Measuring What Matters In Primary Care

Editor's Note: This is one of several posts Health Affairs Blog is publishing stemming from sessions at the June 2015 AcademyHealth Annual Research Meeting (ARM) in Minneapolis.

What Do We Mean By 'Primary Care'

Numerous studies have confirmed the central role of excellent primary care to any health system. Yet how to define the presence of excellent primary care remains a challenge. A recent review found that five characteristics remain the "sine qua non" for primary care practice:

• Accessible (first contact) care
• Continuous care
• Comprehensive care
• Coordinated care
• Accountable/whole-person care.

Each individual feature is necessary, but not alone sufficient, to assure high quality primary care. Clinicians and practices may provide one or even a few of these elements but do not fulfill the primary care role. For example, a retail clinic that provides only first contact care, no matter how accessible, would lack the continuity and coordination inherent to the primary care role. Continuous care of a serious chronic condition like systemic lupus or multiple myeloma is not by itself primary care; to serve in that role the treating rheumatologist or hematologist must also be accessible and able to address common or urgent concerns as well.

Even applying comprehensive clinical skills and providing excellent care coordination do not by themselves constitute primary care. Emergency medicine physicians, critical care physicians, and trauma surgeons may exemplify these features but do not act in the ongoing role of primary care clinician. Only a practice which provides patients all five features in an ongoing way is delivering primary care.

Despite the fundamental nature of these five primary care features, efforts to measure primary care have too often not focused on them nor captured the performance of primary care practices on their components. In this post, we examine the flaws in current primary care metrics and the advantages of refocusing quality indicators on the key primary care characteristics. We also discuss how, as a practical matter, data can be collected on whether practices are delivering primary care that is accessible, continuous, comprehensive, coordinated, and accountable.

What's Wrong With Current Approaches To Measuring Primary Care?

There have been diverse longstanding barriers to providing these five features in US practice. Thus it is hardly surprising that some of these key features may be lacking in titular primary care practices despite generalist training in family medicine, internal medicine, or pediatrics, or as a nurse practitioner or physician assistant.

For example, generalist clinicians have not been rewarded for comprehensive care; therefore, they can minimize time and effort (and maximize reimbursement) by documenting patient problems and referring to specialists for further management, rather than undertaking the effort to maintain broad competencies and personally assess and manage patients' health concerns. Similar financial barriers have persisted for accessibility, continuity, and coordination done by generalist clinicians as well.

The problem of lack of attention to key primary care features may have been compounded by limitations of measures of primary care performance. Perhaps the most obviously flawed primary care performance metrics are those based on fee-for-service (FFS) productivity standards. For example, traditional FFS billing codes have not accounted for extra clinician effort in care coordination or providing hands-on comprehensive care (since prior to the new Medicare Chronic Care Management payment there have been no additional relative value units [RVUs] to be "billed" when doing this extra work).

Furthermore, there has been no easy means to recognize improved access; Medicare has not supported increased payments when individual office visits are provided "after-hours." And while there are billing codes for telephone calls and telehealth communications, Medicare (and many other payers) have not reimbursed for these; thus, they are not entered into billing systems in FFS practices (and not readily available as measures of clinician productivity). Even investing in workload and scheduling adjustments to improve visit access and continuity is not consistently rewarded under FFS payment.

An alternative approach to understanding physician performance has been used in prepaid group practices: focusing on the patient panel size managed by the primary care clinician. While this metric can emphasize primary care clinician "accountability" for a defined patient population, it does not acknowledge greater clinician effort at enhanced access, better care coordination, and more comprehensive care. Thus, practices investing more resources in these efforts may compare unfavorably on panel size relative to practices with fewer resources for these other key features of primary care.

The introduction of quality performance measures, typically based on adherence to guidelines, may not solve this problem. Good primary care requires many hundreds of decisions each day for patients with unique clinical concerns and personal circumstances. Thus, typical quality measures can not address the breadth and depth of comprehensive delivery of primary care. Adding more measures (of quality or efficiency) can complicate this problem by offering myriad distracting and potentially counterproductive signals, as well as risking the problem of "reminder fatigue."

An additional challenge in using quality metrics for assessing primary care arises from the difficulty of applying these metrics to complex patients where competing priorities are common and addressing the different features of primary care may be particularly resource intensive. Providing enhanced access for these patients requires additional staff and resources, not just for more responsive telephone and email management and improved in person after-hours care, but also for in-home assessments and use of remote monitoring.

Complex patients also have a greater need for resource-intensive care coordination since they often need not only multiple clinicians but also various community resources. Assuring comprehensive care for these patients may be a particular challenge. Complex patients have multiple concurrent medical conditions (and psychosocial circumstances) that require evaluation and management by the primary care team.

Since the "patient centered medical home" concept arose to revitalize missing features of primary care, it is not surprising that Medical Home recognition standards acknowledge the importance of several key features. However current medical home recognition programs are designed to initiate steps along the pathway to improved primary care, not to assure robust provision of all five features.

