Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.

After slow growth during much of the 1990s, Medicaid physician fees increased, on average, by 27.4 percent between 1998 and 2003. Primary care fees grew the most. States with the lowest relative fees in 1998 increased their fees the most, but almost no states changed their position relative to other states or Medicare. Physicians in states with the lowest Medicaid fees were less willing to accept most or all new Medicaid patients in both 1998 and 2003. However, large fee increases were associated with primary care physicians' greater willingness to accept new Medicaid patients.

Previous research has not found a strong association between Medicaid reimbursement levels and enrollees' access to medical care, even though higher fees increase the acceptance of Medicaid patients by physicians. This study shows that high Medicaid acceptance rates by physicians in a community are more important than fee levels per se in affecting enrollees' access to medical care. Although high fee levels increase the probability that individual physicians will accept Medicaid patients, high fee levels do not necessarily lead to high levels of physician Medicaid acceptance in an area. Numerous other physician practice, health system, and community characteristics also affect Medicaid acceptance. The effects of Medicaid fees on Medicaid acceptance are substantially lower in areas with high Medicaid managed care penetration and for physicians who practice in institutional settings. The results suggest that a broad range of factors need to be considered to increase access to physicians for Medicaid enrollees.

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