8

Primary Care Measures and Use: Powerful, Simple, Accountable

There will always be a need for primary care: a place where people can work together with a clinician or clinical team to advance their health and address the majority of their concerns in the context of a trusted relationship. Ensuring that the nation’s primary care system can deliver this basic common good requires the ability to monitor quality and accountability. Two reports, To Err Is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001a), catalyzed a quality movement that led to developing quality metrics that have improved the performance of the U.S. health care system (IOM, 2015). However, these metrics tend to focus on individual components of health care, such as diabetes risk and control, cancer screening and prevention, and blood pressure monitoring and management, and are not well suited for measuring the quality of a primary care system that integrates multiple components of care.

This chapter calls attention to the need to align primary care measures with its definition and high-value functions to support the implementation of high-quality primary care. It does not set forth a standard set of superior measures for primary care. Such a set would need to be established through a coordinated process involving key stakeholders and a systematic review of current measures used with consideration both for a reduction in the number of measures employed and an addition of measures able to cover critical gaps in the scope of primary care assessment. This is beyond the scope of this report. Instead, this chapter provides important guidance to support that task.

Advancing meaningful quality assessment, performance standards, and accountability for primary care in the United States requires both

identification and implementation of a parsimonious set of measures. In this chapter, the committee focuses on approaches to build and choose a parsimonious set of measures that are “fit for purpose” (Duffy and Irvine, 2004) in the U.S. primary care environment and that reduce administrative burdens and increase overall systemic value (MacLean et al., 2018). This chapter also highlights the need to change the process for assessing primary care performance and accountability using a simple core set of measures, similar to the strategy promoted in the Vital Signs report regarding how best to design a core set of population-based health measures (IOM, 2015). The committee first establishes a common understanding of key terms. Next, it discusses how the use to which measures are put also shapes their meaning and purpose. In explaining the challenges and tensions of primary care assessment, the committee outlines why current measures, though numerous, are insufficient, and even harmful, to what the nation needs primary care to do. The committee then provides pragmatic guidance to allow development of a more effective slate of primary care measures. The challenge is not necessarily creating new measures but rather measuring key functions of primary care whose value is well established by more than 50 years of research. The chapter concludes with a discussion of possible systems of accountability within the federal government.

The discussion builds on a shared understanding regarding the following key terms:

• A measure—a unit or degree of something at a static point. A measure is typically a unit of something larger and often cannot be understood without that larger context.
• Quality—a standard created by comparing measures of similar things. Quality is the degree to which something meets expectations, allowing for assessing comparative performance among groups/individuals.
• Performance—how well a task is accomplished. Measuring performance is about assessing how well something is done.
• Value—what is thought to be beneficial. It is a judgment based on shared agreement regarding social norms and expectations.
• Accountability—a measure of how well actions are aligned with shared expectations. Accountability measures a subset of activities for which a person or organization has responsibility. It assesses actions that, through shared agreement, align with expectations, values, and professional norms in ways that enable the wider scope of responsibility.

When applied to health care, the Institute of Medicine (IOM) defined quality, and therefore the expectations inherent to assessment, as “the

degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 4). The IOM further distilled these expectations with frameworks of quality measure domains for relevant to health care systems and consumers (IOM, 2001a,b) (see Box 8-1).

QUALITY, MEASURES, AND ACCOUNTABILITY IN PRIMARY CARE

The process of enabling high-quality primary care is governed by the combination of (1) measures aligned with purpose and value and (2) the use to which those measures are put. Combined, these form the ecology of primary care measures. A high-performing ecology of primary care measures facilitates patient care team relationships, integrated health care delivery, design of care teams as best fits health stewardship, and the ability of primary care to mitigate social inequities that may prevent optimal health attainment. This type of dynamic enables primary care settings to provide elements of high-quality care as identified in Box 8-1: safe, effective,

equitable, and both population focused and person centered. The current measures environment pollutes the ecology of primary care measures by overemphasizing external motivations, such as those created by payment systems or productivity requirements, disease-specific measures, and even measures that compete with one another, while underemphasizing patient expectations and known social drivers of health.

