1

Response to the Pay PCPs Act of 2024 Request for Information

U.S. Senators Sheldon Whitehouse and Bill Cassidy introduced the Pay PCPs (primary care providers) Act of 2024 in May 2024, which seeks to address ongoing challenges with payment models for primary care.¹ The proposed legislation was accompanied by a request for information (RFI). The National Academies of Sciences, Engineering, and Medicine (the National Academies) appointed the Committee on the Response to the “Pay PCPs Act of 2024” Request for Information to prepare this consensus report.² The committee’s statement of task, which includes select questions from the RFI, is in Appendix A. The complete RFI is in Appendix B. The draft Pay PCPs Act of 2024 is in Appendix C. Committee member, fellow, and staff biographies are in Appendix D. RFI text the committee is responding to is denoted below in boxes.

HYBRID PAYMENTS FOR PRIMARY CARE PROVIDERS³

___________________

¹ See https://www.whitehouse.senate.gov/wp-content/uploads/2024/05/KEL24351.pdf (accessed July 9, 2024).

² The committee members make up a subgroup of the National Academies Standing Committee on Primary Care, which was appointed in August 2023 to advise the federal government on primary care policy.

³ Hybrid payments and primary care providers are defined in section 3 of the Pay PCPs Act of 2024 (see Appendix C).

Committee Response

• The Centers for Medicare & Medicaid Services (CMS) has more than a decade of experience in successfully attributing Medicare patients to primary care providers (PCPs) within alternative payment models, including the Medicare Shared Savings Program (MSSP) and Center for Medicare & Medicaid Innovation (CMMI) primary care alternative payment model demonstration programs for Medicare beneficiaries such as Comprehensive Primary Care Plus (CPC+) (CMS, 2021).
• Recommendation 1: CMS should prioritize voluntary patient attribution over other methods. When voluntary attribution is not feasible to ascertain due to beneficiaries not reporting information or other administrative reasons, CMS should use claims-based measures to attribute beneficiaries (including those routinely used

by CMS in MSSP). These two methods should form the basis of attribution models under the Pay PCPs Act.

• Voluntary patient attribution is the most compatible attribution method with the goals of high-quality primary care, by virtue of engaging people and their preferences, yet the process is administratively complex and may not always be feasible (Health Care Payment and Learning Action Network, 2016; NASEM, 2021). CMS should promote proactive approaches to systematically collect beneficiary-reported identification of their PCP and facilitate connection to a PCP for beneficiaries without a regular source of primary care.
• Claims-based attribution based on care patterns can be prospective, meaning that clinicians are given a list of whom they are responsible for in the beginning of the year, or retrospective, when they are notified at the end of the year (National Association of ACOs, 2018; Riley et al., 2023). Most attribution rules assign patients based on the plurality of their outpatient visits, while some focus specifically on primary care services (CMMI, 2019; NASEM, 2021).
• Attribution models should be sensitive to team-based care models in which more than one primary care clinician may participate in providing comprehensive primary care services. An example might be a primary care medical group in which one clinician serves as the usual continuity provider but a primary care clinician colleague in the practice provides medication management for opiate use disorder for the same patient. Additional research on attribution methods is needed to continue to refine methods to appropriately identify care teams and distribute prospective payment components fairly among clinician team members.
• Involuntary disruptions in primary care have been shown to result in poorer health outcomes for Medicare beneficiaries (Sabety et al., 2021). Medicare and Medicaid beneficiaries risk not having a stable primary care workforce due to turnover from burnout and poor recruitment and retention into the field (Primary Care Collaborative, 2023; Willard-Grace et al., 2019). To prevent such involuntary disruptions, CMS could minimize administrative barriers to continuity of care by investing in the resources needed to attract and retain the enhanced PCP workforce required to serve Medicare and Medicaid beneficiaries (NASEM, 2021). Payment reform that increases investment in primary care is critical for providing incentives for more trainees to enter primary care fields and for resourcing advanced

primary care teams that make primary care a more sustainable career (Helfrich et al., 2017; Willard-Grace et al., 2014).

