States that have committed to “investing” in primary care are making a large bet that strengthening primary care will improve health, expand access, moderate costs, and reduce avoidable hospital and emergency department use. Quality measurement must determine whether that bet is succeeding and whether it is improving over time. But quality measurement is not merely an evaluation of primary care practices. It is an evaluation of the performance of the entire state healthcare system and its primary care strategy.

The purpose of this article is to examine how states can foster a culture of continuous quality improvement in primary care and provide primary care organizations with the information, resources and support needed to improve performance.

Primary Care Quality Measurement

Outcomes have always been the gold standard for measuring quality.  But outcomes often cannot be attributed reliably to an individual primary care practice because:

• Important outcomes may not materialize or resolve in the same years as care is delivered.
• Patients may receive care from multiple organizations.
• Outcomes are affected by specialty care, hospital care, behavior, and social conditions.
• Small practices may not have enough patients to produce statistically meaningful outcome measures.

And where outcomes may eventually be attributable to a primary care practice, they may be a measure of past, rather than current, quality of care due to the time delay between diabetes or cancer screening, for example, and the onset and resolution of the disease.

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