Autumn Road Family Practice is a small, six-doctor primary care practice that’s been caring for people in Little Rock, Ark., for more than half a century. On a Thursday in mid-March, the entire staff met to update the practice’s response to the coronavirus outbreak, since the first case had just been identified in Little Rock.
The floor dropped out quickly. On Monday, just four days later, to help everyone stay healthy, stay at home, and cooperate with social distancing, the staff worked with patients to cancel appointments and schedule remote follow-up calls. By Wednesday, the practice’s finances were quickly failing. On Thursday they made a list of what they could cut and on Friday, this small practice, an anchor in its community like tens of thousands of primary care practices across the country, was forced to make the grueling decision to furlough 12 members of its staff.
Covid-19 is pushing our entire health care system to the brink, from large hospitals in big cities with overwhelmed ICUs to small primary care practices in rural communities. Independent physician practices make up a sizable portion of the health care workforce in the U.S.: More than half of physicians work in practices with 10 or fewer physicians. And those small practices are suffering. As the former head of Medicare and Medicaid (A.S.) and a leader of a company (F.M.) that works with more than 500 primary care practices across 27 states, including Autumn Road Family Practice, we have seen that suffering firsthand. And we know how policymakers can help ease it.
Few people will be more vital to helping the nation recover than primary care and mental health professionals. Millions of Americans get their health care through independent primary care practices. In many rural areas, where the local hospital has closed, these practices are the sole source of care. But just when we need them most there is reason to worry they won’t be in a position to help.
Today, primary care practices across the country are consistently seeing reductions in patient volume of more than 50%, even after replacing in-person visits with telehealth visits. And as we approach the 11th week of this national emergency, independent practices are rapidly approaching a financial cliff that could be fatal as most of them pay today’s bills with payments for services they delivered within the past 60 days.
This is not just a slowly unfolding disaster. It will also hamper the country’s ability to recover. We’re going to need these independent physician practices to return safely to normal life. Community-based primary care physicians will need to be the frontline testers and treaters of mild cases of Covid-19. They will identify those of us most at risk from the disease. They’ll help us prevent single cases from turning into outbreaks and relieve the strain on hospitals and nursing homes. They’ll also help us care for the many cases of unmanaged heart disease, diabetes, and other chronic conditions that will surge when the Covid-19 crisis ebbs.
Don’t be fooled into equating the size of independent physician practices with their import. They are key to bringing the country back and putting the entire system back on solid footing. Yet the country is not targeting relief directly to them.
Congress is spending previously unimaginable amounts of money to preserve the U.S. health care system from the Covid-19 pandemic. Lawmakers have already appropriated $175 billion for the Public Health and Social Services Emergency Fund and the Trump administration has made hundreds of billions more available through Small Business Administration loans and advance payments from Medicare. This is necessary, and good, and more needs to be done.
But because primary care has traditionally gotten the smallest slice of the health care spending pie, practices like Autumn Family Road are getting the smallest slice of relief as well. Medicaid providers, mental health professionals, and dental practices are in a similar situation.
So far, no funding has been specifically designated for primary care. Primary care physicians received a share of the first disbursements from the emergency fund created by Congress, but the typical primary care doctor received only enough to keep his or her practice open for one week. Some physicians received assistance in the form of advances from Medicare. But Medicare advances need to be paid back in full starting this summer, when most practices most likely will not have rebounded. Physicians saw potential merit in two Small Business Administration loan programs — the Paycheck Protection Program and Economic Injury Disaster Loans — but both have been difficult to access, especially for small practices in which doctors must contend with filling out complicated paperwork between caring for patients and keeping their staffs safe.
We need to target assistance directly to small independent physician practices. They should not be competing with multibillion-dollar health systems and other businesses for the same funds. The Department of Health and Human Services and the Trump administration should turn most of the loans that practices have received into grants. Furthermore, Congress and the administration should provide dedicated grant funding to primary care practices. We estimate that $15 billion could provide a vital lifeline to these practices, helping ensure that the country has the health care capacity to safely reopen.
Primary care physicians will do the right things to keep us healthy. They already make sacrifices, financial and otherwise, but they are running out of time. One week of help isn’t enough.
The Covid-19 pandemic has wreaked havoc across the country, much of it preventable. There is still time to save primary care physicians. But we must act now.