• Hybrid payment models should not prevent a beneficiary from voluntarily changing to a different care provider who might better meet their needs. Research shows that voluntary change in PCP occurs relatively infrequently among beneficiaries (Biniek et al., 2022). As noted above, under CMMI Medicare primary care demonstration models, CMS has successfully administered hybrid payment models that allow patients to change PCPs (CMMI, 2019).
• Recommendation 2: When a beneficiary receives a service from a PCP who is not their attributed provider, the non-attributed provider should receive the full Medicare fee-for-service payment for that service. Similarly, if a beneficiary receives care from an obstetrician–gynecologist, for example, in addition to receiving services from the attributed PCP, the obstetrician–gynecologist should receive payment under standard Medicare fee-for-service payments for those services.

RISK ADJUSTMENT

Committee Response

• Recommendation 3: The risk adjustment method for the prospective payment component under a hybrid payment model should include a few basic demographic characteristics such as age and gender and heavily weight social factors predictive of high need for primary care services (Huffstetler and Phillips, 2019; NASEM, 2017), using place-based measures and geocoding of beneficiary residence to assign small area (e.g., census block) measurements of social factors to the individual beneficiary. Incorporating social risk factors should lead to an upward adjustment to the base payment to ensure that resources are adequate to meet needs. Of note, individual low-income status, indicated by dual eligibility for Medicare and Medicaid, is proposed by CMS as a measure for adjusting payments in the new Advanced Primary Care Management Services bundled payment (CMS, 2024).

• While patient-reported data are highly valued by patients and federal agencies, they are not universally or uniformly collected (National Quality Forum, 2020). Given this challenge, place-based measures may be more reliable and consistent.
• The risk adjustment method should not replicate the Hierarchical Condition Category/Risk Adjustment Factor (HCC/RAF) method used by CMS for adjusting payment to Medicare Advantage plans and for other risk-sharing contracts. This method was not designed to predict primary care service use and has proven to be susceptible to manipulation to inappropriately increase CMS payments to Medicare Advantage plans (MedPAC, 2024).
• The risk adjustment method should be developed and tested based on data for beneficiaries in the traditional Medicare program and not those in Medicare Advantage plans. The new payment method will only be used for traditional Medicare and not for Medicare Advantage plans and should therefore be developed using data on beneficiaries in traditional Medicare. Moreover, CMS has direct control of Part A and Part B claims data that would be used for developing and testing a risk adjustment method and would not need to rely on plan intermediaries in Medicare Advantage to provide individual patient-level data on beneficiaries in those plans.
• The risk adjustment model should be developed to reflect primary care service needs, not to predict total costs of care. The goal of the new payment method is to fairly compensate primary care teams for comprehensive primary care services and to recognize the powerful influence of social drivers of health care need. Thus, the adjustment model should focus on predictors of need for appropriate primary care services. This approach to risk-adjustment would better match payments to primary care practices to the care they are responsible for. Primary care practices should only be at financial risk for the primary care services included in the hybrid payment model (see section below on included services) and not for total costs of care or costs for non-primary care services. An example of a variable that may predict total costs of care, but not primary care need, is a diagnosis of advanced cancer, which predicts high hospital and specialty service use but not necessarily high primary care service use.
• In developing a primary care risk adjustment method that heavily weights social factors, care must be exercised that these methods do not reinforce historical inequities. Many of the same social factors that predict high need for primary care are

also associated with barriers to accessing primary care and may thus predict both higher than average need and lower than average utilization of primary care. Risk adjustment models must carefully consider the outcome for the model to not introduce inequitable algorithmic bias.

• As an example, Cherokee Health Systems (CHS), a federally qualified health center in Tennessee, designed a method of assessing individual patients’ risk via its Biopsychosocial Assessment (BPSA) (O’Brien, 2018). The BPSA uses weighted measures of individual patients’ social needs (e.g., housing security, food security, transportation access), psychological diagnoses and indicators of care levels (e.g., recent inpatient treatment for psychological crises, types of services received including medication management), and medical diagnoses and indicators of care levels to predict the level of care a patient may require during any given clinical encounter (Peterson et al., 2015).

QUALITY MEASURES

Committee Response

• Patient experience is an important measure to include as high-quality primary care should highly value patient knowledge and understand individual needs (NASEM, 2021).
• Recommendation 4: To capture patient experience (and patient reported outcomes), the committee recommends using the validated, patient-reported Person-Centered Primary Care Measure

(PCPCM PRO-PM) (AMA, 2022; American Academy of Family Physicians, 2022; Etz et al., 2019).