Creating an environment that can foster and sustain high-quality primary care requires that the measurement enterprise reorient itself to support primary care quality and accountability aligned with expectations, values, and professional norms as shared across stakeholders. Previous studies, such as To Err Is Human (IOM, 2000), Crossing the Quality Chasm (IOM, 2001a), and Vital Signs (IOM, 2015), focused on quality measures as instruments for corrective action. Those efforts were important and necessary to institute national corrections in overuse, underuse, and misuse of health services. However, they also had the unintended consequence of harming assessment of primary care function and value by focusing on disease-specific particulars—hundreds of them—rather than core, meaningful functions (Stange et al., 2014). Moreover, primary care quality improvement often entails checking boxes for external assessment and payment while trying to deliver good care that is not currently well measured. This is a recipe for burnout, as it pits professional motivation against financial reality and time pressures (Berenson, 2016; McWilliams, 2020; NASEM, 2019; Phillips, 2020; Phillips et al., 2019). Measures specific for primary care, however, can improve performance, support beneficial systems of accountability, and foster professional behaviors and fulfillment while reducing burnout.

Within a high-functioning ecology, measures that assess quality, measures that assess accountability, and measures that inform clinical decision making are best understood as distinct. Many primary care measures subsumed under current mandates for accountability are tangential to the purpose of primary care, such as those related to proof of service delivery or primarily used to differentiate practice settings. Such measures can be useful; however, some measures can do harm if they compete with or crowd out high-value functions. For example, creating a time window target for access to care may encourage behaviors to improve access that inadvertently discourage behaviors to maintain continuity, when both access and continuity are foundational to high-quality care (Campbell et al., 2009; Casalino and Khullar, 2019). Additionally, while many measures, informed by clinical guidelines, are critical to clinical decision making and good care, these can also compete with each other in people with multi-morbid conditions. Variations in these measures may be required for good care and would not necessarily indicate poor quality. For instance, the guidelines that suggest optimal blood pressure control for individuals with diabetes must

often be adapted when that individual suffers more than one condition (as is common) or is over the age of 65, because optimal blood pressure control for that age is at odds with optimal blood pressure control for diabetes.

Assessing Quality

In primary care, quality is governed by the shared norms and expectations among patients, clinicians, care teams, and systems, as well as by medical professionalism, defined as “an active, ongoing, and iterative process that involves debate, advocacy, leadership, education, study, enforcement, and continuous transformation” (Byyny et al., 2017, p. 4; Phillips et al., 2019, p. 2). Quality assessment is most effective when aligned with professionalism and the agreed-upon principles and actions that guide professional behavior. Unfortunately, most of the hundreds of measures currently applied to primary care settings are based on confirmed diagnoses, disease-specific clinical decision making, and the ability to isolate and treat specific diseases, organs, or parts, without considering an individual’s total health profile or the social milieu in which they live (Stange et al., 2014). One unintended result of this misalignment between the content of quality measures used and the clinical reality of primary care is that an approach to measure implementation by practices and systems often focuses on administrative behaviors, rather than shared norms of professional behaviors and expectations.

The challenge, then, is to unhitch primary care from a subspecialty model that uses measures derived from partial representations or pieces of patients and instead link it to measures appropriate for its generalist, whole-person approach to medicine. Such measures actually have a rich evidence base, and they better align with patients’ perspectives on quality. Moreover, current metrics do not measure the ability of primary care clinicians to help people assess and understand ambiguous, sometimes undifferentiated symptoms that may or may not be a threat to their health but often reduce their well-being. Primary care provides this key diagnostic triage and anxiety-allaying function, which delivers great value to people seeking care but is often overlooked. Within primary care, this sorting, triage, and reassurance are framed by a clinical approach that differs from emergency room and subspecialist care. It involves recognizing the full range of health problems and/or opportunities present in any interaction, prioritizing which problems/opportunities should receive attention and action above others in order to promote health and healing, and personalizing the care plan or approach in ways informed by the person’s social and environmental context. When this occurs in primary care, as opposed to emergency rooms or after multiple subspecialist visits, it creates value for both individuals and the health care system (Ellner and Phillips, 2017).

Measures

Measures are the means of conveying an assessment of quality. Whereas quality is the degree to which care meets expectations, measures are tools that highlight the behaviors or aspects of care that most contribute to those expectations. Measures used in primary care will only be effective if they align with what it aims for (its purpose) and what it does (its function). Meaningful measures best serve efforts to implement high-quality primary care when they connect to its purpose, function, and definition (see Chapter 2).

