Core Principles to Improve Primary Care Quality Management

Justin B. Mutter, MD, MSc; Winston Liaw, MD, MPH; Miranda A. Moore, PhD; Rebecca S. Etz, PhD; Amanda Howe, MD, MEd, FRCGP; Andrew Bazemore, MD, MPH


J Am Board Fam Med. 2018;31(6):931-940. 

In This Article

Abstract and Introduction


Quality management in American health care is in crisis. Performance measurement in its current form is costly, redundant, and labyrinthine. Increasingly, its contribution to achieving the Quadruple Aim is under close examination, especially in the domain of primary care services, where the burden of measurement is heaviest. This article assesses the state of quality management in primary care in the United States, particularly the 2015 Medicare Access and Children's Health Insurance Program Reauthorization Act, in comparative perspective, drawing lessons from the Quality and Outcomes Framework in the United Kingdom. The health care delivery function specific to primary care is pivotal to crossing the quality chasm, yet prior efforts to improve the quality of this function have failed more often than succeeded. These failures are the result of quality programs unguided by core principles of primary care. Quality management in primary care requires a more disciplined approach, adherent to 4 foundational principles: optimizing holistic patient and population health; harnessing the Quadruple Aim as a dynamic whole; applying measurements as tools for quality, not outcomes of quality; and prioritizing therapeutic relationships. These principles serve as the foundation for a bridge to high-functioning primary care that will lead American health care closer to the Quadruple Aim.


Quality management in American medicine is in crisis. While advances have been made since the publication of the Institute of Medicine's Crossing the Quality Chasm in 2001,[1] both providers and researchers increasingly recognize that the effort to achieve large-scale quality improvement through reporting programs and performance measurement has produced lackluster or even injurious results. First, measurement has become atomistic. Over the last decade, the number of quality indicators has grown exponentially. According to the National Quality Measures Clearinghouse, there are now nearly 2000 publicly available indicators sponsored by over 100 health care institutions.[2] Of these indicators, only a small fraction represent meaningful clinical outcomes and still fewer reflect patient-oriented or patient-reported indicators.[3] Second, measurement has become costly to the financial and social capital of health care institutions. Recent research has estimated that the per-physician cost of quality reporting exceeds $40,000 annually, requiring greater than 15 hours of total staff work weekly.[4] Finally, despite the volume and cost of these measurements, their use has been of questionable benefit. A systematic review of pay-for-performance (P4P) programs linking quality reporting to financial remuneration, drawn from studies in several industrialized nations, suggested that P4P has, on average, produced just 5% improvement in provider performance, with gains limited to select process-oriented measures.[5] Whether quality measurement influences patient-centered outcomes, such as mortality, quality of life, and function, remains largely unknown.

Such dysfunction disproportionately affects the delivery of primary care services. Primary care providers shoulder a larger financial and administrative burden from quality reporting than do other practitioners.[4] Accreditation, measurement, and incentive programs, such as the patient-centered medical home, can cost up to $115,000 per provider, per year.[6] The opportunity costs of such endeavors are substantial, fostering the perspective that measurement adversely impacts providers' ability to care for patients. In a recent national survey of primary care providers, fewer than a quarter of respondents expressed a "positive" view of current quality measurement requirements.[7]

Although primary care is at the epicenter of our crisis in quality management, it is also the source for its resolution. Extensive research has shown that high-functioning primary care is associated with better population health, at lower cost, with less inequality in health outcomes between groups.[8] The delivery function specific to primary care, widely recognized as the "4C's" of comprehensive services, patient-centered continuity of care, accessible first-contact in care, and coordination of care,[9] is critical to achieving the Quadruple Aim.[10] Primary care must, therefore, serve as the bridge across the quality chasm, which has narrowed yet persisted over time, with worrisome inequalities and geographic variations in care.[11] In this context, getting quality measurement right for primary care is imperative.

In this article, we argue that despite the ample evidence of inadequacies in contemporary quality programs for primary care, policy makers and regulatory agencies have yet to appropriately redesign metric systems. As an illustration of this failure to adapt, we review the research literature on the United Kingdom's Quality and Outcomes Framework (QOF) for primary care, noting several disconcerting results. Turning to the US context, we find that the structure of the 2015 Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) recapitulates the QOF's flaws and, therefore, risks deepening the quality crisis. We maintain that the persistence of largely unmodified performance measurement programs for primary care over the last decade is due to these programs' neglect of guiding principles. Historically, quality reporting has been a cart-before-the-horse phenomenon, where we are "measuring the measurable,"[12] without assiduous attention to the means and ends of measurement. The science of primary care, however, requires a more deliberate, foundational approach to quality. As a corrective, we outline 4 core principles for quality management in primary care.