• The PCPCM PRO-PM is a reliable, comprehensive, and parsimonious measure of the high-value tenets of primary care, as assessed by the patient (AMA, 2022; Etz et al., 2019). The PCPCM PRO-PM was created in response to an identified gap between available measures and the elements most critical to high-quality primary care, including an absence of focus on how to prioritize care, accurately recognize problems, manage patient complexity, center on patient preferences and goals, invest in longitudinal relationships, and adapt care based on personal and community social determinants of health (Etz et al., 2017). The PCPCM PRO-PM is included in CMMI’s new Making Care Primary demonstration model (CMS, 2023).
• The Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, administered by the Agency for Healthcare Research and Quality (AHRQ),⁴ as they are currently designed and administered, have some limitations related to declining response rates, difficulty introducing new measures, speed of delivering results, the length of the questionnaire, and adjusting payment based on “topped out” measures that do not provide meaningful distinctions among clinicians (Bland et al., 2022). Many of these challenges are methodological and may occur regardless of the instrument used. The implementation of any measure of patient experience will need to address these challenges if payment is being tied to performance. Approaches to address these challenges include use of innovative sampling methods, addressing nonresponse through survey and statistical methods, implementing web modes, and incorporating stakeholder feedback (Bland et al., 2022).
• Recommendation 5: While clinical quality measures are critical to include, the committee recommends prioritizing measures of the key functional attributes of primary care (e.g. continuity, comprehensiveness, coordination, and access) rather than only using disease-specific quality measures. This approach was supported by Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (NASEM, 2021).
  • Continuity of care refers to an ongoing relationship between a patient and their interprofessional care team over time (Merenstein, 2021; NASEM, 2021). Continuity has been linked to improved trust and decreased downstream health

___________________

⁴ See https://www.ahrq.gov/cahps/index.html (accessed July 9, 2024).

care use (e.g., in emergency departments and hospitals) and costs (Bazemore et al., 2018). A continuity measure is included in the Merit-based Incentive Payment System (measure ID: ABFM12, CBE #3617)^5,6 and could be considered.

• Comprehensiveness refers to the extent to which a PCP and primary care team recognize and meet most of a patient’s health care needs (O’Malley et al., 2019). Increased comprehensiveness has been linked to decreased emergency department visits, lower hospitalization rates, and decreased Medicare expenditures (Bazemore et al., 2015). A comprehensiveness of care measure is being reviewed for national endorsement this year, and depending on the outcome, could be considered (Center for Professionalism and Value in Health Care, 2023).
• Clinical measures should disaggregate data to identify disparities that may exist across demographic categories, such as race and ethnicity, rural or urban location, and geography. This provides more focused insight into the effect of services across groups of service recipients (National Academy of Medicine, 2022).

• Some service use measures in these areas should be considered. However, rather than measures of total hospital or emergency department (ED) use, they should be limited to measures of preventable hospital and ED episodes (also known as ambulatory care sensitive use measures). Additionally, the CAHPS survey could be updated to include patient experience questions related to team-based care in the ambulatory primary care setting to better understand how team-based delivery can affect service use.⁷
• Recommendation 6: The committee recommends not including referrals as a measure of quality of care.
  • Measures are available (see above) to directly assess the comprehensiveness of primary care in the ambulatory setting, which should be used if endorsed, rather than considering referral rates to be a proxy (inversely) for primary care comprehensiveness (O’Malley and Rich, 2015). There may also be unintended consequences by possibly creating disincentives to appropriate referrals if high rates of referrals are considered ipso facto a marker of lack of comprehensiveness of primary care (Vimalananda, 2018).

___________________

⁵ See https://qpp.cms.gov/mips/traditional-mips (accessed July 10, 2024).

⁶ See https://p4qm.org/measures/3617 (accessed July 11, 2024).

⁷ See https://www.ahrq.gov/cahps/consumer-reporting/measures/index.html (accessed July 11, 2024).

