The most significant barrier to health system resilience, the Academy recently told HHS, "is the lack of a long-term, objective and consistent support necessary for public health and primary care."
Likewise, the AAFP advised a Senate committee, any effort to prepare for a future pandemic must include a clearly defined primary care strategy.
In a pair of July 8 letters, the Academy responded to separate requests for input from health care stakeholders, both spurred by the ongoing COVID-19 crisis: a June 9 Senate Health, Education, Labor and Pensions Committee white paper(www.alexander.senate.gov) soliciting guidance for a potential bill to address future pandemic planning, and a June 5 HHS request for information(www.federalregister.gov) seeking to define and improve health system resilience.
The HELP Committee letter(8 page PDF) was addressed to Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., the committee's chair and ranking member, respectively. The HHS correspondence(3 page PDF) was sent to Assistant Secretary Adm. Brett Giroir, M.D., and Capt. Paul Reed, a deputy assistant secretary. Both letters were signed by AAFP Board Chair John Cullen, M.D., of Valdez, Alaska.
- In separate letters, the Academy recently responded to a June 9 Senate Health, Education, Labor and Pensions Committee white paper on future pandemic planning and a June 5 HHS request for information on health system resilience.
- Strong emergency preparedness, said the Academy, would center on primary care, prioritizing supplies, immunization and funding for primary care physicians.
- The AAFP advised HHS to emphasize PC as a tool to prevent future outbreaks by effectively managing preventive care and chronic conditions and called on the agency to consider several key financial considerations for family physicians.
"Primary care physicians, especially family physicians, play an important role in emergency response, recovery and resilience efforts," the Academy told senators. "Primary care physicians triage patients for testing, provide medication management assistance, support those with chronic conditions, support medical surge efforts, and address individuals' acute care needs. The general population relies on primary care physicians for most care, information, and counseling."
Both letters cited Robert Graham Center for Policy Studies in Family Medicine and Primary Care data indicating(www.graham-center.org) that in 2018, some 22 million people -- about 7% of the U.S. population -- received care in a hospital, compared with the more than 190 million people -- or roughly 60% of the population -- who received care from a family physician.
Moreover, compared with the roughly 260,000 Americans hospitalized for upper respiratory infections each year, 19.5 million patients are seen by primary care physicians for the same condition -- "suggesting that most COVID-19 patients will ultimately be evaluated and cared for in the primary care setting."
"Therefore, establishing a primary care-centered strategy would benefit preparedness efforts," the AAFP told senators. Toward that end, the letter recommended a number of actions, including
- prioritizing distribution of drugs, supplies and equipment -- including a potential COVID-19 vaccine and resources to enhance telehealth capabilities -- for primary care physicians;
- enhancing HHS' primary care coordination efforts with "investments in medical surge information dissemination among national organizations and state chapters," giving particular consideration to physicians in rural communities and medically underserved areas;
- addressing medical supply and immunization needs by, in part, creating a primary care liaison connecting the CDC, HHS' Assistant Secretary for Preparedness and Response and the Federal Emergency Management Agency; and
- moving to sustain and strengthen primary care(3 page PDF) "by providing targeted relief funds to primary care physicians in all practice settings," reinstating the Medicare Accelerated and Advance Payment Program, and supporting Medicaid payment parity -- as called for, the Academy reminded senators, in the Ensuring Access to Primary Care for Women and Children Act of 2020 (S. 4088),(www.congress.gov) which the AAFP praised in a recent letter.(2 page PDF)
Any of the above actions, if taken swiftly, could still have an impact on the COVID-19 emergency. The Academy also took the opportunity to advise the committee on how reinforcing health care strategies for ensuring primary care's viability now is a necessary step toward combating future crises, particularly those that disproportionately affect vulnerable populations.
With that in mind, the AAFP wrote, lawmakers should enhance the PC workforce with "training models that produce enough primary care physicians to meet state population needs and to reduce current maldistribution challenges that significantly affect rural communities."
Start by reauthorizing and funding the Teaching Health Center Graduate Medical Education Program and the Community Health Center program, the letter said, and then expand the Conrad 30 visa waiver program.
HHS' request for information on "Long-Term Monitoring of Health Care System Resilience," meanwhile, opened with a question all but tailored to the Academy's 2020 so far: "What have been the most significant barriers to assessing, monitoring and strengthening health system resilience in the U.S.?"
Support for primary care, answered the AAFP's letter.
"Funding for primary prevention has consistently been under-resourced, public health departments are understaffed, and there is a lack of investment in family medicine and primary care," it said.
"The most significant way to reduce the risks associated with COVID-19 would be to prevent or manage chronic health conditions, address the needs of vulnerable patients, provide administrative flexibility for physicians to enable them to focus on patient care and ensure continuous health care access."
Yet an already fragmented, hospital-biased system is further challenged by disparities in primary care investment among the states,(www.pcpcc.org) the Academy wrote.
To counter this diminution of U.S. health care in the face of future large-scale public health threats, the AAFP advised HHS to consider
- increasing primary care payment rates in Medicaid to at least Medicare rates;
- altering the Federal Matching Assistance Percentage to allow for rapid increases in federal contributions when state economic conditions decline;
- opening special enrollment periods during emergencies to allow uninsured individuals to enroll in health coverage; and
- ensuring permanent telehealth flexibility, with adequate and stable reimbursement for virtual care.
Answering a question about how best to define resilience, the Academy emphasized "the need for a robust family physician and primary care physician workforce," touted its 25x2030 initiative to grow that workforce, and reiterated its support for the THCGME and National Health Service Corps programs.
But that workforce must also be sustained -- a challenge made more dire by the pandemic.
"Data suggest(www.pcpcc.org) that the health and well-being of our citizens are in jeopardy if primary care is not put on a more sustainable path," wrote the Academy, again calling for immediate and targeted funding of at least $20 billion from the Provider Relief Fund to primary care physicians in all practice settings.
"The COVID-19 pandemic has underscored that fee-for-service is an inappropriate payment structure to meaningfully resource primary care," the letter added. "This public health emergency should accelerate shifts to more sustainable models of care such as prospective global payments for primary care which also represent a greater overall investment."
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