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Measuring the Value-Functions of Primary Care: Comprehensiveness of Care

CBE ID
4290
1.5 Project
1.0 New or Maintenance
1.1 Measure Structure
Is Under Review
Yes
Next Maintenance Cycle
Spring 2025
1.6 Measure Description

This measure evaluates the extent primary care physicians (PCPs) provide care-based and procedural-based services core to primary care. For each PCP, the resulting value reflects an average of the weighted proportion of services within each category provided during the measurement period.       

Primary care providers (PCPs) caring for at least 30 patients per measurement period (the performance year and the 12 months prior to the performance year) score between 0 and 100 in scaled scores of comprehensiveness. Scores are based on weighted averages of 19 care-based and 20 procedural-based core primary care services. 

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.10 Measure Rationale

The aim of this physician-level measure is to assess the extent to which a primary care physician provides services that are considered core to comprehensive primary care. Comprehensiveness of care – the “provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs” – is one of the key defining features of primary care.1 Existing studies show that more comprehensive care by primary care physicians lowers patients’ health care costs, prevents hospitalization and emergency department visits.2,3 There is a strong consensus that comprehensiveness of care is one of the key ingredients in providing high-quality primary care to individuals, families, and communities. 1,4–6 Comprehensiveness is a multi-faceted concept that includes both the scope of services offered and the depth and breadth of health conditions managed by the PCP pending the needs of the population.7 Although this physician-level measure assesses one aspect of comprehensiveness – provision of a range of services – there is empirical evidence of its positive association with patient outcomes.2,3 Nonetheless, this measure is flexible enough to implement in most data environments (e.g. administrative claims, EHR or registry), is straight-forward to interpret, and preliminary analysis suggests positive association with patient outcomes.  

 

The methodology for arriving at the list of core primary care services involved a high level of primary care insight from clinicians, patients, educators, and policy makers. The multi-stage process is outlined below: 

 

1. The comprehensive list of primary care services and procedures was obtained from the published literature on scope of practice among family physicians and general practitioners (since they provide care to all age groups) and electronic health records (EHR) of a nationally-representative sample of primary care practices. For the literature, we closely followed Schultz and Glazier (2017) paper and a series of scope of practice papers by the research team at the American Board of Family Medicine (ABFM). 8–11 Based on the data available in the EHR dataset, included services were narrowed down based on relevance to an office-based or outpatient setting. Non-physicians were excluded from the measure solely due to limited data availability (there was unreliable specialty and credential information for these providers). 

2. The services and procedures included are part of primary care medical education, fall under what primary care clinicians are board certified to perform, and data that the American Board of Family Medicine (ABFM) collects about family medicine scope of practice practiced across the United States in primary care practices. The core primary care services were divided into two categories: care-based and procedure-based. The care-based category included a broad range of areas of care activities associated with certain modality, population, health condition, or healthcare setting, while the procedure-based category focused on specific procedures provided in primary care. Initially, there were 29 care-based services and 28 procedure-based services. 

3. A technical expert panel (TEP) consisting of primary care physicians, researchers, health system executives, Federally Qualified Health Center (FQHC) representatives, family medicine advocacy groups and educators, and patient/caregivers (see TEP participants below) was held to finalize the list of core primary care services. Weights were assigned by the TEP in degrees of importance (0 = not important, and 100 = very important), then these weights were averaged. Along with creating the weighting, the TEP also reduced the list of services. 

4. The weights within each category were then re-scaled so that their sum equaled the total number of services in that category (19 for care type, 20 for procedure). Categories were separated so that they could be reflective of relative importance to other services within that category (i.e. the weights in the care services reflect relative importance to other care services, while the weights in the procedure services reflect relative importance to other procedure services).   

 

Our TEP participants included: 

Tyler Barreto MD, MPH - Sea Mar CHC, Seattle, WA 

Sanjay Basu MD, PhD - Center for Primary Care, Harvard Medical School 

Andrew Bazemore MD, MPH – The American Board of Family Medicine Center for Professionalism and Value in Health Care

Reid Blackwelder MD, FAAFP - Quillen College of Medicine, ETSU 

Hoon Byun DrPH – American Academy of Family Physicians- The Robert Graham Center  

Yoonie Chung PhD – American Academy of Family Physicians-The Robert Graham Center  

Julea Garner MD - Baptists Health-UAMS Family Medicine Residency 

Jackson Griggs MD - Heart of Texas Community Health Center Inc. 

