CMS’s Universal Foundation Measures Don’t Benefit Primary Care 2023


CMS launched a “Universal Foundation” for unifying quality measures across its programs in February. CMS specifies an initial list of metrics that primary care must record and comply with. It also contradicts current suggestions to decrease clinician load, connect metrics with care delivery goals, and enhance person-centeredness.

Primary care is where most people see a doctor, where over one-third of all health care visits occur, and the only portion of the health system that improves lives and equity. However, primary care has long-standing shortages and rising fatigue and moral harm.

Burnout-related primary care physician turnover costs CMS about $1 billion yearly. More than one-third of family doctors experienced regular burnout before COVID-19. Primary care providers are meeting patient needs despite 40% reporting mental or financial fragility since the outbreak. Most clinical quality measurements fall on primary care practitioners, who struggle to profit from them.

While there is universal acceptance for CMS’s conceptual goal—to alleviate the tremendous burden of measurement by standardizing a core set of measures across payers—the issue is: How will CMS’s measures list affect primary care’s shaky platform? Not well. Primary care collects and improves these measurements, which don’t correlate with its high-value activities.

Measuring Primary Care: The National Academies

The National Academies of Sciences, Engineering, and Medicine (NASEM) Implementing High-Quality Primary Care study devoted a full chapter to the need for a new primary care measure ecosystem. Measurement ecology investigates how measures fit into care delivery and how they are used. As Don Berwick so eloquently said over seven years ago, both parts of our current ecosystem of metrics have degraded and need adjustment.

The NASEM report, which examined measures to enhance high-quality care, concluded that existing measuring initiatives overemphasize counting items without context. The paper recommends primary care metrics that are meaningfully parsimonious, suitable for purpose, linked to actor internal and external motives, and supportive of primary care value functions.

Fit for purpose: Caregiver and patient expectations must match.

Motivational alignment: The NASEM study calls the present measure ecosystem a “recipe for burnout,” pitting professional drive against financial reality and time demands. Value-based payment models should promote medical professionalism, not work more, according to Lawrence Casalino and Dhruv Khullar.

Supportive of value: Unbalanced attention to market demands to collect proof of services supplied and quantify return on investment hampers assessment of service quality and the detrimental effects of lack of investment. Quality primary care “assumes professional responsibility for an integrated understanding of the fullness of an individual’s experiences through which health is won and lost.” That value has historically been based on strong and therapeutic primary care clinician-patient interactions.

Primary Care Implications?

The proposed Universal Foundation fails numerous NASEM report criteria. It prioritizes checking boxes above connections, separating value from professionalism. Even though much basic care is undiagnosed, the measurements are disease-focused.

The measurements detract from primary care’s role of helping patients with different issues prioritize their needs and priorities. The measurements contain preventative and screening indicators but not patient goals. Primary care goes beyond pathology and monitoring. It must emphasize wholeness, relational worth, and human experience.

The CMS plan calls transactional patient satisfaction surveys person-centered. They differ. Transactional instruments question if you received care, could access care readily, how often you go for care, were you listened to, respected, how you rated your experience, etc. Your last meal may answer these questions. They don’t capture the event’s importance to the respondent.

The NASEM report examined decades of research on patient- and care team-valued care delivery. The Universal Foundation measure set ignores those recommendations. The outcome is a collection of measures that undervalues the professionalism of individuals entrusted with our population’s health and effectively silences what makes us trustworthy to that population and professional standards.

CMS-approved alternatives like the Person-Centered Primary Care Measure are based on patient, clinician, policymaker, and payer feedback. Defaulting to transactional instruments in primary care loses the chance to improve care.

Other factors weaken the idea. Health plans are responsible for 15 of the 19 indicators (first-line psychosocial treatment for children and adolescents on antipsychotics, plan all-cause readmissions, follow up after emergency department visit for drug use). One clinician (depression screening and follow-up plan) tests 17 health plans or practices. Why 15 items are process measures while CMS discourages them is likewise unclear.

Better Base

S.750, An Act Relative to Primary Care for You, has bipartisan support in the Massachusetts legislature and supports numerous state efforts to increase primary care value. The bill’s measuring strategy is vastly different from CMS’s Universal Foundation. This law specifies care quality measures:

“(i) care continuity, comprehensiveness, and coordination; (ii) patient access to primary care; and (iii) patient experience” are patient care quality metrics. “Each quality measure shall be patient-centered, appropriate for a primary care setting, and supported by peer-reviewed, evidence-based research that the measure is actionable and that its use will lead to improvements in patient health.”

The bill requires providers to adopt five of 10 measures. Prioritize patient experience and person-centered measures. This bill addresses Starfield’s three primary care C’s: continuity, comprehensiveness, and coordination. All three have strong links to health and health system improvements. The law mandates parsimony, fit for purpose, motivational alignment, and value support.

Important Measures

The Center for Professionalism and Value in Health Care’s Measures that Matter initiative, like the Massachusetts Senate bill, proposes a suite of measures that better reflect primary care’s professional values and are supported by outcomes and patient preferences.

The Center seeks to “align how the health care professions are valued with their values.” This alignment helps doctors perform high-value patient care and motivates them.

The Center has helped CMS and NQF adopt a continuity measure for Merit-based Incentive Payment System in a Qualified Clinical Data Registry. The Center for Professionalism and Value and the Larry A. Green Center helped NQF and CMS adopt the Person-Centered Primary Care Measure. These two meet patient expectations, professional norms, and NASEM report advice.

Dozens of studies suggest that continuity of treatment reduces cost, utilization, patient and physician satisfaction, and death. CMS has nominated it for almost a decade. Claims data is better for measuring continuity. It was adapted to the CMS-Center for Clinical Standards and Quality digital measurement standard and recalibrated based on fresh research.

The Person-Centered Primary Care Measure accurately measures patients’ primary care experiences and interactions in dozens of nations. It aligns with primary care, focuses on patient goal setting, and has clinician, payer, and patient support.

Comprehensiveness is undergoing endorsement testing. Like continuity, it improves results and is best measured by claims. The Center has included a patient-reported trust measure for testing in the PRIME registry, a national primary care clinical registry.

Global Enhancement

The Universal Foundation’s measures might strengthen a set designed to achieve this program’s admirable goals. The recommended measures are mundane and unimpressive. The Universal Foundation may lessen health system burden, but it puts most of it on primary care, a profession already struggling from persistent underfunding.

Measurement must be meaningful to caregivers and relevant to areas of care that impact person-centered and community health outcomes. The Universal Foundation is a start toward program alignment, but it needs changes to lessen primary care burden and match measurements with high-value care. CMS should follow the Massachusetts measure now in the legislature.

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