year.
Definition of Primary Care
We used a patient-centered definition of primary care that used
responses to a series of questions about core aspects of pri-
mary care to determine whether the respondent was en-
gaged in a primary care relationship. The MEPS first deter-
mines whether respondents have a “usual source of care” by
asking them the name of a physician to whom “you usually
go if you are sick or need advice about your health.” We con-
sidered respondents able to identify such a physician who prac-
ticed outside of the emergency department as having a “usual
source of care.”
To further delineate respondents with primary care, we
used 4 additional questions to replicate the 4 “Cs” of primary
care: first-contact care that is comprehensive, continuous, and
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 Quality and Experience of Outpatient Care for US Adults With or Without Primary Care
coordinated.10 We only included those who responded affir-
matively that they would visit their usual source of care for all
4 of the following: “new health problems” (first contact); “pre-
ventive health care, such as general checkups, examinations,
and immunizations” (comprehensive); “ongoing health prob-
lems” (continuous); and “referrals to other health profession-
als when needed” (coordinated). Adults who answered no to
the usual source of care question or to any of the other 4 ques-
tions were considered to not have primary care. Among re-
spondents with a usual source of care, 95% met the full crite-
ria for having primary care. Respondents could have selected
a health professional from any specialty as their primary care
clinician as long as they met those criteria. Of the health pro-
fessionals selected, 70% were general or family practice phy-
sicians, 19% were general internists, 3% were nurse practi-
tioners or physician assistants, 1% were pediatricians, 1% were
obstetrician/gynecologists, and the remainder were from all
other specialties.
Clinical Quality Measures
We developed clinical quality measures and quality com-
posites from the MEPS as previously described (eTable 1 in
the Supplement).17 We evaluated performance on 39 clinical
quality measures, including 25 high-value measures and 14
low-value measures. From these measures, we constructed
6 clinically meaningful underuse composites (eg, recom-
mended cancer screening) in which delivery of the service is
likely of benefit to the respondent, and 4 overuse compos-
ites (eg, avoidance of imaging in specific clinical situations)
in which delivery of the service is considered either inap-
propriate or of little to no benefit.
To calculate performance for each measure, we first
identified those respondents who were eligible for the mea-
sure (eg, those with diabetes) and then determined whether
or not they received the particular care (eg, retinal exam).
To calculate composites, we divided all instances in which
recommended care was delivered (for high-value measures)
or avoided (for low-value measures) by the number of times
respondents were eligible for care in the category, as others
have previously done.18
Patient Experience Measures
We evaluated a global rating measure that asked about respon-
dent experience with all health providers (range, 0 “worst
health care possible” to 10 “best health care possible”). We also
evaluated a doctor communication composite that asked
4 items (eg, “How often did the doctor spend enough time with
you?”) and an access to care composite that included 2 items
(eg, “How often did you get a medical appointment as soon as
wanted?”)17; responses were coded from “never” (1) to “al-
ways” (4). To better discriminate changes over time, we di-
chotomized all measures such that a positive response in-
cluded 8, 9, or 10 for the items scored from 0 to 10 and 4 for
the items scored from 1 to 4, similar to the Healthcare
Effectiveness Data and Information Set analyses.19 We calcu-
lated both experience composites by first computing the mean
for each respondent and then taking the mean for all
respondents.
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Original Investigation Research
Propensity Score Weighting
We used propensity score weighting to address potential
sources of confounding between receipt of primary care and
the outcomes of interest. Potential sources of confounding
included demographic factors, socioeconomic status, health
and functional status, and engagement with the health
system.20-22 This method resulted in a comparison between
those with or without a primary care relationship, with simi-
lar levels of engagement in care who were balanced on the
above stated factors.
We used survey-weighted logistic regression to create a pro-
pensity score of having primary care, adjusting for all vari-
ables given in Table 1 and whether a respondent needed as-
sistance with activities of daily living, assistance with
instrumental activities of daily living, family income as a per-
cent of the poverty line, and 12-item Short Form Health Sur-
vey Physical and Mental component summary scores (eTable 2
in the Supplement). For those with primary care, we com-
puted the inverse of the propensity score. For those without
primary care, we computed the inverse of 1 minus the propen-
sity score. We then multiplied these weights by the existing
MEPS survey weights.24 Item nonresponse across the survey
was low and after weighting resulted in a loss of 11% and 15%
of respondents with or without primary care, respectively. Un-
less otherwise specified, we present propensity-weighted
analyses. All analyses without propensity weighting are in the
Supplement. Finally, to determine whether there was a “dose-
response” association between primary care and quality and
experience, we also compared respondents with primary care
to those without primary care who also had no outpatient visit
(eTable 3 in the Supplement).
Statistical Analysis
In all analyses, we generated national estimates as recom-
mended by the MEPS by using survey estimation weights, pri-
mary sampling unit clusters, and sampling strata that ac-
counted for the complex survey design of the MEPS and for
nonresponse.25,26 For our main analyses, we aggregated re-
sponses from the most recent 3 years of the survey: 2012 to
2014. To examine whether performance was improved at the
end of the study period relative to that at the beginning, we
compared composites in 2002 to 2004 to those in 2012 to 2014
using χ2 tests, adjusting for the complex survey design.27 Be-
cause we found few temporal changes, the results presented
here focus on the most current data, from 2012 to 2014, but
we give temporal differences where relevant. We performed
all analyses using SAS, version 9.4 (SAS Institute Inc) and con-
sidered a 2-sided P < .05 to be significant.
Results
Respondent Characteristics
Between 2012 and 2014, compared with respondents with-
out primary care, those with primary care were older (mean,
50 [95% CI, 50-51] vs 38 [95% CI, 38-39] years old), more of-
ten female (55% [95% CI, 54%-55%] vs 42% [95% CI, 41%-
43%]), predominately white individuals (50% [95% CI, 49%-
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 Research Original Investigation Quality and Experience of Outpatient Care for US Adults With or Without Primary Care