• Recommendation 7: To reduce the reporting burden on PCPs participating in the hybrid model, the committee recommends that measures be minimal in number, reflect the core functions of primary care, and that CMS rely on claims-based administrative data where possible.
  • This approach will better align measurement with the core tenets of high-quality primary care, including continuity and comprehensiveness, and is supported by findings of the 2021 National Academies’ report Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (NASEM, 2021).
  • Claims-based measures of continuity and comprehensiveness are available and have been validated by researchers (Pollack et al., 2016). Self-report metrics are burdensome for practices to collect, especially for under resourced practices without the necessary resources to fulfill the reporting requirements.
• Recommendation 8: To identify and ultimately help reduce disparities, the committee recommends that equity also be included as an additional measure of quality by stratifying data by race and ethnicity and other characteristics.
  • The Institute of Medicine’s 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century identified equity as a key domain of quality (IOM, 2001), and this committee feels it is critical to include to help ensure that high-quality primary care is accessible to all. The measure could incorporate creative strategies to address health inequities with several practical examples documented in a publication from 2018 (Anderson et al., 2018).
• Of note, it is important that all measures consider services rendered as a team rather than as individual providers (NASEM, 2021). If interprofessional team-based care is necessary to provide high-quality primary care services (NASEM, 2021), payment models should reflect the nuanced interactions that enable team-based care to be successful.

INCLUDED SERVICES IN HYBRID MODELS

Committee Response

• The committee applauds the inclusion of care management services, communications outside of the office visits between patients and their providers, behavioral health integration services, and coverage of office-based evaluation and management visits regardless of modality. The committee agrees that these services are essential to the work of PCPs, but in current payment models these are either not reimbursed or not reimbursed adequately to ensure uptake (Galewitz and Hacker, 2024; Hartnett et al., 2023; Holtrop et al., 2015; Ma et al., 2022; O’Malley et al., 2017; Rotenstein et al., 2021).
• The committee agrees with the inclusion of communications such as e-mails, phone calls, and messaging patients and caregivers via portals in hybrid payments. However, it is also important to include other administrative work not currently reimbursed under fee-for-service such as filling out paperwork for patients, completing prior authorizations, and reviewing records, all of which are known to be onerous and time consuming and disproportionately affect primary care compared to other specialties (AMA, 2024; Rao et al., 2017). Including these additional activities not currently accounted for in the fee schedule will require additional resources.
• Remote physiologic monitoring and remote therapeutic monitoring could also be considered as a covered service, but additional research is needed (Ferrante et al., 2023). Theoretically, allowing primary care to offer these services could help keep care local and close to home, especially for rural patients.
• The committee agrees with the inclusion of behavioral health integration.⁸ To help ensure that primary care delivery sites can successfully develop integrated behavioral health services, for practices that need it hybrid payments should include financial and infrastructure support for workforce development and training, as start-up and ongoing costs associated with integration can be substantial (Nagykaldi et al., 2023; Wallace et al., 2015). This financial

___________________

⁸ See Peek and The National Integration Academy Council (2013) for a definition of behavioral health integration and the services it should include.

assistance should include (but not be limited to) training behavioral health providers to work in primary care and assisting practices in advancing along the integrated care continuum to provide increasingly more comprehensive and integrated care (Galbreath et al., 2024; NASEM, 2021, 2023; SAMHSA-HRSA Center for Integrated Health Solutions, 2020).

• Recommendation 9: In addition to the proposed services for hybrid payments, the committee recommends including services delivered by all members of the interprofessional team that are essential to delivering high-quality primary care. This includes services provided by community health workers, pharmacists, peer-support specialists, physical therapists, doulas, and others. Each primary care practice across the country serves a unique community with unique needs and finite resources so interprofessional team composition can vary greatly across settings. Any type of hybrid payment model should allow for flexibility for primary care practices to cover services by professionals they deem essential to the health of their community. This approach is highly aligned with findings, conclusions, and recommendations from the National Academies’ report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (NASEM, 2021).
  • Tiered prospective payment rates based on the robustness of the primary care team is one team-based payment approach that enables most practices to benefit regardless of their baseline capacity and robustness of their team-based resources. MassHealth (the Massachusetts state Medicaid program) is doing this and is a potential model to consider (Farlow and Schwarz, 2023). Whatever approach is used, it is important that it is evidence-based and results in improved care.
• Strategies to prevent prospective payment from reducing provider incentive to provide services (and thus reducing patient access to services) include:
  • Ensuring that payment is sufficient to support comprehensive team-based care (see above) (NASEM, 2021); and
  • Tracking of measures on access, comprehensiveness, and PCPCM to identify deficiencies that may result in excluding the provider or practice from continuing in the hybrid model. While primary care constitutes 35 percent of all health care visits to physicians, it receives only 3.9—5.6 percent of the health care dollar, depending on the insurer (Jabbarpour et al., 2024; NASEM, 2021). The current physician fee schedule has not provided sufficient reimbursement to support high-quality, team-based primary care, and the hybrid payments

