The COVID-19 pandemic has done a number on primary care—and it will continue to do so in the near future. In part one of our two-part series on COVID-19’s impact on primary care, our panel of experts shared the strains being put on doctors and independent practices alike.
“Primary care has been caught flat footed. A lot of these practices that on the fee-for-service, visit-based model are really struggling. That’s unfortunate because this is the time where good solid primary care should be having an impact, making sure patients at risk are kept safe and those who have needs are being addressed through virtual technology or otherwise,” said Scott Shreeve, MD, CEO of Crossover Health.
The experts also discussed what the financial closures of practices would do to the access of care in certain areas, the long-term impact on primary care and how the pandemic exacerbates existing issues of primary care.
In part two, we focus on solutions to the problem. What actions can health care organizations, specifically payers, take to sustain primary care both during and after the pandemic? What hope does the increased usage of telehealth offer primary care for the future? Our panel discusses all of this and more.
Panel of experts:
Farzad Mostashari, MD, CEO of Aledade, which partners with independent practices, health centers, and clinics to build and lead Accountable Care Organizations (ACOs); former National Coordinator for Health IT
Ateev Mehrotra, MD, associate professor of health care policy and medicine at Harvard Medical School
Christine Bechtel, president and chief strategist, X4 Health, a strategy consultant firm
Scott Shreeve, MD, CEO of Crossover Health, a digital health, national medical group
Chris Koller, Milbank Memorial Fund, an operating foundation that works to improve population health; former Health Insurance Commissioner of Rhode Island
What actions can health care organizations, specifically payers, take to sustain primary care?
Koller: I focus on payers because they are the ones with the one with the money. We have a collective problem in that if you go to any individual insurer, they know they need a strong primary care system. But no single insurer has enough business to change the finances of the primary care practice by themselves. If you think about it, primary care practices accept from Medicare, Medicaid and 10-15 commercial insurers. You need payers to act collectively to address the issues of primary care and preserve it in the long run. We’ve been looking at places where there are a small enough number of payers to make a difference. We’re also following a proposal from the Pacific Medical Group and California Medical Association, which are asking legislatures in the state to require health insurers to make $2.5 billion in prospective payments to independent primary-care providers for this year and next.
Mehrota: There have been a number of ideas proposed to help sustain primary care. The one that’s the most viable is prepayment. If I am a health insurer and I see based on prior data that I give $10,000 to a primary care practice for payment each month for the care they provide, what I’ll do is give them 80 percent of it to tide them over through the pandemic and ease their pain. It could be a lump sum payment or it could be as a conditional on visit patterns post pandemic. Those kinds of programs are helpful and important. We need more implemented between health insurers and Medicare. If these payers lose large primary care practices, it’s worse for their beneficiaries.
Mostashari: Payers should be thinking about which independent primary care practices are most important to you and how will you keep them healthy? Let’s face it, payers will have a surplus this year. Instead of paying them back because you exceeded your medical loss ratio, why don’t you spend some of that on primary care? And do it in a way that sets primary care on a track towards person-based, longitudinal payments, towards value-based care. We see too many people not making a move. “Let me just hold on to this cash because I don’t know what’s going to happen.” You know what’s going to happen. Some of these practices will go out of business and you’ll be in worse shape down the line. Payers need to use long-term thinking and long-term actions.
Bechtel: There is an immediate role in injecting stabilizing funds and there’s a longer-term role for payers to play. Unfortunately, primary care practice, based on our survey data, are telling us the commercial payers are not doing a great job of paying for telemedicine. Not all are doing pay parity and 20 percent of practices are seeing denials of the bills they’ve submitted to commercial insurers. There’s definitely an opportunity for private payers to do better. We asked primary care practices who they feel valued by. Seventy percent feel valued by their patients. That’s awesome. Patients are allies. Only 39 percent felt valued by private insurers. That’s a huge delta with how these practices feel valued by patients vs. commercial and government insurers.
What hope does the increased usage of telehealth offer primary care for the future?
Shreeve: Most people think of virtual care as some kind of video visit done over the internet. We find that only a small percentage of virtual visits are done that way. Most people just want to get in touch with their doctors. The most common way is over the phone. If you look at some of Teladoc’s numbers, there are a ton of telephone calls because that’s a normal, convenient way to get in touch with a doctor. Video visits are interesting and there are certain cases where that’s effective. Most of what we see is asynchronous communication. People want to text and message their provider quickly and then thoughtfully write comments as needed. The approach Crossover took, and where we think the bulk of telehealth will go, is the ability to stay connected to the patient. And most people want to text or message their provider.
