David A. Gould and Carol Raphael
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 has highlighted the vital importance and vulnerability of primary care. Understandably, the media has focused on the overwhelming demand for emergency, inpatient, and ICU care, and, more recently, on the large number of deaths in nursing homes and prisons. The challenges to our nation’s primary care sector have received less attention. Demand for primary care services has plummeted in the past few months: community health center services have declined by more than 50 percent; as many as 60,000 community practices have faced potential closure by June; and hospital outpatient clinics have been sapped as resources and staff shifted to overtaxed inpatient care.
What does this mean for vulnerable people living in underserved communities? Many have complex chronic conditions (e.g., diabetes, chronic obstructive pulmonary disease, and heart disease), which are already exacerbated by such underlying social conditions as poverty, poor housing, food insecurity, and limited open space. These chronically ill people require consistent, coordinated management by primary care providers. But the decline of primary care visits—resulting from closures, reduced access, and a fear of seeking services in what are perceived as threatening care settings—indicates that they are not getting what they need. As a result, their chronic conditions will only worsen and in time present even more complicated demands to the health care system. At the same time, many are missing out on preventive measures, such as vaccinations and prenatal care, which can only lead to increased morbidity and mortality.
So, what must we do to not only restore primary care capacity but to transform it in ways that will meet new demands? In tackling this challenge, it is important to come to grips with the fact that reliance on primary care services—in all its traditional settings—has declined in the past decade. That patients are turning to other settings, including urgent care and retail clinics, suggests that they have a negative perception of how care is being delivered. Ironically, for a decade that has promoted the concept of patient-centered care, patients seem to place increased value on ease of timely, low-burden access to care rather than continuity and comprehensiveness. If primary care is to reestablish the foundation of the health care system, it must deal directly with this emerging trend.
What is to be done?
Ensure more and better structured financing, including global prospective payments. Primary care accounts for between 5–7 percent of total health care spending—a figure in no way commensurate with the demand it faces. COVID-19 has starkly highlighted and exacerbated the problem. In line with other states, the Primary Care Development Corporation (PCDC) has launched a campaign in New York to work with public and private payers to double primary care spending by 2022 through a mix of regulatory and legislative actions. We seek not to increase total spending but to rebalance current expenditures. But additional primary care financing must be structured in ways that support greater value and dependability. Primary care providers cannot implement sustainable growth strategies in an environment buffeted by fiscal cliffs, erratic Medicaid payments, and complex streams of private payments. Nor can they devote so much of their time to satisfying administrative demands to claim per visit payments from multiple insurance plans. When primary care providers are better compensated for the quality of their work, they can spend more time satisfying their professional goal—caring for patients.
Systematically address long-term staffing shortages. COVID-19 has triggered furloughs and lay-offs and has greatly accelerated losses to early retirement and burn-out. In addition to bringing back valued staff, we must aggressively implement effective recruitment and retention strategies. As veteran staff return and new professionals and frontline health care workers are recruited, they will require training in new approaches to service delivery and in learning how to better protect their own physical and mental health. They need to know that they and their patients are safe. In turn, connecting with other professionals in a team-based approach will allow staff to work more effectively and efficiently and in closer collaboration with community-based service organizations.
Thoughtfully explore the potential for consolidating community health centers and small community practices. COVID-19 has jeopardized the ongoing viability of many centers and practices. We cannot afford a period of un-strategic restoration in which we try to rebuild all existing providers or reproduce current disparities in primary care access. A new, better-balanced, and integrated system will require fresh thinking that takes population health at the community level into account.
Carefully establish best practices to maximize the potential of telehealth. Long touted as a promising component of a redesigned care system, telehealth has made a quantum leap during the COVID-19 crisis. Some envision it as the source of primary care’s rejuvenation, anticipating a day when it constitutes half of patient encounters. If telehealth is to meet patient expectations for ease of access—no getting to the office and enduring long waits—for a service that could be delivered at distance while also satisfying clinical needs, it will need sustained attention to maximize its potential and set appropriate limits.
To do this, we will need to document, assess, and share best practices. We need to know when telehealth visits work, and when they don’t. We need to know how telehealth models can be designed and implemented to foster the hallmark of excellent primary care—continuous and trusting relationships. We need the capacity to assess new technologies and train staff to fully use them. We need supportive and responsible reimbursement policies by public and private payers that promote broad adoption and genuine accountability. These multiple and related goals could be better achieved with the guidance of a leadership organization, so that the unnecessary expense and inefficiencies of adopting Health Information Exchanges and Electronic Health Record systems are not repeated.
Forge effective partnerships. In addition to continuing promising approaches for integrating behavioral health services, primary care providers must craft effective relationships with community-based organizations that can address critical social service needs.
By successfully tackling the core challenges described above, primary care providers will be better able to meet the deferred and ongoing needs of chronic care patients, and the myriad needs of the highly stressed, vulnerable communities they serve. Moreover, a revitalized primary care sector should be a valued partner of public health in efforts to conduct the screening and testing so essential to preventing the spread of COVID-19 and future outbreaks. Just as important will be its involvement in post-hospital care to stave off the effects of deferred care, such as unmanaged diabetes, hypertension, and cardiovascular disease (which have been implicated in COVID-19 morbidity and mortality). Primary care must also regain its leadership role in preventing future epidemics of vaccine-preventable diseases such as measles.
If primary care is not better supported in the future, we will be forced to rely on emergency departments and inpatient care, thus inverting the image of the health care pyramid, which should rest on a broad base of accessible, efficient, and affordable primary care. COVID-19 has shown us how costly and harrowing that inversion can be.
David A. Gould, PhD, is the former Senior Vice President for Program at United Hospital Fund and the current Board Chair of the Primary Care Development Corporation (PCDC). Carol Raphael, MPA, is a Senior Advisor at Manatt Health Solutions, the former President and CEO of the Visiting Nurse Service of New York, and the Vice Chair of PCDC.
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 David A. Gould and Carol Raphael looks at how primary care can be strengthened and transformed in ways that will meet new demands. – UHF President Tony Shih