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The National Academies of Sciences, Engineering, and Medicine report, Implementing High-Quality Primary Care,¹ correctly identified that the Biden Administration鈥檚 priority goals for heath equity and a more effective and affordable health system require a sustained initiative to strengthen the nation鈥檚 fragile primary care infrastructure. In this Viewpoint, we reconsider the promise of the Primary Care Extension Program to strengthen and ensure access to high-quality primary care. The Patient Protection and Affordable Care Act (ACA)² originally directed the Agency of Healthcare Research and Quality (AHRQ) to establish the program; however, Congress did not appropriate funds to make it operational.

The Primary Care Extension Program would be modeled after the US Department of Agriculture (USDA) Cooperative Extension System, which developed regional infrastructure, including local extension agents, who educated farmers and supported farm transformation in the 1900s. Today, the Cooperative Extension System maintains an infrastructure in every county in the US, allowing extension agents to develop relationships and tailor support to the counties鈥� agricultural needs. The Primary Care Extension Program would develop a similar infrastructure with local extension agencies understanding the regional health care market and sharing knowledge, creating connections among practices and community-based organizations, and facilitating practice improvement. This program has been modeled in a few locations (eg, New Mexico, Oklahoma, North Carolina)³ for almost 3 decades and was proposed nationally.⁴

Even without Congressional appropriation of new funds, AHRQ implemented a pilot Primary Care Extension Program, the EvidenceNOW initiative, as a research effort. EvidenceNOW funded 7 regional cooperatives spanning New York City, New York, and 11 states: Virginia, North Carolina, Oklahoma, Illinois, Indiana, Wisconsin, Washington, Oregon, Idaho, Colorado, and New Mexico. Cooperatives recruited more than 1700 practices, providing practices with access to facilitators, who are professionals akin to agricultural extension agents. EvidenceNOW focused on enhancing practices鈥� capacity and improving the ABCS of heart health (aspirin, blood pressure and cholesterol control, and smoking cessation). As the lead evaluator on the EvidenceNOW national evaluation (D.J.C.) and initiative advisers (K.G. and R.L.P.), we offer insights for implementing a Primary Care Extension Program at scale.

The AHRQ instructed cooperatives to focus EvidenceNOW efforts on recruiting smaller primary care practices (<10 clinicians) lacking internal quality improvement infrastructure. The AHRQ recognized the important role that these practices play in the primary care ecosystem, particularly in rural and medically underserved areas. Despite market consolidation, about one-third of primary care practices are independently owned, and more than one-half of family physicians鈥� practices have fewer than 10 clinicians.⁵ About 40% of the EvidenceNOW practices were clinician-owned and approximately 75% had fewer than five clinicians. EvidenceNOW cooperatives included an academic hub to forge public-private partnerships (eg, technology, quality improvement and public health organizations), similar to the Cooperative Extension System, to establish the expertise and capacity needed to reach and support more than 200 practices per hub. Facilitators delivered an average of 18 hours of support over 7 months to each of their practices.⁶

Cooperatives helped practices make modest improvements in capacity and clinical outcomes. Practices achieved small improvements in 鈥渁daptive reserve,鈥� a measure of successful work relationships that support a practice鈥檚 ability to adapt to change. Practices demonstrated moderate improvement in quality improvement capacity, which was measured using a subsection of the Change Process Capacity Questionnaire.⁷ Modest gains were achieved in clinical quality, ranging from a 1.9% absolute improvement in blood pressure control to a 5.6% absolute improvement in smoking cessation counseling rates鈥攁lthough only the latter change was statistically significant.^7,8 We estimate that cooperatives collectively reached 5000 clinicians and 8 million patients.

