President-elect Joe Biden is pledging that his first job as president will be to stop the COVID-19 pandemic that is devastating, disrupting, and ending too many American lives. He has already named his coronavirus task force. His action plan includes an economic response for workers, families, and small businesses affected by the crisis, and a public health response that targets restoration of the Centers for Disease Control and Prevention authority for policy-making, widespread availability of free testing, elimination of cost barriers for treatment, continued vaccine development, and coordination of supply chain and treatment resources.
This is a good list, but it’s incomplete. To be successful, Biden’s plan must also invest in the country’s primary care delivery system. This will make our country healthier now, in the midst of this pandemic, and in the future.
Primary care teams — consisting of physicians, nurses, and other health workers — can be key partners for patients and families in delivering their health care. Informed by personal relationships with their patients, these clinicians help prevent illness, diagnose and treat immediate conditions, and assist patients as they navigate the health care system.
Health systems with more primary care just do better by the people they serve. Their patient populations are healthier, live longer, and have fewer disparities in outcomes based on race, ethnicity, and income.
But primary care in the United States is becoming weaker when it needs to be stronger. The portion of health care workforce in primary care is diminishing, as is the portion of total health care spending that goes to primary care, now at less than 5 percent, a pittance. Paid almost entirely on a per visit basis, primary practices do not have a stable revenue source that allows them to invest in the staff, such as nurses, behavioral health specialists, and community health workers, who can help keep people healthy between visits.
At the pandemic’s onset, primary care practices had to reduce services when they could have been most useful. Visits — and revenue — declined by more than 50 percent. Forty percent of practices in one survey had to furlough staff, and 20 percent had to shut down. Practices that stayed open scrambled for personal protective equipment. Care was delayed — most often for adult immunizations, children’s vaccinations, and cancer treatment monitoring.
Primary care was neglected in federal relief efforts. While expansion of Medicare telehealth coverage benefitted all providers, CARES Act dollars flowed to hospitals and health systems, not primary care providers. As a result, the health system’s rich have gotten richer, with some of the largest bailouts going to hospitals and health systems that already had the most cash on hand. Hospitals that serve a greater proportion of wealthier, privately insured patients got twice as much relief as those focused on low-income patients with Medicaid or no coverage at all.
It should not be this way. Primary care is critical to a pandemic strategy — by conducting COVID-19 testing, diagnosing and caring for people with milder cases of COVID-19 or the flu, helping people with chronic conditions to stay healthy and uninfected, helping with contact tracing to mitigate the spread of COVID-19, and administering vaccines when available.
Primary care is already a part of the COVID-response strategy in some parts of the country. The Maryland Primary Care Program has aligned payments from Medicare and Care First, the state’s largest commercial insurer, to keep funds flowing as in-person visits declined, to pay for shared care management, and feed primary care practices information from a statewide health information exchange. As a result, practices stayed open, kept people out of emergency rooms, reached out to chronically ill patients, and coordinated pandemic surveillance with the Maryland Department of Health.
In Oregon, a state law that mandates a minimum portion of health insurer expenses go to primary care providers, and alignment between Medicare and the state’s Medicaid program on per person payments to primary care, has also probably kept more practices open and relieved pressure on overburdened hospitals.
Biden needs to build his pandemic plan on a strong primary care delivery system, specifically by:
▪ Working with Congress to deploy newly passed COVID-19 funding in ways that more explicitly support primary care.
▪ Directing the Centers for Medicare and Medicaid Services to make telehealth changes permanent, and Medicare Advantage health plans and state Medicaid programs to do likewise.
▪ Directing CMS to make more payments to primary care on a per person — not a per visit — basis. This approach gives primary care practices steady revenue while offering more flexibility in how they provide care.
▪ Supporting the development of more community health centers, which take care of 1 in 11 people in the country.
▪ Following the advice of the CDC and support the deployment of community health workers as part of the primary care team to work in communities hardest hit by COVID.
The election of Joe Biden represents a new beginning in many ways, including this: We have the opportunity to stop COVID-19 now and improve our country’s health in the future by realigning our health system toward primary care.
Christopher Koller, who served the state of Rhode Island as the nation’s first health insurance commissioner, is president of the Milbank Memorial Fund, a national health policy foundation.