Part of AHRQ's mission from the public health service act that instituted the agency is,
… conducting and supporting1 research that develops and presents scientific evidence regarding all aspects of health care, including… the ways in which health care services are organized, delivered, and financed and the interaction and impact of these factors on the quality of patient care."3
This aim includes an explicit focus on how the health system is organized and structured. Healthcare financing and payment reform continue to be opportunities to improve access to care and healthcare quality. Fee for service models limit the ability for healthcare systems to pay for services that optimize care, such as care coordination and improvements in healthcare access.18 Healthcare system redesign, including models like the Chronic Care Model and the Patient-Centered Medical Home, have the opportunity to improve both the quality and efficiency of care.19 One way to improve care is to improve coordination between settings and systems of care, such as between primary care and specialty care and during transitions between settings of care. The primary goal for care coordination is to incorporate the needs and preferences of patients and their caregivers into the delivery of high-quality and high-value health care.20
This section includes a summary of AHRQ's primary care grants, initiatives, and resources with a main focus on healthcare systems and infrastructure, including issues of payment.
Grants with a focus on health equity are indicated with this icon.
Grants
There were 24 AHRQ primary care grants that were actively funded during FYs 2021 and 2022 that focused mainly on healthcare systems or infrastructure, including payment. This included 12 R01s (Research Projects), 5 R18s (Research Demonstration and Dissemination Projects), 3 K08s (Mentored Clinical Scientist Development Award), 1 R36 (Dissertation Award), 1 R03 (Small Research Grant), 1 K18 (Research Career Enhancement Award for Established Investigators), and 1 U18 (Research Demonstration/Cooperative Agreement). An additional 11 primary care grants had some focus on healthcare systems or infrastructure and are described in other sections of this report, including Practice and Quality Improvement (4), Health Equity (3), Digital Healthcare (2), Public Health and Community Integration (1), and COVID-19 (1).
Below are tables, organized by subtopic, which include short summaries of the 24 studies focused mainly on healthcare systems or infrastructure. The four subtopics include healthcare financing and payment reform, primary care redesign, care coordination across settings, and building center and laboratory infrastructure to improve patient safety.
Healthcare Financing and Payment Reform
Six studies focus on healthcare financing and payment reform, as described in the following table.
Medicaid Payment Policy and Access to Care for Dual Eligible Beneficiaries (R01) |
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PI: Vicki Fung Organization: Massachusetts General Hospital Examines the impact of temporary Affordable Care Act increases in Medicaid payment rates for primary care providers in 2013 and 2014 on care quality, clinical events, and medical spending. |
| The Effects of Expanding Medicare Prevention Coverage on Colorectal and Breast Cancer Burden: A Mixed Methods Study (R36) |
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PI: Mika K. Hamer Organization: University of Colorado Denver; School of Public Health, Public Health & Preventive Medicine Investigates the impact of the Medicare Annual Wellness Visit on breast and colorectal cancer outcomes. The Medicare Annual Wellness Visit is an annual primary care check-up with no cost-sharing for the patient. |
Reproductive Care in the Safety Net: Women's Health After Affordable Care Act Implementation (EVERYWOMAN) (R01) |
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PI: Erika K. Barth Cottrell Organization: OCHIN, Inc. Studies the impact of Affordable Care Act and Medicaid expansion on reproductive healthcare provided in community health centers, including examining what individual-, clinic-, and State-level factors are associated with improved reproductive health provision. |
| Synergies and Sequencing in Delivery and Payment Reform: Understanding What Works (R01) |
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PI: Julia Rose Adler-Milstein Organization: University of California, San Francisco; School of Medicine, Internal Medicine Examines the participation by primary care organizations in payment reform models including the Medicare and Medicaid EHR incentive program “Meaningful Use,” patient centered medical homes (PCMH), and Accountable Care Organizations. The study team looks at the combined impact of participation in these models on the quality and value of the primary care provided. |
| Primary Care Involvement in End Stage Renal Disease Seamless Care Organizations (ESCOs) and the Quality and Costs of Care for Patients on Chronic Dialysis (R01) |
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PIs: Vahakn B. Shahinian; Richard A. Hirth; John Malcolm Hollingsworth Organization: University of Michigan at Ann Arbor; School of Medicine, Internal Medicine Studies End Stage Renal Disease (ESRD) Seamless Care Organizations (ESCO), including whether ESCOs impact the frequency and quality of primary care provider and nephrologist interactions, involvement of PCPs on financial and clinical outcomes, and outcomes for patients in ESCO versus other payment models including Accountable Care Organizations and Medicare Shared Savings Plans. |
| Analysis of a Tiered Clinic Cost-sharing Health Insurance Benefit Design (R01) |
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PI: Bryan E. Dowd Organization: University of Minnesota; Biomedical Engineering/College of Engineering Evaluates a long running tiered cost-sharing system where Minnesota State employees select a primary care clinic that is responsible for coordinating their care, including referrals to specialists, hospital care, and use of pharmaceuticals. Clinics are assessed on their risk-adjusted total cost of care and cost savings are shared with patients, incentivizing them to select care coordination through lower-cost clinics. This study specifically explores clinical leaders’ perceptions of the system, how they have responded to being included in the system, and the barriers they face to practicing more efficiently. |
Primary Care Redesign
Five studies focus on primary care redesign interventions, including examining the impact of new models for primary care including Patient Centered Medical Home (PCMH) and Centers for Medicare and Medicaid Services’ (CMS’) Comprehensive Primary Care Plus (CPC+).