Meaningful primary care measures should support accountability, be flexible to patient need, and assess value at multiple levels. Such measures enable shared and commonly held expectations of primary care, such as the following (Green and the Starfield Writing Team, 2017):

• Primary care is a function, not a specific discipline, specialty, or service line. It is vital to all people of any age, background, and socioeconomic circumstance (Starfield et al., 2005).
• Primary care accomplishes its desirable results by creating a place for people to address a wide range of health problems. It helps people with most of their concerns, promotes health, guides people through health care systems, and facilitates ongoing relationships with clinicians in which people participate in decision making about their health and health care (Phillips and Bazemore, 2010a).
• Primary care reduces undesired variability in health care services while assuring desired variation to personalize and customize care in the context of family and community (IOM, 1996; Stange et al., 2014).
• Primary care clinicians partner with patients in ways that minimize fear, locate hope, translate symptoms and diagnoses, witness courage and endurance, and comfort suffering (Heath, 2016).
• The key elements of primary care do not operate independently. They exist in common as a whole and must be measured simultaneously (Bell et al., 2019; Etz et al., 2019).

Accountability

Accountability should be based on shared expectations of professionalism, quality, and performance. However, in the United States, accountability has come to be associated with financial rewards or penalties tied to outcomes. For example, the Quality Payment Program created by the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization

Act (MACRA)¹ scores clinicians on four measures—quality, cost, promoting interoperability, and improvement activities—and then modifies Medicare Part B payments based on those scores so that total payment adjustments are budget neutral (AAFP, 2020). Emerging evidence indicates that schemes such as this systematically disadvantage smaller practices and those that care for more disadvantaged patients (Colla et al., 2020).

Poorly designed measures and incentives place accountability at odds with the valuable functions of primary care. They corrupt quality and reduce it to target attainment above all else, regardless of shared expectations and professional behavior, which has the unintended consequence of confining professional responsibility and limiting professionalism (IOM, 2001a; Phillips et al., 2019). Rather than incentivizing physicians to work harder, value-based payment programs should support physician professionalism (Casalino and Khullar, 2019).

With each patient, primary care assumes professional responsibility for an integrated understanding of the fullness of an individual’s experiences, through which they gain or lose health. This understanding and capacity to improve health comes from relationships over time. Narratives framed around proof of activity and proof of desired outcomes are counterproductive to therapeutic relationships and addressing patient priorities. Linking payment and accountability targets compounds these negative consequences by promoting behaviors aimed at meeting those targets rather than those actions that reflect professionalism and value (Gillam et al., 2012). Instead, meaningful accountability is based on the principles of professionalism and value that lead to quality and its associated outcomes, and these are measurable (Bovens and Schillemans, 2014; Kanter et al., 2013).

THE BENEFITS OF AN IMPROVED MEASUREMENT ECOSYSTEM

Several systemic weaknesses in U.S. measurement systems have resulted in the failed national assessment of primary care quality and performance and under-reported the benefits of primary care to populations and health systems. These include a lack of national agreement regarding which parsimonious set of measures should be applied to primary care and how to specify them (Cook et al., 2015; Phillips and Bazemore, 2010b), which often leads to inaccurate assessment of core primary care functions, unclear objectives to guide quality improvements initiatives, and a proliferation of measures (Berenson and Rich, 2010; O’Malley et al., 2015). The sheer number of measures creates a large administrative burden (IOM, 2015),

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¹ Medicare Access and CHIP Reauthorization Act of 2015, Public Law 114-10 (April 16, 2015).

made worse by the number that are of questionable significance to clinicians (Mutter, 2019; Petterson et al., 2011; Raffoul et al., 2015). The result is poorly supported clinical decisions, minimal gains in person or population health, and competing time commitments for clinicians, who struggle to meet measure requirements while also providing the unmeasured work that helps patients. The environment in which measures are put to use is healthiest when measures are meaningful and purposeful.

The needed shift in thinking about quality measurement is to consider alignment between external and internal motivations and embracing both patient- and person-centeredness² in order to promote health equity.

