By Christopher F. Koller and Anthony Shih
Disclaimer: The views presented here are of the authors and do not necessarily reflect the views of United Hospital Fund, its staff, or its board of directors.
The COVID-19 pandemic poses grave threats to our country’s fragile primary care system. In a recent national survey, frontline primary care clinicians reported shortages of supplies, limited testing capacity, and staff who were out sick or quarantined. In addition, 43% reported financial strain that may lead to practice closures. The situation is most likely worse here in New York City, the epicenter of the pandemic, especially among our small primary care practices. The city’s small practices are particularly important, as they disproportionately serve some of its poorest neighborhoods, which have been hardest hit by COVID-19.
The benefits of a strong primary care system, including better community health and reduced racial and ethnic disparities, are well documented. During a pandemic, these benefits may be even more valuable, as they can enhance public health efforts. While the Centers for Medicare & Medicaid Services has taken the lead on supporting primary care during the crisis by covering telehealth at the same rate as in-office visits, for example, additional and promptly implemented private payer policies are needed to support primary care.
Overview of Primary Care’s Epidemic-Mitigation Capacities and Effects
|Leverage established, trusted patient relationships||Amplifies public health education efforts to prevent infection, limit spread, and reassure people|
|Test for and report positive cases systematically||Improves surveillance and early case identification and isolation |
|Participate in contact-tracing efforts||Lowers infection rates|
|Treat positive cases guided by the best evidence and in a safe setting||Improves patient outcomes and minimizes the spread of infection|
|Practice care coordination for cases||Minimizes demands on limited acute-care resources|
Despite the importance of primary care, commercial insurers in many places have lagged behind Medicare in making telehealth a covered benefit and paying for it at parity with in-person visits. For providers with significant portions of commercial membership, this has had dire financial consequences. Even where such payment and parity coverage exist, the pandemic has threatened primary care’s viability because of increased expenses and precipitously decreased visit volume.
The lead commercial insurers in western New York—Independent Health and BlueCross BlueShield of Western New York—were prepared for the crisis, however. These carriers had already instituted telehealth-friendly coverage policies and, more significantly, primary care contracting strategies that prioritized attributing patients to practices and prospectively paying those practices a capitated rate for primary care services.
When faced with the rapid shift to less lucrative, urgent care-type telehealth visits in the wake of the pandemic, many primary care practices in western New York had guaranteed monthly cash flows for a large (but not predominant) part of their volume.
Moreover, in recognition of these financial risks to the primary care practices, Independent Health and BlueCross BlueShield of Western New York put their contracting feet to the gas pedal. Both anticipated increased telehealth utilization. Independent Health added an additional payment equal to the fee-for-service revenue the practice received last year as emergency funding. BlueCross BlueShield increased payment for telehealth visits, raised rates for routine telehealth visits to be equal to in-person rates, and covered pediatric and specific adult wellness visits performed by telehealth. Both payers cover telehealth equally whether the visit is audio-only or audio and video, and both temporarily relaxed measurement reporting requirements. Both accelerated quality payments to the practices to help with cash flow.
Aligning strategies and tactics, for the benefit of a community, is hardly a hallmark of health insurers. To what can this peaceable kingdom in western New York—at least in the primary care field—be attributed? Kenneth Rogers, an independent consultant who works with payers in western New York, points to three elements:
- A recognition by the health plans of the centrality of primary care in any high-performing delivery system and the need to strengthen it
- Locally led, nonprofit health plans with leadership committed to the health of their community, as well as their institution, who recognize no payer has enough leverage by themselves to change provider practice
- An existing sense of community solidarity, a track record of collaboration between plans (including a region-wide health information exchange and participation in Medicare’s Comprehensive Primary Care Plus demonstration), and the relationships and trust that have emerged as a result
Rogers reports that, to be sure, all is not sweetness and light with primary care practices in western New York. Like most health providers, these clinicians feel they are underpaid. Significant portions of primary care practices’ payer mix have not followed western New York’s BlueCross BlueShield and Independent Health with a move to prepayment. And the pandemic still poses risks to the health of their patients, teams, and business.
But in western New York, primary care—which serves as the foundation for the regional health system—is in better shape and better able to care for its residents because of the leadership of enlightened, committed commercial payers.
Christopher F. Koller is president of the Milbank Memorial Fund.
Anthony Shih, MD, MPH, is president of United Hospital Fund.
United Hospital Fund has a long history of bringing together diverse perspectives to address critical challenges in health care in New York. In the current crisis, it’s more important than ever to hear from all parts of the health care system. Today’s commentary from Christopher F. Koller and me looks at how COVID-19 is affecting small primary care practices and how payers can help. It is being co-published by the Milbank Memorial Fund. – UHF President Tony Shih