# Experiences With Maryland’s All-Payer Model Among Surgeons

## TL;DR

This study explores how surgeons in Maryland experience the all-payer model, finding high awareness but limited understanding and inconsistent communication.

## Contribution

The study provides new insights into surgeon perspectives on the Maryland all-payer model, highlighting communication gaps and practice changes.

## Key findings

- Surgeons had high awareness of the model but limited understanding and inconsistent institutional communication.
- The model led to centralization of complex care and changes in surgical practice.
- Surgeons expressed confusion about performance expectations and frustration with lack of feedback on quality metrics.

## Abstract

This qualitative, mixed-methods study investigates the experiences and perspectives of surgeons practicing under the Maryland all-payer model to assess model awareness, institutional communication and engagement, changes in practice, and perceived effects on care delivery associated with the model.

What are the experiences and perspectives of surgeons practicing under Maryland’s all-payer model?

This qualitative, mixed-methods study involving 88 surgeons found that there was high awareness of the model but limited understanding and inconsistent institutional communication about it. Surgeons acknowledged institutional efforts to improve outcomes but perceived that the model contributed to the centralization of complex care, imposed constraints on surgical practice, and felt disconnected from the development of quality initiatives intended to enhance patient care.

Findings suggest that implementing alternative payment models may require more deliberate engagement of clinician stakeholders, clearer communication strategies, and alignment of clinical incentives to ensure high-quality surgical care.

Hospital global budgets gained attention as a strategy to constrain costs and improve outcomes. The Maryland all-payer model (APM), initiated in 2014 as a global budget revenue model, is an example of full-risk payment reform; yet frontline surgeon perspectives on the implementation and impact of this APM have not been evaluated.

To examine surgeon experiences working under Maryland’s APM.

This qualitative study used a convergent mixed-methods design to assess survey responses of surgeon experiences and semistructured interviews between June 15 and November 25, 2024. Maryland surgeons were recruited via purposive and snowball sampling for surveys from academic and community surgical practices. A nested sample of respondents was selected for qualitative interviews using maximum variation sampling.

The primary outcome was surgeon-reported experiences with Maryland’s APM. Surveys and interview guides were designed using the Consolidated Framework for Implementation Research (CFIR) to assess awareness, communication, institutional engagement, changes in practice, and perceived effects on care delivery associated with the APM. Survey responses were summarized, and interview data were thematically analyzed and integrated using CFIR-guided joint displays.

Among 121 identified surgeons, 103 responded to the survey (67 [65.0%] male; practicing a mean [SD] of 16.4 [12.7] years), and 88 (85.4%) reported awareness of the APM. Of these 88 surgeons, a minority (35 [38.8%]) recalled information being distributed by their institution, and 41 (46.6%) reported receiving information from peers. Whereas 52 surgeons (59.1%) agreed that complex care had become more centralized, fewer believed that the model improved referral management (15 [17.0%] strongly agreed or agreed) or reduced preventable hospital use (16 [18.2%] strongly agreed or agreed). Most surgeons stated that the model changed the way they practiced at least slightly (56 [63.6%]). In qualitative interviews (n = 25), surgeons described surface-level understanding of the model and limited institutional communication, relying on peer discussions to interpret its implications. Many surgeons expressed confusion about performance expectations and frustration with the lack of feedback on quality metrics. They also noted that financial incentives shifted complex care to tertiary centers, contributing to resource strain.

In this mixed-methods study of surgeons’ experiences, surgeons reported high awareness of Maryland’s APM, but integrated findings revealed limited operational understanding, inconsistent institutional communication, and indirect effects on practice. Implementing alternative payment models may require more deliberate engagement of clinician stakeholders, clearer communication strategies, and alignment of clinical incentives.