Table 1. Characteristics of the Medical Expenditure Panel Survey Respondents

With or Without Primary Care, 2012-2014

Respondents, % (95% CI)a

Without Propensity Score Weighting With Propensity Score Weightingb
No Primary Care Has Primary Care No Primary Care Has Primary Care
Characteristic (n = 21 133) (n = 49 286) (n = 17 964) (n = 43 766)
Age, mean (95% CI), y 38 (38-39) 50 (50-51) 48 (46-49) 47 (47-48)
Female 42 (41-43) 55 (54-55) 54 (53-56) 52 (51-53)
Race/ethnicity
Non-Hispanic white 43 (41-45) 50 (49-52) 48 (45-50) 49 (47-50)
Hispanic 35 (33-36) 32 (31-33) 33 (31-35) 32 (31-34)
Non-Hispanic black 13 (12-15) 11 (10-12) 11 (10-13) 11 (10-12)
Non-Hispanic Asian 7 (6-8) 5 (4-6) 5 (4-6) 5 (4-6)
Non-Hispanic other or 2 (2-3) 2 (2-3) 3 (2-5) 2 (2-3)
multiple
Census region
Northeast 14 (13-16) 20 (18-21) 17 (14-19) 18 (16-19)
Midwest 17 (16-19) 23 (21-24) 23 (20-27) 22 (20-23)
South 44 (42-46) 35 (33-37) 38 (35-41) 37 (36-39)
West 24 (23-26) 23 (21-24) 22 (20-24) 23 (21-24)
Partner status
Married or partnered 42 (41-44) 56 (55-58) 51 (49-53) 53 (52-54)
Never married 42 (41-44) 22 (22-23) 27 (25-29) 27 (26-28)
Divorced or separated 13 (13-14) 14 (13-14) 15 (14-17) 14 (13-15)
Widowed 2 (2-3) 7 (7-8) 7 (5-9) 6 (6-7)
Educational level
<High school 17 (16-19) 14 (13-14) 15 (13-16) 13 (13-14)
High school/GED/some 58 (57-60) 56 (55-58) 57 (55-60) 57 (56-59)
college
Bachelor degree 17 (15-18) 18 (18-19) 18 (16-19) 18 (17-19)
>Bachelor degree 8 (7-8) 12 (11-13) 10 (9-12) 11 (10-12) Abbreviations: BMI, body mass index
calculated as weight in kilograms
Health insurance coverage divided by height in meters squared;
Any private 54 (51-56) 72 (71-73) 67 (65-70) 68 (66-69) GED, general educational
Public only 13 (12-14) 21 (20-22) 19 (17-22) 19 (18-20) development.
a
Uninsured 34 (32-35) 7 (7-8) 13 (12-14) 13 (12-15) Percentages weighted to be
nationally representative and
Perceived health status account for nonresponse.
Excellent 33 (32-35) 25 (24-26) 26 (24-28) 27 (26-28) Percentages may not sum to 100
Very good 33 (32-34) 33 (32-34) 33 (31-35) 33 (33-34) owing to rounding.
b
Good 24 (23-25) 27 (27-28) 27 (25-29) 27 (26-27) Propensity score weighting adjusted
for all variables in this table and
Fair 7 (7-8) 11 (11-12) 11 (9-12) 10 (10-11) activities of daily living,
Poor 2 (2-2) 4 (3-4) 4 (3-5) 3 (3-3) instrumental activities of daily
living, family income as a
Employed 80 (79-81) 65 (64-67) 67 (64-69) 69 (68-70)
percentage of the poverty line, and
Currently smoke 20 (19-21) 14 (13-14) 17 (16-19) 17 (16-17) the physical and mental
Family income <100% of federal 18 (17-19) 11 (10-12) 14 (13-16) 13 (12-14) components of the 12-item Short
poverty line Form Health Survey (eTable 2 in the
BMI, mean 27.2 (27.0-27.4) 28.1 (28.0-28.3) 28.0 (27.7-28.3) 28.0 (27.8-28.1) Supplement).
c
Chronic diseasec Out of the 20 conditions considered
chronic by the Health and Human
0 78 (77-79) 42 (41-43) 50 (48-53) 50 (49-51)
Services Office of the Assistant
1 14 (13-14) 21 (20-21) 17 (16-18) 20 (19-20) Secretary of Health.23 More detail
2 4 (4-5) 15 (14-15) 11 (10-12) 12 (12-13) and additional characteristics
available in eTable 2 in the
≥3 4 (3-4) 23 (22-23) 22 (19-24) 18 (17-19)
Supplement.

