Primary Care Physicians’ Perspectives on Clinical Integration and Performance Metrics in a Medically Underserved Area

OBJECTIVE: This study explored primary care physicians' perspectives on Clinical Integration (CI) program performance, quality metrics, and incentive structures within a Physician Hospital Organization (PHO) serving a medically underserved urban community. The objective was to complement existing CI performance data by identifying contextual factors that influence physician performance and participation in value-based care programs. METHODS: A qualitative study using a general inductive approach was conducted within a single PHO on Chicago's South Side. All 10 independent primary care physicians participating in the PHO's CI program completed semistructured interviews. Interview questions focused on social determinants of health, staffing, incentive structures, quality measurement, barriers to performance, and support needs. Interviews were transcribed and independently coded by two researchers. Through iterative coding and thematic analysis, preliminary codes were consolidated into higher-order themes. RESULTS: Six major themes emerged. Physicians reported that low health literacy, socioeconomic hardship, and patient nonadherence reduced their ability to achieve quality targets and earn incentives. Staffing shortages and turnover hindered quality improvement activities and population health management. Participants viewed incentive structures as insufficient, poorly understood, and misaligned with the effort required to improve performance. Physicians also believed that CI performance metrics often failed to reflect the quality of care delivered to high-needs populations. Additional barriers included limited specialty care access, transportation challenges, patient mistrust of the health care system, and other social determinants affecting care engagement. Respondents identified increased administrative support, dedicated CI-focused staff, and improved specialty access as important facilitators of success. CONCLUSIONS: Standardized CI metrics and incentive structures may inadequately account for the realities of delivering primary care in underserved communities. PHOs, payers, and health system leaders should consider transparent incentive models, context-adjusted performance measures, enhanced staffing support, and investments in patient engagement and specialty care access to promote equitable performance assessment and strengthen value-based care programs.