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

Report on Federal Primary Care Transformation Initiatives and Alignment with Sustainable Development Goals (SDGs)

Introduction and Scope of Analysis

A review published in JAMA Health Forum analyzed the outcomes of over a decade of federal investment in primary care transformation. The analysis, led by Laura L. Sessums, J.D., M.D., examined 142 studies and reports from five major federal programs. The core objective of these initiatives was to advance the “Quadruple Aim”—improving patient experience, population health, and clinician well-being while lowering costs—which directly aligns with the principles of Sustainable Development Goal 3 (SDG 3): Good Health and Well-being.

The programs under review included:

• 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)

These initiatives, administered by the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ), provided support through enhanced payments, data feedback, and technical assistance. However, the review concludes that while measurable improvements were made in care delivery, sustained reductions in healthcare spending were not achieved, posing a challenge to the long-term sustainability of health systems as envisioned by the SDGs.

Progress Towards SDG 3: Enhancing Health Outcomes and Service Quality

The federally supported programs demonstrated significant progress in advancing key targets of SDG 3 by improving the quality and coordination of primary care. Participating practices made notable strides in several areas critical to achieving universal health coverage and promoting well-being.

• Improved Population Health Management: Practices enhanced their management of chronic conditions such as diabetes and cardiovascular disease, contributing directly to Target 3.4, which aims to reduce premature mortality from non-communicable diseases.
• Enhanced Patient Engagement: Efforts to improve patient experience and engagement support the people-centered approach essential for effective healthcare systems.
• Expanded Access to Services: The integration of behavioral health services and increased screening for social determinants of health address critical health needs and contribute to SDG 10 (Reduced Inequalities) by identifying and mitigating non-medical factors that impact health outcomes.

Economic and Structural Barriers to Sustainable Healthcare Models

Despite improvements in care quality, the initiatives failed to achieve sustained cost reductions, a critical component for the financial sustainability of universal health coverage under SDG 3. While emergency department visits and hospitalizations saw modest decreases, overall expenditures often rose. This highlights systemic barriers that impede the transition to more efficient and sustainable healthcare models.

1. Conflicting Financial Incentives: The continued dominance of fee-for-service (FFS) payment models created incentives that overwhelmed efforts to establish population-based care, discouraging long-term practice redesign.
2. Infrastructure Deficiencies: A lack of interoperable data infrastructure, as highlighted by delays in aggregating claims and electronic health record (EHR) data, limited the ability of practices to track performance and population outcomes. This challenge underscores the need for investment in resilient infrastructure, a goal outlined in SDG 9 (Industry, Innovation, and Infrastructure).
3. Operational and Workforce Constraints: Practices struggled with staffing turnover and limited analytical capacity. Furthermore, the high burnout rates reported in larger, system-owned practices conflict with the objectives of SDG 8 (Decent Work and Economic Growth), which promotes safe and secure working environments.

Recommendations for Aligning with Global Sustainability Targets

The report concludes that for primary care transformation to be sustainable and effective, deeper structural reforms are necessary. The authors’ recommendations provide a clear path toward building a healthcare system that aligns with the comprehensive vision of the Sustainable Development Goals.

• Foster Multi-Stakeholder Partnerships (SDG 17): Align payment models across public and private payers to create consistent incentives that support value-based care rather than volume.
• Invest in Resilient Infrastructure (SDG 9): Develop and invest in interoperable data systems that provide timely and complete information, enabling practices to effectively manage population health.
• Promote Sustainable Practice-Level Improvement (SDG 3): Shift support from short-term performance incentives to long-term investments in practice capacity, ensuring the primary care system can serve as a sustainable foundation for population health.

Ultimately, the findings suggest that while targeted programs can improve care quality, achieving a truly sustainable health system requires a systemic overhaul of payment structures and data infrastructure to fully realize the objectives of SDG 3 and related global goals.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being: The article’s central theme is the transformation of primary healthcare to improve population health, manage chronic diseases, integrate behavioral health, and enhance patient experience, all of which are core components of SDG 3.
• SDG 8: Decent Work and Economic Growth: The article touches upon the well-being of the healthcare workforce, mentioning issues like “clinician well-being,” “staffing turnover,” and “higher burnout,” which relate to the goal of promoting safe and secure working environments.
• SDG 10: Reduced Inequalities: The mention of “screening for social determinants of health” and the inclusion of Federally Qualified Health Centers (which often serve vulnerable populations) indicate an effort to address underlying social factors that contribute to health disparities.
• SDG 17: Partnerships for the Goals: The article analyzes large-scale federal programs that involve collaboration between public entities (CMS, AHRQ), private healthcare practices, and multiple payers. It also highlights the need for policy coherence and aligned payment models, which are key aspects of building effective partnerships for sustainable development.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. SDG 3: Good Health and Well-being

   • Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. The article directly supports this target by noting that the analyzed programs led to “better management of chronic conditions such as diabetes and cardiovascular disease” and “expanded behavioral health integration.”
   • Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services… The article focuses on improving the quality and delivery of primary care, a cornerstone of universal health coverage. However, it also highlights the failure to achieve “sustained reductions in health care spending,” which is a critical aspect of financial risk protection.

2. SDG 8: Decent Work and Economic Growth

   • Target 8.8: Protect labour rights and promote safe and secure working environments for all workers… The article’s discussion of challenges within healthcare practices, such as “staffing turnover” and “higher burnout” among clinicians, directly relates to the quality and sustainability of the working environment for the health workforce.

3. SDG 10: Reduced Inequalities

   • Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all… The article mentions that participating practices saw an “increased screening for social determinants of health.” This action is a direct attempt to identify and address non-medical factors that create health inequalities among different population groups.

4. SDG 17: Partnerships for the Goals

   • Target 17.14: Enhance policy coherence for sustainable development. The article identifies a major barrier to success as the “long-standing tensions between fee-for-service (FFS) incentives and population-based care goals.” The recommendation to “align payment models across public and private payers” is a direct call for greater policy coherence to achieve health goals.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Target 3.4 (Non-communicable diseases and mental health)

   • Indicator (Implied): Quality metrics for management of chronic conditions. The article states that practices reported “better management of chronic conditions such as diabetes and cardiovascular disease.”
   • Indicator (Implied): Level of behavioral health integration in primary care. Progress is noted through the finding of “expanded behavioral health integration.”

2. Target 3.8 (Universal health coverage)

   • Indicator (Mentioned): Emergency department (ED) utilization rates. The article specifies that “emergency department (ED) visits… decreased modestly.”
   • Indicator (Mentioned): Hospitalization rates. A specific metric is provided: “hospitalization rates fell by 11 per 1,000 beneficiaries by year six.”
   • Indicator (Mentioned): Total health care expenditures. The article uses this as a key measure of failure, stating that “overall expenditures often rose” and “total costs continued to climb.”

3. Target 8.8 (Safe working environments)

   • Indicator (Mentioned): Clinician burnout rates. This is identified as a negative outcome, with the article noting “higher burnout” in larger, system-owned practices.
   • Indicator (Mentioned): Staffing turnover. This is cited as a persistent struggle for practices, indicating a challenge in maintaining a stable work environment.

4. Target 10.2 (Inclusion and equality)

   • Indicator (Mentioned): Rate of screening for social determinants of health. The article points to progress in this area with the finding of “increased screening for social determinants of health.”

4. Table of SDGs, Targets, and Indicators

Source: medicaleconomics.com