Measure Description
The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patientreported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.
Instructions
This measure is to be submitted once per performance period. For each MIPS eligible clinician, group, subgroup*, virtual group, and APM Entity, a minimum of 30 PCPCM PRO instruments per clinician are needed for submission of this measure. All valid survey results (as defined in the specification) should be included in the aggregate score. For MIPS eligible groups, subgroups*, virtual groups, and APM entities with 5 or more clinicians, a minimum of 150 PCPCM PRO instruments per TIN for each site/location associated with the clinicians’ part of the group, subgroups*, virtual groups, and APM entities are needed for submission of this measure. If the MIPS eligible group, subgroup*, virtual group, and APM entity with 5 or more clinicians encompasses multiple sites/locations, each site/location would need to meet the PCPCM PRO instruments requirements as stated.
NOTE: Data for the measure are collected using the PCPCM PRO instrument. The target population is all active patients attributed to the clinician or practice. Every active patient receives an invitation to complete the PCPCM PROM during their birth month. A patient is defined as active if the patient has had a documented interaction with the practice within 12 months of their birth month during the measurement period.
*Subgroups are only available through MVP reporting. All measure-specific criteria must be met by the subgroup.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
Denominator
Total number of completed PCPCM PRO instruments received in the reporting period
Definition:
A completed PCPCM PRO instrument – A PCPCM PRO instrument for which the patient has responded to at least 8 of 11 items.
Active patient – The patient has had a documented interaction with the practice within 12 months of their birth month during the measurement period.
DENOMINATOR NOTE: The target population is all active patients attributed to a clinician or practice during the performance reporting period who had a documented interaction within the 12 months prior to the patient’s birth month. The target population is defined the same, regardless of unit of analysis (clinician, practice, or system). The PCPCM PRO is the same for all patients, regardless of age. Because the PCPCM PRO applies to all patients and is not particular to a clinical encounter, it is administered once a year to each patient during their birth month. All surveys received during the measurement period should be counted.
For each MIPS eligible clinician, group, subgroup*, virtual group, and APM Entity, a minimum of 30 PCPCM PRO instruments per clinician are needed for submission of this measure. For MIPS eligible groups, subgroups*, virtual groups, and APM entities with 5 or more clinicians, a minimum of 150 PCPCM PRO instruments per TIN for each site/location associated with the clinicians’ part of the group, subgroups*, virtual groups, and APM entities are needed for submission of this measure. If the MIPS eligible group, subgroup*, virtual group, and APM entity with 5 or more clinicians encompasses multiple sites/locations, each site/location would need to meet the PCPCM PRO instruments requirements as stated.
*Subgroups are only available through MVP reporting. All measure-specific criteria must be met by the subgroup
Table 1- PCPCM PRO instrument questions
| How would you assess your primary care experience? | Definitely = 4 | Mostly = 3 | Somewhat = 2 | Not at all = 1 |
|---|---|---|---|---|
| My practice makes it easy for me to get care. | Definitely | Mostly | Somewhat | Not at all |
| My practice is able to provide most of my care. | Definitely | Mostly | Somewhat | Not at all |
| In caring for me, my doctor considers all factors that affect my health. | Definitely | Mostly | Somewhat | Not at all |
| My practice coordinates the care I get from multiple places. | Definitely | Mostly | Somewhat | Not at all |
| My doctor or practice knows me as a person. | Definitely | Mostly | Somewhat | Not at all |
| My doctor and I have been through a lot together. | Definitely | Mostly | Somewhat | Not at all |
| My doctor or practice stands up for me | Definitely | Mostly | Somewhat | Not at all |
| The care I get takes into account knowledge of my family | Definitely | Mostly | Somewhat | Not at all |
| The care I get in this practice is informed by knowledge of my community | Definitely | Mostly | Somewhat | Not at all |
| Over time, my practice helps me to stay healthy. | Definitely | Mostly | Somewhat | Not at all |
| Over time, my practice helps me to meet my goals. | Definitely | Mostly | Somewhat | Not at all |
Denominator Criteria (Eligible Cases):
All patients with a completed PCPCM PRO instrument during the reporting period
Numerator
The calculated PCPCM PRO-PM performance score
NUMERATOR NOTE: Scoring for the PCPCM PRO-PM is completed through a simple 4 step process using the PCPCM PRO to assess the broad scope of primary care from a patient’s perspective.
- Step One: Exclude incomplete patient responses. Any PCPCM PRO instrument for which a patient failed to answer at least 8 of the 11 items is excluded from calculations.
- Step Two: Calculate PCPCM PRO item specific mean scores. Patients choose one of four response options for each item in the PCPCM PRO instrument. In scoring the PCPCM PRO, the first step requires determining an item mean score for each of the 11 items. Since the instrument scale is word based – Definitely, Mostly, Somewhat, Not At All – each response option must be assigned a value. Values are assigned as follows: Definitely = 4, Mostly = 3, Somewhat = 2, Not At All = 1.
Calculating the mean score for each item then requires looking across all PCPCM PRO instruments received for the entity being assessed during the analysis period. For example, if the entity is a clinician, then all completed (see Step One) PCPCM PRO instruments collected for that clinician are included in the calculation. If the entity is a practice, then all PCPCM PRO instruments collected for that practice are included in the analysis
An entity’s score for each PCPCM PRO item is calculated as a mean, i.e., the summary of all responses across PCPCM PRO instruments received for the entity, divided by the number of instruments received. This process leads to 11 item specific PCPCM PRO scores. Means should be reported to two decimal points. - Step Three: Calculate the PCPCM PRO total score. The PCPCM PRO total score for the entity is calculated by determining the mean of the 11 scored PRO items. This is done by adding the mean scores of all 11 PRO items and then dividing by 11. PRO means should be reported to two decimal points.
- Step Four: Converting PCPCM PRO total scores and to PCPCM PRO-PM performance score. In order to use the PCPCM PRO as a performance measure for reporting, the 4 point PCPCM PRO scale must be converted to a 0-100 performance scale. To do this, the PCPCM PRO total score for an entity, as calculated in Step Three, is divided by 4 and then multiplied by 100.
Rationale
The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM PROM - a comprehensive and parsimonious set of 11 patient-reported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice. Patients identify the PCPCM PROM as meaningful and able to communicate the quality of their care to their clinicians and/or care team. The items within the PCPCM PROM are based on extensive stakeholder engagement and comprehensive reviews of the literature. It is not a consumer satisfaction survey – it is a patient assessment of whether the functions of primary care are being met by their clinician, or practice, and to what extent.
Clinical Recommendation Statements
The IOM Report on Primary Care calls for care to be personalized at the patient level, with care integrated for whole people to overcome the many problems of fragmented and depersonalized care. The PCPCM-PM complements more narrow disease-specific quality measures, and can be used to integrate care for whole people. (Institute of Medicine. Donaldson MS, Yordy KD, Lohr KN, and Vanselow NA, editors. Committee on the Future of Primary Care, Division of Health Care Services. National Academy Press. Washington, D.C. 1996.)