Situation: Value-based payments to primary care frequently employ measures that are misaligned with the high-value functions of primary care. Current measure sets presume that quality of care is the sum of quality measures for individual diseases. Financial incentives drives behavior to maximize these low-value measures at the cost of high value functions, resulting in tremendous opportunity costs, increased clinician burnout, and diminished value of primary care for people and populations.
Background: Well-designed and supported primary care is an important source of improved outcomes in high performing health systems even though it may produce lower disease-based quality measures. This has been called the Paradox of Primary Care. The United Kingdom went down a similar disease measurement path with the Quality Outcome Framework 15 years ago and have since largely abandoned it due to burnout and lack of population health improvement. This does not mean that measures or payment schemes that use them are bad, but it does suggest a need for better alignment between measures that matter and providing sufficient resources to address them.
Assessment: The Center for Professionalism & Value in Health Care aims to assess and promote the most meaningful measures in several health care sectors starting with primary care. The Center aims to produce comprehensiveness measures (highest quartile has 15% lower total costs and 25% lower hospitalization rates), continuity measures (highest quartile have 25% lower total costs and 25% lower hospitalization rates), as well as total cost of care and low-value care measures. Based on this research, CMS has approved the latter for use in our QCDR as a MIPS measure. The American Board of Family Medicine Foundation funded research with the Larry A. Green Center that produced the Patient Centered Primary Care Measure, a PRO which won the National Quality Forum’s (NQF) 2019 Patient-Reported Outcomes Abstract Award and has been fast-tracked for NQF and CMS endorsement. The research underpinning this PRO demonstrated close association with continuity and comprehensiveness, and strong endorsement by both patients and providers. The Center will continue to develop and study these measures using the PRIME Registry as a testbed, and using claims data to assess them across most family physicians, training programs, and health systems. JAMA and Annals of Family Medicine published our studies done in collaboration with the Robert Graham Center showing that physicians’ cost-related behaviors are highly correlated with where they trained and last for 15+ years after training. These measures not only have utility for clinicians, but for identifying training programs and health systems that are not supporting high-functioning primary care.
The Center’s aims in developing Measures That Matter for primary care practices is to better align assessment and payment policies with what patients and clinicians know to be valuable, to reduce burden, and to reduce burnout.