Farzad Mostashari, MD, CEO of Aledade
In the future, we think you will engage health care how you engage with most of areas of your life. You start engaging patients digitally and, when needed, you can flip that to an in-person or synchronous visit. One of the biggest challenges for primary care is it’s under resourced. We don’t have enough primary care providers. One of the huge advantages of telehealth is it can expand the reach and access for people. The number of patients that a physician can manage increases with telehealth. There are a whole new range of things possible.
Mostashari: I think there are some kinds of visits that are easier and better with telehealth. Being able to do advanced care planning is easier and better, if you can get the family members on the call as well. That’s hard to do with a face-to-face visit. Transitional care visits are also easier. Engaging with the patient after they’ve left the hospital. Right after a hospitalization, patients have mobility challenges. It’s hard for them to get out of the house and into the office for a follow up visit. It’s almost like a home visit. You can see the surroundings of the patient. You can see the level of care and see how they’re assembling their medications next to their bed. You can see their state of confidence in the home. You can see who else is in the house. You can see an increase in percentage of patients who had a hospitalization with a transitional care follow up visits.
It’s also limiting. Blood pressure is hard. Taking a fishhook out of a finger is impossible. It has clearly earned a place in primary care. We should continue to have the flexibility to do telehealth. As a policymaker, I’m a little worried. After this period passes, we could see tele–visits indiscriminately used as an income source in fee for service, increasing overall costs. Being used not to substitute face-to-face visits, but just as an added cost. That’s hard from a fraud/waste/abuse perspective to police. My suggestion is we use this is an opportunity to drive more flexibility for people who have accepted total cost of care accountability.
What advice do you have for health care CEOs to ensure primary care survives this pandemic and thrives once it’s over?
Mehrota: The number one thing I can emphasize right now, particularly to health plans, is the provider community is unsure of what the payment environment will look post pandemic. To the degree that payers, and Medicare in particular, signal how it will be like for the long term, providers will respond. If I’m a primary care provider in Cambridge, Mass. I’ve started using telehealth in the context of the pandemic. Now I’m in this stage where Massachusetts is opening up a bit, what am I going to do? Am I going to go full hog and embrace telehealth? Meaning I have to invest in a better telehealth platform than a Zoom call. I have to train staff, train patients, change my schedule. Maybe I’ll do telehealth one day per week doing visits. I’m going to have to help to get my patients who need certain technologies in their home. That’s a lot of investment in time and money. If payers signal to me that after the pandemic, they’re not covering this at all, I’m not going to put that investment into telehealth. It won’t have any returns. But if this is the payment environment afterwards, I’ll start investing a lot more right now so I can be ready and useful during and post pandemic. That’s what primary care practices are looking for right now.
Koller: If you look at the problems we’re encountering in our health care system. Poor chronic care. The threat of COVID. The inequitable outcomes based on race. All those can be addressed and improved significantly with strong primary care. What’s important for payers is to pay primary care commensurate with value. And to work with other payers to make sure that happens. We work with the Medicare Comprehensive Primary Care project in 18 markets. And those markets are seeing the value of what happens when payers get together and say, “We need strong primary care. I can’t do this by myself. We have to work collectively.”
On the delivery system side, alternative payment models and value-based care won’t succeed without strong primary care. The literature is really clear on that. To succeed at value-based payment, you need strong primary care. Health system leaders have to recognize that and invest in it.
Shreeve: Every bit of research and literature recognizes that a good solid primary care infrastructure is the foundation of any good health system. Investments need to be made to make sure that foundation is strong, that it’s capable, that it has the reach and the efficiency to really set a baseline of care. Health care CEOs, whether they’re on the pharma side, insurance side, or provider delivery side, I don’t think this is really an argument. This isn’t a point of contention. Everyone agrees with that. We need to create the financial systems, the technological infrastructure, and models of care that allow primary care to take its rightful place in driving better outcomes. If we can make those investments, you’re going to see a much-improved system that’s more efficient and effective in achieving the objectives that we all hope for health care.