From crisis to opportunity: Time to invest in primary care

The COVID-19 pandemic has exposed an inadequate and antiquated reimbursement system for primary care, compounded by a neglected public health system.

The COVID-19 pandemic has laid bare a truly broken U.S. health care system that costs too much, leaves too many behind, has major health inequities, and is focused on sick care instead of overall health and wellness. It is a system that values high-cost, aggressive, procedure-oriented treatment of end-stage disease associated with large hospital-based systems, rather than well-coordinated and well-funded primary care and public health focused on wellness, prevention, population health, and optimal control of chronic diseases in the community outpatient setting.

The crisis

The pandemic quickly exposed our inadequate and antiquated fee-for-service primary care payment system and minimalist public health system that have been ignored and whittled away for decades. We were totally unprepared to efficiently respond to the virus, and physician offices, local hospitals, and county health departments were left to scramble for personal protective equipment and other resources to evaluate, test, and treat patients with COVID-19.

As physicians, we were also left to scramble for options to care for patients with chronic diseases during the pandemic. How could we address their health concerns in a manner that kept them safe, in addition to keeping our clinic staff and ourselves safe? How could we readjust the schedule to have fewer patients in the office at any given time? What would be the new workflows? How could we use a combination of telehealth and in-person visits to accommodate patient needs? How could we adequately assess patients to keep their chronic diseases under control without actually seeing them in the office?

Most primary care physician offices like mine were quickly inundated with calls for care over the phone, while facing a sudden and dramatic decline in face-to-face fee-for-service appointments, only now with no payment. This meant primary care offices would be unsustainable within two to four weeks, unable to keep staff employed and unable to see patients without clinic staff help. Also, how could we continue to maintain staff positions for our employees who now had children attending school virtually from home?

The financial implications, especially for small practices, have been overwhelming. ACP has been there to help from the beginning with resources and advocacy. With pressure from ACP and other physician organizations and an emergency effort to help patients and their physicians, CMS lifted restrictions on telehealth during the public health emergency. Pay parity for those services along with the Paycheck Protection Program were rapidly put into place to sustain practices for at least two months.

Six months later, in the fall and winter of the pandemic, some private payers are rolling back many of the new telehealth agreements and pay parity for non-COVID-19-related visits. All of these temporary agreements will disappear completely without changes in policy from CMS and private payers at the end of the public health emergency expected later in 2021.

In ACP's New Vision for the U.S. Health Care System, published as a supplement to Annals of Internal Medicine in January 2020, the College reiterated how the “underinvestment in primary care in the U.S. contributes to suboptimal outcomes.” The New Vision papers emphasized the evidence showing that greater use of primary care is associated with decreased health expenditures, higher patient satisfaction, fewer hospitalizations and ED visits, and lower mortality.

In a data analysis of primary care spending in the U.S., published in JAMA Internal Medicine in May 2020, only 6% of all health care resources from 2002 to 2016 were spent on primary care. More recently, in a report published Dec. 2, 2020, the Primary Care Collaborative reviewed survey data across all payers from 2017 to 2019 and found that the primary care spend was down to 5.4% of all health care resources.

In my last column, I talked about the “Fauci effect” of more college students becoming interested in going to medical school. But what specialty will they choose, with a current average of over $251,000 of educational debt, a young family to start and educate, and a minimum of three or more years left of training, earning an average of $63,400 a year, according to Medscape's Residents Salary and Debt 2020 Report? The Medscape report also noted that more than 90% of trainees say future earnings have an impact on their chosen specialty. Medical students are voting with their feet, along with nurse practitioners and physician assistants. The majority of these clinicians consistently go into specialty areas of medicine and surgery in urban and suburban settings where the pay is high, the focus is on one organ system, and the default response for anything not related to that organ system is “return to your PCP.”

Primary care internists and hospital medicine internists are being used as the default service “provider” for doing all the things nobody else wants to do. Primary care is being derailed with administrative burdens and no time to do the comprehensive complex care we love and are well trained for. No wonder we are burning out. We are becoming data entry clerks who are pushed hard to see 20 or more patients per day to make enough relative value units to cover the overhead.

