Coronavirus puts primary care physicians out of business
Some coronavirus patients have a mild fever or never know they have been infected. Others crash quickly and unpredictably, five to 12 days later develop symptoms; every frontline doctor has been humiliated by a patient who is fine in the morning and on a ventilator in the afternoon. To combat this, the 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 asking them to self-isolate at the House. We’re looking for signs of an impending crash. We are also reaching out to our most vulnerable patients and giving them instructions on what to do if they contract the virus.
I made 30 such calls in the past week to people living alone, struggling with food insecurity, or struggling with mental health issues. These are some of the most meaningful conversations of my career. Our primary care teams have undoubtedly saved many lives through telephone monitoring, which takes up about 30% of our doctors’ time and almost all of our nurses’ time. Primary care practices across the country are rolling out similar programs.
We also do it, apparently, for peanuts. Covid-19 has led to a revolution in telemedicine, but insurance companies will only pay 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 pre-covid groundwork evaporated. We ask patients not to come in for preventive or chronic care, both for their safety and – to preserve our protective equipment – ours.
That won’t stop us, of course; the heroism I see every day has nothing to do with pay. But the pandemic, not to mention the impending backlog of delayed medical carewon’t reverse quickly and it won’t help patients if primary care providers go bankrupt.
I’m lucky to work for a well-funded nonprofit hospital system, where expensive advanced tests and difficult procedures like bone marrow and heart transplants help subsidize the expensive work my peers do in primary care to maintain the health of our communities. But these are uncertain times, even at Mass General: We expect a 50% 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 doctors provide. We hope our infrastructure and assets will help us weather the storm.
Most primary care physicians in our country do not have this support system. America started this pandemic with a primary care shortageand without help, they now face an existential peril.
Most physicians are paid for each in-person service they provide. In Massachusetts, where I practice, Medicare reimburse $130 for an annual exam and $121 for a follow-up visit. Any work done between these visits does not generate income. This model is called fee-for-service, and it was a disaster for primary care long before the coronavirus swept the country.
Much of healthcare has changed rapidly during this pandemic, but not the payment model. Therefore, while many physicians perform heroic acts of service, the nationwide health care system faces a 55-70% drop in revenue, thanks to the sudden absence of in-person visits. Nearly half of medical practices say they have had to lay off staff and 22% have made permanent layoffs. These numbers will increase.
At my hospital, we’re lucky: officials say we won’t take pay cuts, benefit changes or forced furloughs for at least eight weeks. It helps: it’s time to focus on caring for our patients. And it was a wonder to watch. In our respiratory disease clinic, primary care doctors like me are now working alongside orthopedic surgeons and gynecological oncologists, despite the fact that the treatment of flu-like illnesses is well outside their comfort zone. We rolled out new delivery models (as part of a three-year strategic plan) in just three weeks: paramedics providing mobile home health care; intensive care unit clinicians help manage ventilators in community hospitals via video. These changes will remain after the coronavirus is gone.
But a settling of scores is coming. If it were a stand-alone business, a successful primary care network like mine would operate with a net loss of 20-30% per 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 coaches – healthcare professionals who are essential to the well-being of our patients but whose work is not is not reimbursed by insurers. We hire these professionals and pay them ourselves.
In a large hospital system, this works, because profit margins elsewhere offset our losses, and our population health work is considered mission critical. But thanks to the pandemic, orthopedic surgeons, dermatologists and gastroenterologists have stopped performing 60-80% 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 support the explosive number of coronavirus patients.
Things are even worse elsewhere. Half of all family medicine doctors work in small practices that are not subsidized by other lucrative specialties. Instead, they rely on high volumes and minor procedures. Under normal circumstances, I might see 15 adults a day, when 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 typically a day of seeing 30+ kids has become 8-15 kids in telemedicine,” says pediatrician Ryan Kearney, who works there. His bosses applied for, but did not receive, a Payroll Protection Program loan. They had to lay off a third of the workforce, including reception staff, physician assistants, nurses, a doctor and two nurse practitioners. David Steele, the managing partner, worries: “We will never go back to the world we had.”
Northampton Area Pediatrics is unfortunately one of many practices that are rapidly diminishing. The American Academy of Family Physicians projects that up to 60,000 primary care practices could close by 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 pressure on primary care practices is impacting their ability to keep staff employed and doors open.” Only 47% of respondents said they have enough cash to stay open for four more weeks, and 42% are furloughing or laying off staff. Some practices I’ve talked about hope to rehire employees once the economy reopens. But others expect 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 sick, primary care is where testing and treatment of newly ill coronavirus patients will take place. In other words, reopening America will depend in part on a functioning primary care infrastructure, and that infrastructure is collapsing.
Providing quality care to a population is not one-on-one face-to-face encounters between doctor and patient – the way it is funded today – but rather a team sport that requires expensive computing and groups of providers working together. As the new executive director of the American Academy of Family Physicians Put the: “Primary care is comprehensive, continuous, holistic, transferable and patient-centred”, while fee-for-service “focuses on units of care, units of time and service sites”.
What does holistic care look like during this pandemic? Perhaps the surest way to treat the frail elderly is to visit them at home. Contact tracers and community health workers can be part of each patient’s care team. Many more patients will need mental health and addictions treatment than we can currently serve. But the fee-for-service system does not allow for the kind of flexibility and adaptation needed to meet these needs.
The good news is that the Center for Medicare and Medicaid Innovation had already designed a Project 2021 moving some primary care practices to a “global budget”. It is a pay-per-patient, per-month system that allows doctors to treat a population in any way necessary. If the government wants primary care practices to survive, it should roll out this project now, on the largest 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 a all industry billers, coders, and IT professionals whose goal is to resolve friction between insurance companies and doctors in paying bills. No other country organizes a payment like this, and the waste is staggering. Global budgets will help eliminate this waste. For the rest of fee-for-service care, the government could require health systems and insurance companies to pay bills while patients are still in the office. Insurers would pass the money on 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 sustain a thriving population in times of prosperity or during a pandemic.
Finally, saving primary care won’t matter much if Americans don’t have easy access to health insurance. The ranks of the uninsured are now booming. The only chance for many unemployed workers to have coverage is with an expanded public option.
It has been heartwarming to see our country recognize health care workers for the heroes they are. At the same time, these workers face deep insecurity surrounding their work – both the availability of basic amenities and the stability of their employers. We face these challenges with bravery and idealism. It would help to know that our faith will be rewarded by a more rational system.