The value of ambulatory care measures: A review of clinical and financial impact from an employer/payer perspective

To understand the value for payers and purchasers of primary care quality measures in an insured population, we conducted a 2-part analysis. In the first part, we reviewed the economic and clinical literature supporting 62 quality metrics panning primary care that had been proposed for use in a physician recertification program and in a pay-for-performance program, We then ranked these metrics by both economic and clinical evidence of effectiveness. For many of the metrics, there was little clinical or economic support for inclusion in a pay-for-performance program. For the 20 with both clinical and economic evidence of effectiveness, we constructed actuarial models to understand the potential financial effect that attainment of these metrics would have in an insured population, from the perspective of a payer. Of those, 16 were found to be cost-saving in the short term with respect to direct medical costs incurred by payers. This analysis suggests that many recommended primary care quality measures may have little clinical evidence of effectiveness beyond expert opinion, and may provide scant clinical or economic benefit to payers if achieved. A minority, however, may deliver substantial savings in the short term. Given the current emphasis on pay-for-performance and pay-for-reporting programs, and recent studies showing a lack of relationship between measures and clinical/economic value, this analysis informs payers, purchasers, providers, and policymakers about the importance of choosing the right metrics and the methods for collecting them.