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Health systems research (also known as health services research) examines how healthcare is organized, financed, and delivered to patients—and whether the care provided is affordable, safe, and effective.^11–13  As the foundation of a high quality and cost effective healthcare system, a focus on primary care in health services research is especially important. Findings from health systems research can inform changes in healthcare processes, benefits, and policy to improve the safety, quality, person-centeredness, and accessibility of care.¹¹ 

������Ƶis the only federal department tasked with supporting health systems research, including how “healthcare services are organized, delivered, and financed and the interaction and impact of these factors on the quality of patient care.”¹⁴ AHRQ’s efforts in this area have been estimated to have saved American healthcare systems more than $12 billion.¹² 

Health systems research is a broad term that applies to primary care studies described throughout this report. In this section, we describe grants and resources that specifically focus on how healthcare organizations (i.e., practices, health centers, and health systems) structure and pay for primary care, and how changes in these areas affect patient care and health outcomes. This includes studies that examine various models of care, different organizational structures and ownership arrangements, health financing approaches and payment reform models, and the development of learning health systems. Learning health systems are defined by ������Ƶas healthcare organizations where “…internal data and experience are systematically integrated with external evidence, and that knowledge is put into practice.”¹⁵

Grants

Across the AHRQ primary care research grants with active funding in FYs 2023 and 2024, 15 focus mainly on healthcare systems and infrastructure. This includes nine R01 grants (Health Services Research Projects Program), three R03 grants (Small Research Projects), two P30 grants (Research Program Projects and Centers), and one K08 grant (Mentored Clinical Scientist Development Award). 

There are an additional 14 grants with some focus on healthcare systems and infrastructure, which are described in other topic area sections, including five in Healthcare Disparities, three in Digital Healthcare, two in Patient Safety, one in Behavioral Health and Substance Use Disorders, one in Practice and Quality Improvement, one in Primary Care Workforce, and one in Public Health and Community Integration. 

We summarize the 15 grants focused on healthcare systems and infrastructure below, organized by subtopic. The subtopics are: 

• Care Models.
• Healthcare Financing and Payment.
• Healthcare Ownership and Organization.
• Learning Health Systems. 

Care Models

Six studies examined various care models. 

(R01) 
PI:  Laura Hatfield 
Organization: Harvard Medical School 
Grant Start Date: August 1, 2022 
Examines 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 patient demographics and Medicaid eligibility status.

(R01) 
PI:  Leslie Page Scheunemann 
Organization: University of Pittsburgh at Pittsburgh 
Grant Start Date: June 1, 2024 
Tests, via a randomized controlled trial, the Post-Intensive Care Transitional Care, Rehabilitation, and Family Support (PIC-TRFS) model that aims to improve outcomes and prevent rehospitalizations for intensive care unit (ICU) survivors. The intervention supports the health and social care needs of patients in the six months following a critical illness hospitalization as they transition from the hospital setting to the home setting with healthcare support from home health and primary care.  

(R03) 
PI:  Anna M. Kerr 
Organization: Ohio University – Athens  
Grant Start Date: September 15, 2023 
Aims to understand facilitators and barriers to high-quality care coordination and continuity of care for patients with vascular anomalies in primary care, specifically those living in rural areas. The study includes interviews with vascular anomalies specialists, patients, and their caregivers, as well as pediatricians. 

(R01) 
Organization: Columbia University Health Sciences 
Grant Start Date: February 1, 2019 
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. This study aims to show how to facilitate teamwork and identify the most effective team attributes to assure best quality of care and outcomes particularly for patients with chronic diseases.

(K08) 
PI:  Leslie Page Scheunemann 
Organization: University of Pittsburgh at Pittsburgh 
Grant Start Date: September 30, 2019 
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.

(R01) 
PI:  Simon A. Mahler 
Organization: Wake Forest University Health Sciences 
Grant Start Date: April 1, 2023 
Assesses the use of Cardiovascular Ambulatory Rapid Evaluation (CARE) as an alternative to hospitalization for those experiencing chest pain. The CARE strategy consists of a follow-up within 72 hours of being discharged from the emergency department using medical management of cardiovascular risk factors and determining whether further cardiac testing is necessary. The study aims to understand whether CARE safely reduces healthcare utilization and whether patients prefer CARE to traditional hospitalization.