52%] vs 43% [95% CI, 41%-45%]), more frequently smokers
(14% [95% CI, 13%-14%] vs 20% [95% CI, 19%-21%]), more of-
ten poor (11% [95% CI, 10%-12%] vs 18% [95% CI, 17%-19%]),
and had a higher chronic disease burden (23% [95% CI, 22%-
23%] with ≥3 chronic diseases vs 4% [95% CI, 3%-4%])
(all P < .001) (Table 1). They also had lower rates of uninsur-
ance (34% [95% CI, 32%-35%] vs 7% [95% CI, 7%-8%]; P < .001).
These differences were stable between 2002 and 2014. After
propensity score weighting, there were no significant
differences in these measured attributes between respon-

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 Quality and Experience of Outpatient Care for US Adults With or Without Primary Care
Table 2. Propensity Score–Weighted Health Care Use With or Without Primary Care, 2012-2014a
Health Care Use No Primary Careb (n = 17 964)
Encounters, mean No. per year (95% CI)
Office visits 5.9 (4.8 to 6.9)
Emergency department visits 0.2 (0.2 to 0.3)
Hospital admissions 0.1 (0.1 to 0.1)
Prescribed medicines, mean total No. of fills per year 10.7 (9.3 to 12.1)
(95% CI)
Preventive visit within past year, mean % (95% CI) 57.5 (55.2 to 59.7)
a
Health care use without propensity score weighting in eTable 4 in the
Supplement and for 2002 to 2004 in eTable 7 in the Supplement.
b
Propensity score weighting adjusted for all variables in Table 1 and activities of
daily living, instrumental activities of daily living, family income as a
percentage of the poverty line, and the physical and mental components of
dents with or without primary care (Table 1; and eTable 2 in
the Supplement).
Health Care Use With or Without Primary Care
After propensity score weighting, respondents with or with-
out primary care used health care with a similar frequency
(Table 2), including similar mean numbers of annual office vis-
its (6.7 vs 5.9; difference, 0.8 [95% CI, −0.2 to 1.8]; P = .11), an-
nual emergency department visits (0.2 for both; difference, 0.0
[95% CI, −0.1 to 0.0]; P = .17), and annual hospital admis-
sions (0.1 for both; difference, 0.0 [95% CI, 0.0-0.0]; P = .92).
By contrast, respondents with primary care filled more pre-
scriptions each year (mean, 14.1 vs 10.7; difference, 3.4 [95%
CI, 2.0-4.7]; P < .001) and more frequently had a routine pre-
ventive visit within the past year (mean, 72.2% vs 57.5%; dif-
ference, 14.7% [95% CI, 12.3%-17.1%]); P < .001).
High-Value Care With or Without Primary Care
Respondents with primary care received more high-value care
compared with those without primary care in 4 of 5 compos-
ites (Table 3). Approximately 78% of respondents with pri-
mary care received high-value cancer screening compared with
67% without primary care (difference, 10.8% [95% CI, 8.5%-
13.0%]; P < .001). The largest differences were for colorectal
cancer screening (16.1% [95% CI, 12.0%-20.3%], P < .001) and
mammography (14.2% [95% CI, 8.8%-19.6%], P < .001).
Respondents with primary care also received more rec-
ommended diagnostic and preventive testing (difference, 9.9%
[95% CI, 8.7%-11.2%]; P < .001). For example, an adjusted 10.4%
(95% CI, 6.1%-14.6%) more received an influenza vaccine, and
9.5% (95% CI, 8.3%-10.6%) more had blood pressure checked
(both P < .001). For respondents with primary care and dia-
betes, an adjusted 7.8% (95% CI, 1.2%-14.4%) more received
high-value diabetes care (P = .02). High-value counseling
among respondents with primary care was also higher (differ-
ence, 6.9% [95% CI, 4.1%-9.7%]); P < .001), particularly for