should include services that have not been reimbursed under the physician fee schedule (NASEM, 2021). It has been estimated that more than 25 percent of primary care activities are not reimbursed under the fee schedule (Berenson et al., 2020). Tying the hybrid payments to increased investment in primary care may help mitigate unintended consequences that may limit patient access to care.

TECHNICAL ADVISORY COMMITTEE TO HELP CMS MORE ACCURATELY DETERMINE FEE SCHEDULE RATES

Committee Response

• Recommendation 10: Membership of the technical advisory committee should include:
  • Medical specialty representation that reflects the ecology of care delivery in the United States. As stated previously, approximately 35 percent of all health care visits in the United States are to a primary care physician (NASEM, 2021). At

a minimum, this percentage of physicians on the committee should represent primary care.

• Interprofessional primary care team members, such as clinical pharmacists, community health workers, integrated behavioral health professionals, to ensure that the time, effort, and complexity of team-based care delivery is understood and accounted for.
• Health economists and actuaries to advise on coding approaches, bundling, and the assessment of practice expenses (Berenson et al., 2023).
• Health information technology and artificial intelligence experts to advise on how to use technology to better capture objective data (Berenson et al., 2023).
• National and/or state-level primary care policy and research experts to advise on innovative empirical methods of data collection and policy considerations (Berenson et al., 2023).

• The above members of the committee should include perspectives representing geographic diversity (e.g., rural, urban), as well as such other measures of diversity as race and ethnicity, career stage, and gender.
• Recommendation 11: The structure of the technical advisory committee should include:
  • Use of empirically collected data rather than reliance on provider-reported surveys for time and practice expense calculations, as the latter are known to be subject to bias (Berenson and Hayes, 2024; Berenson et al., 2023; MedPAC, 2011; Zuckerman et al., 2016).
  • Clear processes for revisiting and revising prior determinations.
  • Transparency of decision-making processes and data to interested stakeholders and the public and be compliant with the Federal Advisory Committee Act (FACA)⁹ (Berenson and Hayes, 2024; Berenson et al., 2023; GAO, 2015).
• CMS could take a more active role in fee-for-service rate setting overall by overseeing this newly proposed FACA-compliant advisory committee and by continuing to innovate with streamlining primary care coding for Medicare as it has done in the recently proposed rule for Advanced Primary Care Management Services (CMS, 2024).

___________________

⁹ See https://www.gsa.gov/policy-regulations/policy/federal-advisory-committee-management (accessed July 11, 2024).

REFERENCES

CMS. 2024. Physician fee schedule: CY 2025 proposed rule. https://www.cms.gov/medicare/payment/fee-schedules/physician (accessed July 22, 2024).

Etz, R. S., M. M. Gonzalez, E. M. Brooks, and K. C. Stange. 2017. Less and more are needed to assess primary care. Journal of the American Board of Family Medicine 30(1):13-15.

Etz, R. S., S. J. Zyzanski, M. M. Gonzalez, S. R. Reves, J. P. O’Neal, and K. C. Stange. 2019. A new comprehensive measure of high-value aspects of primary care. Annals of Family Medicine 17(3):221-230.

Farlow, M., and R. Schwarz. 2023. How Massachusetts Medicaid is paying for primary care teams to take care of people, not doctors to deliver services. https://www.milbank.org/news/how-massachusetts-medicaid-is-paying-for-primary-care-teams-to-take-care-of-people-not-doctors-to-deliver-services/ (accessed July 9, 2024).