Two key findings emerged from the EvidenceNOW evaluation that suggest how a national Primary Care Extension Program could have even greater impact than that accomplished by the AHRQ pilot. The first is to tailor the program to the sector of the primary care ecosystem that is, on average, most fragile and in need of support: smaller, clinician-owned practices. These types of practices not only engaged more with facilitators, they experienced greater benefit and demonstrated larger improvements in study outcomes than those of hospital- and health system鈥搊wned practices.⁸ The second is that the effectiveness of cooperatives may grow over time as extension teams gain knowledge and their practice relationships deepen. Only 2 of the 7 EvidenceNOW cooperatives had substantial prior experience.⁶ These cooperatives recruited a more diverse and dispersed group of practices in greater need of support (ie, with lower baseline capacity and clinical quality), delivered substantially more⁶ and higher quality facilitation,⁹ and their practices made greater gains in improvement capacity and clinical quality than practices in the other 5 cooperatives.⁶

While AHRQ displayed leadership with the EvidenceNOW initiative, we believe that national implementation would need to be led by the US Department of Health and Human Services (HHS), as it will require a national platform, collaboration among federal agencies guiding health care, and long-term funding. The USDA has more than a century of experience and would be an adviser and potential infrastructure partner.¹⁰ Sustained support is needed to build infrastructure and the regional and national partnerships to strengthen primary care at scale. The HHS can develop the innovative public and private partnerships that will be foundational to successful national implementation of the Primary Care Extension Program.

States and perhaps urban regions within states (eg, New York State and New York City might have connected extensions) are the right geographic scope for a Primary Care Extension Program given population density, regional politics, and local variations in health care markets and population need. The HHS will need to play a convening role so that extensions learn from each other, build trust among regions and federal leaders to promote open sharing of challenges and solutions, and set a collective vision for implementing high-quality comprehensive primary care. This last point is crucial. Rather than focus on one disease-focused outcome at a time, extensions should work on the foundational building blocks of primary care. This effort would include helping practices to develop the teams, tools, and resources needed to assure access, comprehensiveness, coordination, and continuity, as well as to build the relationships and whole-person care that are the real value-add of primary care.

The National Academies of Sciences, Engineering, and Medicine primary care report¹ and Initiative to Strengthen Primary Health Care led by the Office of the Assistant Secretary for Health make the case for the importance of primary health care to improve declining health outcomes in the US and the urgent need to fortify the capacity for high-quality primary care. As the HHS considers establishing a coordinating authority for primary health care, the federal government needs to consider funding and implementing the Primary Care Extension Program originally authorized in the ACA. Implementing extension infrastructure would be complex, but EvidenceNOW cooperatives overcame many complexities, developing regional partnerships and linkages with community organizations that benefited their practices. Extension infrastructure would also require financial investment. Using the ACA budget, which envisioned an increase,² and USDA figures,¹⁰ we estimate a cost of approximately $600 million to $1 billion annually. EvidenceNOW shows why this investment is worth consideration. The Primary Care Extension Program can work synergistically with payment reform, workforce development, and the development of advanced electronic infrastructure to assist smaller practices with workforce redesign and technology implementation as well as create better community linkages that can strengthen vitally important smaller practices and help them implement advanced primary care approaches and remain viable in a tumultuous health care environment.

Published: February 24, 2023. doi:10.1001/jamahealthforum.2022.5410

Open Access: This is an open access article distributed under the terms of the CC-BY License. 漏 2023 Cohen DJ et al. JAMA Health Forum.

Corresponding Author: Deborah J. Cohen, PhD, Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (cohendj@ohsu.edu).

Conflict of Interest Disclosures: Dr Cohen reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study. Dr Grumbach reported serving as an unpaid adviser to the US Senate Committee on Health, Education, Labor and Pensions in its drafting of the section of the Patient Protection and Affordable Care Act authorizing the Primary Care Extension Program. No other disclosures were reported.

Additional Contributions: David Meyers, MD, the AHRQ, developed the EvidenceNOW initiative as a way to study and support US primary care practices. He also provided his operational leadership and support throughout the initiative. Without his massive contributions, this initiative and its overall contributions would not have been possible.