smoking cessation counseling (difference, 12.3% [95% CI, 6.2%-
18.5%]; P < .001). By contrast, respondents with or without pri-
mary care received similar rates of high-value medical treat-
ments, such as receipt of a β-blocker for treatment of coronary
artery disease (difference −4.6%, [95% CI, −14.3 to 5.0]; P = .34).
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Original Investigation Research
Has Primary Careb (n = 43 766) Difference (95% CI)c
6.7 (6.5 to 6.9) 0.8 (−0.2 to 1.8)
0.2 (0.2 to 0.2) 0.0 (−0.1 to 0.0)
0.1 (0.1 to 0.1) 0.0 (0.0 to 0.0)
14.1 (13.7 to 14.5) 3.4 (2.0 to 4.7) d
72.2 (71.2 to 73.1) 14.7 (12.3 to 17.1) d
the 12-item Short Form Health Survey (eTable 2 in the Supplement).
c
Positive difference, respondents with primary care had more use; negative
difference, respondents without primary care had more use.
d
Significant difference, P < .01.
For the relatively small number of patients with heart fail-
ure or pulmonary disease (30 and 48, respectively), respon-
dents with primary care received less high-value care. For ex-
ample, those with primary care received fewer β-blockers in
heart failure (difference, −8.4% [95% CI, −10.3% to −6.6%];
P < .001) and fewer controller medications in poorly con-
trolled asthma (difference, −15.4% [95% CI, −18.5% to −12.4%];
P < .001). Of those with primary care included in the β-blocker
measure, 62% also were also seen by a cardiologist, and of those
with primary care included in the asthma measure, 48% were
also seen by a pulmonologist.
Low-Value Care With or Without Primary Care
Respondents with or without primary care received similar low-
value care in 3 of 4 composites (Table 3). Approximately half
(49% [95% CI, 47%-51%]) of primary care respondents re-
ceived low-value cancer screening, which was not signifi-
cantly different from the 44% (95% CI, 37%-50%) without pri-
mary care (P = .12). Within this composite, only low-value
prostate cancer screening differed significantly (difference,
9.8% [95% CI, 7.4%-12.2%) for those with primary care;
P < .001). We observed no significant differences in receipt of
low-value medical treatments (11% for both groups; differ-
ence, 0.0% [95% CI, −2.7% to 2.6%]; P = .99) or low-value
imaging (approximately 10% in both groups; difference, −1.3%
[95% CI, −5.1% to 2.5%]; P = .50). Respondents with primary
care received more low-value antibiotics (59%) than those with-
out primary care (48%; difference, 11.0% [95% CI, 2.8%-
19.3%]; P = .01).
Respondent Experience and Access
With or Without Primary Care
Despite similar levels of use of both outpatient and inpatient
care, respondents with primary care had better experience than
those without primary care (Table 3). For example, 79% of re-
spondents with primary care reported an excellent global rat-
ing of their health care compared with 69% without primary
care (difference, 10.4% [95% CI, 6.9%-13.8%]; P < .001). Phy-
sician communication was highly rated for a greater propor-
tion of those with (64%) vs without (54%) primary care
(difference, 10.2%; 95% CI, 7.2-13.1; P < .001), and report of
(Reprinted) JAMA Internal Medicine Published online January 28, 2019 E5
 Research Original Investigation Quality and Experience of Outpatient Care for US Adults With or Without Primary Care

Table 3. Propensity Score–Weighted Outpatient Quality and Experience With or Without Primary Care, 2012-2014a

No Primary Care (n = 17 964) Has Primary Care (n = 43 766)

