Expand COBRA, but do it the right way
Primary care doctors could be COVID-19's next victims
Front-line health workers responded to the tsunami of severe COVID-19 cases at hospitals across the United States. Less visible were the health workers in thousands of primary care practices who saw those patients when they first developed symptoms. These doctors and nurses also were on the front lines as they triaged patients with possible COVID-19, often working with few resources and inadequate supplies of protective equipment.
Primary care providers have made heroic efforts to protect their patients from COVID-19 and keep them healthy, and have pivoted to engage patients via telemedicine services - real-time video visits, phone calls and electronic prescriptions. Many patients with complex needs, such as those with complicated pregnancy or chronic conditions including heart disease, diabetes, hypertension and cancer, depend on primary care providers to keep them healthy and out of the hospital.
The COVID-19 pandemic highlighted the value of primary care. But primary care is in deep trouble: Without additional help from the U.S. Congress, up to 60,000 primary care physicians could go out of business by the end of June. Hospitals lost revenue due to the COVID-19 response; primary care practices are no different, except that their problems are being largely overlooked.
The pandemic also exposed the fundamental irrationality of how we pay for most health care in this country - per patient visit, instead of per patient's health. When many patients avoided both routine and urgent health care out of fears that they might become infected with COVID-19, this not only risked their health but also crashed the income of medical practices. Expansion of telemedicine services has provided important care, but required financial and human resource investments, and revenue from telemedicine visits, has not replaced earnings from traditional care. As a result, many practices are losing half or more of their usual income.
Some practices accepted loans from the federal Paycheck Protection Program. But requirements of the program are complex, and many providers will be unable to repay them. Furthermore, loans don't address the fundamental risk of insolvency for these practices. Closure of a store, restaurant or movie theatre may be an important loss for a community, but the closure of a medical practice can be life-threatening.
The recent federal CARES Act, and the proposed Heroes Act, provide some funding for primary care through Federally Qualified Health Centers but, wonderful as these facilities are, they serve only one of 13 Americans people in the U.S. Outside of these centers, there is no dedicated financial support for the primary care practices that serve the remaining 300 million Americans of us. And the ratio of funding for primary care to funding for hospitals and the rest of the health care system - less than 5 percent of health care spending, and less than 1 percent of dedicated funding in the CARES Act - reflects the low priority given to primary care in the U.S.
Small primary care practices are the only health care source for many Americans, especially people living in rural areas. If these practices shutter, for some rural patients the nearest health care facility will be hundreds of miles away. In urban areas, fewer primary care practices will lead to more crowded, overburdened emergency departments and urgent care centers. The result will be a health system even less well equipped to deliver the testing, diagnostics and care urgently needed to control COVID-19 - and to build the personal and community resilience needed to save lives, prevent hospitalizations, and blunt the impact of the pandemic.
Loss of primary care will inevitably lead to neglected prenatal care, delayed or missed routine vaccines and cancer diagnoses, and poorly controlled chronic conditions such as hypertension and diabetes. This neglected or deferred care will result in more costly late-stage disease complications, decreasing our overall health and driving costs up in the long-term.
Primary care is the small business of health care; it is not too late to save it. New federal legislation should support primary care practices. Substantial funding is needed, and this should be provided in a new structure - capitated care, with at least part of the monthly per-patient fee dependent on health outcomes. A model of global capitation payments for wrap-around primary care services would provide a fixed monthly payment per enrolled patient, something already done by some health insurance plans. Steady, predictable monthly payments - whether care is in person, via video or by telephone - would be far better for patients and physicians; there can be additional incentives based on patient experience and improved health outcomes.
This payment model would provide these practices with the financial stability needed to weather uneven income flows and improve their ability to maintain practices and treat patients. It also would reduce the administrative burden of piecemeal insurance claims necessitated by the fee-for-service model. Furthermore, it would enable and incentivize practices to expand use of the full range of health care professionals and provide more effective, less expensive care through team-based service models.
Higher capitation payments enable better primary care services, optimizing the value for patients, communities and the health system. This type of compensation could enable primary care practices to implement multi-disciplinary team structures centered on patient needs, not on billing requirements, and allow use of more non-physician health workers. Lay community health workers could provide proactive population health outreach.
These funds must be provided with as little administrative burden as possible so they can be accessed by all, including the many small, independent practices that can't afford accounting departments and finance consultants. Additional measures to save these primary care practices could involve Congress providing funds to simply forgive loans already provided - possibly including loans for medical school - and to address private insurer support for primary care.
Despite many areas of controversy in funding and allocation of health care, all should be able to agree on this simple idea: We should pay our primary care providers to keep us healthy and establish a payment system that enables them to do this without risk of bankruptcy.
The COVID-19 pandemic has unmasked many weaknesses in our public health and health care systems. But the outbreak also has accelerated, within weeks, useful health care innovations that would have normally taken years to develop. A strong, resilient primary care infrastructure could be a casualty - or a landmark achievement - of our response to this pandemic. For the sake of our health, Congress must act.
Tom Frieden, M.D., is Senior Fellow for Global Health at the Council on Foreign Relations, President and CEO of Resolve to Save Lives (an initiative of Vital Strategies), former director of the U.S. Centers for Disease Control and Prevention, and former commissioner of the New York City Health Department. Follow him @DrTomFrieden, LinkedIn, and Instagram.
Dan Schwarz, M.D. MPH, is the Director of Primary Health Care at Ariadne Labs. He is a general internist and pediatrician in Boston and an instructor at Harvard Medical School.