CMS’s Universal Foundation Measures Are Not Universally Good For Primary Care

Primary care is where most people have relationships with a health professional, where more than one-third of all health care visits happen, and the only part of the health system that demonstrably produces longer lives and more equity. However, primary care is experiencing widespread and longstanding shortages and skyrocketing rates of burnout and moral injury. Primary care physician turnover, often associated with burnout, is estimated to cost CMS nearly one billion dollars annually. Before the COVID-19 pandemic, more than one-third of family physicians reported frequent burnout. Since the pandemic, primary care physicians are stepping up to meet patient needs even while 40 percent say they are mentally or financially fragile. Primary care clinicians already bear much of the burden for the most commonly used clinical quality measures and struggle to derive benefit from this effort. [..]

The CMS proposal [“Universal Foundation” for aligning quality measures across its own programs]also rebrands transactional patient satisfaction surveys as person-centered. They are not equivalents. Transactional instruments ask if you received care, could access care easily, how often you go for care, were you listened to, were you respected, how you would rate your experience, and so forth. These questions could easily apply to your last dining experience. They do little to capture the value or significance of that event to the person being surveyed. The NASEM [National Academies of Sciences, Engineering, and Medicine] report reviewed decades of research that demonstrate those aspects of care delivery most valued by patients and their care teams. The proposed Universal Foundation measure set fails to take that guidance into account. The result is a set of measures that undervalues the professionalism of those entrusted with our population’s health while also effectively silencing what makes us trustworthy from the perspective of that population and professional standards. Better options, such as the Person-Centered Primary Care Measure, derive from input from patients, clinicians, policy makers, and payers and have CMS endorsement. While this measure is specific to primary care, defaulting to transactional instruments and applying them to primary care misses the opportunity to improve care. [..]

Measures that Matter

[..] the Center for Professionalism and Value in Health Care’s Measures that Matter initiative has proposed a suite of measures better aligned with the professional values of primary care for which there is also considerable evidence for outcomes and patient preferences. The Center aims to “align how the health care professions are valued with the values of the professions.” This alignment supports health professionals in doing high-value functions for patients and supports their intrinsic motivation.

Toward this end, the Center has shepherded a continuity measure through endorsement by CMS for Merit-based Incentive Payment System in a Qualified Clinical Data Registry and through National Quality Forum (NQF) endorsement. In conjunction with the Larry A. Green Center, the Center for Professionalism and Value has also shepherded the Person-Centered Primary Care Measure to both NQF and CMS endorsement. These are the first two in a parsimonious set that align with patient expectations, professional norms, and NASEM report guidance.

Continuity of care is a measure supported by dozens of studies that show a strong association with reduced cost and use, improved patient and clinician satisfaction, and even reduced mortality. It has been nominated as a CMS measure for nearly a decade. Continuity is best measured using claims data to track patients’ clinical relationships across settings. The Center has retrofitted it to the CMS-Center for Clinical Standards and Quality digital measurement requirement and recalibrated based on new research.

The Person-Centered Primary Care Measure has been tested in dozens of countries and reliably measures patients’ experiences and relationships in primary care. It is notable for its alignment with the purpose and function of primary care; its attention to patient goal setting; and its support from clinicians, payers, and patients alike.

Another measure, comprehensiveness is moving through testing for endorsement. Like continuity, it is also associated with better outcomes, and likely best assessed as a claims-based measure. The Center has also recently implemented a patient-reported measure of trust for testing in the PRIME registry, a national clinical registry for primary care.”

Full editorial, RL Phillips and R Etz, Health Affairs Forefront, 2023.5.8