Measure or Composite No. Mean % (95% CI) No. Mean % (95% CI) Difference, Mean (95% CI)b
High-value cancer screening composite 8667 67 (65 to 70) 28 750 78 (77 to 79) 10.8 (8.5 to 13.0)c
Cervical cancer screening 6300 83 (81 to 85) 15 756 89 (88 to 90) 6.1 (4.0 to 8.1)c
Breast cancer screening 1447 66 (60 to 72) 9632 80 (79 to 81) 14.2 (8.8 to 19.6)c
Colorectal cancer screening 3320 50 (46 to 54) 17 860 66 (65 to 68) 16.1 (12.0 to 20.3)c
High-value diagnostic and preventive testing composite 17 861 70 (69 to 71) 43 699 80 (79 to 81) 9.9 (8.7 to 11.2)c
Dental checkup 17 809 53 (50 to 55) 43 605 65 (64 to 66) 12.3 (9.8 to 14.9)c
Blood pressure measurement 17 354 85 (84 to 86) 43 274 95 (94 to 95) 9.5 (8.3 to 10.6)c
Cholesterol measurement 8572 92 (91 to 93) 31 975 96 (96 to 96) 4.3 (3.3 to 5.3)c
Influenza vaccine 3574 50 (46 to 54) 21 331 60 (59 to 62) 10.4 (6.1 to 14.6)c
High-value diabetes care composite 459 64 (58 to 71) 5419 71 (70 to 73) 7.8 (1.2 to 14.4)c
HbA1c measurement 281 69 (58 to 81) 3614 79 (77 to 81) 10.2 (−0.9 to 21.3)
Foot examination 448 63 (53 to 74) 5319 73 (71 to 74) 10.6 (−0.4 to 21.5)
Eye examination 452 64 (55 to 73) 5367 67 (65 to 68) 3.3 (−5.3 to 12.0)
High-value counseling composite 12 062 45 (42 to 47) 31 533 52 (51 to 53) 6.9 (4.1 to 9.7)c
Weight loss counseling 11 134 40 (37 to 44) 29 551 46 (44 to 47) 5.3 (1.8 to 8.7)c
Exercise counseling 11 143 47 (44 to 49) 29 584 53 (52 to 55) 6.9 (3.8 to 9.9)c
Smoking cessation counseling 2194 55 (50 to 61) 5654 68 (66 to 70) 12.3 (6.2 to 18.5)c
High-value medical treatment composite 1587 41 (37 to 45) 17 307 43 (42 to 44) 1.8 (−2.3 to 5.9)
Anticoagulation for atrial fibrillation 118 33 (18 to 49) 1339 36 (32 to 39) 2.4 (−2.4 to 7.3)
ACEi/ARB for heart failure 30 82 (67 to 97) 372 65 (56 to 75) −16.8 (−17.3 to −16.3)c
β-Blocker for heart failure 30 75 (54 to 97) 372 67 (58 to 76) −8.4 (−10.3 to −6.6)c
Salicylates or platelet aggregation inhibitors for CAD/MI 247 29 (19 to 40) 3403 30 (28 to 33) 1.2 (−9.5 to 11.9)
β-Blocker for CAD/MI 247 64 (55 to 74) 3403 60 (57 to 62) −4.6 (−14.3 to 5.0)
Statin for CAD/MI 247 60 (50 to 71) 3403 64 (62 to 67) 3.9 (−6.6 to 14.5)
Statin for dyslipidemia 846 68 (62 to 74) 11 633 73 (72 to 75) 5.2 (−0.5 to 10.9)
ACEi/ARB for diabetes and hypertension 302 55 (45 to 65) 4841 60 (58 to 63) 5.6 (−4.7 to 15.8)
Statin for CVA 67 57 (36 to 78) 882 57 (52 to 62) −0.3 (−2.9 to 2.2)
Antiplatelet for CVA 67 36 (14 to 58) 882 34 (29 to 38) −2.1 (−4.4 to 0.3)
Controller medication for poorly controlled asthma 48 74 (52 to 96) 579 59 (53 to 64) −15.4 (−18.5 to −12.4)c
Controller medication for poorly controlled COPD 51 56 (27 to 86) 555 34 (29 to 39) −22.5 (−23.7 to −21.3)c
Low-value cancer screening composite 416 44 (37 to 50) 6046 49 (47 to 51) 5.0 (−1.3 to 11.4)
Cervical cancer screening in older adults 314 42 (34 to 51) 4602 48 (45 to 50) 5.6 (−3.0 to 14.1)
Colorectal cancer screening in older adults 202 32 (22 to 42) 3240 39 (37 to 42) 7.1 (−3.0 to 17.2)
Prostate cancer screening in older adults 86 61 (43 to 78) 1243 71 (67 to 74) 9.8 (7.4 to 12.2)c
Low-value antibiotic use composite 442 48 (40 to 57) 3027 59 (57 to 62) 11.0 (2.8 to 19.3)c
Antibiotics for acute upper respiratory tract infection 310 56 (46 to 66) 2426 64 (62 to 67) 8.3 (−2.4 to 18.9)
Antibiotics for influenza 137 24 (14 to 34) 652 37 (32 to 42) 13.5 (12.5 to 14.4)c
Low-value medical treatment composite 2702 11 (8 to 13) 21 329 11 (10 to 11) 0.0 (−2.7 to 2.6)
Anxiolytics, sedatives, or hypnotics in the elderly 640 6 (3 to 9) 8490 9 (8 to 10) 3.4 (0.3 to 6.5)c
Benzodiazepine for depression 838 7 (4 to 11) 4733 10 (9 to 11) 2.8 (−1.0 to 6.6)
Opioid for headache 84 3 (−1 to 8) 676 1 (0 to 2) −2.4 (−2.6 to −2.1)c
Opioid for back pain 441 6 (2 to 10) 2902 6 (5 to 7) −0.4 (−4.4 to 3.7)
NSAID use for hypertension, heart failure, or kidney 1466 15 (11 to 20) 15 122 15 (14 to 16) −0.4 (−5.0 to 4.1)
disease
Low-value imaging composite 520 11 (7 to 15) 3489 10 (9 to 11) −1.3 (−5.1 to 2.5)
MRI/CT for back pain 441 8 (2 to 13) 2902 7 (6 to 8) −0.9 (−6.5 to 4.8)
Radiography for back pain 441 15 (10 to 20) 2902 13 (11 to 14) −2.2 (−7.4 to 2.9)
MRI/CT for headache 84 8 (1 to 16) 676 9 (6 to 12) 0.9 (−0.2 to 2.0)
Respondent experience: global rating of health care 5698 69 (65 to 72) 32 120 79 (78 to 80) 10.4 (6.9 to 13.8)c

