Balancing on an Edge: State of Primary Care

By Matt Fisher, Esq
Twitter: @matt_r_fisher
Host of Healthcare de Jure#HCdeJure

What is the state of primary care physician practices as a result of COVID-19? The answer is at best not clear, but very likely in a bad place. Primary care faced significant stress even before the pandemic, but months of not seeing patients and continuing to be on the front line of care will only compound stresses. It all adds up to balancing on an edge.

Before getting into some of the current troubles, it may be helpful to understand where primary care stood before the COVID-19 pandemic created a seismic shift in patient interactions. Pre-COVID-19, primary care practices were already concerned about reimbursement levels since specialty medical care traditionally received higher reimbursement. Additionally, the shift to various quality initiatives or value based care meant that varying metrics needed to be met in order to get the same or declining reimbursement in the door. Overall, less money to go around often meant less money available for primary care even though responsibilities were being heaped on the physicians and clinicians who were first to see patients.

The brief description of the pre-COVID-19 landscape identifies a lot of concerns. All of those concerns were just pushed to the side when COVID-19 came about. As patients were justifiably told to stay at home, many primary care practices found that no visits were occurring. Then practices were given the directive to adopt telehealth solutions as reimbursement was finally provided for care delivered through those mediums. Many practices certainly were up to the challenge and did what was needed to continue providing care and access to patients. However, volume was clearly way down and the revenue coming would not be enough to cover all operating expenses.

What is the result? Many primary care practices are in financial danger with no clear end in site. Further, as the healthcare industry (and the rest of the economy and business world) move to reopen, primary care practices will once again be thrust to the frontlines. The frontlines in this instance could mean becoming initial testing sites for suspected COVID-19 patients and otherwise seeing patients at higher risk of various illnesses. Even in the absence of the heightened concern about the issues patients will present with, strict restrictions around reopening will mean patient volumes will remain low. If more resources are needed to operate in this fashion, will there be enough revenue coming in to even support those needs? It is a conundrum that likely no one can answer at this point.

In light of all of those challenges, what can be done? A lot of the debate will come back to parity in reimbursement and continued expansion of telehealth services (which also need to see continued reimbursement). The monetary needs are unavoidable, which means the issue come to how more can be directed to primary care. Such an approach represents a fairly substantial change from prior practice and setup. The backing for such a move has arguably been mounting with the focus on value based care and other quality based reimbursement systems. For example, many of the more successful accountable care organizations are groups of primary care focused practices that can then focus on managing and coordinating care. Should that become more of the norm? It could certainly work for some, but not all.

The expansion of telehealth and more proactive care can also be a game changer. If preventative measures such as remote patient monitoring can be expanded and fit into the continuum of care, it is likely that many clinicians and patients would be interested. Most people do not want to end up with an acute issue, but would prefer to address concerns before an inflection point. Again though, many different modalities of telehealth require some sort of investment or partnering for access to technology and services. Money may not be available overnight, but then again a system better structured to encourage that form of care delivery might play a role in implementation.

On top of expanding how care is delivered, what about the payment mechanisms? Is it truly best for primary care (and others) to be solely reimbursed based on the number of services provided? One of the main complaints about the current per service system is that it results in patients being churned through an office without much time to interact with the physician. The short amount of time with the physician has also been exacerbated over recent years due to the workflow interruptions caused by electronic medical records. A number of suggestions have been made during the course of the pandemic that shifting to more value based care centered models could address these concerns. First, a capitated (or set monthly payment) against which services are provided could insulate primary care to some degree against an inability to see the same number of patients or other disruptions. The monthly payment would come in regardless of what is happening outside. However, to succeed in that sort of system more support is needed in making practices comprehensively informed about patients. It is not an easy overnight switch. However, just because a change is difficult does not mean it should not occur.

All of the pending challenges mean that there are just as many opportunities. Primary care might be balancing on the edge at the moment, but the point of falling can be pushed farther away by moving ahead with reforms and innovations. Bold action will be necessary by every participant in the healthcare industry. Primary care is so often the heart of healthcare, which means it is time to take care implement good care to that vital beating heart.

This article was originally published on Mirick O’Connell’s Health Law Blog and is republished here with permission.