Why Primary Care Providers Are Failing With Value-Based Contracts

With quality measure saturation in value-based contracts, many primary care physicians feel set up to fail.

Research conducted at the Providence health system shows primary care physicians are overwhelmed with quality measures in value-based contracts.

One of the primary criticisms of payers' value-based contracts is that there is little to no coordination of quality measures for which clinicians are held accountable. In addition, value-based contracts have been adopted for quality improvement in primary care despite mixed evidence of their positive impact.

A research letter published recently by JAMA Health Forum found that primary care providers at Providence have been saddled with an overwhelming number of quality measures in value-based contracts. The research features data collected from more than 800 primary care providers from 2020 to 2022.

The research letter includes the following key findings:

• Value-based contracts contained a mean of 10.24 quality measures.
   
• Primary care physicians faced a mean of 57.08 quality measures across 7.62 value-based contracts.
   
• Medicare value-based contracts had more quality measures than commercial or Medicaid value-based contracts. The mean number of quality measures in Medicare value-based contracts increased from 13.14 in 2020 to 15.04 in 2022.

"Previous research on value-based contracts suggests these models have not lived up to their potential," the research letter's co-authors wrote. "We found saturation of the quality measure environment as a possible explanation: average physicians were incentivized to meet 57.08 different quality measures annually."

An overload of quality measures represents an unsustainable burden on primary care practices, according to the research letter's co-authors.

"Value-based contracting is intended to incentivize care improvement, but it is unlikely a clinician or practice can reasonably optimize against 50 or more measures at a time," the co-authors wrote.

Impact of quality measure saturation

The senior author of the research letter told HealthLeaders that the study's findings were unexpected.

"We were shocked by what we found," said Ari Robicsek, MD, chief analytics and research officer at Providence. "Effectively, the level of industry disorganization leads to a situation where individual physicians have way more quality metrics than they can possibly be expected to manage."

Robicsek compared the situation to the Olympic biathlon event, where competitors cross-country ski as fast as they can, then stop to try to hit targets with a rifle.

"Primary care physicians are expected to provide care to as many patients as they possibly can and deal with their patients' problems in the office," Robicsek said, "then all of a sudden, the physicians have to interrupt the flow of patient care to hit targets on quality metrics."

Most primary care practices are not configured to do both things simultaneously, according to Robicsek.

"It is disruptive, frustrating, and ultimately, when you have a large number of quality metrics, they become white noise," Robicsek said. "The quality metrics either become ignored or they create a sense for providers that they are set up to fail."

There are two ways to ensure that a primary care practice hits a target on a particular quality metric such as making sure patients are getting their breast cancer screening, Robicsek explained.

One way is to put the burden of the work on administrators, which requires hiring staff to look at lists of patients who have not yet received their breast cancer screening. Administrative staff will reach out to these patients, communicate back and forth with the patients if they have questions, place the screening orders, and follow up to make sure the screening was conducted.

"There is administrative cost to hitting a target on a quality metric this way," Robicsek said.

The other way is to expect primary care physicians to hit quality metric targets as part of their daily workflow. Under this system, when patients come in to see primary care physicians, the physicians must talk to the patients about quality metrics such as breast cancer screening or diabetes screening.

"The challenge is that primary care physicians are working with patients to address their problems in relatively short visits, then we are expecting them to fit in the administrative task of hitting quality metrics," Robicsek said.

Instead of expecting primary care physicians to remember to "close gaps" in quality measures, many practices have reminders in the electronic medical record (EMR) to prompt physicians to talk with their patients about quality metrics such as breast cancer screening. As the doctor is trying to go through their workflow and the patient wants to talk about a particular clinical problem, the EMR interrupts with quality metrics that need to be addressed.

"These alerts are interruptive, distracting, and can substantially affect the flow of a physician-patient encounter," Robicsek said.

Quality metric saturation contributes to physician burnout, according to Robicsek.

"If you feel set up to fail, and you feel that you can't do your job, that is going to contribute to feelings of moral distress and exhaustion," Robicsek said.

Reforming value-based contracts

Quality metrics in value-based contracts need to be redesigned so they are more manageable for physicians, according to Robicsek.

"There is no way that any physician is going to be able to manage 57 different quality metrics in their practice, while also trying to be a doctor," Robicsek said.

In principle, quality metrics that create incentives to provide great care are a good thing, but the current execution of quality metrics in value-based contracts is counterproductive, Robicsek explained.

"When they are done in a completely uncoordinated way such that a physician has way more metrics than can possibly be salient in their day-to-day practice," Robicsek said, "you do something worse than having no quality metrics at all."

The first step in the redesign process would be coordination among the different payers about what a limited set of quality metrics would be for use across the board for primary care physicians, according to Robicsek.

"Ideally, metrics would be chosen where there is an evidence base that demonstrates that incentives for metrics improve outcomes for patients," Robicsek said. "There also needs to be an evidence base suggesting that the set of metrics when used simultaneously benefits patients."