Core Principles to Improve Primary Care Quality Management

Looking Back, Looking Forward: MACRA Through the Lens of the QOF

The acceleration toward value-based payment for US primary care has an important counterpart in the United Kingdom. In 2004, the United Kingdom's National Health Service (NHS) initiated the QOF, which remains the most ambitious, comprehensive P4P program for primary care in the world. Now into its second decade, the QOF has linked as much as 25% of general practitioners' income to an extensive collection of quality metrics for up to 20 chronic conditions.¹³ Over the last few years, several reviews of the QOF's impact have been published, and its precise future is under debate.¹⁴ Although limited by the lack of an adequate control group against which to compare its effects on health care in the United Kingdom,¹⁵ the QOF, implemented in a highly integrated health system with patients enrolled in primary care, under a single payer system, with a unified reporting system, is an experiment in quality management from which invaluable lessons can be learned.¹⁶

By all accounts, the QOF has been modestly effective in achieving its targets. Overall, metric achievement rates improved consistently, and disease-specific reviews have found advances in chronic disease management, such as with diabetes.^{13⇓⇓⇓⇓⇓⇓⇓–21} These gains have narrowed some population-level inequalities between populations in the delivery of clinical standards of care, although it is important to note that there was no corresponding narrowing of inequalities in health outcomes in the United Kingdom.²¹ Nearly all reviews, however, report a plateau in the curve of improvement after the first year or 2 of adoption, suggesting once the lower limit of a target had been satisfactorily reached, most practices did not extend the mark.

Unfortunately, these achievements came with significant costs. Research has indicated that nonincentivized quality indicators languished in comparison to the QOF measurements, raising concern that despite accounting for only a quarter of practitioners' income, the process of meeting QOF metrics required a majority of their time. Furthermore, as the “doctor's gaze” focused on the QOF,¹³ patients' views were at risk of being neglected. Research found little to no improvement in patients' experiences of care¹⁹ and has noted the dominance of a biomedical approach to patient encounters, with concomitant neglect of more holistic care.²²

Finally, there is no clear evidence for correlation between quality improvement under the QOF and patient-centered outcomes. Although some modeling has suggested a possible minor mortality benefit, this suggestion has not been consistently corroborated by observational studies of death rates or other patient outcomes, such as avoidable hospitalizations.¹³ Only one of the clinical indicators used throughout the years of the QOF is a “health outcome” instead of an “intermediate outcome” or clinical process: documenting that a patient with epilepsy has been seizure-free for at least 12 months.¹⁸ Notably, there is some evidence that acute care use for this disease domain has improved under the QOF.¹⁷

In response to the perceived inability of the QOF to impact population health, the NHS is experimenting with alternative contracts and payment models. For example, as P4P financing through the QOF has diminished, providers and policy makers in the United Kingdom have developed “capitated outcome-based and incentivized contracts.” These new contracts aim to correct the shortfalls of other value-based purchasing programs by focusing on patient-oriented outcomes, longer-term contracts to meet those outcomes, and capitated payments.²³ Although no peer-reviewed research on their impact has been published, case reports have shown promise.²⁴ Such contracts are just one potential tool in the hands of clinical commissioning groups, the general practitioner-led, financial and administrative bodies established by the Health and Social Care Act of 2012 tasked with management of NHS provider contracts at the local levels. The work of clinical commissioning groups has been compared with that of accountable care organizations in the United States²⁵; however, their potential impact on quality management and patient outcomes in the United Kingdom has yet to be determined.

The NHS is engaged in adaptive learning from the shortcomings of the QOF, whereas many quality programs in the US continue to build on its flawed structure. A central mechanism for achieving the Centers for Medicare & Medicaid Services' (CMS) goal of tying 90% of all expenditures to quality or value by 2018,²⁶ MACRA is an exemplary case in point. Among other provisions, MACRA includes a process for streamlining prior quality measurement methods into a single scoring system for the Merit-Based Incentive Payment System (MIPS) by 2019. Providers will be judged across 4 domains, which include quality of care, resource use, advancing care information (or the meaningful use of electronic health records), and clinical practice improvement activities. Top performers will receive positive adjustments to Medicare Part B rates while the lowest performers will be negatively adjusted.²⁷ Because MIPS will become the default Medicare payment system for all primary care providers who do not qualify for an Advanced Alternative Payment Model, a substantial majority of primary care practices caring for Medicare patients will be paid through MIPS.

