From Data to Delivery: Measuring Advanced Primary Care in California

The health care delivery system in the United States faces significant challenges, ranking poorly in quality, efficiency and outcomes among peer countries. Despite high spending on health care, primary care, a crucial element for better population health, is underfunded in the U.S. In California, over 65% of physicians work in solo or small practices and primary care providers often lack resources and technology, contributing to subpar patient outcomes.

Through the California Advanced Primary Care Initiative, PBGH’s California Quality Collaborative (CQC) and partner Integrated Healthcare Association (IHA) are working to understand and address these issues to help strengthen the state’s primary care delivery system. To that end, CQC and IHA executed a pilot project in California, bringing together four large health care purchasers — Covered California, California Public Employees’ Retirement System (CalPERS), eBay and San Francisco Health Services System — and 13,055 primary care practices.

Measurement Pilot Goals

The measurement pilot’s goal was to test the effectiveness of a measure set outlining key attributes of high-quality, comprehensive and patient-centered care and to test the use of existing IHA data to measure the performance of individual primary care practices. This data includes a significant portion of the commercial market and some Medicare Advantage and Medi-Cal data from health plans and providers in California. This would then help determine how well primary care practices performed when assessed against these rigorous patient care measures.

Key Findings

The analysis evaluated the performance of practices and observed which practices scored highest, average and lowest for each measure. This provided a picture of how practices are doing in California and helps identify measures where data collection can be improved.

The measure set was developed through a multi-stakeholder process that included input from purchasers, health plans, providers and patients. Measures focus on outcomes, represent both adult and pediatric patients and avoid redundancy. The measure set also aligns with other existing measurements where possible to reduce the reporting and administrative burden for providers.

Summary of the results for each measure:

• Controlling High Blood Pressure (CBP): Out of the 13,055 practices in the pilot, 2,352 had enough patients to assess CBP in a statistically significant way. 35 practices performed above the 66th percentile while others had zero success with this measure. This highlights the need for solid clinical data for practice-level measurement.
• Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8%): 1,639 practices had a high enough number of patients to be statistically significant and 77 performed above the 66th percentile. This measure could be improved with more complete data.
• Colorectal Cancer Screening (COL): 4,089 practices had enough patients to demonstrate valid results. This measure had more practices receive an average score (199) compared to other measures.
• Childhood Immunization Status (CIS): Only 221 practices had enough patients for this measure to be assessed, and those who were scored poorly. More data, especially from the California Immunization Registry, would help improve this measure.
• Risk Adjusted Acute Hospital Utilization (AHU): 1,720 practices were identified as average performers. On average, there were 18 hospital discharges per thousand member years, which is equivalent to the highest national benchmark.
• Risk Adjusted Emergency Department Utilization (EDU): 2,419 practices had high enough patient populations to be statistically significant for this measure. On average, there were 129 emergency department visits per thousand member years. 1,154 practices performed at the average score, showing that this measure performed better overall than other clinical quality measures that were assessed.

Recommendations for the California Health Care Delivery System

Examining how individual practices performed on the Advanced Primary Care Measure Set revealed the following needs within the California health care system. Each of the identified opportunities for improvement listed below can be addressed by leveraging partnerships between payers, purchasers, providers and data exchange organizations.

1. Expansion of Clinical Data Exchange: Enhance reporting capabilities and foster payer/purchaser collaboration to reduce administrative hassles for providers, such as logging into multiple interfaces to view and assess data. Refer to the California Advanced Primary Care Initiative for an example of multi-payer alignment work.
2. Comprehensive Views of Practice-Level Data for Providers: Interoperability of systems, standard data specifications and alignment of formats can facilitate bringing data together for improved insight. Full views of performance with more of a provider’s population included will result in clear goals for enhancing patient care and reducing disparities.
3. Improved Performance: Focus on practice-level improvement for key primary care quality indicators with low scores, especially the quality indicators with the overall lowest scores in this pilot (blood pressure control, depression screening and childhood immunizations).
4. Additional Resources: Boost care delivery quality by providing shared tools, technical assistance programs such as CQC’s Practice Transformation Initiative and team support for practices.

For a more detailed look at the results and recommendations, read our latest issue brief.