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

Importance: 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. Objective: To identify outcomes of federal investment in primary care delivery transformation on patient experience, costs and utilization, population health, and practice experience. Evidence Review: 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. Findings: 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. Conclusions and Relevance: 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.