Some coronavirus patients experience a mild fever or never know they were infected. Others crash quickly and unpredictably, five to 12 days after developing symptoms; every doctor on the front lines has been humbled by a patient who is fine in the morning and on a ventilator in the afternoon. To combat this problem, primary-care teams at my hospital are trying something new: calling patients on Days 2, 5 and 8 after we’ve diagnosed them with covid-19 and instructed them to self-isolate at home. We’re looking for signs of an impending crash. We’re also reaching out to our frailest patients and giving them instructions about what to do if they contract the virus.
I made 30 such calls last week to people living alone, struggling with food insecurity or grappling with mental health issues. These were some of the most meaningful conversations of my career. Our primary-care teams have undoubtedly saved many lives with the telephone surveillance, which takes about 30 percent of our doctors’ time and nearly all of our nurses’ time. Primary-care practices across the country are deploying similar programs.
We’re also doing it, apparently, for peanuts. Covid-19 has led to a revolution in telemedicine, but insurance companies will pay only for services that directly replace in-person visits. Our frequent calls don’t do that; a patient wouldn’t come back two days later just to check in. At the same time, our core pre-covid work has evaporated. We ask patients not to come in for preventive or chronic care, for both their safety and — to preserve our protective gear — ours.
That won’t stop us, of course; the heroism I see every day has nothing to do with remuneration. But the pandemic, to say nothing of the looming backlog of deferred medical care, will not retreat quickly, and it doesn’t help patients if primary-care providers go out of business.
I’m lucky to work for a well-funded, nonprofit hospital system, where expensive advanced testing and difficult procedures like bone marrow and heart transplants help subsidize the money-losing work my primary-care peers do to sustain the health of our communities. But these are unsure times even at Mass General: We project a 50 percent loss in patient-care volume over three to four months, which will have a major impact on the $1.2 billion annual revenue our 2,900 physicians bring in. We hope that our infrastructure and assets will help us weather the storm.
Most primary-care doctors in our country don’t have this support system. America began this pandemic with a national primary-care shortage, and without help, they now face existential peril.
Most doctors get paid for each in-person service they provide. In Massachusetts, where I practice, Medicare reimburses us $130 for an annual checkup and $121 for a follow-up visit. Any work done in between those visits does not generate revenue. This model is called fee-for-service, and it was a disaster for primary care long before the coronavirus swept the country.
So much of health care has rapidly changed during this pandemic, but the payment model has not. As a result, while many doctors are performing heroic acts of service, the health-care system nationally is facing a 55 to 70 percent decrease in revenue, thanks to the sudden absence of in-person visits. Nearly half of medical practices say they’ve had to furlough staff, and 22 percent have made permanent layoffs. Those numbers will grow.
At my hospital, we’re fortunate: Officials say we’ll face no salary cuts, changes to our benefits or forced furloughs for at least eight weeks. That’s helpful: This is a time to focus on caring for our patients. And it’s been a wonder to watch. In our respiratory illness clinic, primary-care doctors like me now work alongside orthopedic surgeons and gynecologic oncologists, despite the fact that treating influenza-like illness is way outside their comfort zone. We’ve deployed new delivery models (part of a three-year strategic plan) in just three weeks: Paramedics provide mobile health care at home; intensive care unit clinicians help manage ventilators in community hospitals via video. These changes will remain after the coronavirus is gone.
But a reckoning is coming. If it was a stand-alone business, a high-functioning primary-care network like mine would operate at a net loss of 20 to 30 percent a year, or an average annual cost of $150,000 per physician, according to our internal modeling. That’s partly because we employ diabetes educators, geriatric case managers, social workers and addiction-recovery coaches — health professionals who are essential to the well-being of our patients but whose work is not reimbursed by insurers. We hire those professionals and pay them ourselves.