Prevent Waste, Create a Unified Vision, and Divorce Measures from a Myopic Focus on External Motivations

Achieving value in health care requires a refinement of how quality is measured, starting with reduced inefficiencies and redundancies. Current measurement activities require health systems to devote an average of 50–100 full-time equivalent employees at a cost of $3.5 to $12 million per year (IOM, 2015). The Quality Payment Program in MACRA reflects federal investment in payment models and measures that shift the focus from volume of care to value (CMS, 2017) (see Chapter 9 for more on payment models). The move from volume to value holds great promise if aligned with purpose, given that systems emphasizing primary care purpose and function have lower per capita costs and better health outcomes (Starfield et al., 2005). However, the administrative burden related to the high number of misaligned and non-meaningful quality measures on which primary care is required to report undermines effective use of primary care resources (Casalino et al., 2016; Dean and Adashi, 2015). Primary care reports on dozens of measures from different sources that are not always in agreement. For example, the Centers for Medicare & Medicaid Services (CMS) inventory includes 70 measures, whereas the National Quality Forum (NQF) Quality Positioning System has 126 (CMS, 2020c; NQF, 2021). Additional research shows that primary care physicians spend an average of 3.9 hours per week on measurement reporting, at a national average cost of $40,000 per physician per year (Casalino et al., 2016). Reducing the measures used, beginning with those only tangentially related to the function and purpose, can represent a first important step in correcting the dysfunction of the current primary care measure use environment.

MACRA has created a federal mandate to assess and pay primary care practices based on quality outcomes, yet no national agreement exists

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² As discussed in Chapter 4, the concept of person-centeredness takes into account the family and community contexts that affect a person’s health and the need to learn about and address problems in these contexts.

regarding what outcomes best match with primary care quality (CMS, 2016). A unified vision within primary care will be critical to enabling a high-function measures use environment. In addition, attention to full scope primary care requires measures that extend beyond the scope of clinical processes and outcomes (Stange, 2002; Stange et al., 2014; Starfield, 2011b). For 15 years, primary care in the United Kingdom employed a unified vision for primary care measures. The Quality Outcomes Framework relied heavily on external motivations, and it specifically targeted predictable clinical outcomes associated with primary care. In 2017, the United Kingdom changed use of the Quality Outcomes Framework when it found that the framework caused physicians to focus on process activities unrelated to care quality to hit outcome targets. In addition, it failed to support functions that were not clinically defined, such as problem recognition (Starfield, 2009), relationship-based care (McDonald and Roland, 2009), and patient goal–oriented care (Campbell et al., 2009; Gillam et al., 2012).

Balance Patient-Centered Care with Person-Centered, Team-Based Care to Promote Health Equity

High-quality primary care cannot be supported by payment models that divorce accountability from shared agreement about primary care values and professional norms among stakeholders. Payment and systemic forms of accountability are important, but they too often reduce measures’ function to target attainment, as achieved through the actions of a single clinician rather than a care team and as evidenced by outcomes assumed to result mainly from the actions of that person. This cuts out any reasonable focus on other non-physician care team leaders or important team members and contributes to structural obstacles that can prevent attention paid to the social drivers of health. Health and illness both result from a complex variety of factors, which is why primary care is deeply invested in both horizontal and vertical integration that helps individuals gain optimal health through a variety of interrelated strategies and partnerships between medical and social systems of support while guided by a clinician and care team best matched to individual needs and resources.

Primary care is not limited to diagnosing and treating illness, but as previous chapters have explained, it includes the full lifespan, individuals’ long-term goals, and opportunities for health promotion, preventive care, and relief of suffering of both mind and body. Measurement of patient-centered care alone is insufficient to this mission. Assessment of primary care must include both patient- and person-centered measures (Starfield, 2011b), and embracing both types of measures requires balance (see Chapter 4 for more on person-centered primary care). Measures able to assess the personalizing function of primary care can enable adopting measures

generated from disease-specific guidelines and combining them with the many other biological and biographical particulars of an individual, such as adapting suggested guidance for blood pressure control in a person with diabetes, over the age of 65, and with other comorbidities.

