In January 2020, I probably would have talked about the fact that primary care continues to be an important, and under-supported, backbone for the whole endeavor of value-based care. I would have said there are massive continual payment shifts and more opportunities for primary care to have different and more sustainable models for delivering team-based care. I would have talked about the growing number of new players in the primary care landscape. Pharmacy chains are not only offering retail clinics, but they’re also starting to provide chronic disease care. There are private equity groups buying up practices and setting up long-term contracts around risk. Large, multinational companies are starting to provide primary care for their employees.
It’s both the same and different now. What’s happened in primary care through this pandemic is a massive stress test, an intense focus on the dangerous dependency for the financial viability of most practices on in-person visits. That dependence on in-person visits and a lack of financial reserves, even in large systems, has meant economic chaos for many primary care practices. According to surveys done by the Larry A. Green Center for Primary Care at VCU that I have collaborated on, up to 5 percent of practices have closed, and 20 percent are at risk of closure. These closures will lead to many consequences, including huge barriers to access, and then the downstream effects of [patients receiving] less necessary or preventive care and experiencing more delays in care.
Telehealth has filled part of the gap, but it hasn’t addressed the core problem which is that we have a payment model in the US that’s not designed to support the delivery and provision of team-based comprehensive primary care. COVID outlines the fracture and the risk of this misalignment. Now the question we have to ask ourselves is can we be smart as a country and move forward to fix that grave risk? Or do we lose a lot of wonderful primary care assets for our communities as another consequence of this pandemic?
It’s a policy question. It’s a practice question. It’s an economic question. It’s a question of societal priorities. It’s a question of the literal viability of primary care services for the communities who need it most, so it’s an equity question.
It’s also a question of rebuilding better and smarter. In the necessary discussions about what COVID-19 means and what role primary care has in the mitigation of current and future pandemics, we should think about how primary care can be the bridge between health care and public health. We should think about how primary care needs new data flows and new support to be that bridge. We can build on successful models that employ community health workers to invest in the communities they serve. We should think about how health workers can be supported to help rebuild the health system and improve health in their communities amid pandemic, economic, and racial justice challenges.
What are the advantages and potential problems of the widespread adoption of telehealth?
Number one, it’s sort of a “Welcome to the 21st century!” moment because it’s taken so long. The rapid adoption of telehealth offers a lesson for all those interested in improvement and transformation and it has nothing to do with cameras and virtual visits. It has to do with the ways in which we shackle our thinking, in which we say change can’t happen until an exogenous force makes it happen. The rapid expansion of telehealth is an amazing story of what can happen in a matter of weeks that was assumed would take a decade. That should give us pause to think about why necessary change does and doesn’t happen in the US health care system.
Telehealth has also expanded access and made care more respectful of people’s time. For a typical visit, a person takes two and a half to three hours of their day to travel to a clinic, sit in a waiting room, and then get labs. It’s often not a respectful, joyous experience. The old system is designed around idiosyncratic provider constraints and not around what patients need. Most of my patients love the immediacy, convenience, and efficiency of telehealth. Getting on a virtual visit for 20 minutes as opposed to taking a few hours to drag somebody in is a big part of our move forward in primary care.
The drawbacks are clear. Number one is equity. Not everybody has access to broadband and to cameras and to phones. Not everyone is technology and health literate. Many aren’t but most are. I will say that we also need to challenge our assumptions here. For many of my patients who have been at some points completely isolated in their assisted living facilities for months during the pandemic, telehealth visits were some of the only connections they had with the outside world. Are you sure an 82-year-old can’t manage a telehealth virtual visit? Maybe yes, maybe not. You should ask, not assume.
Another concern is a question of substitution. In telehealth visits, we can’t perform the same diagnostic maneuvers. I’ve done many an exam via telehealth. It’s tricky. You can’t quite see the skin or the issue at hand perfectly. I don’t think it’ll fully substitute for in-person visits any time soon.
I’m also concerned about relationships. People spend a lot of time virtually right now, and there is something important and humanly connective that many of us miss about being safely in a room together with someone else. I see telehealth as an augmentation, not a substitution, and a good one for the most part if we monitor for those potentially negative effects and mitigate them.
How can we ensure telehealth is equitable?
Addressing equity in access to telehealth services means addressing hardware, payment, and provision of services. I think a lot about how many public school districts decided to provide lower-cost laptops for every student as they’ve moved to remote learning. That might seem like a big investment, but there’s a logic to it from an equity basis because you can’t assume everyone has a computer and it helps standardize the platform everyone uses.
I’m not suggesting that clinics and health systems should provide free hardware for all their patients, but this idea should prompt us to think creatively, just as discussions around social determinants of health have prompted necessary shifts in thinking about what to include in a bundle of covered services and resource connections. The last time I checked my medical textbooks, the treatment for hunger was food. Similarly, if we have patients who are homeless or economically insecure and have no access to telehealth tools, wouldn’t providing a cheap, dependable phone be a great investment for a health system or a payer to consider? It would help patients stay in touch and help keep them out of the emergency room or hospital.
The issue of payment structures is a little more complicated. We need to decide as a country how we wish to pay for longitudinal, relationship-oriented primary care. The literature suggests that most primary care should be paid for with proactive population-based payments to provide all the necessary services patients need. In the absence of that, if we are going to maintain fee for service, then to keep primary care practices open that serve vulnerable populations, we need to make sure that they’re paid enough through their telehealth services and other additional payments to stay open.
Finally, telehealth is a great tool that’s finally in wide use, but it’s not the most exciting part of the future. You’ll never fully bridge the digital divide, so the resumption and maintenance of essential primary care services is the true long-term, equity-promoting pathway. This includes home-based services, community health worker services, care management outreach, and other options that don’t require patients to come into the four walls of a health center or hospital.
Was there anything else you wanted to say about primary care during this pandemic?
We have a real opportunity here. We need to ask ourselves some fundamental questions: Is the old model what we want to go back to post-COVID-19? Or is now the time to take a leap forward and take that improvement journey to build back in a new and transformative way?
We don’t know how long the COVID-19 pandemic will last. Sometimes in that ambiguity, we can miss the fact that — as providers, patients, practitioners, and policy makers — we are making decisions every day around a critical set of choices: Are we going to use this discontinuity, this difficulty, to get to something different and better? Or are we going to regress back to the status quo and believe the conventional wisdom that nothing much ever changes?
You only need to look very superficially to see how COVID-19 highlights all that we already knew was wrong with our health system, all that we now need to work together to fix. Every day we accept the idea that all we need to do is just get back to where we were on March 1, 2020, is a day we do a disservice to the patients and communities that we serve. Every day we accept inertia, conventional thinking, and a lack of zeal for transformative change, we do a disservice to ourselves as providers, who are burning out and losing faith in this profession. We do a disservice to this country and to the enormous resources that are expended on health care at the expense of other important social sectors. We owe it to society to do better, and to do better not with little pilots in increments, but with substantial improvements over the next few years.
Editor’s note: This interview has been edited for length and clarity.
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