The Dose - We Need Primary Care More Than Ever to Fight COVID-19

Episode Date: June 12, 2020

Every day, primary care providers are on the front lines of the COVID-19 pandemic, treating sick patients even as they worry about bringing the virus home to their families. Many still lack adequate protective gear, and many worry about the financial stability of their practices. With the U.S. starting to reopen, we need our primary care practices to keep their lights on — not only to test and treat people with mild symptoms but also to address health concerns that people have neglected while staying home. On this episode of The Dose podcast, health policy expert Farzad Mostashari, M.D., who advises and supports hundreds of primary care practices across the country, explains what it will take to ensure doctors can continue caring for Americans throughout the pandemic.

The Dose is a production of the Commonwealth Fund, a foundation dedicated to healthcare for everyone. So, you know, I'm talking to you sitting in my basement in Bethesda, and that's where I've been for the past couple of months. But our primary care doctors in all the practices across America, they actually have a very different situation. They are sitting and waiting for patients to come in. Patients with cough, patients with fever come into their office and they close the door and they sit in the room with a closed door with them, taking care of them, caring for them. And they do it patient after patient, day after day. Many of them have seen their own staff or other staff, people in the community,

get sick in those primary care practices. We've had spouses. They're worried about taking it home to their families. And while they're doing all this, you know, the other thing they're worrying about, they're worrying about how to make payroll and having to furlough their staff because they're not meeting their practice finances. Oh, and plus, they can't find masks because their regular supplier will not honor a request for three boxes of masks from some small doc practice in rural Arkansas. That's what it's like being a small practice primary care doctor today. Hi, everyone. Welcome to The Dose. You just heard from Farzad Mostashari about some of the challenges of being a primary care provider in times of coronavirus. Almost everyone has seen a primary care doctor in their

lives for a routine checkup, a broken bone, everything in between. And it's no secret that the entire U.S. healthcare system is reeling from trying to care for people with COVID-19. But I wanted to focus on primary care today because this is the lifeblood of our health system. And we need primary care doctors to keep their doors open as we figure out how we're going to get out of this pandemic. Farzad is a health policy expert and through his company, Allidade, works with 550 primary care practices across the US. Farzad, welcome to the show. Thanks for having me.

So tell me a little bit more. What are you hearing from the practices that you work with? You described a scene, but what's it really like? It must be incredibly stressful. You know, these practices that we work with are the best case because of a couple of things. One is that they have actually embraced a move away from pure fee-for-service. And let's be clear, what's broken here is how we pay for primary care by saying in order to get paid, you got to have someone come in and spend X number of minutes and document X number of things to get paid. You're getting paid for basically visits. care of a human being, which is what they want to do. So we figured out all of these workarounds in the fee-for-service system to keep these primary care practices afloat, even though it's

the wrong payment model. My company helps give them another alternative, a way to make money from value-based contracts if they can keep people healthy and out of the hospital, which requires patient-centered care where you're really worried about and out of the hospital, which, you know, requires patient-centered care where you're really worried about and thinking about the person, the human being. So many of our practices are in a very good situation because they have another source of income. We have, you know, practices getting checks for their savings that they're creating. The other reason why they're in a specially, you know, good position is because they have us. Yeah, what was your company doing before all this started? I mean, before this started, we were using data and technology to help them manage the entire

population of at-risk patients and help find ways and new habits for the practice to keep their patients healthy and out of the hospital. So, you know, we were training them and giving them tools for calling patients after the, if any patient went to the emergency room, that they would get a call from their primary care doctor. We were helping them think through prevention. So specifically, what are you doing to help your practices provide? And I know that's, you know, probably changes every week, but... Well, we asked them when very early on in early March, I mean, one of the advantages for me of having been an epidemic intelligence service officer of the CDC was like, I understood exponential growth of epidemics.

And on March 7th, when I saw what was happening in New York City, I realized this is going to be a major, major impact on every practice we have with that sort of rapidity of spread and morbidity. So we assembled an incident command structure, and we immediately shut off all practice visits. We went, did work from home that week and 100% remote. And we started asking our practices, what do you need? Are you ready? Do you know how to, can you get PPE, personal protective equipment? Can you see patients? Can, let's, let's send your patients notices to don't come in, stay home and stay safe if you can. And protocols for testing, how to keep your staff and how to keep your other patients safe,

how to do testing in the parking lot. And all of those, I think, helped. You said they've seen a huge reduction in the volume of patients coming in. Obviously, people are staying home because they're worried about getting sick. What about telehealth? Are people calling in? ironies of this whole thing is that even as the practices are struggling with revenue, they've never been busier. They're coming in earlier, they're staying later, they're spacing out the patients, they're responding to hundreds of phone calls and worried patients. You know, the CDC says like, if you know, if you think you might be sick, call your call your doctor, and they're picking up the phone. And they, you know, a lot of that they weren't getting, there's no reimbursement for that. Then CMS changed the rules and allowed much wider use of telehealth. There's still all sorts of state regulations and stuff that we had to help with, and picking a vendor and integrating it with their workflows and training how to do it.

