Guest Post: The next generation of primary care quality measures

- Steve Martin, MD

Nov. 2015 update: Care That Matters published a position paper on quality measurement and health care in PLOS Medicine.

Everybody talks about the weather ... but nobody does anything about it." 

Charles Dudley Warner (1887)

Unlike the weather, there is something that can -- and must -- be done about quality measures. Soon. Here's what's over the next hill:

The Centers for Medicare & Medicaid Services (CMS) is moving towards linking 30% of Medicare reimbursements to the “quality or value” of providers’ services by the end of 2016 and 50% by the end of 2018 through alternative payment models. More recently, CMS announced a goal of tying 85% of traditional fee-for-service payments to quality or value by 2016 and 90% by 2018. Earlier this year, the Medicare Payment Advisory Commission cautioned that “provider-level measurement activities are accelerating without regard to the costs or benefits of an ever-increasing number of measures.”

Where will these measures come from? To realize this vision, America’s Health Insurance Plans (AHIP) and its member plans’ Chief Medical Officers convened leaders from The Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF), as well as national physician organizations, to form The Core Quality Measures Collaborative in 2014.

This looks to us like the usual policy makers -- not practicing primary care clinicians or patients. That has to change.

Be sure to register now and join is on Thursday October 29th from 1-5 pm at a pre-conference of the Family Medicine Education Consortium (FMEC) on The Next Generation of Primary Care Quality Measures. We'll be joined by representatives of Community Catalyst, the RightCare Alliance, and Dynamed. Dynamed is completing a review of the evidence of current BCBS Alternative Quality Contract metrics and we will share the results at this gathering.

Care that Matters, a group of primary care trainees, clinicians, and faculty, is leading this effort. We'd welcome your joining us. Please see the beginnings of our website here and contact us to join in this work.

In the meantime, please be sure to sign on for RightCare Action Week, to be held this October 18-24. What is RightCare Action Week? Our healthcare system has strayed from its mission: Healthcare that is effective, affordable, needed and wanted by well-informed patients, and especially, free of clinical decisions that are made with financial or business considerations in mind. From Oct. 18 to 24, 2015, people like you across the country will take action to show patients that we have not forgotten what good medical care is. Actions can be as simple as taking a deeper social history or doing a house call.

To recap, please:

1. Join us for The Next Generation of Primary Care Quality Measures on Thursday, October 29th

2. Join Care that Matters for work on metrics that matter

3. Sign on for RightCare Action Week to be held October 18-24

The Next Generation of Primary Care Quality Measures
Held in conjunction with the 2015 FMEC Annual Meeting
DoubleTree by Hilton and CoCo Key WaterPark
Boston North Shore
50 Ferncroft Road, Danvers MA 01923

The best recent posts you may have missed

Every few months, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from May, June and July:

1) The good news, at last, in prostate cancer screening (6/19/15)

2) Countering a too-neat narrative on screening mammography (7/16/15)

3) For medical schools, mission statements matter (6/11/15)

4) The paradox of health and screening for prediabetes (7/31/15)

5) Overuse of health care: can -ologists help themselves? (5/18/15)

If you have a personal favorite that isn't on this list, please let me know. Thank you for reading!

Community health workers can complement primary care

In late 2011, I attended an academic meeting where the subject of community health workers came up in a discussion. Earlier that year I had read about Vermont's ambitious blueprint for medical homes integrated with community health teams, so I volunteered that we needed fewer specialists and more trained laypersons with ties to their communities to implement prevention strategies. Another physician objected that while community health workers might work well in lower-income countries like India, we didn't need to deploy them in America, where people already know from their doctors that they should eat healthy foods, watch their weight, exercise, and not smoke and don't need others nagging them about it.

But should community health workers be viewed merely as extensions of medical institutions when large proportions of the population will not visit a doctor in a given year? An alternative model, wrote Health Affairs editor Alan Weil,

views CHWs as part of the communities in which they work. The roles of community health workers are defined by the community and CHWs through a process of community engagement. CHWs are valued for their contribution to community health, not for the savings they generate for health plans or providers. CHWs are embedded in the community, not in a clinician’s office or hospital. Advocacy is required to effect a transfer of resources out of clinical care into the community.

On the other hand, a New England Journal of Medicine commentary observed that the absence of connections between community health workers and family physicians can leave them working at cross-purposes:

CHW services are commonly delivered by community-based organizations that are not integrated with the health care system — for example, church-based programs offering blood-pressure screening and education. Without formal linkages to clinical providers, these programs face many of the same limitations — and may produce the same disappointing results — as stand-alone disease-management programs. CHWs cannot work with clinicians to address potential health challenges in real time, and clinicians can't shift nonclinical tasks to more cost-effective CHWs. Indeed, clinicians often don't recognize the value of CHWs because they don't work with them.

