Primary care practices are in crisis — here’s how to save them

Primary care was in crisis in the United States - and then COVID-19 happened.


In the first of two interviews, Rebecca Etz, PhD, an associate professor of family medicine and population health at Virginia Commonwealth University and co-director of the Larry A. Green Center, discusses what the country must do to save primary care and the physicians who practice it.

The following transcript has been edited for length and clarity.

Medical Economics: Let's talk a little bit about how the pandemic has affected primary care practices. Can you talk a little bit about how these practices have been impacted both in terms of patient care and financially?

Etz: The impact has been really severe in primary care and not well covered in the media so far. For patients, it has meant lack of access to face to face visits, and primary care practices closing their doors because initially they were under stress, they did not have the protective equipment to be able to see patients, and they didn't have the ability to see them in a socially distanced environment. what's incredible, though, is that practices overnight actually changed the way they delivered care. 500 million visits happen in primary care every year. That's over half of all medical visits across the nation. We do that with 30% of the workforce and 7% of the health expenditure. So we do it on very little.

And what you need to think about that with is that health care is the fourth largest industry in the country. We're a country of 330 million people. This is the fourth largest industry and primary care is the largest platform it has, at the start of the pandemic, on March 13, it was business as usual. And by the 17th, all offices were seeing patients virtually, it's an incredible transformation that happened across the country, and they did it without any training without any financial support. They just turned pivot on a dime. It created great access for patients. And we've actually seen that while the majority of patients see primary care, maybe 46% of the population sees primary care in a year. In the last eight weeks, over 50% have patients have seen primary care - that's a dramatic change. So face-to-face volume in care has gone down. But the amount of work that primary care has been doing during the pandemic has accelerated.

Medical Economics: The Larry A. Green Center has been doing weekly surveys of physicians. Can you talk a little bit about what your data is showing, and a little bit about what you're hearing from physicians. What are some of their fears? What are some of their hopes? What are some of the challenges that they're experiencing?

Etz: So the first fear that most physicians talk about is lack of connection to their patients. Telehealth has been really helpful to them in order to be able to maintain that kind of contact. And we do surveys of patients too, and we found that patients are equally concerned about staying connected to their practices.

The biggest strains right now have been worry about the chronic conditions, the immunizations, the sorts of preventive care not actually being addressed. It's a growing burden. And we see in our patient surveys, that mental strain and difficulty with addiction and chronic diseases uncap is starting to accelerate really high. So primary care worries about the status of their patients, and they worry about people putting off care and not coming in.

Their next worry is about being able to stay open. And this is a bigger worry than I think most people realize. it is not hyperbolic to say that the pandemic could be an extinction-level event for primary care. We see that practices have seen a reduction in the face-to-face visit of almost 70%. You need to keep in mind that payment for primary care is based on face-to-face visits. So while we have seen the amount of volume of need in primary care in the last two months equivalent to all that we saw in 2019, we've also seen a dramatic reduction by over 50% of the income for primary care. Most of the bailout and relief and stimulus packages that have been out there have not actually paid a lot of attention to primary care. And although practices have been applying for those things, and as many as 38% to 40% of practices have been able to get something, it's not enough.

It's not nearly enough after decades of anemic support for this platform. We have undervalued, primary care to our detriment, and now we're feeling it. It is actually literally the floodgates that prevent our hospitals and our tertiary and secondary care from becoming over flooded, and yet primary care practices are closing because they can't make it when we routinely do our surveys and their weekly.

We found that four weeks out is all practices can see in their future. We have routinely 10% of practices saying they don't know if they can make it four weeks and, again, this is the largest platform in the fourth largest industry in the US, and 10% don't think they can make it for four weeks. We saw 7% of practices closing last week in our surveys.

If you want to know about the impact of that, you need only to look at the overall financial picture of what's going on in the U.S. We entered the Great Recession with about 4% unemployment. And then we hit about 10%. During the pandemic, we entered with a 3.5% unemployment but we've already reached 24% unemployment. Uou're talking about at least an extra 10 million people who are going to have to enter Medicaid at times when Medicaid is starting to make cuts because states can't afford it. So if we see these practices shutting down, we're going to see millions of visits that can't happen.

We saw some movement with Medicare to offer telehealth visits and phone visits on parity with in-person visits. We have not seen that among private insurers. Some of them are starting to do a little, but it's really, really insufficient. It's the result of a true lack of leadership and fragmented approach to the health care system. So we have an industry that has been woefully and inadequately supported for decades, at a time when it transformed its entire business regardless of payment overnight to meet the needs of the population, when we have 27% of clinicians that have not been paid in the last two months but they continue to see patients, despite the fact that 65% of them don't have protective equipment. And then you realize that we're not paying these people.

It's not whining, it is survival. A stimulus that simply looks at the short term and says for the next three months we will support you, but does not provide for a long-term solution - such as getting rid of the fee for service that dominates payment for medicine - that's an extreme failure that I'm hoping we'll be able to correct.

Medical Economics: The difficult question is if the short term fix is not enough, what do we need to do to ensure that primary care practices can not only survive the coming challenges but thrive?

Etz: The answer for that is complex and simple. The simple reality is we have to stop accepting the unacceptable. We've done that at a national level. And the crises we see now with the protests going on in so many cities are indicative of that. This is not something that has just popped up from primary care, like how structural racism is not something that just popped up overnight. This is due to a systemic lack of concern for inequities, and for the basic dignities of humanity. That's something that we need to correct and we have to have the will to do it. I'm hopeful that we will find that.