Andy Slavitt is the board chair of United States of Care. He was the administrator of the Centers for Medicare and Medicaid Services from 2015 to 2017. Farzad Mostashari is an internal medicine physician and the co-founder and CEO of Aledade, which supports independent physicians in value-based payment models. He previously served as the national coordinator for health IT at the Department of Health and Human Services and was assistant commissioner for New York City’s Department of Health and Mental Hygiene.
The authors completely miss the point
The winners have been chosen
It’s not the independent practices
Health systems will use their bailout money to pick up distressed practices, further consolidating healthcare delivery.
With the bailout, Health systems and the federal government are now full on partners, Much like the federal government and too big to fail banks after 2008.
Clinicians realize that they can’t compete now that the market, which was previously rigged against them, had been completely captured by their competition.
The number of clinicians contacting me and my fellow career transition professionals is something to behold—-Even medical students are reaching out because they want no part of the world to come.
I advise Patients to get as much of their care as possible outside the system such as through cash pay practices.
Because the care you’re going to receive within the system Is likely to be directed at acquiring your data rather than getting you well.
We have seen quite a few small businesses, primarily restaurants, manage to get PPP funding. We work with ethnic operators who don’t even have a solid command of our language, and yet they are getting it done. If a medical practice manager cannot get PPP funding I would doubt their resourcefulness.
I share your concerns. but you include mental health providers in your concerns but not in your proposed solutions. Don’t leverage the mental health issue to gain momentum for a proposal that does nothing to help mental health.
Don’t you feel that primary care is often the first line in mental health though? Saving primary care cushions mental health care, even if nothing is specifically addressed for mental health, though I agree it should and MUST be.
There is a solution for primary care with a proven track record of lowering costs, increasing access to care and improving patient and physician satisfaction–Direct Primary Care (DPC). Many like Dave Chase and AAFP are touting DPC like payment models NOW for primary care as FFS payment system has been crushed by COVID19. The DPC Alliance (www.dpcalliance.org) has a PATH plan to help primary care docs transition to membership payment model using free training, support and mentorship. Find out more here: https://dpcalliance.org/dpc-path?fbclid=IwAR2L-YIeyU9T-7iUN-1fjjzTMmmgP7uYX8HnTZsfRWBhLBDtm7K-1jgHzYk
Sure, and don’t forget to check out the first and really only independent actuarial study to measure exactly how much cost savings DPC actually produces, prepared by Milliman for the Society of Actuaries. https://www.soa.org/globalassets/assets/files/resources/research-report/2020/direct-primary-care-eval-model.pdf The conclusion: Direct Primary Care INCREASED costs. Oops.
As for FFS being crushed, a survey cited twice in DPC Alliance ‘s own PATH plan showed that DPC practices were applying for PPP loans at a 60% higher rate than FFS practices (52% vs 32%) https://drive.google.com/file/d/14QxhDwZxlJAszqm6P3MXFjTfAEqlocOc/view – linked in footnote 4 of the PATH plan.
One question for you Mr Ratner, do you find the Milliman study accurate? Is it a “good” study? Or is it heavily flawed?
Thanks
Dr. Purcell, Thanks for the question.
Milliman’s is the best study of DPC of which I am aware. However, the 1.3% increase in overall costs is based on an assumed average DPC fee of $61 PMPM. I do “fault” the study for assuming, rather than learning, what the DPC fees actually were. The employer appears to be Union County, NC, and the DPC contract is matter of public record. Apparently, the County paid an average DPC fee of $95 PMPM. If so, the DPC innovation actually increased total costs by almost 8%.
The “fault” made this particular DPC contract look better than it actually was. More importantly, though, it could lead to people over-estimating the ability of a more typical $61 PMPM DPC. Here’s why.
The extra $34 PMPM would have brought into the provider about $425,000. While a typical DPC promises same day/next day visits, the Union County DPC could easily have upped that game to same HOUR/same day visits, and then thrown in some house calls. That would supercharge the ability of the Union County DPC to reduce unnecessary ED visits. Since the cost savings Milliman observed were largely driven by reduced ED visits, it is reasonable to suggest that a less richly funded DPC clinic might not reach the same level of ED visit reduction. Certainly, if I were an employer armed with this information, I’d be very skeptical of any DPC provider’s ability to match the 25% ED visit reduction observed in Union County on any budget significantly less than the $95 PMPM Union County paid.
I have a quibble with one of Milliman’s other assumptions, but I did not run it to ground after I calculated that its maximum impact to be less $1 PMPM, or 0.2%. Possibly, then, the real loss to Union County from implementing DPC was only 7.8%!
