Massachusetts Can Finally Measure the Health of Primary Care

(An editorial published online by The Boston Globe on January 25, 2023, by Barbra G. Rabson and Katherine Gergen Barnett)

The National Academies of Sciences, Engineering, and Medicine (NASEM), a nationally renowned institution of science, recently asserted that “primary care is a common good” and went on to depict what the United States would look like if people no longer had access to high-quality primary care. In this dismal picture, “minor health problems can spiral into chronic disease, chronic disease management becomes difficult and uncoordinated, visits to emergency departments increase, preventive care lags, and health care spending soars to unsustainable levels.”

Perhaps the NASEM assertion that primary care is the only specialty that improves life expectancy and reduces health inequities is not surprising to many. What is surprising, however, is how few people are paying attention to how ill primary care has become and how we may be spiraling toward the grim portrayal of a health care system lacking high-quality primary care.

While patients and those of us on the front lines have many ideas of how local and federal investments must shift to improve primary care delivery, the traditional measures to assess the strength of primary care are outcomes on patients’ health metrics. Measuring how well primary care is controlling a patient’s diabetes, high blood pressure, or depression is indeed critical, but it’s only one side of the equation. In order for patients, providers, policy makers, and leaders to more fully understand how to move primary care forward, we also need the tools to assess and track the health of the very entities that deliver primary care services.

Massachusetts Health Quality Partners (MHQP), a nonprofit organization originally founded to measure and publicly report comparable hospital quality information, has been closely tracking the patient experience and clinical performance of primary care practices in Massachusetts since 2006. Primary care’s fragility was apparent even before COVID-19′s devastating impact. Such practices are increasingly asked to accommodate increased patient volume, respond to more patient communications through patient portals, succeed in a greater number of health quality metrics, meet new demands of monitoring and addressing social and behavioral health needs of patients, and competently care for patients with extremely complex care needs. All of this while primary care continues to receive the same financial support and simultaneously faces emerging competition from concierge practices and corporations such as Amazon and CVS, which offer patients an off-ramp from traditional primary care.

Compelled to highlight the instability of our primary care system, Massachusetts Health Quality Partners set up a series of meetings with primary care clinicians, patients, and community and organizational leaders and solicited hundreds of ideas about how we might measure the health of the primary care system. During this time, the Center for Health Information and Analysis (CHIA), an independent state agency, began to track primary care spending in response to a legislative proposal filed by then-governor Charlie Baker to increase investments in primary care and behavioral health. Asking some of the same questions, MHQP and CHIA became partners in this work and developed a first-in-the-nation dashboard, to be released this week, that will measure and monitor the health of the primary care system in Massachusetts.

The dashboard tracks metrics from multiple publicly available sources in four key dimensions of primary care, with examples below:

Finance: Systemwide spending on primary care services. Primary care spending represents less than 8 percent of overall medical spending and declined across all insurance categories from 2019 to 2020.

Capacity: Primary care workforce and pipeline. In 2020, 33.7 percent of primary care physicians in Massachusetts were age 60 or older, an increase from 31.8 percent in 2018.

Performance: Care and access. More than one-third of residents reported in 2021 that they had difficulty obtaining necessary health care in the past 12 months, an increase from 2019.

Equity: Racial and ethnic disparities in the Massachusetts health care system. In 2021, only 64 percent of Hispanic residents reported that they had a preventive care visit in the last year, versus 81 percent of white residents.

Over the past 15 years, MHQP’s statewide measurement efforts have highlighted how well primary care practices in Massachusetts have managed patients’ chronic diseases and provided preventive care services. Yet the dashboard is already showing us that performance on achieving health metrics is trending down, with consistent lack of financial investments in primary care, diminishing primary care capacity, and increased equity gaps.

As a public good, primary care deserves our collective attention, however, this requires a foundational understanding of its weaknesses. To effectively advocate for primary care, health care leaders, policy makers, and patients need accountability so that advocacy is based on evidence. Dashboards such as the one codeveloped by MHQP and CHIA will shed a light on how our system is doing and provide the necessary baseline data to monitor progress. While this dashboard will continue to evolve over time, it provides an important accountability tool that can be used to improve and sustain our primary care system as a truly valued resource for generations to come.

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Barbra G. Rabson is president and CEO of Massachusetts Health Quality Partners. Dr. Katherine Gergen Barnett is vice chair of Primary Care Innovation and Transformation in the Department of Family Medicine at Boston Medical Center, a clinical associate professor at the BU Chobanian & Avedisian School of Medicine, an associate at Harvard’s Center for Primary Care, and a health innovator fellow at the Aspen Institute.

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