What is the Person-Centered Primary Care Measure (PCPCM)?

Primary care physicians and clinicians play a critical role in the delivery of patient-centered care. Beyond promoting healthy lifestyles and helping to prevent and detect disease, primary care clinicians act as a bridge between patients — as well as their families and communities — and the broader healthcare ecosystem.

However, measuring the quality of the care they provide has long been a challenge. And measurement matters, particularly as primary care clinicians increasingly transition toward value-based care (VBC) models.¹

Notably, the Person-Centered Primary Care Measure (PCPCM) may provide a measurement framework you can use to help enhance your VBC outcomes. Here's a closer look at the PCPCM and the role it can play in laying a foundation for value-based care.

Although healthcare enterprises continue to rely on numerous quality measures when assessing the effectiveness of the care they provide, the Person-Centered Primary Care Measure (PCPCM) has been gaining traction as a key metric that can be incorporated into value-based care models.

What is the Person-Centered Primary Care Measure (PCPCM)?

Developed in 2017 by the Larry A. Green Center, the PCPCM was formally established by the American Academy of Family Physicians (AAFP) in 2019.² It is an 11-item assessment tool that uses patient-reported outcomes to measure the quality of primary care. It does so by examining rarely-captured aspects considered responsible for the effects of primary care on population health, equity, quality, and costs.³

As part of its organizational structure, the PCPCM considers not only the patient experience, but also the experiences of the healthcare team; the impact of primary care on patients, their families, and their communities; and related factors within the healthcare system and among payers considered to affect the potential for high-quality primary care.

Why the PCPCM was developed

Prior to the development of the PCPCM, thousands of primary care measures were being used both inconsistently and ineffectively.⁴ As a result, clinicians often struggled with administrative and financial challenges in their efforts to measure the effectiveness of their work. In addition to hampering clinical decision-making, this situation was creating policy confusion. The PCPCM was conceived as a way to replace this patchwork approach, while driving improved performance and value.

What domains the PCPCM considers

To determine which domains to include in the measure, its creators surveyed 412 patients, 525 primary care clinicians, and 85 healthcare payers before consulting with an additional 70 primary care and health services experts at an international conference held in Washington, D.C.⁵ Together, this collective of experts and stakeholders considered elements related to the receipt, provision, outcomes, and ecology of care before developing a framework designed to measure the following 11 domains:

1. Accessibility: How easily can patients receive care?
2. Advocacy: Do the practice and its clinicians stand up for patients?
3. Community context: Is the care informed by knowledge of a patient's community?
4. Comprehensiveness: Can the practice support most of a patient's healthcare needs?
5. Continuity: Is the care delivered cohesively over time?
6. Coordination: Does the practice coordinate care across the healthcare ecosystem?
7. Family context: Is the care informed by knowledge of a patient's family?
8. Goal-oriented care: Over time, does the practice help patients meet their health goals?
9. Health promotion: Over time, does the practice help patients stay healthy?
10. Integration: Do physicians consider all factors that affect patient health?
11. Relationship: How supported and known do patients feel by their physicians?

What role does the PCPCM play in value-based care models?

Although healthcare enterprises continue to rely on numerous quality measures when assessing the effectiveness of the care they provide, the PCPCM has been gaining traction as a key metric that can be incorporated into VBC models. Endorsed by both the Centers for Medicare & Medicaid Services (CMS) and the National Quality Forum (NQF), the PCPCM can be used in government-based VBC programs such as the Merit-Based Incentive Payment System (MIPS).⁶ Private payers have also piloted the PCPCM in several states⁷ as part of the Patient-Centered Medical Home (PCMH) program, a VBC model that incentivizes you to actively engage patients through shared decision-making, personalized care plans, and reliance on technology like electronic health records (EHR) to enhance communication.

The benefits of PCPCM for value-based care providers

Part of the measure's popularity lies in its focus on producing better health outcomes for patients while also keeping healthcare costs down — central pillars of value-based healthcare.

By zeroing in on the individual needs of patients, the PCPCM aims to increase engagement by empowering patients to take greater control over their own health outcomes. At the same time, its focus on shared decision-making and the development of authentic relationships can help you reduce the risk of errors, ultimately elevating the quality of care patients receive.

The PCPCM is also administered only once a year. This encourages patients to consider their care holistically, rather than on a visit-by-visit basis, helping you improve practice efficiency while aligning care with both patient and payer priorities.

How the PCPCM differs from other value-based care metrics

Healthcare organizations currently rely on multiple primary care quality measures as part of their VBC contracts. These can include clinical metrics (such as improvements in chronic disease management), utilization metrics (such as reduced emergency room visits), or process metrics (such as the percentage of patients who receive preventive screenings).

The PCPCM differs from these approaches in several ways. For instance, the measure:

• Takes a holistic view of the quality of care by considering a patient's family dynamics, community context, and personal healthcare goals — rather than focusing narrowly on specific diseases or clinical endpoints.
• Aims to reduce over-measurement by using a single annual survey to assess what patients value.
• Recognizes the role that comprehensiveness, continuity, coordination, and accessibility play in enhancing patient outcomes and improving cost efficiency across populations.

As the transition toward value-based healthcare accelerates, these types of metrics can help you drive improved patient experiences while streamlining administration.

Value-based healthcare: beyond the metrics

With the CMS goal to move virtually all Medicare beneficiaries into accountable relationships by 2030⁸, healthcare organizations are under growing pressure to adopt VBC models. Assessment tools like the PCPCM could help accelerate that transition. No matter which metrics you adopt, however, the need to track patient outcomes and close quality gaps remains.

To unlock the opportunities and mitigate the risks associated with the shift toward VBC, you need the ability to natively capture the right data and understand how to use it to improve the delivery and coordination of care.

Whether you're seeking to enhance preventative care through automated patient outreach, simplify the identification of chronic care management, optimize VBC program performance with point-of-care alerts, or assess how to integrate VBC into your practice, athenaOne® can help.

With athenaOne you can improve patient outcomes with better informed care while tracking and getting paid for the quality care you provide.