(continued)

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 Quality and Experience of Outpatient Care for US Adults With or Without Primary Care Original Investigation Research

Table 3. Propensity Score–Weighted Outpatient Quality and Experience With or Without Primary Care, 2012-2014a (continued)

No Primary Care (n = 17 964) Has Primary Care (n = 43 766)

Measure or Composite No. Mean % (95% CI) No. Mean % (95% CI) Difference, Mean (95% CI)b
Respondent experience: doctor communication composite 5807 54 (51 to 57) 32 433 64 (64 to 65) 10.2 (7.2 to 13.1)c
Doctor listened to you 5711 55 (51 to 58) 32 139 66 (65 to 67) 11.6 (8.2 to 15.0)c
Doctor explained so you understood 5785 56 (53 to 59) 32 362 66 (65 to 67) 9.7 (6.3 to 13.0)c
Doctor showed respect 5763 59 (55 to 62) 32 323 70 (69 to 70) 10.9 (7.6 to 14.2)c
Doctor spent enough time with you 5766 48 (45 to 51) 32 309 57 (56 to 58) 8.6 (5.2 to 12.0)c
Respondent experience: access to care composite 6113 52 (49 to 55) 31 240 59 (58 to 60) 7.0 (3.8 to 10.1)c
Got care when ill or injured as soon as wanted 2888 55 (50 to 60) 12 561 64 (63 to 66) 9.5 (4.5 to 14.4)c
Got medical appointment as soon as wanted 4737 51 (47 to 54) 29 221 58 (57 to 59) 7.0 (3.5 to 10.4)c
Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, eTable 3 in the Supplement. Table 3 data from 2002 to 2004 is in eTable 8 in
angiotensin receptor blocker; CAD/MI, coronary artery disease/myocardial the Supplement.
infarction; COPD, chronic obstructive pulmonary disease; CT, computed b
Positive difference, respondents with primary care received more (high- or
tomography; CVA, cerebral vascular accident; HbA1c, hemoglobin A1c; MRI, low-value) care or had better experience; negative difference, respondents
magnetic resonance imaging; NSAID, nonsteroidal anti-inflammatory drug. without primary care received more (high- or low-value) care or had better
a
Outpatient quality and experience without propensity score weighting is given experience.
in eTable 5 in the Supplement. Sensitivity analysis showing respondents with c
Significant difference, P < .05.
no outpatient visits and no primary care vs those with primary care is in

