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December 2018
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Measuring Value in Primary Care: Enhancing Quality or Checking the Box?

Over the last three decades, numerous health care process measures and surrogate health outcome measures have exploded onto the scene, often driven by payers wanting to show commitment to “value.” With increasing popularity of pay-for-performance and other value-based incentive programs aimed at maximizing quality while minimizing costs, primary care practices are confronted with an ever-increasing sea of quality metrics that they are urged to satisfy. In our health system at the University of Michigan, Blue Cross Blue Shield—a payer that spends one in five medical claim dollars on value-based payment arrangements—incentivizes at least 200 different quality metrics (Abelson 2014). Primary care physicians (PCPs) constantly chase this dizzying array of metrics, recognizing that such measures frequently fail to help them care for their sickest, most vulnerable patients. When seeing a homeless patient with uncontrolled diabetes and food insecurity, for example, recording their smoking history seems less pressing. Time spent at a practice on such “quality metrics” diverts from addressing the highest priority areas for the patient—areas that often do not have a quality checkbox from a payer. PCPs face this tension daily in balancing “checkbox” care that supposedly achieves high “quality” with the actual clinical value they strive to provide vulnerable patients.

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