Implementing Comprehensive Care to Improve Outcomes

“Collaborative care means all of us working for the patient, and we have really good outcomes to show for it.”

An appealing aspect of family medicine is the ability to “do it all” when treating patients. Sometimes that means delivering babies. Sometimes that means treating diabetes. Always it means listening to patients and understanding their concerns.

There are a million ways that primary care physicians provide comprehensive care for their patients, and American Board of Family Medicine (ABFM) Diplomates consistently seek to expand the abilities of their practice to treat their patient’s needs. However, the US health system rarely assesses the comprehensiveness of care that each primary care practice provides.

The Center for Professionalism & Value in Health Care (CPV), a program funded by the ABFM Foundation, is working to change that. As an extension of ABFM, CPV conducts research and activities dedicated to informing policymakers and the public about the value of primary care. An important focus of the program is explaining how investments in training, reimbursement, and relationship-based care result in better access and outcomes.

As part of that focus, CPV has developed four Measures That Matter to Primary Care (MTM), a suite of clinical quality measures designed by primary care physicians. One of these measures, especially important to access in rural areas, is comprehensiveness of care.

“Most physicians are evaluated on disease specific measures,” said Jill Shuemaker, ABFM Director of Clinician Measures. “What does primary care bring to the health care system that’s unique? Comprehensive care, continuity of care that values relationships, and patient-centered care. Those valuable functions of primary care are correlated with improved patient health and reduced costs. Yet these functions aren’t currently being measured and incentivized, and we want to elevate their importance.”

The Comprehensiveness of Care Measure is included as part of the ABFM’s PRIME Registry, the largest registry of primary care physicians in the US. In 2025, CPV will apply for a national endorsement of comprehensiveness of care as a performance measure, apply to be included in the Medicare Merit-Based Incentive Payment System (MIPS) program, and encourage health plans and states to adopt the measure for their own quality review programs.

“The goal is to include comprehensiveness of care as a standard of practice for all family physicians.” Shuemaker said.

Each practice approaches comprehensiveness of care differently. For some hospital owned practices, a transition to MTM quality measurements will require education and advocacy to hospital leadership. Other family physicians see the benefits and have already embraced the concept of comprehensiveness from the perspective of integrated care. Take, for example, Kate Atkinson, MD, of Atkinson Family Practice in Massachusetts.

While primarily a family medicine practice, numerous other health care professionals work on site. This allows patients and referrals to remain in-house for the majority of their care. The diverse group of professionals integrated into their practice includes three therapists, a psychiatrist, two psychiatric nurse practitioners, a psychologist, a child therapist, two massage therapists, a physical therapist, a health coach, a nutritionist, and a chiropractor.

“We’re in an area where people really like collaborative care,” said Atkinson Family Practice Medical Director and ABFM Diplomate Kate Atkinson, MD. “We are not just about the disease. That isn’t how you make people healthy. You make people healthy by treating them as a whole person and seeing a full view of everything in their lives.”

While her practice has yet to participate in the Comprehensiveness of Care Measure, Dr. Atkinson said that this diversity of disciplines and comprehensiveness of care within the practice is beneficial for several reasons.

“We have regular interdisciplinary meetings where patient cases are presented, and we give each other advice. These can be very exciting as everyone pitches in from a different perspective. You really do come up with something better when you have more people weighing in to help the patient.”

Dr. Atkinson explained that referring patients to specialists in your very same building prevents communication breakdowns or triangulation from having a negative impact on care.

“Triangulation is when a patient may try to turn physicians against each other,” said Dr. Atkinson, discussing how a therapist within the practice texted her that a patient felt they were prescribed a medicine with little explanation.

“I said, ‘Hang on.’ I ran upstairs, walked in, and asked the patient, “What questions do you have?’ It just took an extra minute, and it made a world of difference,” she explained. “Collaborative care means all of us working for the patient, and we have really good outcomes to show for it.”

Although the benefits are substantial, Dr. Atkinson explained that being properly compensated for the work being done remains a challenge. “Behavioral health is grossly underpaid. Psychiatrists are grossly underpaid. We take Medicaid patients, which most other behavioral health providers in the area do not, and you are not allowed to charge a fee if those patients don’t appear for the scheduled visit. Proper payment is an ongoing issue for our practice.”

There’s no way to sugar coat that paying for health care services is important and complex. Although measuring comprehensiveness can be used for quality improvement activities or performance improvement, it can also be used as a payment incentive through health plan contracts, or through legislation for state and federal health care programs.

“Delivering comprehensive care is associated with lower total Medicare expenditures per beneficiary per month, fewer hospitalizations, and fewer ED visits per year. Patients experience lower acute care utilization and lower expenditures,” said Shuemaker, also noting that comprehensive care is correlated with lower levels of burnout among family physicians.

While there will always be circumstances where a family physician needs to refer to a specialist outside of their practice, the Comprehensiveness of Care Measure is meant to encourage a physician practice to offer a fuller range of services to their patients consistent with their skills and training.

“This is about aligning how we measure primary care with the true value it provides to patients,” Shuemaker explained. “Physicians know that comprehensiveness and continuity of care are important concepts for improving patient health, so we want to encourage health systems and payers to measure these concepts and reward the practices that provide it. That’s what patients value. It builds trust, supports equitable care, and encourages joy in practice.”

If you’re interested in learning more about the Comprehensiveness of Care Measure, contact the Measures That Matter to Primary Care team at MeasuresThatMatter@theabfm.org.

To learn more about the PRIME Registry, email prime@theabfm.org or visit primeregistry.org to enroll today.

Aaron Burch serves as Editorial Content Manager for the American Board of Family Medicine. He has been writing professionally in the health care field since 2014.