Gordon and Betty Moore Foundation Grant Funding

The Institute of Medicine labeled continuity of care a defining characteristic of primary care, one that Starfield and others demonstrated as essential to primary care’s positive impact on health equity, cost reduction, and improved quality of care. Described as an implicit contract between physician and patient in which the physician assumes ongoing responsibility for the patient, continuity frames the personal nature of medical care, in contrast to the dehumanizing nature of disjointed care. Building on the idea that knowledge, trust, and respect have developed between the patient and provider over time, allowing for better interaction and communication, continuity at the patient level is associated with a host of benefits.

The American Board of Family Medicine has been awarded funding by the Gordon and Betty Moore Foundation to demonstrate that continuity is related to better diagnosis, and to specifically demonstrate how a clinician-level Continuity of Care measure is a valid and robust measure that can be associated with reduced diagnostic errors and improved quality of care. We hope to demonstrate this relationship not only in the diagnosis of cardiovascular disease and its risk factors (e.g., Diabetes and Hypertension), but also for Cancer and Infectious Disease, two other core areas of interest for the Foundation. Second, we aim to advance the Continuity of Care measure through the CMS Merit-Based Incentive Payment Program.

The overall Aims of the grant include:

Aim: Estimate the impact of continuity on intermediate predictors of cardiovascular outcomes influenced by timely and accurate diagnosis. These predictors are high value treatment for early and on target diagnosis of comorbidities, including metformin, statins, and ACE-inhibitor use

Aim: Refine ABFM’s continuity of care quality measure for submission to CMS’ MUC list for endorsement and implemented in public and private payment and accountability programs

For more information on the grant deliverables, contact: Jill Shuemaker.

The Continuity of Care Measure

The Continuity of Care measure was developed in collaboration with the Robert Graham Center. Continuity of Care is defined as seeing the same primary care clinician over time and remains one of the pillars of a high functioning health care system. The Continuity of Care measure has been vetted through the National Quality Forum’s (NQF) rigorous endorsement process and received NQF endorsement in 2021.

High care continuity is shown to improve patient outcomes and physician well-being and is associated with decreased health care costs including total costs, ED costs, inpatient costs, primary care costs, and costs for specific conditions or treatments. It is also associated with decreased health care utilization such as ED visits and hospitalizations. As a byproduct of building a continuous, trusting relationship over time, issues of equity and social risk can be addressed.

The Continuity of Care measure is available in the PRIME Registry, a qualified clinical data registry (QCDR) open to all primary care clinicians and is endorsed by CMS for use in the Merit-Based Incentive Payment System (MIPS) quality payment program. The PRIME Registry supports MIPS and other CMS quality payment programs.

For measure specifications, please click here.

The Person-Centered Primary Care Measure (PCPCM) Patient Reported Outcome Performance Measure (PRO-PM)

The PCPCM PRO-PM is a patient reported measure of exemplary primary care that has been developed in collaboration with the Larry A. Green Center based on extensive development work with patients, clinicians and health care payers. The PCPCM PRO-PM has been vetted through the National Quality Forum’s (NQF) rigorous endorsement process and received NQF endorsement in 2021.The measure is also the winner in the Patient-Reported Outcomes category of the NQF Next-Generation Innovator Abstract Award.

The PCPCM focuses attention and support on the integrating, personalizing, and prioritizing functions that patients and clinicians say are important. A measure based on these principles may reduce both the de-personalization experienced by patients, and the measurement burden, burnout and crisis of meaning experienced by clinicians.

The PCPCM uses a survey to ask patients to assess 11 distinct yet highly interrelated items regarding their assessment of the care they receive. The 11 items were developed with input from hundreds of patients and physicians, and are associated with better personal and population health, equity, quality and costs.

The PCPCM has been approved for broad use in the CMS Merit-based Incentive Payment System (MIPS) Quality Payment Program (QPP). Additionally, it has been approved:

• As part of the Family Medicine measure set
• As part of the Internal Medicine measure set
• As part of the Optimizing Chronic Disease Management MVP for CY 2023

For measure specifications, please click here.

The Comprehensiveness of Care Measure

The Comprehensiveness of Care measure was developed in collaboration with the Robert Graham Center. Comprehensiveness is lauded as 1 of the 5 core virtues of primary care. When measuring associations between variations in comprehensiveness of practice among family physicians and healthcare utilization and costs for their Medicare beneficiaries, we found that increasing family physician comprehensiveness of care, especially as measured by claims measures, is associated with decreasing Medicare costs and hospitalizations.

The Comprehensiveness of Care measure is currently being tested in the PRIME Registry and is slated for submission for National Quality Forum (NQF) endorsement in 2023 and for the CMS Merit-Based Incentive Payment System (MIPS) Quality Payment Program (QPP) in 2024.

Value Care Measure

The -Value Care measure is in the conceptualization phase and is being funded through an AHRQ grant. Primary care is where most outpatient healthcare is delivered and where more than one-third of all visits take place. However; how primary care clinician decisions and behaviors affect total costs of care is being studied.

Trust Patient Reported Outcome Performance Measure (PRO-PM)

The Trust PRO-PM is in the conceptualization phase. Trust is a bedrock of medicine as an institution, as a profession and as a set of personal relationships between patients and clinicians and within care teams. Trust is also a key constituent of an organizations’ ability to delivery high-quality health care.