Yalda Jabbarpour MD – American Academy of Family Physicians - The Robert Graham Center

Vivian Jiang MD - University of Colorado Medicine 

Susan Lowe - Patient Representative 

Amy Mullins MD - American Academy of Family Physicians 

Ann O'Malley MD MPH- Mathematica 

 

References: 

  1. Institute of Medicine (US), Division of Health Care Services, Committee on the Future of Primary Care. Primary Care: America’s Health in a New Era. (Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds.). National Academies Press (US); 1996.
  2. Bazemore A, Petterson S, Peterson LE, Phillips RL. More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations. Ann Fam Med. 2015;13(3):206-213. doi:10.1370/afm.1787
  3. O’Malley AS, Rich EC, Shang L, et al. New approaches to measuring the comprehensiveness of primary care physicians. Health Serv Res. 2019;54(2):356-366. doi:10.1111/1475-6773.13101
  4. World Health Organization. Primary Health Care. Geneva: World Health Organization. 1978.
  5. Haggerty JL, Beaulieu MD, Pineault R, et al. Comprehensiveness of care from the patient perspective: comparison of primary healthcare evaluation instruments. Healthc Policy Polit Sante. 2011;7(Spec Issue):154-166.
  6. Bitton A. The Necessary Return of Comprehensive Primary Health Care. Health Serv Res.  2018;53(4):2020-2026. doi:10.1111/1475-6773.12817
  7. O’Malley AS, Rich EC. Measuring Comprehensiveness of Primary Care: Challenges and Opportunities. J Gen Intern Med. 2015;30 Suppl 3: S568-575. doi:10.1007/s11606-015-3300-z
  8. Schultz SE, Glazier RH. Identification of physicians providing comprehensive primary care in Ontario: a retrospective analysis using linked administrative data. CMAJ Open. 2017;5(4):E856E863. doi:10.9778/cmajo.20170083
  9. O’Neill T, Peabody MR, Blackburn BE, Peterson LE. Creating the Individual Scope of Practice (ISOP) scale. J Appl Meas. 2014;15(3):227-239.
  10. Coutinho AJ, Cochrane A, Stelter K, Phillips RL, Peterson LE. Comparison of Intended Scope of Practice for Family Medicine Residents with Reported Scope of Practice Among Practicing Family  Physicians. JAMA. 2015; 314(22):2364-2372. doi:10.1001/jama.2015.13734
  11. Peterson LE, Fang B, Pu er JC, Bazemore AW. Wide Gap between Preparation and Scope of Practice of Early Career Family Physicians. J Am Board Fam Med. 2018;31(2):181-182.  doi:10.3122/jabfm.2018.02.170359 
1.20 Types of Data Sources
1.25 Data Source Details

The measure can be used in any data source that captures individual-level health care encounters across care settings (such as medical claims) and/or clinical data (such as from electronic health records or a registry) regarding demographics, services and procedures from primary care visits. ABFM tested the measure using two separate data sources: claims data and EHR data.  Information on the two tested data sources (MarketScan for Claims data and American Family Cohort for EHR data) can be found below:  

 

MarketScan (Claims): 

The MarketScan Research database captures individual-level healthcare utilization, expenditures, and enrollment across the patient care setting spectra. Claims for inpatient, outpatient, prescriptions drugs in the outpatient settings, and carve-out services are included in these data. The data come from a large selection of employers, health plans, and government/public organizations. The annual medical database includes private-sector health data from approximately 350 payers representing 20 billion service records. The data also represent the health care experiences of insured employees and their dependents of active employees, early retirees, and those receiving COBRA benefits (Consolidated Omnibus Budget Reconciliation Act). Included in these data are Medicare-eligible retirees that have employer-sponsored Medicare Supplemental plans. 

 

The database has limited geographical location information: Specific zip code level information and address are not available for either the patient or provider in this dataset. These data have been reviewed by their internal and external statisticians and found to be incompliance with HIPPA Privacy Rules. The data contained for all enrolled beneficiaries are considered de-identified. The ABFM has a signed data use agreement with MarketScan which grants ABFM access to their claims extracts via the Stanford Department of Population Health Sciences (PHS), whose Data Core team reviews and approves access for the individual user. For those included and enrolled during the measurement period, all encounters with primary care physicians should be captured and included in these data. 

 

American Family Cohort (EHR): 

Derived from the ABFM PRIME Registry, the American Family Cohort is a clinical data repository of electric health record data from more than 2,000 primary care clinicians across the United States, with the electronic medical record data elements pulled from visits in the primary care setting. These data were established by the American Board of Family Medicine with the mission to measure clinical quality as well as develop specific clinical measure for quality reports and dashboards for primary care practices. The data contains a convenience sample of 1,000 practices representing over 5 million patients with the focus of care received by family physicians, general internists, general pediatricians, and advanced clinical practitioners, such as nurse practitioners and physician assistants. In the American Family Cohort, which is the research database representing extracts from the original PRIME Registry, there exist detailed demographics, diagnosis codes, procedures, some laboratory results, medication data including prescriptions, and free-text clinical notes.