Here is what the Milliman writers said in the report (in excerpts) :
“However, even after adjusting for differences in health status, the DPC cohort experienced a statistically significant reduction in total claim costs relative to the traditional cohort during the same time period, meaning that enrollment in the DPC option was associated with a reduction in overall member demand for health care services.
The DPC cohort experienced statistically significant reductions (p-values < .05) in risk-adjusted costs relative to the traditional cohort for three of the eight detailed types of service, with at least 5.0% of baseline claim costs(Outpatient: Emergency Department, Outpatient: Other, and Physician: Preventive Services).
The employer did not provide us with its actual DPC membership fees, so we based our ROI analysis on assumed DPC membership fees from our DPC market survey. If the employer’s actual DPC membership fees varied from our assumed level, then the actual ROI would have also varied from our estimated level.
The total estimated DPC claim savings estimated from illustrative Figure 13 are $59.56 PMPM ($438.02 − $497.59), and the single largest driver of DPC claim savings is carved-out DPC services. These are services furnished by the DPC provider, covered under the monthly DPC membership fee rather than FFS claims to be paid by the plan. The second-largest driver of DPC claim savings is reduced outpatient facility claims, mostly from a projected reduction in emergency department usage. Carved-out DPC services and reduced emergency department usage account for nearly two-thirds of the total estimated DPC claim savings. The estimated level and distribution of DPC claim savings will vary depending on an employer’s baseline claim costs, the structure of the DPC option and the characteristics of the population expected to enroll in the DPC option. (Figure 16 on page 41)
OVERALL
"The DPC option was associated with a statistically significant reduction in overall health care claim costs and emergency department usage after controlling for differences in age, gender and health status between the DPC and traditional cohorts. The DPC option was also associated with a lower inpatient facility admission rate, but the difference was not statistically significant due to the small number of admissions during the two years analyzed. We also estimated that the introduction of a DPC option reduced total nonadministrative plan costs for the employer, after consideration of the DPC membership fee and other plan design changes for members enrolled in the DPC option."
"Depending on the baseline level of claim costs in an employer’s plan, how the DPC option is structured and the cost savings generated by the DPC delivery model, the introduction of a DPC arrangement could be done on a cost-neutral basis or may potentially lead to overall cost savings for the employer. “
Their words not mine. None of that says anything about patient satisfaction or physician satisfaction with DPC model. The article does list multiple reason why physicians left tradition practice: "The primary motivators for choosing to operate a DPC practice were the “potential to provide better primary
care under a DPC model” (96%), “too little time for FFS visits” (85%), and “too much FFS paperwork to complete” (78%)." All those things matter too as 2 of the 4 corners of quadruple aim to better healthcare are patient and physician satisfaction.
So, either their information here is terrible and wrong which leaves this study useless or the study is pretty good and helpful. There is no Holy Grail DPC study out there and doubtful there ever will be because cynics will always find fault. On the flip side, there is NO Holy Grail study for traditional FFS medicine either, proving it is the only way to care for patients. I liken it to the Pharisees in the Bible, no matter your thoughts on Jesus. The religious leaders, the Pharisees, were constantly trying to trap Jesus with questions and kept asking him to perform miracles–prove to us you are GOD. Never mind many of them had seen him feed 5,000, healed the lame and blind, and raised the dead. There was never enough proof. So, it is for DPC. Oddly enough, DPC is just an age old form of primary care practiced for centuries. Only thing different is how we are paid, which is only thing that seems to matter to folks. Even though, America spends 1/3 less than other advanced countries do on primary care. But DPC is the devil.
Jerry
If you are part of the current healthcare delivery “system,” DPC is indeed the devil.
The greatest threat to the skim is that providers opt-out and take covered lives with them.
That’s why arguing through research is a waste of time, academic, professional, and industry institutions are “all-in,” grooming the next generation of clinicians for our current state/industry partnership and its controlled wage slavery.
In an environment as rife with gaslighting officialdom as ours currently is, critical thinkers know to simply go back to the basics.
Is a price-transparent market of defined cash-for-services between clinician and patient better than an opaque “system” where the goals of the payer and the goals of the customers clearly diverge?
The default answer clearly must be yes.
Next, go ahead and test it.
But any other answer is an extraordinary claim requiring extraordinary and unbiased proof.
I have yet to see any contra-DPC research which reaches that threshold.
First they ignore you
then they laugh at you
then they fight you
then you win.