Primary care practices are facing a double whammy of serving on the front lines of the COVID-19 pandemic while also seeing their practice revenues fall.
As the U.S. is starting to reopen, primary care practices need to keep their lights on to test and treat those with COVID-19 symptoms and address health concerns that people have neglected while staying home.
But these practices are going to need a bigger financial lifeline from the government to stay afloat, said health policy expert Farzad Mostashari, M.D.
Many physician organizations have called for federal COVID-19 relief funding targeted directly to primary care providers.
The provider relief funding doled out the White House and Congress has translated to "one week’s worth of revenue for primary care," the policy leader said.
"We have to treat primary care special for three reasons. One is, it’s not you saving primary care. It’s primary care saving you, right? They’re the ones on the front lines of COVID early diagnosis and treatment," said Mostashari, founder and CEO of Aledade, during a Commonwealth Fund podcast interview with Shanoor Seervai, senior research associate.
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"We got to get primary care to be able to survive so that when you have symptoms, you can go in and get tested and you can get advice on how to stay safe in isolation," said Mostashari, who previously worked as an epidemic intelligence service officer at the Centers for Disease Control and Prevention and served as the National Coordinator for Health IT within the Department of Health and Human Services (HHS).
He added, "Yes, everyone’s hurting, right? The ophthalmologists are also really, really hurting, but they’re not on the front lines of helping get us the heck out of this problem. Primary care is, that’s number one."
Primary care practices across the country also are addressing the "hidden pandemic" of people with untreated chronic diseases.
"We are seeing less primary care, less primary care for people with heart disease, lung disease, kidney disease, like all those people who are now staying at home, like my parents are going to have problems if we don’t keep primary care and strengthen their ability to deliver primary care to them. And we’re going to see, compounded across America, the problems of untreated chronic diseases. And who’s in charge of that—primary care," he said.
Healthcare leaders and policymakers also need to consider the long-term impact that consolidation is going to have on patient access in rural communities, as well as the impact on cost and quality, he said.
"It’s not good," he added.
As doctors treat sick patients they also worry about their own health and safety and the risk of bringing the virus home to their families, said Mostashari, who had his own coronavirus scare. (He tested negative.)
Many still lack adequate protective gear, and many worry about the financial stability of their practices.
On June 11, HHS granted $6 million to primary care associations to conduct COVID-19 training and technical assistance activities but many say it's not enough.
As communities reopen, primary care doctors will need to play a bigger role in testing and that will require more investment, said Mostashari.
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"That work will require not only the swabs and devices and cartridges and so forth, as well as reimbursement, but also PPE because being the site where people go to get tested is a high-risk endeavor," he said.
Until there is a COVID-19 vaccine, the pandemic has necessitated major changes to how practices operate, from creating "virtual" waiting rooms to conducting nasal swabs in patients' cars to disinfecting exam rooms to ensuring enough protective gear for staff.
"There’s a whole set of infection control practices that primary care has never had to do before on this scale. And that’s costly, it’s expensive, it’s time-consuming, and it’s not paid for," said Mostashari. "So at a time when they have lower revenue, they have higher costs. And something’s got to give."
Many practices have quickly adopted telehealth to continue to care for patients while reducing the risk of spreading the virus.
Aledade works with 550 primary care practices across the U.S. and among those practices about 40% of patient visits are now done through telehealth, Mostashari said.
"I believe telehealth will be here to stay because it’s actually a superior form of primary care delivery for certain things," he said. "For some things like transitional care visits, it’s fantastic—you even get a peek inside the patient’s home. And there’s a lot that you can do with telehealth."
Now that primary care has embraced telehealth, there is the potential to integrate remote monitoring tools to enable more innovative care delivery.
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Policy and reimbursement changes are needed to promote broader adoption of remote monitoring technologies and other devices that can track patient's health at home, he said.
"One thing I worry a lot about is blood pressure and Medicare right now has a bright-line policy around durable medical equipment, which says that we will pay for things that treat an existing condition like a stroke caused by high blood pressure. So they’ll pay for your motorized wheelchair, but we’re not going to pay for the devices for prevention, like blood pressure monitoring, automated blood pressure monitoring cuffs. So that policy is just dumb," Mostashari said.
The COVID-19 pandemic has underscored that the healthcare industry needs to pay more for preventive health services and that's where primary care doctors come into play.
"For the time being much of what primary care does is talk to patients, and that’s been the problem with primary care reimbursement is we don’t pay very much for talking to people."
When asked by Seervai what he would do to help primary care if he had a magic wand, Mostashari replied, "Change how we pay for care.
"I would create equity in terms of the actual value created by primary care versus the value created by everybody else who deals with the failures of primary care... I would create a system where there is more parity there in terms of paying for the outcomes we want," he said.