Ferrante, T. B., R. B. Goodman, and N. M. Lacktman. 2023. Top 5 rules for medicare 2024 remote patient monitoring and remote therapeutic monitoring: What companies need to know. https://www.foley.com/insights/publications/2023/11/top-5-rules-medicare-2024-rpm-rtm/ (accessed July 25, 2024).

Galbreath, L., S. Wilkniss, and J. Rohrer. 2024. Behavioral health system modernization along the continuum. Washington, DC: National Academy for State Health Policy.

Galewitz, P., and H. K. Hacker. 2024. Medicare’s push to improve chronic care attracts businesses, but not many doctors. https://kffhealthnews.org/news/article/medicare-chronic-care-management-monitoring-business/ (accessed July 9, 2024).

GAO (Government Accountability Office). 2015. Medicare physician payment rates: Better data and greater transparency could improve accuracy. Washington, DC: Government Accountability Office.

Hartnett, T., G. Loud, J. Harris, M. Curtis, G. W. Hoagland, and M. W. Serafini. 2023. Strengthening the integrated care workforce. Washington, DC: Bipartisan Policy Center.

Health Care Payment and Learning Action Network. 2016. Accellerating and aligning population-based payment models: Patient attribution. Baltimore, MD: Health Care Payment and Learning Action Network.

Helfrich, C. D., J. A. Simonetti, W. L. Clinton, G. B. Wood, L. Taylor, G. Schectman, R. Stark, L. V. Rubenstein, S. D. Fihn, and K. M. Nelson. 2017. The association of team-specific workload and staffing with odds of burnout among VA primary care team members. J Gen Intern Med 32(7):760-766.

Holtrop, J. S., Z. Luo, and L. Alexanders. 2015. Inadequate reimbursement for care management to primary care offices. Journal of the American Board of Family Medicine 28(2):271-279.

Huffstetler, A. N., and R. L. Phillips, Jr. 2019. Payment structures that support social care integration with clinical care: Social deprivation indices and novel payment models. American Journal of Preventive Medicine 57(6 Suppl 1):S82-S88.

IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Jabbarpour, Y., A. Jetty, H. Byun, A. Siddiqi, S. Petterson, and J. Park. 2024. The health of US primary care: 2024 scorecard report—no one can see you now. New York, NY: The Milbank Memorial Fund and The Physicians Foundation.

Ma, K. P. K., B. L. Mollis, J. Rolfes, M. Au, A. Crocker, S. H. Scholle, R. Kessler, L. M. Baldwin, and K. A. Stephens. 2022. Payment strategies for behavioral health integration in hospital-affiliated and non-hospital-affiliated primary care practices. Translational Behavioral Medicine 12(8):878-883.

MedPAC (Medicare Payment Advisory Commission). 2011. Moving forward from the sustainable growth rate (SGR) system. Washington, DC: MedPAC.

MedPAC. 2024. Report to the Congress: Medicare payment policy. Washington, DC: MedPAC.

Merenstein, Z. 2021. Continuity of care bibliography. Washington, DC: Center for Professionalism & Value in Health Care.

Nagykaldi, Z., B. Littenberg, L. Bonnell, R. Breshears, J. Clifton, A. Crocker, J. Hitt, R. Kessler, B. Mollis, R. E. S. Miyamoto, and C. van Eeghen. 2023. Econometric evaluation of implementing a behavioral health integration intervention in primary care settings. Translational Behavioral Medicine 13(8):571-580.

NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Accounting for social risk factors in Medicare payment. Edited by L. Y. Kwan, K. Stratton, and D. M. Steinwachs. Washington, DC: The National Academies Press.

NASEM. 2021. Implementing high-quality primary care: Rebuilding the foundation of health care. Washington, DC: The National Academies Press.

NASEM. 2023. Achieving whole health: A new approach for veterans and the nation. Edited by A. H. Krist, J. South-Paul, and M. Meisnere. Washington, DC: The National Academies Press.

National Academy of Medicine. 2022. Catalyzing innovative health system transformation: An opportunity agenda for the Center for Medicare & Medicaid Innovation. Washington, DC: The National Academies Press.

National Association of ACOs. 2018. Evaluation of potential ACO performance bias from retrospective and prospective assignment. Washington, DC: National Association of ACOs.

