As the U.S. nears 60,000 deaths due to Covid-19, primary care could be among its next casualties.
Half of the primary care practices in America are small businesses, which means they are battling the virus on the frontlines even as they are on the verge of going out of business. The reason for this dynamic is that most of these practices, and much of our health care system, rely on an outdated payment model: Each in-person visit with a patient generates a payment. Without in-person visits, there is little to no revenue.
To prevent the spread of Covid-19, primary care and specialty care practices are actively discouraging patients from coming into the office for routine care. Fewer than 20% of the usual visits are now in person. While it is true that insurers are generally paying doctors for telemedicine visits during this state of emergency, Medicare is currently reimbursing visits done this way at roughly half of the fee of in-person visits.
Smaller independent practices face an even steeper uphill battle. As one of us (D.H.) wrote recently in the Washington Post, without the financial backing of hospitals or health systems they will not be able to survive on half of their usual revenue.
Some practices have already closed, and others may soon follow. A recent national survey revealed that only one-third of primary care clinicians feel sure that their practices have enough cash on hand to function for four weeks. The $2 trillion federal stimulus package does not, at this point, specifically allocate funding to small or independent medical practices. In light of this, it’s no surprise to see projections that up to 60,000 primary care practices nationwide may close or significantly scale back.
One primary care doctor at a small practice we spoke with put it simply: “This is profoundly depressing. I have worked my whole life to serve my community, and I don’t see how I can keep my practice running for another eight weeks.” Despite this reality, many of our primary care colleagues have stepped up to work in hospitals or lead Covid-19 treatment teams.
We can prevent the mass closure of independent primary care practices — and support those working within larger health systems — by providing immediate financial relief in the form of a “global budget” during this crisis. Instead of being dependent on in-person visits, primary care practices would be paid a monthly fixed fee to care for their patients through any appropriate venue (office visits, telephone calls, video visits, or home visits). This type of payment model has been used by public and private payers in recent years, ranging from bundled payments for surgical and cancer care to population-based global budgets for health care delivery systems.
The first step is simple: provide all primary care practices nationwide with a reasonable fixed payment, say on average $50 per patient per month, retroactive to April 1 and through the end of 2020. This fixed payment would replace any previous fee-for-service payments the practice would have received during this time. Practices that serve patients with greater health needs could receive a larger budget than those that serve healthier patients, a risk-adjustment process used by most public and private payers today.
After the Covid-19 pandemic abates, a global budget would ideally remain in place to allow primary care to help restore and advance the America’s health. Primary care teams would initially manage patients with Covid-19 moving forward, including testing, treatment, and administering vaccines. The economic devastation and social isolation wrought by Covid-19 will require primary care teams to address mental illness, substance misuse, and poorly controlled chronic disease even more than they are already doing.
And yet, the U.S. is underinvesting in primary care: Just 6 cents or less of every health care dollar are spent on primary care, even though we spend more on health care per capita than every other industrialized nation.
Envision the following: You go to your primary care practice amid a bout of depression and are immediately able to see a behavioral health provider. You struggle with alcohol use or opioid addiction and a recovery coach checks in with you weekly as you pursue recovery. Your loved one develops dementia and a nurse case manager helps coordinate his or her care. If we change the way we pay for primary care, that’s the kind of care our nation could attain. In the current system, though, almost none of these members of the health care team generate significant revenue, so most practices can’t afford to hire them.
Like airlines, primary care has long depended on people showing up. But unlike air travel, primary care’s role of keeping people healthy continues — and is arguably even more important — when people stay home. The Covid-19 crisis is revealing the financial peril of relying on billable, in-person visits as the main way to pay for primary care, which provides little backstop in times of crisis.
Let’s heed the lesson of the Covid-19 crisis to protect primary care in a foundational way that will matter even more once the pandemic is over.
Daniel Horn is a primary care physician and director of population health for the Division of General Internal Medicine at Massachusetts General Hospital. Wayne Altman is chair and professor of family medicine at Tufts University School of Medicine and president of the Family Practice Group in Arlington, Mass. Zirui Song is an internal medicine physician at Massachusetts General Hospital, assistant professor of health care policy and medicine at Harvard Medical School, and a faculty member in the school’s Center for Primary Care.
