Primary care has long been described as the foundation of a high-performing health system, yet the way health systems measure its performance tells a strikingly different story. In a new viewpoint published in the Journal of General Internal Medicine, Mark D. Schwartz of NYU Grossman School of Medicine argues that the metrics dominating modern health care—visit counts, billing codes, screening rates, disease targets, and documentation checks—capture only a narrow slice of what primary care actually does. The paper contends that much of the value generated by primary care occurs between visits, in the relationships, guidance, and stewardship that help patients live better over time, and that these functions remain weakly measured, poorly rewarded, or entirely invisible to the systems that depend on them.
The argument builds on a intellectual tradition that dates back decades. Barbara Starfield’s famous four Cs—first contact, continuity, comprehensiveness, and coordination—have long served as the clearest description of primary care’s distinctive value. More recently, the National Academies of Sciences, Engineering, and Medicine went further, describing primary care as a common good that improves health, promotes equity, and strengthens the health system as a whole. Schwartz’s contribution is to translate these well-worn principles into a practical measurement challenge: if primary care creates value through accessibility, relationships, integration, and stewardship, why do almost none of the metrics used by health systems and payers reflect those functions?
The mismatch between purpose and measurement has real consequences. Measurement shapes priorities—what health systems measure drives what leaders discuss, what organizations fund, and what clinicians spend their time doing. Patients rarely ask whether their physician met a quality benchmark. Instead, they want to know whether they can get help when they need it, whether someone knows their story, whether their clinicians communicate with one another, and whether their treatment fits the realities of their lives. These questions sit at the heart of primary care’s mission, yet they are largely absent from performance dashboards. The result, Schwartz warns, is a system that rewards transactions while neglecting the relational infrastructure that makes primary care effective in the first place.
As a remedy, the viewpoint proposes a Primary Care Value Dashboard organized around three deceptively simple questions. The first is whether patients can get care. Access, in this framework, means far more than appointment availability. It encompasses the ability to reach the care team, obtain timely guidance, and navigate the health system without needless barriers or long delays. In an era when patients increasingly expect low-friction digital and telephone contact alongside in-person visits, this broader conception of access reflects how people actually experience care rather than how schedules are filled.
The second question asks whether patients are known and guided. Continuity and trust are among the defining strengths of primary care, but the paper is careful to modernize these concepts for team-based medicine. Continuity no longer means repeatedly seeing the same physician; it means maintaining a coherent relationship and care plan over time, even when a patient sees several clinicians. A patient can experience genuine continuity if their story is known, their goals are understood, and someone helps hold the whole picture together. Trust, meanwhile, is presented not as a soft sentiment but as a measurable clinical variable: patients who trust their clinicians are more likely to share concerns, adhere to treatment plans, and engage in shared decision-making, and the evidence links trust to improved outcomes.
The third question is whether care helps patients live better. Here the framework emphasizes integration across settings, reduction of fragmentation, limitation of treatment burden, and stewardship—the discipline of helping patients get the care they need while avoiding tests, referrals, medications, and burdens that add little value. Stewardship, Schwartz argues, is one of primary care’s most important and least recognized contributions. These outcomes often track patient goals more closely than disease-specific targets do, and they speak directly to the growing problem of treatment overload, particularly for patients managing multiple chronic conditions.
A crucial technical point of the viewpoint is that these supposedly intangible functions are now measurable. Treatment burden instruments, such as the Multimorbidity Treatment Burden Questionnaire developed and validated by Duncan and colleagues, quantify the workload that health care places on patients and its impact on their daily lives. Continuity measurement has evolved beyond simple visit counts to capture relational and team-based continuity, and systematic reviews have linked continuity of care to patient mortality. The Person-Centered Primary Care Measure, described by Etz and colleagues in the Annals of Family Medicine, captures high-value functions including continuity, coordination, comprehensiveness, and trust. The National Committee for Quality Assurance has demonstrated a feasible approach to assessing progress toward patient-defined goals through its Person-Centered Outcome Measures. Taken together, these tools show that the remaining challenge is not technical capability but institutional will—whether health systems choose to measure what matters.
Examples of this shift are already emerging internationally. The United Kingdom and the Netherlands routinely collect patient-reported measures of access, continuity, and patient experience. In the United States, the Comprehensive Primary Care Initiative paired prospective care-management payments with measures of patient experience and quality, offering a test case for how new metrics could be woven into payment reform. But these efforts remain fragmented, and the central question is how best to use such measures to improve care, guide payment, and strengthen accountability without creating a new bureaucratic burden for already strained practices.
The viewpoint lays out a staged pathway for different actors. Health systems can begin by routinely measuring patient-reported access, continuity, trust, coordination, and treatment burden—initially for learning and quality improvement rather than payment, so that practices can identify barriers, redesign care, and understand what patients actually experience. Payers can test these measures within hybrid and population-based payment models, because fee-for-service payment is structurally ill-suited to reward continuity, stewardship, and coordination: much of this work occurs between visits or prevents visits altogether. More flexible payment approaches can support investments in care management, outreach, behavioral health integration, coordination, and low-friction access. National organizations, including CMS, NCQA, specialty societies, and primary care organizations, can accelerate progress by identifying a small set of measures, testing them across diverse settings, and aligning expectations across public and private payers.
Schwartz is candid that better measurement alone will not solve primary care’s crises. Workforce shortages, decades of underinvestment, fragmented care delivery, and misaligned payment systems remain pressing concerns that no dashboard can fix. But measurement still matters, because it shapes discussions, rewards, and system improvements. Measures of hospital readmissions, patient experience, and preventive care changed what health systems tracked and how they invested resources; primary care’s unique outcomes deserve the same attention. The value of primary care has been described for decades, the paper concludes—what has been missing is a practical way to recognize and reward it. With the tools now available, the choice to measure relationships and stewardship is no longer a technical question but a strategic one. Failing to act, the author warns, risks reducing primary care to a collection of transactions rather than supporting it as the relationship-based infrastructure for health that patients need.
Subject of Research: Measurement of patient-centered value, continuity, trust, and stewardship in primary care
Article Title: Measuring What Matters in Primary Care: Continuity, Trust, and Stewardship
Article References: Measuring What Matters in Primary Care: Continuity, Trust, and Stewardship. (n.d.). https://doi.org/10.1007/s11606-026-10936-z
Image Credits: AI Generated
DOI: 10.1007/s11606-026-10936-z
Keywords: primary care, continuity of care, trust, stewardship, treatment burden, quality measurement, patient-reported outcomes, payment reform, health policy, Journal of General Internal Medicine, care coordination, health systems
News Source: Ophelia Keating. (October 13, 2026). New Framework Urges Health Systems to Measure Trust and Continuity in Primary Care. Scienmag.
