• COVID-19 Shows What Is Truly Valuable in Health Care

    Adrienne Johnson, M.D., owns a family medicine practice in York, Pa. Security Family Medicine has long been a bedrock of her community, and it is one of the few independent practices left in the area.

    If longevity is an indication of being a good place to work, consider that Johnson's most junior staff member had been an employee for more than five years. However, Johnson recently was forced to lay off that person and another staff member and to make the seven remaining staff members part-time employees. Johnson herself is now getting by on credit cards in lieu of a salary.

    Jennifer Bacani McKenney, M.D., of Fredonia, Kan., also has had to make difficult adjustments to her family medicine practice to keep its doors open. Switching care to include more telemedicine has helped sustain revenue when face-to-face care is discouraged, but expenses for clinic needs such as personal protective equipment have also increased. Staff volunteered to take an extra half-day off to reduce the payroll burden, which has helped stanch operating losses. Each of her health care professional colleagues has also approached Bacani McKenney to offer to take a pay cut, which she has thus far been able to avoid. Bacani McKenney has not paid herself in the past four weeks.

    Johnson, Bacani McKenney and others generously shared their experiences with me to call attention to the threat the COVID-19 pandemic poses to family medicine. Their stories are not the only examples of the destabilization caused by the abrupt need to protect lives by changing care delivery. Indeed, the most recent survey by the Primary Care Collaborative found that only one-third of respondents reported their practices had enough cash on hand to last one month, and 60% of practices were unsure whether they would be able to keep their doors open after that period. COVID-19 has delivered a seismic shock felt throughout primary care.

    All primary care practices -- from solo practices to large health systems to federally qualified health centers -- are undergoing a massive stress test. I have focused on stories like those from Drs. Johnson and Bacani McKenney because as smaller practices, they are feeling the effects first and are a warning that we need to protect them, and the rest of our primary care system, before the situation becomes even more desperate. Indeed, HealthLandscape, the AAFP's web-based mapping tool, published a statistical model projecting that by the end of May, nearly 39,000 family physicians -- almost 30% of the workforce -- could be out of work.

    I am from California and grew up accustomed to earthquakes, even quite large ones. Although the shaking itself is bad, the destruction wrought by the ground turning to quicksand -- a process called liquefaction -- can be worse, destabilizing foundations and making homes buckle. Primary care is the foundation of health care, both in normal times and especially now, during a pandemic. The collapse of primary care would devastate our health system.

    As AAFP President Gary Leroy, M.D., told MedPage Today, "We have nearly 200 million office visits each year that we provide for this country. You take that away and you've kicked the legs out from a teetering system."

    The Academy has worked to ensure the government delivers necessary and meaningful help for primary care by advocating for relaxation of CMS telehealth rules and many of the relief measures in the Coronavirus Aid, Relief and Economic Security Act. Nevertheless, the existential threat many family medicine practices have felt from the COVID-19 quake begs an essential question: Why were family medicine practices so vulnerable to begin with?

    I would not be the first to point a finger at the fee-for-service payment system for many of the ills in health care. Instead of rewarding improved health, FFS rewards only productivity. When COVID-19 robbed doctors of their primary means of being productive -- seeing patients in the office -- we saw an unnerving collapse of our health care system. For the first time in memory for many, substantial numbers of U.S. physicians are collecting unemployment, despite a desperate need for more doctors on the front lines. COVID-19 has revealed what unstable ground we have built our house on.

    Some may argue that modernizing our payment system to recognize the technologies we use to provide care is the solution because it would allow practices to recoup much of their productivity. I agree that telehealth payment parity and paying for telehealth visits, whether they include video or only voice, are belated changes that all payers need to make. However, while necessary, these changes alone are insufficient for two reasons.

    First, disparity of data and telephonic access is deeply entrenched in our country, especially in rural areas, but also in urban areas. Almost half of the U.S. population lacks access to the minimum internet download speeds of 25 Mbps that meet the Federal Communications Commission definition of broadband. Furthermore, areas without broadband often lack adequate cell service, and many low-income Americans quickly reach their mobile data cap.

    Johnson confirmed that in her region, cell phone service is an issue in the Amish, Mennonite and other farming communities. I have had colleagues in urban community health centers relay that patients are unreachable because they quickly reach data caps or have phone service cut off for lack of payment. Relying only on telemedicine creates yet another barrier to care for our country's most vulnerable.

    Second, and fundamentally, FFS does not recognize all the value family physicians provide to ensure their patients can attain optimal health by fulfilling the population and public health functions that are otherwise unavailable to much of the country. Johnson organizes food bank deliveries for her patients with food insecurity, helps patients apply for government benefits and holds a diabetes class with a local chef. Highlighting the role family physicians play in public health, Bacani McKenney and her staff do visits and testing in the parking lot to protect other patients. Bacani McKenney communicates with her patients 24/7 to keep them calm during the pandemic, and you may have seen some of her patient education videos on Facebook that she creates on her own time. Bacani McKenney's practice is part of the front line that's preserving hospital capacity for the critically ill.

    This service is highly valued by Johnson's and Bacani McKenney's patients, and both practices play an important public health role -- especially in rural settings -- even if their care cannot be covered by a CPT code. Family physicians like Bacani McKenney and Johnson, in effect, give subsidies to health insurers through care they provide.

    As a specialty, family medicine has pushed for incremental reforms to make our practices more sustainable in a fee-for-service system. In retrospect, we only spackled and painted a house laid on unstable ground because we didn't know it could come down. The pandemic has revealed exactly how unstable that ground is, and we find health care and the health of the public in a precarious situation because of it.

    Here and now, the viability of primary care should be a call to arms for all stakeholders in the health care system. Government relief is necessary, but health insurers also have skin in this game. AAFP Senior VP for Advocacy, Practice Advancement and Policy Shawn Martin has made a cogent and forceful argument for prospective payments for primary care for the duration of the pandemic, also known as the Primary Care Marshall Plan, named for the U.S.-led effort that rebuilt post-War Europe.

    After this is over and we can finally reemerge for the face time and hugs with our colleagues that we have long craved, there will be rebuilding to be done. COVID-19 has created a lot of wreckage in a fee-for-service world. The lesson is clear. We need to quickly move away from FFS and complete our transition to prospective value-based payment models. Let's make sure we rebuild on solid ground. Primary care should be fighting and preventing health crises such as COVID-19 pandemic, and never again fighting for its life.

    Brent Sugimoto, M.D., M.P.H., A.A.H.I.V.S., is the new physician member of the AAFP Board of Directors. You can follow him on Twitter @BrenticusMD.  


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