But for our practices, we've seen now about 40% of all of their visits are actually telehealth now, which is great. And we've seen actually, you know, I really hope telehealth, and I believe telehealth will be here to stay because it's actually a superior form of primary care delivery for certain things. We've seen people responding super positively in all age groups. We actually ran this analysis recently, and we found no evidence of groups, whether it's by racial ethnic group getting less care,

which certainly at a time like this we were particularly sensitive to and want to make sure that we're not seeing disparities emerge as a result of this in terms of primary care access. But even by age, there was very little drop-off in the older age groups in terms of use of telehealth. And as I said, for some things like transitional care visits, it's fantastic. You even get a peek inside the patient's home. And there's a lot that you can

do with telehealth. So let's get really specific about that. What are the medical conditions that people go to their primary care doctor with that actually is fine if you just deal with via telehealth? And then what do you actually need to go and see the doctor for in person? And that's why we need these practices to stay open. Yeah, I think I think the we're still figuring that out. And I think the range of things that can be done through telehealth is only going to expand. I there's one of the things that we gave our practices was some physical examination guides through telehealth. And, you know, some of it's like, you know, have the person, you know, hop if they can. And then, you know, you see if there's, if they have a certain infection in the

stomach. So it's really, I think there's a lot more that we can do there and a lot more that might actually come out with remote monitoring tools integrated with telehealth. But for the time being, much of what primary care does is talk to patients. And that's been the problem with primary care reimbursement is we don't pay very much for talking to people. We pay you for sticking things into people. And that's why even the primary care business, their highest margin services and procedures are the ancillary procedures. It's not the evaluation and management visits. So those E&M visits, a lot of it you can do through telehealth. A lot of that, you know, when you went to the doctor and they put the colt stethoscope on your back, that's kind of theater.

That's kind of, you kind of establishing rapport, right? They don't actually have to do that. Take a deep breath for figuring out what's going on with you. But I think one thing I worry a lot about is blood pressure. And Medicare right now has a bright line policy around durable medical equipment, which says that we will pay for things that treat an existing condition, like a stroke caused by high blood pressure. So they'll pay for your motorized wheelchair. But we're not going to pay for devices for prevention, like blood pressure monitoring, automated blood pressure monitoring cuffs. So that policy is just, that's just dumb. We've got to change that policy so that we can have much broader adoption of home blood pressure

monitoring and making that something that could be done in the home as well. Then, you know, there's, you know, fishhook in the finger, right? Literally like a fish hook in the finger that you don't want everyone to have to go to the emergency room to deal with that stuff. Certainly not now. And so there's a lot of that stuff that primary care does as well. One of the big concerns during this time is keeping the people who might have COVID symptoms from infecting other people who don't yet. So and that's the concern, right? Why people are hesitant to go to the doctor.

And so you have to change the entire, you know, it's, you know, Paul Farmer's, you know, four S's, you got to look at your staff, you got to look at your the stuff you know, Paul Farmer's, you know, four S's. You got to look at your staff. You got to look at the stuff you need. You got to look at your space. You got to look at your systems. You got to change up all that so that you can safely segregate people and essentially take universal precautions now because there are so many pre-symptomatic and asymptomatic infections that you have to assume that every staff member and every patient could

have it. And then for patients who do have symptoms, you got to be extra careful and ideally have separate entrances or have people stay in their cars, go out to the parking lot to do nasal swabs, to disinfect rooms, to disinfect surfaces, to change up your gown between visits. I mean, there's a whole set of infection control practices that primary care has never had to do before on this scale. And that's, you know, it's costly, it's expensive, it's time consuming, and it's not paid for. So at a time when they have lower revenue, they have higher costs and, you know, something's got to give. So we're in this situation where the revenue is going down because there aren't as many patients going in and the costs are going up because you have to do all these

additional things, take additional precautions, do nasal swabs in cars. And the federal government is trying to provide funding for industries in crisis, right? So what's the federal government doing for primary care? Nothing special. So what we saw was, you know was rich hospital systems with tens of billions of dollars of extra money, some of them nonprofits, got hundreds of millions of dollars of payments. They don't need that. And instead, we got kind of that peanut butter smear if you're lucky at best to have primary care get their 4.4% share, which they didn't even get that much. And so it translates to if you don't do anything special, and it translated all the, you know, provider relief fund that they that they gave out translated to one week's worth of revenue for primary care. That's what happens if you say, well, we're not going to treat