National Quality Forum. 2020. Patient-reported outcomes: Best practices on selection and data collection—final technical report. Washington, DC: National Quality Forum.

O’Brien, M. 2018. Lessons from Cherokee Health Systems: A truly integrated, and inspiring, model of care. https://www.careinnovations.org/resources/lessons-from-cherokee-health-systems-a-truly-integrated-and-inspiring-model-of-care/ (accessed July 9, 2024).

O’Malley, A. S., and E. C. Rich. 2015. Measuring comprehensiveness of primary care: Challenges and opportunities. Journal of General and Internal Medicine 30(Suppl 3):S568-S575.

O’Malley, A. S., R. Sarwar, R. Keith, P. Balke, S. Ma, and N. McCall. 2017. Provider experiences with chronic care management (CCM) services and fees: A qualitative research study. Journal of General and Internal Medicine 32(12):1294-1300.

O’Malley, A. S., E. C. Rich, L. Shang, T. Rose, A. Ghosh, D. Poznyak, and D. Peikes. 2019. New approaches to measuring the comprehensiveness of primary care physicians. Health Services Research 54(2):356-366.

Peek, C. J., and The National Integration Academy Council. 2013. Lexicon for behavioral health and primary care integration concepts and definitions developed by expert consensus. Rockville, MD: Agency for Healthcare Research and Quality.

Peterson, A. L., J. L. Goodie, and F. Andrasik. 2015. Introduction to biopsychosocial assessment in clinical health psychology. In Biopsychosocial assessment in clinical health psychology. New York: The Guilford Press.

Pollack, C. E., P. S. Hussey, R. S. Rudin, D. S. Fox, J. Lai, and E. C. Schneider. 2016. Measuring care continuity: A comparison of claims-based methods. Medical Care 54(5):e30-e34.

Primary Care Collaborative. 2023. Health is Primary: Charting a path to equity and sustainability—2023 evidence report. Washington, DC: Primary Care Collaborative.

Rao, S. K., A. B. Kimball, S. R. Lehrhoff, M. K. Hidrue, D. G. Colton, T. G. Ferris, and D. F. Torchiana. 2017. The impact of administrative burden on academic physicians: Results of a hospital-wide physician survey. Academic Medicine 92(2):237-243.

Riley, W., K. Love, and C. Wilson. 2023. Patient attribution—A call for a system redesign. JAMA Health Forum 4(3):e225527.

Rotenstein, L. S., A. J. Holmgren, N. L. Downing, and D. W. Bates. 2021. Differences in total and after-hours electronic health record time across ambulatory specialties. JAMA Internal Medicine 181(6):863-865.

Sabety, A. H., A. B. Jena, and M. L. Barnett. 2021. Changes in health care use and outcomes after turnover in primary care. JAMA Internal Medicine 181(2):186-194.

SAMHSA–HRSA Center for Integrated Health Solutions. 2020. Standard framework for levels of integrated care. Washington, DC: Department of Health and Human Services.

Vimalananda, V. 2018. Tools to improve primary care specialty care referrals in the VHA. Presented at HSR&D Cyberseminar, September 19 (virtual).

Wallace, N. T., D. J. Cohen, R. Gunn, A. Beck, S. Melek, D. Bechtold, and L. A. Green. 2015. Start-up and ongoing practice expenses of behavioral health and primary care integration interventions in the Advancing Care Together (ACT) program. Journal of the American Board of Family Medicine 28(Suppl 1):S86-S97.

Willard-Grace, R., M. Knox, B. Huang, H. Hammer, C. Kivlahan, and K. Grumbach. 2019. Burnout and health care workforce turnover. Annals of Family Medicine 17(1):36-41.

Willard-Grace, R., D. Hessler, E. Rogers, K. Dubé, T. Bodenheimer, and K. Grumbach. 2014. Team structure and culture are associated with lower burnout in primary care. J Am Board Fam Med 27(2):229-238.

Zuckerman, S., K. Merrell, R. Berenson, and S. Mitchell. 2016. Collecting empirical physician time data: Piloting an approach for validating work relative value units. Washington, DC: Urban Institute.

This page intentionally left blank.