Dr. Wayne Altman, is my PCP and my friend. Just one example of the value and importance of a vibrant primary care practice component in our health care system: he, along with Kerri Hawkins, Registered Dietitian and Nutritionist in the primary care practice, developed a group wellness program for weight-loss, fitness and nutrition via lifestyle changes of which I have been a part for 10 years. That I am healthier and more fit than in decades (perhaps “ever” as an adult) as I approach octogenarian-hood speaks volumes. I would be devastated were they and their colleagues no longer there for me.
You are absolutely right. I am not telling you anything you don’t know to say the problem is more than a ridiculous payment scheme. It is a health care system that is too damned expensive and not effective enough. Primary care practices and the rest of us–doctors, nurses, hospitals, etc.–need to be paid for giving appropriate care to ‘covered lives’ in a single payer system whether provided by government or strictly regulated private or semipublic entities. This crisis is making plain how inequitable are many social structures, and health care is the most obvious.
I’m the only healthcare provider in my very poor, sickly rural area in southwest Georgia. We are near several of the counties with the highest COVID-19 infection rates in the entire country. I had no experience with telehealth, but we switched within a few days as things deteriorated.
However, out here, with poverty, poor education levels, lack of wifi (even 3G in some cases), MOST patients do not have ready access to a screen, a signal, and the technical knowhow to use it.
I think this general problem, especially for elderly Medicare patients, is not unique to us. I know my mother would not be able to navigate a virtual visit.
Our state’s Medicaid has already allowed us to be reimbursed for using the best technology that is available, which is usually the telephone. (Almost) everyone has one and knows how to use it.
And let’s be serious. Most of the video visits that are completed, consist of the patient holding the smartphone to their mouth, my screen showing their forehead and ceiling. The video usually provides no useful information, it just requires extra time and stress.
For immediate relief, we need Medicare to reimburse all virtual visits at a sustainable rate, during the pandemic and beyond.
It is a travesty that primary care is being hit so hard, just when it is needed the most. However, this is more a reflection of a dysfunctional healthcare system that has been in need of drastic change for a long time. Medicine is woefully behind in use of modern technology to benefit patients, rather than third-party payers and their payment models. I agree with Dr. Gold, that Direct Primary Care practices have continued to provide primary care services without a hiccup during the COVID-19 pandemic. Already adept at modern technology (offering secure text messaging, phone and video appointments) and utilizing an affordable membership model (think “gym” membership), minimizing in-office visits during this pandemic neither damaged DPC practices, nor became a hindrance to ongoing patient care. Envision the following: having a primary care doctor that knows you through direct communications without layers of staff members, that you can access through secure text message, at your convenience, when concerns arise; having a primary care doctor that helps to find affordable cash pricing when you know you’ll never meet your deductible and would end up paying huge test bills through the insurance-negotiated rates; having a primary care doctor that works with you directly on your well-being in addition to acute concerns, including stress management, exercise programs, healthy eating, and mental health. I completely agree that the COVID-19 pandemic is revealing the peril of the outdated, fee-for-service model; but Direct Primary Care is weathering this storm and proving itself to be a model that is successful for both practitioners and patients.
Excellent piece. I will even go further and simplify it to make it even more robust and beneficial to every patient in our country. Let the middlemen reimburse or pay the beneficiary (ie for medicaid and medicare give beneficiaries a means-tested medical savings card for primary care) and get out of the patient/physician transaction and the administrative burden and increased overhead third parties have caused for decade. Abolish their control and mandatory “referrals aka permission slips”, “metrics” and reporting that have never shown to improve anything as far as outcomes or cost containment. Given the current crisis/pandemic lets stop putting one toe/foot in the water and dive right in to rebuild a system that makes sense and works. Us DPC docs are on little life rafts right now as the Titanic is going down. Do you want to be on that boat playing violin or on your way to shore? If we continue to let government and insurers control the dollar, regardless oh how its paid, we will never be able to practice true medicine without interference:
DPC for All. Mic. Drop.
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