anyone special, right? And I would say, we have to treat primary care special for three reasons. One is, it's not you saving primary care, it's primary care saving you, right? It's, they're the ones on the front lines of COVID early diagnosis and treatment. We got to get primary care to be able to survive so that when you have symptoms, you can go and get tested. And you can get advice on how to stay safe in isolation. And what if I have symptoms when I'm in isolation, when I'm too sick, should I go to the emergency room. You need those frontline workers, you know, like, yes, there are everyone's hurting, right? The ophthalmologists are also really, really hurting, but they're not on the front lines of helping get us the heck out of this problem.

Primary carriers, that's number one. Number two is, you know, what's going to happen right on the heels of the COVID pandemic is a pandemic, a hidden pandemic of people with untreated chronic diseases. If more primary care is good, and we've seen that in our work, then less primary care is axiomatically bad. We are seeing less primary care, less primary care for people with heart disease, lung disease, kidney disease. Like all those people who are now staying at home like my parents are going to have problems if we don't keep primary care in strength and their ability to deliver primary care to them. And we're going to see compounded across America

the problems of untreated chronic diseases. And that's – who's in charge of that? Primary care. And then finally, and this may seem a little bit kind of cold in a time like this, but we've got to consider the long term impact that consolidation is going to have on patient access in rural communities, on cost, on quality. It's not good. I want to come back to the pandemic. We are by no means out of this pandemic, but we are seeing more and more people, either they're impatient because they've been home for three months or they really want to go get back to work. They've lost their jobs. They need their income.

We are starting to talk about reopening. And as you pointed out, we really need our primary care practices to stay open. What do we need from them as we try to reopen, as we try to figure out to be sites of much expanded testing. I think we have now, fortunately, a much bigger ability to do testing. But the challenge now is actually the labs are saying, we have capacity, but we're not getting specimens in. So the challenge now is going to be actually empowering and enabling those primary care practices to be able to do what would just massively ramp up their ability to test patients with symptoms or with exposures. And that work will require not only the swabs and devices and cartridges and so forth, as well as reimbursement, but also PPE because, you know, testing, being the site where people go to get tested is a high-risk endeavor. So, and then the workflows and the staff training and, you know, hazard pay, as it were, for

people who get infected or exposed. So that's, I think, number one is, as we reopen, we need to be much more vigilant about making sure that a much larger portion of all those infected people are actually diagnosed and put into the public health contact tracing programs. Farzad, when we first spoke, you mentioned that you had your own COVID scare. And so I was wondering if you would tell us a little bit more about that. So, you know, I've been careful. I've been careful. And so, you know, Thursday night, I get like shaking rigors where I can barely, you know, brush my teeth. My hand is shaking so bad. And, you know, fitful night and, you know, body ache and headache and, you know, feeling feverish, although I didn't get out of bed to measure my temperature.

And so I'm like, oh, crap, you know, did I somehow get this? And so whereas early days in the epidemic, the advice would have been stay home. Don't go get tested. Stay home. Isolate yourself. Don't, you know, don't risk spreading it. At the space, place we are now in the outbreak, as an epidemiologist, my advice to others and therefore to myself is go get tested. So I was able to call and, you know, I actually looked at CVS and, you know, tried to see if I could get it done there. But then I got through to my primary care provider and they were super organized. And I drove into the parking lot and I put my, you know my ID on the dash. They looked at it through the window. They said, okay, roll down your window just a little bit.

And her gloved arm reached in, swabbed my nose, and that was it. And the next day I had the test results, which were negative. They're negative. Don't worry. That's relief. Yeah. So that to me is a model of what it's going to take. thing, make one change to make it easier for primary care doctors to do their jobs now and coming out of the pandemic, what would that be? If I had a magic wand, I would change how we pay

for care. And I would create equity in terms of the actual value created by primary care versus the value created by everybody else who deals with the failures of primary care. Don't pay, don't make people rich if they deal with the consequences of a failure of prevention and make people struggle if they're focusing on talking to patients about how to stay healthy. I mean, that's the fundamental of it. And so I would create a system where there is more parity there in terms of the outcomes, paying for the outcomes we want. The Dose is hosted by me, Shana Rasirvai, our sound engineer is Joshua Tallman. We produced this show for the Commonwealth Fund

with editorial support from Barry Scholl and design support from Jen Wilson. Special thanks to our team at the Commonwealth Fund. Our theme music is Arizona Moon by Blue Dot Sessions. Our website is thedose.show. There you'll find show notes and other resources. That's it for The Dose. Thanks for listening.