Healthcare Financing and Payment

Four studies investigate the impacts of health financing and payment reform models.

(R01) 
PI: Bryan E. Dowd 
Organization: University of Minnesota 
Grant Start Date: August 5, 2022 
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; cost savings are shared with patients, incentivizing them to select care coordination through lower-cost clinics. This study specifically explores clinic leaders’ perceptions of the system, how they have responded to being included in the system, and the barriers they face to practicing more efficiently. 

(R01) 
PI: Zirui Song 
Organization: Harvard Medical School 
Grant Start Date: April 1, 2024 
Examines the effect of policy changes aimed at increasing primary care spending in four leading states (Rhode Island, Oregon, Delaware, and Colorado). For Oregon, Delaware, and Colorado, uses public and private claims data to analyze changes in healthcare spending, utilization, and quality associated with newly enacted models. For Rhode Island, extends a prior evaluation of short-term effects on commercial insurer spending to include a full decade after policy changes, to identify potential long-term impacts, including utilization and quality outcomes. Also assesses spillover effects on Medicare and Medicaid populations in all four states. Findings from this study can be used to help inform other states considering similar legislation.

Learn more about this study in a Primary Care Research Profile: Understanding the Impacts of State Efforts to Increase Primary Care Spending (PDF, 208 KB).

(R03) 
PI: Avi Dor 
Organization: The George Washington University  
Grant Start Date: March 1, 2023 
Aims to explore the effects of changes in Medicaid reimbursement on the utilization and costs of Community Health Center (CHC)–provided services and the financial health of CHCs in general. Uses data from the National Association of Community Health Centers (NACHC) combined with the federal Uniform Data System (UDS).

(R01) 
PIs: Vahakn B. Shahinian; Richard A. Hirth; John Malcolm Hollingsworth 
Organization: University of Michigan at Ann Arbor 
Grant Start Date: April 1, 2020 
Studies end stage renal disease Seamless Care Organizations (ESCO), including whether ESCOs affect the frequency and quality of primary care provider (PCP) 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. 

Healthcare Ownership and Organization

Three studies looked at how healthcare institutions are structured and how ownership type affects care. 

(R03) 
PI: E. Marshall Brooks 
Organization: Virginia Commonwealth University  
Grant Start Date: September 1, 2024 
Assesses the impact of health system ownership of primary care practices on key elements of high-quality primary care and whole health and describes the contextual factors that may affect care using a mixed-methods design. 

Learn more about this study in a recent NCEPCR webinar: The Impact of Consolidation and Ownership on Primary Care.

(R01) 
PIs: Amelia Bond; Dhruv Khullar 
Organization: Weill Medical College of Cornell University   
Grant Start Date: April 1, 2023 
Assesses whether health system expansion improves care for medically complex Medicare patients, particularly those in acquired primary care practices. The study aims to understand what health system strategies and characteristics contribute to successes or failures in improving quality of care. 

Learn more about this study in a recent NCEPCR webinar: The Impact of Consolidation and Ownership on Primary Care.

(R01) 
PIs: Jane Mingjia Zhu; Zirui Song 
Organization: Oregon Health & Science University 
Grant Start Date: September 1, 2023 
Aims to understand how private equity (PE) acquisition of primary care practices changes provider behavior (including utilization of low-value services and diagnostic coding intensity) as well as how PE acquisition affects the health and healthcare of Medicare beneficiaries. Using Medicare data, the study examines how PE ownership affects provider behavior under the different financial incentives of traditional Medicare and Medicare Advantage and estimates the effects on care quality and patient outcomes. 

Learn more about this study in a recent NCEPCR webinar: The Impact of Consolidation and Ownership on Primary Care. 

Learning Health Systems

The two grants described below are part of the Learning Health System Embedded Scientist Training and Research (LHS StaR) Centers. 