In terms of financial support, there are three things that we have to do to make sure that primary care can get off the ground. The first is we have to stop the hemorrhaging. We need to get money out the door and into those practices. Because, remember, four weeks is their best window right now. We can't let this system fail. If primary care fails, so too does our health system. So we have to stop the hemorrhaging and get money out right away. That means we can't do it through complicated payment mechanisms and billing that changes week to week, we simply have to send the money that insurers have already collected through premiums.

After we stop the hemorrhaging, we need to stabilize the platform, and we stabilize it not by creating payment solutions that lasts for four months or six months, we stabilize it by starting right this very minute to address the inherent weaknesses in the system that led us to this position. And that is our insistence on fee-for-service, partial payment, and lack of value for anything other than procedural or service-oriented care. Primary care is a platform that is about having somebody worthy of your trust that you can go to when you're most vulnerable. And that will take care of a majority of your needs when and where you need them in the ways that you need them. That's what primary care does. If people go to primary care, they don't end up with health burdens, they don't end up costing the health system, it is essential that we protect this platform. We need to actually show that primary care is primary. We need to actually show that we want to pay for value. And that means payments not based on cost, but based on what people actually need and find meaningful.

Then the third thing we need to do is strengthen the platform and we can do that by investing better in Research and in workforce that is applicable to the needs of primary care. So right now we anemically fund primary care. And you might think I'm being hyperbolic with that. So I'm just going to put a number on it: 0.2% of NIH funding goes to primary care. 0.2%. So when I say our funding levels for primary care has been have been anemic - I mean, it's a rounding error. It's actually kind of pathetic. And the lack of our administration and our health plans to understand that this needs to be addressed right now is unacceptable.

Medical Economics: One of the trends that has been occurring over the last few decades is a decline in the number of independent practices and more practices affiliated with hospitals and larger health systems. What do you think the pandemic will mean for this consolidation trend in health care?

Etz: It's a great question, and it's a hard one to predict. I know that most of my colleagues would say that it's going to accelerate the trend, that the independent practices are going to die, and that the owned practices or the employed physicians are going to rule the day.

But what we've seen in our survey is truly that COVID-19 is a virus. It's not a payment plan. And as such, it affects all practices and different management and organization structures, it simply changes the way it affects them, but it affects them just the same. So the percentage of independent practices that are suffering financially, is actually the same as the percentage of hospital and owned practices that are suffering financially. Most people will tell you about the reasons are different. The stimulus money that's going to the hospital systems is not being spent in their ambulatory care settings. It's being sent internal to the larger organization. Now, I am the last person to suggest that you need to funnel away money away from the ED. I understand that need. All I'm saying is that we have an idea that independent practices are somehow more vulnerable. But we are all equally vulnerable to this pandemic, it just hits us in different ways.

I don't think that the pandemic itself is going to cause a greater buy-up of practices. That's a financial investment that people do when they have cash and most systems are hurting for cash right now. It's not the time to expand. But there are going to be some venture capitalists out there I'm sure we will see, you know, buy low, sell high. Some practices will be scooped up. But they will not be then safe for the long term. They will be vulnerable to the market once it shifts, and like we've seen before, practices are purchased and discarded regularly whether it benefits the health system or not, with little regard to what it actually means for our primary care system in the U.S.

Medical Economics: As a follow-up, what about the broader question on independenc?. How important do you feel independence is in medicine? Is it a vital part of a functioning health care primary care system? Is independence in-and-of-itself valuable?

Etz: It's extremely valuable. And I think the most important thing to understand here is there actually is a difference between economic independence and professional independence. Primary care actually suffers both. The professional independence of primary care is reduced when primary care clinicians are employed or when their practices are part of larger systems. That's different than the economic impact that we talked about with independent practices. So if I look at those two things side by side, the first I would say is that during the pandemic, practices that were part of systems had their leadership telling them they had to continue to see patients face-to-face, even though they didn't have protective equipment, even though they had no ability to test and even though they were facing a virus for which there was no treatment and no vaccine, they were told they had to meet patients face-to-face, those who were able to make those decisions independently, immediately limited the exposure of their patients and acted on behalf of the population’s health, not on behalf of what would benefit accounts receivable. And again, I don't want to create a strawman of health systems that are trying to figure out how to make a buck. I'm just saying that practices that are able to act independently show that medical professionalism is not based on the payment model. It is based on the needs of the community and the needs of our patients, how we meet them, when and where. And that's what we see happen.

There's also a professional independence that's related to regulation. A lot of practices struggle right now, because they're required to report on measures that actually bear little relationship to the quality of care. So we know and we accept that the medical platform is responsible for 20% of health outcomes, and yet we hold it accountable for 100% of population health outcomes. If we understood what it really meant to be accountable and what it meant to be meaningful, we would hold them accountable for providing care for being attentive to the needs of people, and the context in which they live and function.

We are incredibly ambiguous creatures, and we lead incredibly ambiguous lives. Primary care loves that world. About 80% of our work doesn't involve a diagnosis or a lab. It involves you walking in, you needing help, and we're going to help you, we're going to figure it out. That's what we do. That's what we need to learn how to value and that's what it means to be professional, is to use your judgment, best medical knowledge, best evidence, and awareness of the person in front of you, what their goals are, what their needs are, what works best for them. We call it personalizing, prioritizing and integrating care. That's what you get when you're in dependent. Economic independence is important, because it allows practices that are independent to transform more rapidly. So they were able to maintain a stronger connection to their patients, they were able to maintain a more direct relationship with their patients. And we've seen, through our surveys, patients adore that. About 35% of them say they would be panicked or heartbroken if they lost that relationship. And over 70% of them said it was the most valuable thing when they had in health care.