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"Financially, many primary care practices are hanging on the edge right now, trying to get through the crisis and wondering what happens post-COVID."
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Questions to Guide the Future of Primary Care

By Donald Berwick | Friday, October 9, 2020
Questions to Guide the Future of Primary Care Photo by Aaron Burden | Unsplash

After practicing as a primary care physician for 20 years, that’s still how I see myself at heart. And that’s why I’ve watched the many changes in primary care over the years with empathy and gratitude.

The COVID-19 pandemic has led to massive changes in primary. The speed of learning and change in primary care has been amazing. After a big dislocation while practices rapidly converted to telehealth, I sense more practitioners are becoming more comfortable with virtual visits.

As a patient, I’d say my experience of telehealth has been better than satisfactory. My own last two encounters as a patient with health care have been virtual and I liked that I didn’t have to get in my car. I didn’t have to fight traffic for 45 minutes. I didn’t have to sit in a waiting room.

For one of my encounters, I needed help from several different specialists, so we met together in the same virtual space. Pre-COVID, that would rarely have happened. All the communication went beautifully. I’m hearing this kind of story from many people.

Of course, the picture is not all rosy. Financially, many primary care practices are hanging on the edge right now, trying to get through the crisis and wondering what happens post-COVID. One survey in Massachusetts found that as many as 20 percent of primary care practices are thinking of closing their doors at a time when we need more primary care, not less.

We are at an important inflection point. With humility, and all due respect for the complexity of the situation, I hope we in health care can consider the following questions:

  • Do we want to go back to the old normal? Or can we imagine a new and better normal? It’s awfully hard to maintain energy and optimism when you’re under the kind of pressure health care has been under in recent years and months, but the best way out of this morass may be to start by imagining something better.
  • What have we learned from COVID-19 that we want to keep? I, for one, hope we can keep the open-mindedness and sense of creativity I’ve witnessed.
  • What doesn’t primary care need to do anymore? I believe fee-for-service medicine has — with good intent — convinced us about habits in care, periodicity for follow-up checks, for example, or the plan to do more tests than may be truly needed. We’ve developed some habits without much evidence to support them.
  • What would make work even more satisfying, smoother, and more integrated? What regulatory and financial payment barriers are in the way? What payment system would be helpful? What new forms of training might help?
  • What is primary care’s role in addressing racism? COVID-19, the George Floyd killing, and the Black Lives Matter movement compel us to give our attention to the chronic, 400-year-old problem of racial equity for African Americans and for many other excluded or marginalized groups. Social conditions — including structural racism, the persistence of poverty, and othering — strongly affect the burdens of illness we try to address with patients. We can’t keep ignoring or just talking about racism.
  • How will we address issues of access? A study done on a population of Medicare patients asked how many people have access to a web-enabled smartphone or a computer that can do a video call. Depending on the demographic, 20, 30, or 40 percent of elders don’t have the needed technology. People of color and those who live in rural areas, especially African Americans and Latinos, have less access to these devices. People who live in rural areas may also lack broadband service. If we are going to depend on virtual care, we’ll need to make structural changes to ensure equitable access.
  • What will help the financial sustainability of primary care? I think we will need a new financing model that is responsive to the conditions we’re facing for what I suspect is at least another year of COVID, if not longer.
  • What would it look like to get engaged with primary care redesign? What are the ways to contribute to the conversations going on right now about what comes next?

These issues don’t have easy answers, but we can look for examples of possible ways forward. For example, I had the great privilege of being involved for a while with a visionary pre-COVID project called Linking & Amplifying User-Centered Networks through Connected Health (Launch). It was created by the National Cancer Institute, the Federal Communications Commission, the University of Kentucky, and the University of California, San Diego. LAUNCH’s goal was to see whether it was possible to project world-class cancer care to remote parts of the United States that face the dual challenge of higher cancer mortality rates and lower levels of broadband access. The project started by focusing on rural western Kentucky.

LAUNCH found that the challenges of attaining “connected health” (“the use of technology to facilitate the efficient and effective collection, flow, and use of health information”) are daunting, but they can be overcome. Cooperative systems thinking is necessary for success because getting the expert and the patient online isn’t enough if they can’t get a strong and reliable internet connection.

I thought the potential of this kind of effort was enormous. One could begin to imagine that anybody, anywhere — at much lower cost and with a much lower carbon footprint — could get access to world-class cancer guidance that was much harder to get through a visit-based system.

I could be wrong, but I think that we might get some surprising insights when health services researchers study the changes in primary care since the start of the pandemic. We may have our assumptions challenged and learn which forms of care delayed or abandoned were actually needed, and which were not. We may discover that a lot of the telehealth that’s going on is better, with or without COVID, and that would be one good thing to come out of this whole tragic situation.

Donald M. Berwick, MD, MPP, FRCP, is President Emeritus and Senior Fellow, Institute for Healthcare Improvement. 

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