access to care was also better (59% vs 52%; difference, 7.0%
[95% CI, 3.8%-10.1%]; P < .001).
Changes in Quality and Experience Across Time
With or Without Primary Care
Over time, we observed no changes in the above findings, with
only 1 exception (eTables 6-10 in the Supplement). There was
a reduction in low-value cancer screening for respondents with
primary care (53% [95% CI, 52%-55%] in 2002-2004 vs 49%
[95% CI, 47%-51%] in 2012-2014; P < .001).
Primary Care vs No Engagement
Our sensitivity analysis examining patients who were not at
all engaged in care showed substantially larger differences
(eTable 3 in the Supplement). Those with primary care re-
ceived more high-value care but also received more low-
value care. For example, approximately 78% of respondents
with primary care received high-value cancer screening com-
pared with 47% without primary care and no outpatient visit
(difference, 31.6% [95% CI, 26.5%-36.7%]; P < .001).
Discussion
In this large, nationally representative survey study, we quan-
tified the potential benefit of primary care with respect to re-
ceipt of high- and low-value health services and experience
with and access to care within the current health care deliv-
ery environment. We found that receipt of primary care was
associated with more high-value care, somewhat more low-
value care, and better respondent access and experience. Re-
spondents without primary care, even though they were re-
ceiving a similar amount of care, missed substantial health care
benefits: about 10% fewer went without high-value cancer
screening, diagnostic and preventive testing, diabetes care, and
counseling. Similarly, about 10% fewer respondents without
primary care rated their overall care, physician communica-
tion, and access to care as excellent. These differences are note-
worthy when considered in the context of mixed or flat im-
provements in quality during the last decade. 17 To our
knowledge, this is the first study to directly compare outpa-
tient quality and experience when delivered inside or outside
of a primary care relationship.
Primary care, however, was not uniformly associated with
more high-value care. For instance, primary care was associ-
ated with worse care for heart failure and pulmonary disease,
albeit with relatively small numbers of respondents without
primary care qualifying for these measures (approximately
50 patients or fewer for both). Approximately half of patients
with primary care who qualified for these measures also had
visits with a relevant specialist. Prior research shows that, in
general, specialists provide higher quality care in their area,
but largely do not address issues outside of their specialty; thus,
these findings should not be interpreted as suggesting that a
specialty dominated model would be better.28 Care for pa-
tients with heart failure or pulmonary disease could poten-
tially be improved with better primary-specialty care co-
management, increased education of primary care physicians,
or other interventions.
The association between primary care and low-value care
presents a more mixed picture. We observed more preven-
tive visits, which some have criticized as low-value care in some
cases29 although, generally, this controversy relates to “an-
nual” preventive visits, and most observers agree that some
frequency of preventive visits is likely worthwhile. Ameri-
cans with primary care had similar rates of low-value care on
3 of 4 composites and increased low-value antibiotic use. An-
tibiotic prescribing in the primary care setting has been an area
of intense interest in the last 20 years. Related measures have
been a standard part of many pay-for-performance pro-
grams. Thus, we would have expected that primary care would
have been associated with less low-value antibiotic use. It is
possible, as currently structured, that primary care does not
sufficiently protect against low-value care, but as the United

