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 The reason for this dynamic is that most of these practices, and much of our health care system, rely on an outdated payment model: Each in-person visit with a patient generates a payment.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.