 (P30) 
PIs: William J. Riley; Michael White 
Organization: Arizona State University – Tempe Campus 
Grant Start Date: January 1, 2024  
Creates a learning health system model to support training, professional development, and rapid-cycle implementation skills of physicians and researchers embedded in safety net healthcare organizations in Arizona. The SSNE-STaR is a collaboration among inpatient and ambulatory care health systems, federally qualified health centers, Tribal health centers, community partners, and other stakeholders – with primary care, maternal care, and disabilities as research priorities. There are multiple components of this research center grant, including an  (PI: William Riley). 

(P30) 
PIs: Paula Lozano; James D. Ralston 
Organization: Kaiser Foundation Research Institute 
Grant Start Date: January 1, 2024    
Establishes the WA LHS E-STAR Center to provide researchers with training and mentorship focused on increasing participatory research, formalized stakeholder engagement, and health equity. The Center’s goals include building new research-healthcare partnerships, training seven early-career researchers, and embedding learning health systems research in participating primary care organizations. There are multiple components of this research center grant, including an , a , and a  (all with Paula Lozano as PI). 

Initiatives and Resources

Medical Expenditure Panel Survey (MEPS) 

������Ƶmaintains the  (MEPS), a large national secondary data source for measuring how people use and pay for medical care in the United States. MEPS includes survey data from individuals, medical providers, and employers. Although MEPS includes information about a broad set of medical services beyond primary care, it is a helpful source of data for primary care researchers. 

There were two primary care–relevant resources from FYs 2023 and 2024 related to Healthcare Systems and Infrastructure, described below. 

Measuring Primary Healthcare Spending

This , developed by AHRQ’s  and published in May 2024, presents initial steps for establishing a standardized approach for estimating spending for primary care in the United States. The authors reviewed a wide range of definitions, data sources, and approaches used across states to estimate primary care spending and identified areas of consensus and differences. 

Compendium of U.S. Health Systems

Data added to AHRQ’s Compendium of U.S. Health Systems in 2024 allow researchers to explore trends in primary care. The data include information from 2022 about outpatient sites by practice type, specialty, and whether practices are in a primary care shortage area. 

An interactive data visualization of compendium data allows users to explore information about practice ownership. Data can be filtered by state to show the proportion of practices that are independent, are part of an integrated delivery network, or have corporate ownership. 

������ƵLong COVID Care Network

������Ƶfunded nine grants in September 2023 and another three in July 2024 to support existing multidisciplinary Long COVID clinics across the U.S. These grants allowed Long COVID clinics to expand access and care, develop and implement new or improved care delivery models, and foster best practices for Long COVID management. ������Ƶalso funded a technical assistance and evaluation contract: “Supporting and Evaluating AHRQ’s Initiative to Implement New Models of Comprehensive, Coordinated, Person-Centered Care for People with Long COVID”.  Some of these grants are particularly relevant to primary care, including: 

• (PI: Laura A. Malone)—Aims to expand and strengthen the Kennedy Krieger Institute Post-COVID-19 Rehabilitation Clinic to provide care to more children with long COVID. The project will educate primary care providers and community partners on the diagnosis, care, and management of children with long COVID.
• (PIs: Sarah E. Jolley and Donald E. Nease)—Implements and evaluates the Colorado Multidisciplinary Translation Network (CO-MTN) to better integrate long COVID care. CO-MTN includes a community of practice, primary care practice-based research network, and a tele-education system to train healthcare providers.

More about this initiative, including profiles of the 12 grants, can be found on the ������Ƶwebpage for the Long COVID Care Network. 

Developing and Sustaining State-Based Infrastructure to Support Primary Care Quality Improvement

In 2024, ������Ƶreleased a how-to guide for developing and sustaining state-based cooperatives designed to provide external QI support for primary care practices and strengthen their capacity to deliver evidence-based, whole-person care. Drawing primarily from the experiences of AHRQ’s EvidenceNOW: Building State Capacity grantees, the guide includes effective approaches, lessons learned, and example materials. The guide is designed to be useful to groups planning or developing similar infrastructure, including programs with a focus broader than primary care.