As the pandemic enters its second year, the health care workers who care for patients with Covid-19 and other serious conditions deserve our gratitude and support. Many on the frontlines are not just tired but are also in precarious financial straits and lack the resources to “build back better.”
This is a dangerous place for the country. A key response to the pandemic is fundamental reform in how we pay — and how much we pay — primary care providers.
After years of underinvestment, primary care is more vulnerable to external shocks like Covid-19 than most other parts of our health care system. Small and independent primary care practices have not received targeted relief from the $178 billion provider relief fund created in the CARES Act, even as primary care has become more valuable than ever, given its critical role in triaging and managing Covid-19 patients and in addressing worsening health inequities.
In contrast to large health systems, most independent primary care practices lack financial reserves, investment income, and access to capital as ways of weathering major disruptions such as Covid-19, as documented in regular, real-time surveys conducted by the Primary Care Collaborative, which one of us (A.C.G.) leads. As growing numbers of patients postponed appointments over concerns about contracting Covid-19, many practices suffered financially. Some are being bought by large health systems, insurers, and investors as “distressed assets,” a trend likely to accelerate when the pandemic wanes. Other practices are downsizing, and even closing, as some primary care physicians retire early.
These trends could worsen perverse incentives in our health care system, which largely rewards higher volume instead of higher quality, and which emphasizes specialty and hospital-based care over prevention, testing, and earlier-stage interventions that help Americans stay healthy.
Equally troubling: Consolidation is raising health care costs for American workers and families without necessarily providing added care or quality.
As Congress and the Biden administration work to build a better health care system, primary care clinicians, consumer organizations, and large employers, which play an outsized role in providing Americans with health care benefits, urge them to lay a stronger foundation of comprehensive primary care.
They can begin by overhauling the entrenched Medicare and Medicaid fee-for-service payment platform, which sets discrete, relative fees across clinical work such that procedures are valued more highly than diagnosing and managing chronic conditions. It produces fragmented, inefficient care, and underpays for prevention and chronic care management. Commercial payers all too often reinforce these payment inequities and misaligned incentives while paying higher prices overall.
Recent studies indicate that spending on primary care is declining, while efforts to move away from fee-for-service payment are moving too slowly. The Biden administration must achieve bold and aggressive targets to move the bulk of Medicare and Medicaid payment from fee-for-service to patient-centered capitated payment models, which pay primary care practices adjusted monthly fees per patient. These models can leverage primary care’s proven ability to realize better, more equitable patient outcomes while simultaneously coordinating these reforms with commercial payers.
Now is the time to act, given the dismal experience of most primary care practices during Covid-19 under the country’s dominant fee-for-service payment system. In contrast, primary care groups paid in advance for care were not only more financially resilient, but they were also able to better respond to the needs of their patients by quickly delivering virtual and telephonic care and deploying primary care-led teams to manage complex patients at home, including those with Covid-19. These interdisciplinary teams helped communities manage Covid-19 surges and reduced the burden on emergency services. The teams supported testing and tracing efforts and want to deliver vaccines. This nimble care should be the new normal for the post-pandemic era.
At the same time, we need to integrate mental health care into the rest of health care delivery. As health care’s “front door,” primary care can identify and support patients in need of mental health care, the need for which has only increased during the pandemic. By expanding primary care teams to include mental health clinicians and effective digital support, mental health needs can be met holistically. This requires better payment models and coverage policies across public and private plans and purchasers. Telehealth can play an effective role if clinicians are paid in a global payment model with patient outcomes subject to rigorous evaluation.
During 2020, large health systems, many with already strong balance sheets, received disproportionately more CARES Act relief funds relative to their needs than rural providers, independent physician groups, and behavioral health professionals. Insurers have saved money because of deferred care.
By acting now to improve primary care, the Biden administration and Congress can also begin to close the health equity gaps that have been widened by underinvestment in primary care, behavioral health services, and public health. Too many members of Black and brown communities, rural communities, and workers in lower-wage jobs lack a regular source of primary care.
As we build back better and extend the coverage gains made by the Affordable Care Act, we must strengthen the platform on which achieving better, more equitable, more affordable care depends: primary care.
Ann C. Greiner is the president and CEO of the Primary Care Collaborative. Elizabeth Mitchell is the president and CEO of the Purchaser Business Group on Health.