High-quality primary care includes the ability of the clinician and/or care team to prioritize individuals’ needs by combining expertise based on their experiential, social, and scientific profile and navigating a series of competing needs and demands as best fits the whole person. It recognizes those persons’ accumulated knowledge and understands person-based needs as nested within population-based needs. The same high-quality care, delivered in the same relational and purpose-driven way, may result in different timelines for health goal attainment or clinical improvement based on many factors, such as a lack of trust in the health care system, challenges in health literacy, or social inequities, such as limited access to healthy foods, insecure housing, or limited access to education. Measurement systems based solely on patient-centered rather than person-centered care fail to account for such things.

Rather than allow measurement to be dominated by diseases, organs, life expectancies, and what is easily counted, there should be a balance between the easily counted and measures that also reflect how individuals live, their experiences in life, and what they find valuable about primary care. This can be accomplished by adopting meaningful primary care measures, aligned with primary care purpose and function, and making greater use of patient-reported assessments of care.

GUIDANCE FOR SELECTING PRIMARY CARE MEASURES

Primary care measures enable clinicians and care teams to achieve the purpose of primary care by providing actionable markers for improvement of the relationship with the patient and the coordination of care beyond episodic interactions. A reasonable goal for primary care measures is that all stakeholders can easily understand what good care is and how it is effectively assessed. The need for quality and performance assessment will also need to be balanced with the purpose, burden, and use environment for the information or measures collected. A national Starfield Summit of 70 national and international experts in primary care that included patients, insurers, employers, and clinicians of all primary care disciplines established that superior primary care measures are ones that (Etz and the Starfield Writing Team, 2017):

1. Are meaningful—to patients, families, health systems, policy makers, and clinicians;

2. Assess primary care as defined, practiced, experienced, and co-created between patients, clinicians, and teams;
3. Assess the intended outcomes of primary care (e.g., achievement of health and health goals, illness prevention and health promotion, healing, avoidance of unnecessary pain and suffering, and equity);
4. Balance the tensions endemic to primary health care: standardization alongside customization, predictability alongside ambiguity;
5. Are flexible—adaptive to setting (from the individual to national levels), lifespan (infant to elderly), health state (changing health status), and individual differences (context, family, and preferences);
6. Provide evaluation and improvement information actionable at the local, regional, and national levels;
7. Support self-assessment, self-learning, and aspiration;
8. Are feasible, reliable, and without undo data collection burden;
9. Point out and establish the importance of things that cannot yet be counted;
10. Inform evaluation of a broad vision that understands health and illness exist within a social and cultural framework; and
11. Reflect the complexity of the discipline—the whole is more than an additive sum of parts. Embrace interconnectivity, reject reduction to cause and effect of individual elements, assess and support emergence—where just adding up what happens to parts (diseases, individuals) does not equal the whole (people, populations).

Achieving parsimony is one goal of effective and efficient measurement of primary care, because a core set of measures increases focus, reduces burden, and is an opportunity to increase alignment across payers, patients, health systems, and clinicians. Current low-value care measures do little to advance high-quality primary care, even while they may be appropriate in other settings (Barreto et al., 2019). It is more likely that research on known core aspects of primary care, including care coordination, comprehensiveness, relationships, and trust, and how they interrelate with each other and with health outcomes, may explain more about reducing low-value downstream costs associated with hospitalizations and subspecialty services.

The American Board of Internal Medicine Foundation has a renewed focus on trust as a measure (Lynch, 2020), which has been used in the past; research has shown it to be significantly associated with patient satisfaction, though it is not clear how it is related to other outcomes (Safran et al., 1998). Trust may also be a function of continuity and comprehensiveness or be best captured by self-reported outcomes. Investigators have developed several tools to assess team-based care, but a systematic review concluded

that setting-specific team effectiveness measurement tools need further development (Kash et al., 2018).

Equity is increasingly important as an outcome goal for all of health care, and yet a ready-for-use measure of equity in primary care does not yet exist. Equally important, primary care lacks evidence regarding how the critical functions of prioritizing, integrating, and personalizing care work to inform better outcomes (Stange et al., 2014). Such evidence is required to create meaningful primary care measures that are able to support high-quality care and advance the knowledge base in primary care–related professions.

Pediatrics, as a subspecialty of primary care, has had a shortage of appropriate measures. The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) accelerated interest in pediatric quality measurement and created the opportunity to improve the quality of health care delivered to the nation’s children, including the almost 40 million enrolled in Medicaid or CHIP (CMS, 2020c; NQF, 2017). When CHIPRA was enacted, the Agency for Healthcare Research and Quality (AHRQ) and CMS began working together to implement selected provisions of the related legislation, and NQF launched its Pediatric Measures project in 2015 to evaluate the measures that AHRQ and CMS develop.

