Federal primary care programs improved quality but not costs, study finds

A review published November 7 in JAMA Health Forum concludes that more than a decade of federal investment in primary care transformation led to measurable improvements in how practices deliver and coordinate care but did not achieve sustained reductions in health care spending.

Led by Laura L. Sessums, J.D., M.D., of the American Board of Internal Medicine, researchers analyzed 142 studies and evaluation reports from five major federal programs:

• The Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) demonstration
• The Multi-Payer Advanced Primary Care Practice (MAPCP) model
• The Comprehensive Primary Care (CPC) initiative
• CPC Plus (CPC+)
• EvidenceNOW Advancing Heart Health (ENOW)

Collectively, these initiatives — run by the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) — supported practices through enhanced payments, performance requirements, data feedback and technical assistance.

The programs aimed to advance the “Quadruple Aim” of improving patient experience, population health and clinician well-being while lowering costs.

Improvements with limits

The review found that federally supported practices made significant strides in population health management, patient engagement and clinical care quality. Practices participating in the initiatives reported better management of chronic conditions such as diabetes and cardiovascular disease, expanded behavioral health integration and increased screening for social determinants of health.

However, the studies showed that spending and utilization trends were far more resistant to change.

Across models, emergency department (ED) visits and hospitalizations decreased modestly, but overall expenditures often rose. In the CPC and CPC+ models, for example, hospitalization rates fell by 11 per 1,000 beneficiaries by year six, but total costs continued to climb.

“Expecting organizations that are paid single-digit percentages of the total cost of patients’ health care to change the cost of care is a proposition that has not borne fruit,” the authors wrote.

Structural and financial barriers

The findings underscore long-standing tensions between fee-for-service (FFS) incentives and population-based care goals. While CMS provided care management payments to practices, FFS remained the most predictable and dominant revenue source.

This discouraged sustained practice-wide redesign, the authors noted.

Data access also proved to be a persistent obstacle. Aggregating claims and electronic health record (EHR) data across payers was often delayed or incomplete, limiting practices’ ability to track performance or population outcomes. Practices further struggled with staffing turnover, analytic capacity and the costs associated with using otherwise “free” technical assistance programs.

Ownership and size also shaped outcomes. Larger and system-owned practices reported more resources and technical capacity but less autonomy and higher burnout. Physician-owned practices tended to adapt more quickly but lacked data specialists and financial stability to meet complex program requirements.

The authors ultimately concluded that, while the programs clearly improved quality and coordination, they did so at a cost.

To make primary care transformation sustainable, they recommend aligning payment models across public and private payers, investing in interoperable data infrastructure and targeting support toward practice-level improvement rather than short-term performance incentives.

“Primary care transformation can reduce ED utilization and acute medical hospitalizations but not the more costly acute surgical hospitalizations,” the authors wrote. “Yet, the constant waves of FFS incentives across the health system — including FFS in the practices themselves — overwhelm the efforts to change payment to shore up the foundational health system primary care bulwark.”

The study adds to growing evidence that transformation efforts, while effective at improving quality, still need deeper, structural reforms to payment and data systems if they are to meaningfully reduce total costs of care.