How can we bridge this gap? A recent review in the Annals of Family Medicine provided a list of structure, process, and outcome factors to consider for patient-centered medical homes to partner with peer supporters (a.k.a. community health workers).

For complex patients with multiple health conditions, care coordination is a key role where community health workers could potentially be more successful and cost-effective than expensive projects led by registered nurses or physicians. Reviewing the past decade of Medicare demonstration projects, researchers from the Robert Graham Center drew five lessons for future coordinated care models:

(1) Minimize expenses by sharing resources and avoiding cost ineffective interventions
(2) Concentrate on high utilizers
(3) Foster relationships with both providers and patients
(4) Track patients across the medical neighborhood in real time
(5) Extend rather than duplicate the efforts of primary care practices

Although optimal integration between the roles of community health workers and primary care teams is easier to describe than to achieve, moving both groups toward the common goal of communities of solution will be essential to protecting the health of the whole population.

Why precision medicine threatens population health

Scientific guidelines produced by the American Heart Association tend to spill lots of ink on recommending complex and/or expensive tests, drugs, and procedures for patients who already have heart problems. Even when the topic is ostensibly cardiovascular prevention, as in the current AHA-endorsed cholesterol management guideline, the end result may be prescribing statins to many millions (or even billions) of additional adults. So it was a pleasant surprise to me earlier this summer when the AHA released the insightful consensus statement "Social Determinants of Risk and Outcomes for Cardiovascular Disease." In the introduction, the authors wrote:

There is increasing awareness that the benefits of advances in prevention and treatment [of cardiovascular disease] have not been shared equally across economic, racial, and ethnic groups in the United States. Overall population health cannot improve if parts of the population do not benefit from improvements in prevention and treatment. ... The premise underlying this scientific statement is that, at present, the most significant opportunities for reducing death and disability from CVD in the United States lie with addressing the social determinants of cardiovascular outcomes.

In other words, addressing social determinants of health and health disparities across the U.S. - population health interventions - are likely to have far greater benefits than providing any conceivable number of individual cardiac stress tests, cholesterol-reducing drugs, or coronary artery stents. Bravo to the AHA for acknowledging a reality that may unsettle many of its members whose incomes depend on the latter! Unfortunately, we know much less than we need to about measuring and changing social determinants of health. But the simplicity of focusing on traditional cardiac risk factors rather than nebulous concepts such as "socioeconomic position" may be leading physicians down the wrong path, as David Loxterkamp observed in a 2013 BMJ essay:

A patient recently slumped into my office clutching a paper from his employer. On it were empty boxes for me to enter blood pressure, weight, waistline circumference, cholesterol, and fasting blood sugar readings. We reviewed recent results. Only his glucose level was slightly raised, so we spent the majority of our 20 minutes talking about diet, exercise, and targets for weight loss. None of this concerned him, he revealed on his way out the door, as much as the tension in his marriage and the difficulties he and his wife were having with their autistic son.

Dr. Loxtercamp went on to argue that the primary care clinician's central role is "facilitating change," not only positive changes such as smoking cessation and healthy lifestyles, but also coming to terms with adverse changes such as divorces, illness and deaths of friends or family members, or other traumatic life experiences.

What they [patients] need from us is reassurance, commonsense advice, coordination of community resources, and knowledge of their family values. This was once our vital function, but no longer. We are on a merry-go-round, too, and now see a greater value in access and efficiency than continuity of care. ... Patients are not (only) data fields for the doctor to harvest, objects to be imaged, or problems to be solved. They are also our neighbors asking for help, using posture, gait, gesture, and facial expression to indicate where and how to proceed. Let’s first acknowledge them beneath their symptom complex and accept the story of their illness in their own words.

An obsessive focus on measurement is not the only or even the foremost threat to medicine's role in improving population health. In a recent NEJM commentary, Ronald Bayer and Sandro Galea expressed concern that the Precision Medicine Initiative may prove to be a damaging and costly distraction from the most burdensome U.S. health problems:

“What is needed now” is quite different ... if one is concerned about why the United States has sunk to the bottom of the list of comparable countries in terms of disease experience and life expectancy, or if one is troubled by the steep social gradient that characterizes who becomes sick and who dies. The burgeoning precision-medicine agenda is largely silent on these issues, focusing instead on detecting and curing disease at the individual level. ... The challenge we face to improve population health does not involve the frontiers of science and molecular biology. It entails development of the vision and willingness to address certain persistent social realities, and it requires an unstinting focus on the factors that matter most to the production of population health.

I think their concern is justified. Population health interventions may never prove to be as sexy as precision medicine. Even outstanding narratives about the statistical basis of health policy can't captivate human interest as powerfully as the girl in the well. That doesn't mean that our public investments in health should not or cannot be prioritized by what will provide the most good for the greatest number of people.