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PI: Nathaniel Bell Organization: University of South Carolina at Columbia; School of Nursing Examines proximity and utilization of patient-centered medical homes (PCMH) for pediatric Medicaid patients in South Carolina to better understand the association between where a patient lives and their use of a PCMH instead of a hospital for care. |
| Social Networks in Medical Homes and Impact on Patient Care and Outcomes (R01) |
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PI: Lusine Poghosyan Organization: Columbia University Health Sciences; School of Nursing Uses social network analysis to examine how staff connections affect team performance and patient outcomes within primary care practices using the Patient Centered Medical Home model. |
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PI: Laura Hatfield Organization: Harvard Medical School; School of Medicine Tests the impact of the Comprehensive Primary Care Plus (CPC+) model on health outcomes for Black Medicare beneficiaries, including an examination of the variation in responses to CPC+ within subgroups by gender, disability, and Medicaid eligibility status. |
| Impact of a Team-Based Approach to Primary Care: A Natural Experiment in Primary Care Redesign (K08) |
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PI: Anita Diana Misra-Hebert Organization: Cleveland Clinic Foundation Implements and tests the team-based care medical assistant (MA) model in primary care compared to usual care. In the team-based care MA model, two MAs are paired with each medical provider to support documentation and other administrative work. |
| Costs and Quality of Primary Care Services: Implications for Community Health Centers (R01) |
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PI: Avi Dor Organization: George Washington University; School of Public Health, Public Health & Preventive Medicine Conducts an economic analysis of community health centers, including examining whether service expansion and integrating primary care visits with specialty visits leads to increased cost-savings and improved care quality. |
Care Coordination Across Settings
Seven studies focus on care coordination across settings, as described in the following table.
| Comprehensive Pediatric Hypertension Diagnosis and Management (R01) |
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PI: Michael L. Rinke Organization: Albert Einstein College of Medicine Engages pediatric primary care practices to test different models of subspecialist involvement in pediatric hypertension diagnosis and management. |
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PI: Meghan Brennan Organization: University of Wisconsin—Madison; School of Medicine, Internal Medicine Develops and pilots an integrated care algorithm to reduce amputation from diabetic foot |
| Implementing Personalized Cross-Sector Transitional Care Management to Promote Care Continuity, Reduce Low Value Utilization, and Reduce the Burden of Treatment for High-Need, High-Cost Patients (R01) |
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PI: Sharon Hewnerh Organization: State University of New York at Buffalo; School of Nursing Tests a personalized, cross-sector, transitional care management model in primary care and behavioral health settings to improve care coordination across settings using a health information exchange infrastructure. |
| Tele-Recovery: Engaging Stakeholders to Adapt and Pilot Test a Scalable Transitional Rehabilitation Intervention for Older, Rural ICU Survivors (K08) |
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PI: Leslie Page Scheunemann Organization: University of Pittsburgh at Pittsburgh; School of Medicine, Pediatrics Tests a transitional care model, TeleRecovery, where a nurse practitioner and occupational therapist deliver telehealth-based rehabilitation services for older adults and their caregivers in rural areas after a transfer from the intensive care unit to home. The TeleRecovery teams work with home health providers to implement the patients' care plans until they are well enough to be managed in primary care. |
| Integrating Pharmacists into an Automated Discharge Process to Promote Comprehensive Medication Management (R18) |
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PI: Joel F. Farley Organization: University of Minnesota Examines pharmacist-provided comprehensive medication management to coordinate care for high-need/ high-cost patients when they transition between the hospital and primary care settings. In this program, a health information exchange’s automated electronic alert system notifies primary care sites when patients need pharmacist-provided comprehensive medication management after a hospital visit. |
| Improving How Older Adults at Risk for Cardiovascular Outcomes Are Selected for Care Coordination (K18) |
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PI: Lisa M. Kern Organization: Weill Medical College of Cornell University; School of Medicine, Internal Medicine Examines different models for assigning care coordinators to Medicare beneficiaries after hospital discharge to improve the coordination of their care. |
| Closed Loop Diagnostics: AHRQ R18 Patient Safety Learning Laboratories (R18) |
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PIs: Russell Scott Phillips; James C. Benneyan; Gordon David Schiff Organization: Harvard Medical School Uses systems engineering methods to reduce diagnostic errors by creating “closed loop systems” or systems that ensure diagnostic tests and referrals are completed, results are conveyed to patients and primary care providers, and patients inform primary care providers about changes in symptoms that could alter a diagnosis. This study designs, develops, tests, and refines this “closed loop system” for diagnostic tests and referrals. |
Building Center and Laboratory Infrastructure to Improve Patient Safety
Three studies focus on building centers and laboratory infrastructure to improve patient safety.