Although MACRA was hailed initially, several concerns have already surfaced during its early implementation.²⁸ First and most importantly, MACRA's aim to improve care is highly imprecise, without clearly defined objectives for primary care quality. Primary care providers select 6 measures to report (out of approximately 50 to 60 options), at once far fewer and more arbitrary than the 33 metrics required for accountable care organizations.²⁹ Ironically, although MACRA purports to restructure payment toward value, it is substantially more vague than the QOF in its anticipated achievements. If half of primary care practices choose 6 different metrics from the other half, how can their outcomes be appropriately compared and evaluated? Metric options for primary care in MACRA, nonetheless, still mirror the disease-specific, process-oriented design of the QOF. Because of this design, MACRA also risks widening health disparities rather than improving population health. MIPS measures focus narrowly on office-based clinical effectiveness, neglecting other features of comprehensive primary care services, including access, patient experience, social determinants of health, and interpersonal care.³⁰

In summary, past lessons from the QOF and contemporary lessons from MACRA are at least threefold. First, without an overarching strategy for improving health, P4P programs in primary care may use successful tactics, but disease-specific and process-oriented tactical targets do not necessarily lead to victory in the battle for population health. Second, all quality schemes have opportunity costs and unintended consequences that may significantly offset potential benefits.³¹ Although this fact is well known, it is nevertheless rare that such costs are incorporated into metric design and implementation. Third, current modalities for risk adjustment in quality measurement are mediocre at best.³² How P4P can widen rather than narrow health disparities has been well documented.³³ The results of the QOF and the inadequate design of MACRA show that without an appropriate adjustment for social risk, P4P in primary care has the potential to transfer resources from providers treating high-risk patients to those treating low risk ones.²⁹

Four Foundational Principles of Quality Management for Primary Care

The worrisome deficiencies of the QOF and MACRA—and, in fact, the broader crisis of quality management in health care throughout many industrialized nations—have not arisen by accident. Much of the criticism of past and current quality schemes focuses on errors of commission: for example, failure to choose the right metrics^34–35; neglect of provider input and wellness^36–37; and regulatory preference for linear rather than complex systems.³⁸ While we find many of these concerns to be salient, they obviate a more fundamental error of omission in primary care quality management: the absence of organizing principles to guide its optimization. To avoid the propensity to “measure the measurable,” P4P and other quality programs in primary care must design and evaluate metrics with principles commensurate with the science of primary health care. Using the metaphor of a foundation on which the bridge to quality should be built, we propose 4 indispensable principles for quality management in primary care (Table 1).

To demonstrate the usefulness of our principles, we introduce a case study of a typical, but fictional patient followed by a primary care team. Mr. Jones is a 55 year old living with diabetes, high blood pressure, obesity, and mild chronic obstructive pulmonary disease, who continues to smoke several cigarettes daily. His primary care team follows 3 common disease-specific quality metrics in his care: blood pressure target less than 140 systolic over 90 diastolic, hemoglobin A1c levels less than 9%, and documentation of smoking cessation counseling. Annually over a period of 3 years, his care team reports his hemoglobin A1c is 6.5%, 7.5%, and 8.5%. His blood pressure readings vary somewhat but are typically just below the upper target limit. Despite brief behavioral counseling for his tobacco abuse received every year, he is unable to stop smoking. During these 3 years, the factory where he has held a part-time job closes, and he encounters financial difficulty with food and housing insecurity. He is rapidly gaining weight and experiences clinical depression. Consider now the marked difference between the documented narrative suggested by the 3 quality metrics and the lived narrative of Mr. Jones and his care team. Unguided by primary care's foundational principles of quality, the metrics miss critical concerns, including worsening diabetes control, weight gain, the hazards of ongoing tobacco abuse, and declining psychosocial determinants of health. The metrics are artificial and largely irrelevant to the “whole” patient; the medical record reflects both a “virtual quality” and a virtual reality.³⁹ Although hitting its targets, Mr. Jones's care team has risked missing the point.

In what follows, we outline our 4 principles of quality measurement for primary care and discuss how their consistent application might transform metric systems, all the while keeping patients like Mr. Jones in mind. No longer should the practices of quality management be constructed without rigorous adherence to these foundational principles.