For example, The National Committee for Quality Assurance (NCQA) recognition standards for comprehensiveness do not assess the breadth and depth of ongoing management of patient conditions but rather focus on assuring a documented "comprehensive health assessment." Similarly NCQA requirements for care continuity emphasize documenting patient choice of personal clinician and monitoring the proportion of visits held with this clinician; the actual degree of interpersonal continuity could vary widely between practices meeting Level 3 Medical Home standards.

Thus, current medical home recognition programs require practices to pay attention to aspects of several of the core features of primary care, but they are not designed to provide practices with information on their relative performance on these features.

Why Measure The Features Of Primary Care

The challenge for any busy clinical practice is determining which of the innumerable potential performance metrics available should be their highest priorities for improvement. This challenge is particularly daunting for primary care, where the broad range of clinical problems and diversity of patient needs create an almost infinite number of opportunities for both measurement and improvement. Since the five core features of primary care are both essential to excellent primary care and underemphasized in most current settings, performance measurement of these features can be a logical first step to improvement.

Measuring these core features of a primary care practice can also focus attention on metrics under more direct control of generalist clinicians than many current performance metrics are. Given the diversity of patient circumstances in primary care, many commonly used metrics may not seem readily actionable.

For example, blood pressure for a diabetic patient could be greatly influenced by the patient's financial access to medications as well as by individual health literacy or competing mental health or substance abuse challenges. In many highly fragmented health care markets, hospitalizations for acute or even for chronic conditions may be more under the control of specialist physicians and facilities than the primary care practice. Thus, feedback on these types of performance measures may not be very helpful to practices aspiring to improve their performance in primary care.

Providing performance feedback on each key feature of primary care may be helpful in assisting practices to overcome the inertia induced by longstanding perverse incentives. It may also alert practices to the multidimensionality of excellent primary care as they make the trade-offs necessary to manage available clinic staff and other resources for improvement.

Another advantage of performance measurement on the features of primary care is orienting improvement toward dimensions of practice recognized as strongly associated with better quality, higher patient satisfaction, and more efficient use of health resources. Addressing these core features of primary care may help practices improve many aspects of care quality while focusing on just a few, albeit essential, aspects of the primary care role. Thus this approach can help ameliorate the pervasive "signal to noise" problem that arises with the proliferation of primary care performance metrics, especially those outside the direct control of the practice.

How To Measure What Matters In Primary Care

Key features of primary care could be measured via claims and survey data (and possibly one day via electronic health record data), gathered or acquired through networks of affiliated primary care practices. These affiliations need not be as formal as integrated delivery systems or prepaid group practices — independent practice associations, physician-hospital organizations, or accountable care organizations could support such practice-focused primary care performance measures.

Feedback could be directed to the practice sites where small teams of generalist clinicians and their staff seek to provide primary care to their patient; i.e. the "team-let" (typically the primary care clinician and nurse/medical assistant) or the small group of team-lets sharing a specific practice site delivering primary care. These teams could review information on how well they perform relative to other practices in their local network.

For example, to measure the specific primary care feature of Whole-Person Accountability, one could use patient survey items like "frequency with which the primary care provider listens carefully to the patient" from the CAHPS Clinician & Group Survey (CG-CAHPS). Similarly, CG-CAHPS allows assessment of Accessibility through items such as "after-hours access to care" and "ease of getting same-day answers to phoned-in questions."

Coordination of Care could be measured by CG-CAHPS survey items like "frequency of discussion between patients and their primary care providers about prescribed medicines" and "how often primary care provider follows up on lab/x-ray results." Claims data analysis could be informative for assessing Care Coordination as well, e.g. percentage of hospitalized primary care patients with a follow-up ambulatory visit to primary care practice within 14 days of discharge.

Likewise both survey and claims data could be used to inform practices on their Continuity of Care. CG-CAHPS items such as "provider's knowledge of the patient's medical history" convey some idea of the "informational continuity" that can be an important aspect of continuity of care. Claims data can assess aspects like interpersonal continuity, e.g. the proportion of visits made to the patient's primary care clinician relative to all outpatient visits to any provider.

Comprehensiveness may be the one key primary care feature challenging to measure using available survey or claims based measures. However, various efforts are underway to develop better definitions of this construct as well as validated metrics.

Such feedback to practices could help focus attention on these fundamental attributes of primary care. Interviews with practice leaders suggest primary care clinicians can understand (and buy in to) these defining elements. More importantly, such feedback could provide practices information that is professionally meaningful, grounded in strong conceptual theory, and supported by decades of primary care research.

These metrics can seem actionable to clinic site leaders so long as local clinic sites have control over key work processes and staffing and their modes of reimbursement provide incentives for improvement. Much work remains to be done, but perhaps it is time to shift the focus of primary care measurement to what clinicians should care most about — providing their patients accessible, continuous, coordinated, and comprehensive care.

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