# Federal Investment in Primary Care Transformation: A Systematic Review and Qualitative Analysis

## TL;DR

Federal investments in primary care transformation from 2010 to 2021 improved clinical care and patient engagement but had mixed effects on costs and utilization.

## Contribution

This study systematically reviews the outcomes of five federal primary care transformation programs over a decade, highlighting both successes and limitations.

## Key findings

- Federal investments improved clinical care delivery and patient engagement.
- Modest reductions in utilization were observed, but expenditures increased.
- Practice-level data access and payment system challenges limited the impact of these programs.

## Abstract

This systematic review identifies outcomes of federal investment in primary care delivery transformation on patient experience, costs and utilization, population health, and practice experience.

What are the myriad outcomes of the multifaceted federal programs to change primary care delivery from 2010 to 2021?

In this systematic review of 142 records, programs supported practice-level changes in care delivery through payment changes, performance requirements, data feedback, and technical assistance, while federal investments were associated with substantial improvements in clinical care delivery, greater patient engagement, modest reductions in utilization, and net increases in expenditures. However, common measured outcomes were variable, with external factors possibly limiting impact.

Ten years of federal programs to transform primary care provides useful lessons for practices, program implementers, and policymakers.

Understanding the results of federal investment in primary care delivery and transformation is essential for informing practitioners, future program developers, and policymakers on how best to improve delivery of primary care.

To identify outcomes of federal investment in primary care delivery transformation on patient experience, costs and utilization, population health, and practice experience.

Publicly available program evaluation reports and articles published between July 2011 (the start of the earliest identified programs) and December 31, 2024, were identified on PubMed, Scopus, CINAHL, Embase, Web of Science, and the Cochrane Library. The review included independently evaluated federal programs started after January 2011 and completed by December 2021.

A total of 142 records were included in the analysis from 5 programs that met inclusion criteria: the Federally Qualified Health Center Advanced Primary Care Practice demonstration, the Multi-Payer Advanced Primary Care Practice model, the Comprehensive Primary Care (CPC) initiative, CPC Plus, and EvidenceNOW Advancing Heart Health. Programs supported practice-level changes in care delivery through payment changes, performance requirements, data feedback, and technical assistance. Federal investments were associated with substantial improvements in clinical care delivery, greater patient engagement, modest reductions in utilization, and net increases in expenditures. There was an association between practice efforts and intrinsic practice characteristics, and practices were limited by funding amounts and modality, difficulties in using electronic health records and payer data to support care improvement, staff turnover, and extrinsic factors.

This systematic review found that investing in primary care was associated with improvements in practice experience and population health, while outcomes regarding patient experience, costs, and utilization were mixed. Access to practice-level data and payment system challenges limited these impacts, and most outcomes were not seen until after at least 2 years. Countervailing payment incentives may have affected outcomes. Future primary care transformation efforts should focus on addressing practice-level barriers, aligning payment, and targeting support for practice-level organizational improvement based on local needs.