At a big hospital system, this works, because profit margins elsewhere offset our losses, and our work on population health is seen as central to the mission. But thanks to the pandemic, orthopedic surgeons, dermatologists and gastroenterologists have stopped performing 60 to 80 percent of their hip replacements, biopsies and colonoscopies, according to preliminary volume reports here. These specialists are now working side by side with us on the hospital floor to care for the exploding numbers of coronavirus patients.
Things are even more dire elsewhere. Half of all family medicine physicians work in small practices that aren’t cross-subsidized by other lucrative specialties. Instead, they rely on high volumes and minor procedures. Under normal circumstances, I might see 15 adults per day, while they see 20. At Northampton Area Pediatrics, a 40-year-old primary-care clinic in western Massachusetts, volume has plummeted during the pandemic. “What was a day typically spent seeing upwards of 30-plus kids became seeing anywhere from 8 to 15 children on telemedicine,” says pediatrician Ryan Kearney, who works there. His bosses applied for, but did not receive, a Payroll Protection Program loan. They’ve had to lay off a third of the workforce, including front-desk staff, medical assistants, nurses, a physician and two nurse practitioners. David Steele, the managing partner, worries, “We will never return to the world we had.”
Northampton Area Pediatrics is unfortunately one of many practices that are rapidly shrinking. The American Academy of Family Physicians projects that up to 60,000 primary-care practices may close between now and the end of June. A national survey of more than 2,600 primary-care clinicians conducted April 10-13 by the Primary Care Collaborative found that “financial strain on primary care practices is impacting their ability to keep staff employed and doors open.” Only 47 percent of respondents said they had enough cash on hand to stay open for four more weeks, and 42 percent are furloughing or laying off staff. Some practices I spoke with hope to rehire employees once the economy reopens. But others expect that in-office volumes and uncertainty around telehealth reimbursements won’t keep them viable.
As the point of first contact for most Americans when they are ill, primary care is where the testing and treatment of newly sick coronavirus patients will occur. In other words, the reopening of America will depend in part on a working primary-care infrastructure, and that infrastructure is collapsing.
Providing great care to a population is not about individual face-to-face encounters between a doctor and a patient — the way it is financed today — but is instead a team sport that requires expensive IT and groups of providers working together. As the incoming chief executive of the American Academy of Family Physicians put it: “Primary care is comprehensive, continuous, holistic, portable and patient-centered,” while fee-for-service “is focused on units of care, units of time and sites of service.”
What does holistic care look like during this pandemic? Perhaps the safest way to treat frail elders is to visit their homes. Contact tracers and community health workers may become a part of every patient’s care team. Many more patients will need mental health and addiction treatment than we can currently serve. But the fee-for-service system doesn’t allow for the sort of flexibility and adaptation required to meet these needs.
The good news is that the Center for Medicare and Medicaid Innovation had already devised a 2021 project to move some primary-care practices to a “global budget.” It’s a per-patient per-month payment system that allows doctors to care for a population in whatever ways are necessary. If the government wants primary-care practices to survive, it should roll out that project now, at the biggest scale possible. Commercial insurers and Medicaid will follow.
It is also true that health care in America is too expensive. We spend more than $248 billion a year on an entire industry of billers, coders and IT professionals whose purpose is to resolve the friction between insurance companies and physicians in the payment of bills. No other country organizes payment like this, and the waste is astounding. Global budgets will help eliminate this waste. For remaining fee-for-service care, the government could require health systems and insurance companies to adjudicate bills while patients are still in the office. Insurers would transmit the money the same way you pay Starbucks for your coffee — at the time you receive your service. These changes could easily fund the kind of patient care that would support a thriving population in good times or during a pandemic.
Finally, saving primary care won’t matter much if Americans don’t have ready access to health insurance. The ranks of the uninsured are now soaring. The only chance for many unemployed people to have coverage is through an expanded public option.
It has been heartwarming to see our nation recognize health-care workers as the heroes they are. At the same time, those workers are contending with profound insecurity surrounding their work — both the availability of basic gear and the stability of their employers. We are weathering these challenges with bravery and idealism. It would help to know that our faith will be rewarded with a more rational system.