Many days it seems hard to do anything much more than whack-a-mole in a 15- to 20-minute office visit. Patients with multiple chronic medical problems cannot be properly seen and cared for in an environment based on volume of visits, not value provided to the patient and the whole system of health care. Primary care physicians are faced with doing the most expeditious and profitable thing: referring to medical and surgical subspecialists for chronic problems, most of which these primary care physicians are quite capable of handling and are trained to treat.

The opportunities

With every crisis comes opportunities. We have opportunities to correct many of these problems. ACP's New Vision presciently focused on how to provide better care with better health outcomes, lower costs, and improved physician and clinician support. It also outlined a change in the ways care is delivered with a focus on the less costly front end of care—prevention and management of chronic disease—rather than the expensive back end of care, with intervention in end-stage or late-stage disease.

ACP laid out the vision of a health care system where:

  • everyone has coverage for and access to the care they need, at a cost they and the country can afford;
  • primary care is supported with a greater investment of resources; payment levels between complex cognitive care and procedural care are equitable; and payment systems support the value that internal medicine physicians offer to patients;
  • social determinants that contribute to poor and inequitable health are ameliorated; barriers to care for vulnerable and underserved populations are overcome; and no person is discriminated against based on characteristics of personal identity; and
  • spending is redirected from unnecessary administrative costs to funding public health, health care coverage, and research, as well as interventions regarding social determinants of health.

In December 2020, seven major primary care physician organizations representing internists, family physicians, and pediatricians together published “Investment in Health as the New Paradigm for Financing Primary Care as a Public Good.” The paper underscores that the investment needed in primary care would shift a relatively small amount of resources to create significant improvement in health outcomes. It stated, “Advancing primary care as a public good will require shifting the paradigm of primary care financing, creating a unified approach among all payers, and dismantling the regulatory and financing structures that institutionalize the status quo.”

The paradigm compares our 60-year-old financing models for health care, which constrain “payment to the cost of care delivery by clinicians, teams, and systems rather than payment that encompasses the value of care received by patients,” to a new paradigm of primary care that invests in health that is longitudinal, relational, and integrated. The paradigm recommends that “the financing of primary care should be based on the long-term health and value created for patients and populations, rather than on the historical costs to clinicians and systems as assessed through an antiquated model.”

In October 2020, ACP's Executive Committee of the Board of Regents authored a brief paper published in Annals of Internal Medicine that analyzed the health care platforms of both U.S. presidential candidates. Since we now know that Joseph R. Biden Jr. is our next president, we can anticipate many of the possibilities for health care in the new administration based on the Democratic party platform of 2020 and the Biden-Harris Health Care Plan, which include supporting the Affordable Care Act and policies that increase the number of primary care physicians and clinicians, developing alternative payment options and innovative plans designed to pay for health outcomes rather straight fee-for-service care, and eliminating health disparities as well as racial, ethnic, gender, and geographic gaps in insurance rates and access to quality care.

Mr. Biden's nominations for his health care team include faces familiar to internal medicine, such as Vivek Murthy, MD, as surgeon general; Anthony S. Fauci, MD, MACP, as chief medical advisor to the president on COVID-19; Rochelle Walensky, MD, FACP, as CDC director; and Marcella Nunez-Smith, MD, as chair of the COVID-19 Equity Task Force. In addition, Mr. Biden has nominated Xavier Becerra, California attorney general and a former congressman, for HHS secretary. Mr. Becerra has been a champion for affordable health care access and coverage and has stated that the COVID-19 pandemic is currently the nation's number-one priority.

The way forward

ACP, along with many other physician and health care organizations, has systematically identified the major problems in our health care system and the decades-long underinvestment in primary care. These organizations have also laid out what needs to change and what the new vision for health care and the new paradigm for primary care should be. We now hope the new Biden-Harris administration, with important internal medicine leaders and other health care experts in key positions within the government, will be genuine partners in the mission to transform health care in general and primary care specifically. We hope they will make our vision for a better health care system become a present reality.

It seems the key stakeholders are coming into better alignment. It gives me hope for 2021 and beyond that we will see a transformation of our health care system and primary care. With so much at stake, we must make it happen.