COVID-19, Health Equity, and Measures

The COVID-19 pandemic has provided an unprecedented opportunity to reevaluate the capabilities of the nation’s medical and public health systems and the means by which the quality of care delivery is assessed. The weaknesses of a health care system designed primarily as a reactive and financially driven enterprise are clear. As communities reel with overcrowded inpatient and intensive care unit beds, inadequate testing infrastructure, and increasing mortality, the reality of the inequities that leave the most disadvantaged and underserved communities, especially Black, Indigenous, and Hispanic groups, at high risk for exposure, infection, and death raises sincere questions about a reactionary health system’s ability to provide equitable care. Race and racism are social drivers of health (Gee and Ford, 2011; NASEM, 2017; Walker et al., 2016), and despite evidence of their impact on medical decision making and patient outcomes (Dovidio and Fiske, 2012; van Ryn et al., 2011), there are currently no measures tailored to achieve the desired outcome—removing bias and eradicating health disparities based on race, ethnicity, and other socially defined markers of inequity.

During the pandemic, many insurers and health systems temporarily suspended the need to systematically report current primary care quality

measures (CMS, 2020b). The shifts in care delivery required to meet the unique, pandemic-related challenges exposed both the amount of time current measures require and the disconnect between those measures and care quality. In addition to being disease centric, most measures focus on in-office, predictable, and algorithmic work processes and commonly known intermediate health outcomes, as surrogates for care quality. These methods were not adequate to capture care delivery and quality during the pandemic. Improvement might require a change in emphasis from interventions developed to achieve improvements on a specific measure to those intended to support the elements of high-quality care and evaluated using a core set of high-value measures. This would represent a paradigm shift from seeking successful measures to seeking measurable success (McWilliams, 2020).

IMPLEMENTATION NEEDS

The U.S. health care system needs quality measures adequate to the task of assessing, valuing, and fostering continuous improvement within the fields of primary care (Appleby et al., 2016; Epstein and Street, 2011; IOM, 2001a; O’Malley et al., 2015; Stange, 2002, 2010). The shift in national conversations from “volume to value” (HHS, 2015; Saver et al., 2015) within health services delivery has gained significant traction, as signaled by two publications: Vital Signs: Core Measures for Health and Healthcare Progress (IOM, 2015) and MACRA (CMS, 2016). Vital Signs outlined the cost and waste associated with current performance measurement systems, and it set the tone for future work by recommending a relatively small, parsimonious set of measures able to assess U.S. population health. The authors of Vital Signs advised that key stakeholders at every level, rather than the usual content “experts,” must be central to any effort focused on generating meaningful health care measures. This is true now more than ever. The shift from volume to value relies on the ability to recognize and assess value through performance measurement. MACRA legislation makes this point and recognizes that current quality measures, particularly those for primary health care, are not up to the task. The central messages of Vital Signs, MACRA, and primary care leadership are aligned: quality measures are necessary to achieve national health objectives, yet current measurement systems are costly and provide limited return.

Policy makers and health care leaders have called for reducing the number of quality measures applied to primary health care (Berwick, 2016; Casalino et al., 2016; IOM, 2015; O’Malley et al., 2015). Hundreds of measures are in use (Conway, 2015), and yet most of these are not aligned with its purpose or function, for either adult or pediatric populations (CMS, 2020a; Rich and O’Malley, 2015). The work of NQF helps to reduce the number of measures most often applied, yet that number still

remains in the hundreds (Conway, 2015; Dunlap et al., 2016; Roski and McClellan, 2011). Reducing it will decrease the administrative burden associated with measurement reporting. However, with a focus on adapting current measures rather than redesigning them, these efforts fail to address the challenges endemic to the current system (Meltzer and Chung, 2014; O’Malley et al., 2015; Rollow and Cucchiara, 2016; Stange, 2002; Stange et al., 2014), including the following:

• a myopic focus on disease-specific clinical processes and outcomes (Campbell et al., 2009; McDonald and Roland, 2009; Stange, 2002; Starfield, 2011b);
• measures reactive to the needs of policy and payment rather than proactively informed by health and healing (Epstein et al., 2010; O’Malley and Rich, 2015; Reuben and Tinetti, 2012);
• misrepresentation and under-representation of primary health care’s contributions (Baicker and Chandra, 2004; Epstein et al., 2010);
• a disconnect between health outcomes important to care-seekers and those items being measured (Epstein and Street, 2011; Stange, 2013; Starfield, 2011b); and
• the absence of a unified vision regarding what should be measured and why (Mold et al., 1991; O’Malley and Rich, 2015; O’Malley et al., 2015; Stange et al., 2014; Starfield, 1979).

