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.