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 Research Original Investigation
States transitions to a value-based system, efforts to de-
crease low-value care may be more effective.30
We also found that Americans’ use of primary care was
relatively low. About one-quarter of adults reported not
having primary care, yet 67% of Americans without primary
care had health insurance (and the majority had private
insurance). Poor primary care supply or access may be
hurdles,31 or some Americans do not perceive the potential
value of primary care, particularly if they are younger (the
mean unadjusted age for those without primary care was
38 years, as opposed to a mean age of those with primary
care of 50 years) and healthier. These findings contrast with
those of other health systems throughout the world; for
example, universal primary care registration is required in
the United Kingdom32 and the Netherlands.33
There are 2 main sources of confounding that should be
considered when interpreting the present results. First,
some people actively avoid interacting with the health care
system and thus have very few opportunities to receive rec-
ommended (or nonrecommended) services. Including such
persons in the “no primary care” comparison group, there-
fore, would bias our results. Second, the presence or
absence of an endorsed source of primary care also could be
associated with health status or the presence of acute or
chronic health conditions. In some cases, those with severe
health conditions might choose to see only specialist physi-
cians without identifying a single first-contact physician as
their primary care physician. Alternatively, those who are
relatively healthy simply might choose to forego having a
primary care physician, instead choosing to access care as
issues arise.
To guard against these 2 confounders, we used a pro-
pensity score weighting approach to balance sociodemo-
graphic and clinical characteristics. We did not include use
measures in our propensity score model, yet weighting on
all other characteristics resulted in near-identical levels of
use (eg, similar numbers of outpatient, emergency depart-
ment, and inpatient visits). Thus, our findings show the
potential benefits of having an endorsed source of primary
care for respondents with similar health status and condi-
tions, all of whom are engaged with the health care system
to a similar extent, rather than simply showing that some
care is better than no care. We also performed a sensitivity
analysis comparing respondents with primary care to those
without primary care and without any outpatient visits. Not
surprisingly, those with very limited engagement in the sys-
tem had markedly worse quality and experience.
To our knowledge, this is the first study to directly com-
pare outpatient quality and experience when delivered
inside vs outside of a primary care relationship. Our work is
consistent with, but also adds substantially to, prior studies
showing that areas with more primary care clinicians had
higher quality, lower costs,9 lower mortality, and better self-
reported health.10 Our results are also consistent with prior
research that demonstrates that adults with a usual source
of care,34-37 those who are attributable by claims to a physi-
cian or group,38 or those who report highly patient-centered
care39,40 are more likely to receive preventive services. In
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Quality and Experience of Outpatient Care for US Adults With or Without Primary Care
particular, several prior studies used earlier versions of the
MEPS to examine similar questions. DeVoe and colleagues41
used 1996 data from the MEPS to compare receipt of pre-
ventive services for insured adults with a usual source of
care and uninsured adults without regular care (akin to our
sensitivity analysis) and found that the latter were substan-
tially less likely to have received preventive services. Later
studies found better reported communication42 and higher
rates of blood pressure and hemoglobin A 1C assessment
among respondents with diabetes for those with vs without
a usual source of care.43 The comparison group in most of
those studies, however, was a group that was minimally
engaged in care. In addition, a prior study by VanGompel40
also used the MEPS to assign a continuous 7-point “primary
care attributes” score to respondents and then examined
receipt of preventive services. That approach, however, did
not allow for the comparison of those with or without
defined primary care and did not use propensity score
adjustment. Our work builds on these studies, adding
multiple facets of outpatient quality and patient experience
beyond preventive services, examining outcomes over more
than a decade, and using more robust propensity score
analyses.
Limitations
Our study had limitations. First, although our definition of
primary care was directly aligned with the 4 “C’s” of pri-
mary care and was patient-centered, it may differ from
other definitions of primary care.8 Instead of assigning a
patient to primary care by virtue of a claims algorithm, for
example, our definition was derived from the patient’s per-
spective. We acknowledge that we may have been unable to
detect the intricacies of each primary care service model,
but if we were indeed missing important intricacies, our
findings represent the minimum difference between those
with or without primary care. Second, our study was obser-
vational; thus, we could not interpret the associations we
observed as causal. Third, our use of propensity score
weighting adjusted for observable factors but not unob-
served confounders. Fourth, our quality measures did not
address all outpatient quality. For instance, we lacked mea-
sures of intermediate outcomes, such as control of hyper-
tension or diabetes. However, to our knowledge, the MEPS
represents one of the largest nationally representative sets
of consistently collected quality measures available for
more than a decade. 17 Fifth, propensity score weighting
resulted in a small loss of data, but those respondents with
more missing data were less likely to have primary care and
more likely to have worse quality of care. Therefore, omit-
ting respondents with more missing data biased our results
toward the null.
Conclusions
Receipt of primary care characterized by first-contact continu-
ous care that was whole-person oriented and responded to pa-
tient needs was associated with significantly more high-
jamainternalmedicine.com
 Quality and Experience of Outpatient Care for US Adults With or Without Primary Care
value care, slightly more low-value care, and better health care
experience. Policymakers and health system leaders seeking
ARTICLE INFORMATION
Accepted for Publication: October 6, 2018.
Published Online: January 28, 2019.
doi:10.1001/jamainternmed.2018.6716
Author Contributions: Drs Linder and Landon
contributed equally to this article. Dr Levine had full
access to all of the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Levine, Linder.
Critical revision of the manuscript for important
intellectual content: Landon, Linder.
Statistical analysis: Levine, Linder.
Administrative, technical, or material support:
Levine, Linder.
Supervision: Landon, Linder.
Conflict of Interest Disclosures: None reported.
Funding/Support: Dr Levine reported receiving an
Institutional National Research Service Award
(T32HP10251) from the National Institutes of
Health and funding support from the Ryoichi
Sasakawa Fellowship Fund.
Role of the Funder/Sponsor: The funders had no
role in the design and conduct of the study; the
collection, management, analysis, and
interpretation of the data; or the preparation,
review, or approval of the manuscript.
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