Evidence shows that the United States lacks a quality measurement system able to assess key aspects of primary care, such as problem recognition (Starfield, 2009), patient-centered care (Etz et al., 2019), patient-reported outcomes (Mold et al., 1991; Weiner et al., 2010), or healing relationships (Epstein et al., 2010). The measurement atlases compiled by AHRQ and the core set of quality measures recently proposed by CMS and America’s Health Insurance Plans are important steps (Conway, 2015), yet strategies that rely on revising and centralizing current measures fail to address the gap between the work of primary care, as defined in this report, and the ways in which that work is assessed (Appleby et al., 2016; O’Malley et al., 2015; Rollow and Cucchiara, 2016; Starfield, 2011a).

ACCOUNTABILITY

As this report argues, relying on market mechanisms to shore up the glaring shortcomings of policy and payment design will not produce the high-quality primary care system required to improve population health and slow the rise of health care spending. Rebalancing a system that is off kilter will require seeing primary care as a common good, worthy of societal investment, and being a state and federal policy priority. The investments and

actions needed are of sufficient magnitude as to require mechanisms that will ensure that policy and fiscal allocations are coordinated throughout the various layers of government and the private sector. The nation may have failed to adopt the recommendations in Primary Care: America’s Health in a New Era because no entity was accountable for implementing them (IOM, 1996). That report did call for creating a public–private consortium to lead the implementation, but the report lacked detail on which actor(s) would organize or participate in the proposed consortium. With no one organization or agency tasked explicitly to do so, key stakeholders looked to each other, and ultimately no one entity stepped up to lead the work.

This committee is charged specifically with creating an implementation plan that builds on the 1996 recommendations (see Chapter 12 for the plan). It agrees with the 1996 study committee that an accountability mechanism is needed, and it offers more specifics and a clearer path to create that mechanism. Critically, a responsible and clearly identified entity is needed to oversee accountability for policy goals, coordinate disparate research and policy efforts, establish a standard and parsimonious set of measures, synchronize training and workforce initiatives, and align efforts for payment reform. Private-sector stakeholders are disparate and have demonstrated that they largely cannot overcome competitive self-interest and fiduciary duty to investors or stakeholders to come together effectively on their own. As a result, this committee believes that the primary accountability mechanism must ultimately rest within a federal government entity, as it does for other areas of health sector activity.

Currently, the federal government plays an active, albeit uncoordinated, role in primary care. For example, through CMS, the federal government directly pays for close to 40 percent of all health care and influences commercial payers (CMS, 2018) (see Chapter 9 for more detail). It also can convene private-sector payers with appropriate safe harbors and hold them accountable to major new policy initiatives (Peikes, 2019). While this mandate is regionally effective, states alone cannot carry it out, and other market actors, such as clinician groups, can participate but are not in position to advance the whole of the necessary work.

Given the rationale for a central federal entity to advance the work of aligning existing primary care activities and implementing primary care policy and workforce recommendations, it is then important to consider which entity or entities within the federal government might be able to carry out these tasks in a coordinated manner. CMS is the major payer in the United States, but its purview is technically limited to the over age 65 and disabled population, individuals with end-stage renal disease or amyotrophic lateral sclerosis, and state Medicaid programs. These are important large groups, but they leave many areas uncovered. The Health Resources and Services Administration (HRSA) is responsible for improving health care among

geographically isolated or economically or medically vulnerable people. However, it does not generally focus on the insured or providing primary care for populations not defined as vulnerable or underserved. AHRQ works to improve the quality of care in the United States through research and implementation grants, and it has a National Center for Excellence in Primary Care Research (NCEPCR) that notably remains unfunded (AHRQ, 2019). AHRQ does not generally coordinate policy and has historically been under fiscal threat of defunding at the agency level (McCann, 2012; Sheber, 2018). In fact, the 2021 President’s Budget proposed to consolidate AHRQ into the National Institutes of Health (NIH) (AHRQ, 2020; Bindman, 2017). No clear private-sector entities are available to coordinate necessary public–private policy research, workforce, and payment alignment.

