Tired of the Same Old MIPS Measures? Try Something New: The Person-Centered Primary Care Measure

May 20, 2025

Dr. Sara Pastoor, MD, MHA

If you work in primary care, you probably know the feeling: another year, another round of quality metrics. Since the Centers for Medicare and Medicaid Services (CMS) launched the Quality Payment Program (QPP) in 2017, the Merit-based Incentive Payment System (MIPS) has become the gold standard for measuring—and rewarding—primary care performance. Whether you’re reporting through traditional MIPS, the MIPS Value Pathway, or an Alternative Payment Model, the sheer volume and complexity of these measures can feel overwhelming. Instead of supporting better care, the measurement process often becomes a project in itself, draining resources and time from what matters most: your patients.

Traditional quality measures aren’t making us healthier

For too long, the focus has been on finite care processes like cancer screenings, biometric indices, and other proxies for “better healthcare.” These are the metrics that drive reimbursement and shape practice priorities. According to the 2024 Commonwealth Fund Mirror Mirror report, the U.S. actually outperforms most peer nations on these process-based quality measures. But here’s the catch: despite excelling in these areas, the U.S. lags far behind in actual health outcomes—think life expectancy, maternal mortality, chronic disease management, and preventable deaths. If quality measures are supposed to improve outcomes, why aren’t we seeing the results?

The answer lies in what we choose to measure. Financial incentives matter, but so does the focus of our attention. Measures direct our time, energy, and resources, and increasingly, they even influence our right to practice by serving as proxies for clinical competency. But as Goodhart’s Law reminds us, when a measure becomes a target, it can lose its value. Chasing narrowly defined metrics can distract from the broader, higher-value work that truly improves patient health.

A new approach to measuring primary care

Primary care is about so much more than ticking boxes for disease-specific screenings. Yet, the current framework reduces the rich, complex work of primary care to a checklist, missing the bigger picture. It overlooks the essential role of relationships—the very heart of primary care’s power to change lives. The COVID-19 pandemic made this disconnect painfully clear. As the crisis disrupted quality payment programs, it exposed just how burdensome and out-of-touch many of these measures are with the realities of patient-centered care. In the aftermath, it’s obvious: American primary care needs a new approach to measurement—one that preserves the human connection, reduces documentation burden, and helps restore professional fulfillment.

At its core, primary care is a relationship-based discipline. The most effective care happens when there’s trust and continuity between patient and physician. This relationship is the foundation for comprehensive, personalized care that addresses the whole person—not just a disease or a body part. The American Academy of Family Physicians (AAFP) puts it best: “Measures of primary care should focus on the unique features that are most responsible for better outcomes and lower costs and are under reasonable control of the primary care physician.” These features include access, comprehensiveness, coordination, patient and caregiver engagement, continuity, and care management—all of which depend on a strong patient-physician relationship.

Introducing the Person-Centered Primary Care Measure (PCPCM)

Until recently, no quality measure truly captured these essential elements. That changed in 2017, when the Starfield III: Meaningful Measures for Primary Care Summit brought together 70 national and international stakeholders to rethink primary care measurement. The result was the Person-Centered Primary Care Measure (PCPCM), developed by the Larry A. Green Center. The PCPCM is a patient-reported outcome performance measure (PRO-PM) that asks patients about their access to care, relationship with their physician, and ability to achieve health goals. It recognizes patients as the best source of insight into the quality of their care.

The PCPCM is designed to integrate, personalize, and prioritize care. Its eleven questions assess the core elements linked to better health, equity, quality, and sustainable costs—each unique to primary care. It’s been rigorously tested and, in 2018, was accepted by CMS for use in MIPS as a high-priority Qualified Clinical Data Registry (QCDR) measure. It’s also included in the primary care MIPS Value Pathway quality measure set.

Best of all, the PCPCM is easy to implement. The survey is brief, available in 28 languages, and can be completed electronically or on paper. Because patients provide the data, the administrative burden on clinicians is minimal. Responses can be automatically captured in the EHR or entered by staff, making it a practical tool for busy practices.

For more information on how to implement and report on the PCPCM, the following resources will help:

Visit The Smart Measures for an easy and affordable way to field the PCPCM with your patients. To report on the measure to CMS, we recommend partnering with a QCDR Registry vendor like MD Interactive.
Family physicians who are members of the American Board of Family Medicine can both field the PCPCM and report on the measure to CMS through the PRIME Registry.

Ready to move beyond the same old MIPS measures? Implement the Person-Centered Primary Care Measure today and refocus on what matters most—your patients and their outcomes.