| Re-engineering Patient and Family Communication to Improve Diagnostic Safety Resilience (R18) |
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PIs: Kathleen Elizabeth Walsh; Christopher Paul Landrigan Organization: Boston Children’s Hospital Develops a Diagnostic Center of Excellence focused on improving clinician-patient/family communication in pediatric outpatient settings. |
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PI: Sigall Bell Organization: University of Texas Health Science Center Houston; Internal Medicine Develops a Diagnostic Center of Excellence that uses teaming science and patient engagement to bring patients and healthcare providers together to reduce diagnostic errors and improve safety in ambulatory care. |
| PROMIS Learning Lab: Partnership in Resilience for Medication Safety (R18) |
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PI: Yan Xiao Organization: University of Texas Arlington; School of Nursing Creates the Partnership in Resilience for Medication Safety Learning Lab (PROMIS Lab) which promotes patient safety in primary care. The PROMIS Lab is intended to develop and test strategies to reduce medication-related harms in older adults. |
Other Healthcare Systems and Infrastructure Topics
The final three studies each focus on a unique topic.
| Consumer Assessment of Healthcare Providers and Systems V (CAHPS V) (U18) |
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PI: Ronald Dale Hays Organization: RAND Corporation Expands the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to include modules related to patient experience, shared decision-making, care coordination, patient engagement, and patient safety. Among other activities, this study looks at how primary care practices use the CG-CAHPS survey and patient-centered medical home items during PCMH transformation, and assesses how pay-for-performance impacts CAHPS survey responses about the care provided by primary and specialty care safety net providers. |
| Novel, High-Impact Studies Evaluating Health System and Healthcare Professional Responsiveness to COVID-19 (R01) |
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PI: Rebecca Sarah Etz Organization: Virginia Commonwealth University; Family Medicine Examines the impact that COVID-19 has had on digital healthcare expansion in primary care, using a set of surveys developed and implemented during the public health emergency. |
| Physician Organization and the Use, Cost and Outcomes of Care (R01) |
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PI: Laurence C. Baker Organization: Stanford University; School of Medicine, Internal Medicine Examines the impact of the growing role of physician organizations on healthcare cost, use, and outcomes. A physician organization is a business entity where physicians form a group practice to support an affordable care organization or managed care organization.21 The study examines whether physician organization size or practice composition (single versus multispecialty groups) affects cost, use, and health outcomes. |
Initiatives and Resources
AHRQ invests in data collection activities that can support research in healthcare systems and infrastructure that have implications for primary care. The data resources are described below with links to additional information or to the specific material.
The Medical Expenditure Panel Survey (MEPS) is the largest national data source for measuring how people use and pay for medical care in the United States. It includes a set of surveys of individuals and households, their medical providers, and employers across the United States. While MEPS includes information about a broad set of medical services beyond primary care, it may be a helpful source of data for primary care researchers.
As described on the MEPS webpage: "MEPS currently has two major components: the Household Component and the Insurance/Employer Component. The Household Component provides data from individual households and their members, which is supplemented by data from their medical providers. The Insurance Component is a separate survey of employers that provides data on employer-based health insurance."22