Several possible entities could contribute to or lead the implementation of this committee’s recommendations. The first option could be for HRSA’s Bureau of Primary Health Care (BPHC) to lead on the workforce-related recommendations. Currently, BPHC has oversight of safety net systems and shortage areas through its Health Center Program that serves only approximately 8 percent of people in the United States (NACHC, 2020). Moreover, despite its name, its purview is not limited to primary care. Expanding its remit beyond its current form requires an act of Congress, and it does not have capacity or ownership over a broad research program, nor has it coordinated workforce or quality efforts outside of safety net systems and federally qualified health centers. If strengthened and broadened, it could coordinate key workforce priorities and align with other entities below to carry out these recommendations. This would still leave payment policy out of its reach since this responsibility sits within CMS.

A second option would be to fund the AHRQ NCEPCR to implement the research-related recommendations in this report. It is currently directed to lead research on primary care but has never received direct funding for it. It is also required to align what research it supports with a definition of primary care that is not consistent with this report. NCEPCR could coordinate practice-related primary care research (PCR) and basic science and expand the field of inquiry and implementation. However, if funded, it would still be separate from NIH-related PCR that would either need to be aligned, at minimum, or perhaps encompassed partly within this AHRQ research center. It is unlikely that NCEPCR could have purview outside of research, given AHRQ’s limited scope and chronic funding and authorization challenges. Nonetheless, it is an established entity with a mandate for PCR that could accomplish much more, if fully funded, than it currently does (see Chapter 9 for more on PCR).

These options, while not mutually exclusive, do little to coordinate primary care activities across the government and would require congressional action. Another, and likely the most effective, option to coordinate

primary care activities across government and centrally hold the different actors accountable for implementing changes would be to establish a Secretary’s council on primary care within the U.S. Department of Health and Human Services (HHS) that would expressly be charged with carrying out the recommendations in this report through interagency coordination. One advantage to this option would be that it could be established relatively quickly, coordinate and hold the individual agencies accountable, oversee the implementation of the recommendations, and fill gaps as they arise. Creating such a council would not need legislative approval and likely not entail a major outlay of resources. To help guide its work and ensure that diverse stakeholder voices and interests are included, the council could further be informed by regular guidance and recommendations from an advisory committee, established under the Federal Advisory Committee Act,³ with membership from national organizations that represent significant primary care stakeholder groups, such as patients, certifying boards, professional organizations, health care worker organizations, payers, and employers. The committee recognizes that establishing this council (and advisory committee) would require political capital and buy-in at high levels of federal government policy making. However, the scale of the task ahead to implement high-quality primary care would likely require this level of commitment to investing in primary care to see it through to success.

FINDINGS AND CONCLUSIONS

Current measures applied to primary care are not aligned with its purpose and function and therefore fail to adequately assess its quality and accountability. Effective primary care measurement relies on appropriate design of the use environment and should align both external and internal motivations of actors. It should do so in ways that embrace both patient- and person-centeredness in order to promote health equity.

Primary care also currently suffers from a dual challenge of having too many measures (many of questionable benefit) and an absence of measures fit to the purpose of assessing primary care’s value, added benefit, and functions. The number of measures that exists should be reduced and new measures created that appropriately support primary care.

No single entity is yet working to ensure that the field of primary care writ large is held to account for its performance. The private sector has demonstrated that it cannot effectively assume this role. No single agency or function is equipped to coordinate the various activities related to primary care across government, and existing agencies are not equipped, in their current form, to take on this role. Such an entity could ensure that

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³ Federal Advisory Committee Act, Public Law 92-463 (October 6, 1972).

the various government primary care activities are coordinated and held to account. It could also coordinate the implementation of this report’s recommendations attributable to government and increase the chances of implementation of recommendations by private-sector actors. To be effective, such an entity should have adequate authority and influence to be an effective agent for change.

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