Experiences With Maryland's All-Payer Model Among Surgeons

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.