Encore! EP295: The Not Entirely New but Definitely Improved Way to Measure Primary Care, With Rebecca Etz, PhD

I wanted to resurface this episode because when it originally aired over a year ago, the topic may have been ever so slightly ahead of its time. Look, here we are right now with everybody trying to do three big things relative to measuring PCP (primary care provider) performance:

1. Come up with a fair measure for PCP performance.
2. Account for diverse populations with diverse risks so that some docs don’t get dinged because their patient populations have lots of comorbidities or behavioral health challenges or live in food deserts, or any one of the other social determinants of health.
3. Not make measuring performance a total procedural nightmare.

Right? We want fair measures, we want to account for equity issues essentially, and we want this whole measurement fandango to be as easy as possible.

Enter Rebecca Etz, PhD, and The Larry A. Green Center with a really well-validated “instrument,” as she calls it, to measure primary care performance. I can think of more than one PCP frankly right off the top of my head who would be thrilled to be measured using this methodology. Even more so because it’s one thing that’s simple and not a jumble of numerators with various mix-and-match denominators.

PCPs are really important to population health. Primary care is the foundation of any well-functioning health system, I am sure many listening to this podcast know well. For the Triple Aim to happen, patients really need access to robust primary care. This has been affirmed by almost anyone who looks into it. And yet, in this country, our system sort of anemically supports our primary care colleagues.

As a general statement, poking and prodding and procedures are compensated at a far higher rate than anything requiring cognitive services. What a PCP or a pediatrician mainly does all day is really cognitive. It’s listening and thinking and counseling and coordinating.

But here is maybe an underappreciated point: If we’re going to measure PCP performance, then we need the right measures to measure that performance. You might be doing this measurement as a basis for incentives or maybe for continuous improvement programs. Either way, if you don’t have the right measures, then maybe great primary care is under-rewarded or your continuous improvement process is counterproductive—you’re incenting the wrong things, you get the wrong activity. And to add to that, PCPs (ie, practices) can spend upwards of $40,000 a year of uncompensated time trying to add and subtract and tote up the difference in all these varied and potentially inapplicable measurement standards coming at them from all manner of directions.

My guest in this healthcare podcast is Rebecca Etz, PhD. Dr. Etz and the team over at The Larry A. Green Center have worked hard to create a set of 11 performance measures for primary care. These measures went through the wringer as far as their creation and validation. These 11 measures take into account what patients want, what primary care clinicians (including pediatricians, nurse practitioners, and others) think is most important and possible to provide, and what payers want to pay for. These 11 measures are aligned across the three stakeholders, and they are actionable.

Rebecca Etz, PhD, is associate professor of family medicine and codirector of The Larry A. Green Center, which is in Richmond, Virginia, at the Virginia Commonwealth University.

You can learn more at green-center.org.  

Rebecca S. Etz, PhD, is an associate professor of family medicine and population health at Virginia Commonwealth University (VCU) and codirector of The Larry A. Green Center—Advancing Primary Health Care for the Public Good. Dr. Etz has deep expertise in qualitative research methods and design, primary care measures, practice transformation, and engaging stakeholders. Her career has been dedicated to learning the heart and soul of primary care through three main lines of inquiry: (1) bridging the gap between the business of medicine and the lived experience of the human condition, (2) making visible the principles and mechanisms upon which the unique strength of primary care is based, and (3) exposing the unintended, often damaging consequences of policy and transformation efforts applied to primary care but not informed by primary care concepts. As a member of the VCU Department of Family Medicine and Population Health and previous codirector of the ACORN practice-based research network, Dr. Etz has been the principal investigator of several federal and foundation grants, contracts, and pilots, all directed toward making the pursuit of health a humane experience. Recent research activities have included studies in primary care measures, behavioral health, simulation modeling, care team models, and adaptive use of health technologies. Dr. Etz currently leads the fielding of a weekly survey regarding the response to and impact of COVID-19 on US primary care practices. She also serves on the National Academies of Medicine consensus study, “Implementing High-Quality Primary Care.”

04:58 Why is primary care one of the “best-kept secrets” of better health outcomes?
09:45 “Measures are a form of communication.”
09:58 “If the way that you are assessed does not actually match up with the work you do or what you find to be important, it’s pretty demoralizing.”
12:48 “It is the outcome of healthcare, but it is not the same thing as quality.”
17:18 “It creates a financial incentive to hit a target by any means necessary.”
18:53 “We incentivize people to have good outcomes, and what that means is that electronic medical records are no longer simply databases that tell us what the health of the population is. They are databases that tell us what is the optimal picture that a clinician is able to paint of their patients.”
21:54 “Primary care is a relational field.”
23:02 “How does this relate to cost and utilization?”
27:45 How has the measure of PCPs in the time of COVID held up?
28:03 What measure performs worse in the time of COVID?
29:59 EP270 with Dave Chase and EP272 with Guy Culpepper, MD. 

You can learn more at green-center.org.