Primary Care Marshall Plan
Minimizing the Negative Impact of COVID-19 by Ensuring Family & Primary Care Practice Viability
Summary of Action Required
Have insurers (including the 100M people in self-insured employer plans) pay primary care physicians/practices a prospective fee to care for patients for the duration of the COVID-19 pandemic to avoid worsening the situation on the primary care frontlines. This would replace the severely flawed, fee-for-service model that is making our country more vulnerable to the pandemic. For the insurer (fully insured or self-insured), it should be budget neutral as they’d be paying based on the prior year. [Note: as of 3/28, CMS has announced something similar for those caring for Medicare recipients.]
Lessons from Italy
The following are key lessons from the NEJM study of the Italian experience that demand immediate action making it vital to enable primary care to focus on care, not payments:
- To have any hope of avoiding that disaster in the U.S., the health care system needs to decentralize and make the community a focus of interventions. A key finding is that hospitals might be “the main” source of COVID-19 transmission according to leading Italian doctors. The related coronavirus illness MERS also has high transmission rates within hospitals, as did SARS during its 2003 epidemic.
- Major hospitals are themselves becoming sources of [coronavirus] infection with COVID-19 patients indirectly transmitting infections to non-COVID-19 patients. Ambulances and infected personnel, especially those without symptoms, carry the contagion both to other patients and back into the community. As one physician leader stated, “[COVID-19] patients started arriving and the rate of infection in other patients soared. That is one thing that probably led to the current disaster.”
U.S. Situation & Recommendations
One end of the U.S. healthcare system is running out of beds. The other is running out of patients. The damage, in both cases, might be permanent.
A cruel irony of the Covid-19 pandemic is that family physicians and other primary care physicians suddenly can’t pay their bills, as patients forgo visits and elective procedures get canceled. This situation is a stark reminder of the irrational primacy of specialty care over primary care in our system. Too often in the United States, we treat primary care as an afterthought – a point driven home yet again by the just-passed stimulus bill that includes $100 billion to help hospitals and not much for independent primary care physicians.
In the current crisis, there are significant concerns about the hospital-driven model. Writing in the NEJM Catalyst Innovations in Care Delivery, 13 clinicians working in Bergamo, Italy, call for a new, community-driven approach to fight the virus. Their most chilling statement:
“[H]ospitals might be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients … Pandemic solutions are required for the entire population, not only for hospitals.” [emphasis in original]
We still don’t know if facilities will be able to handle the surge of expected patients in the coming weeks. But we do know that we can reduce hospital burden and preserve resources by keeping the patients who don’t need extreme measures of care out of emergency departments. Right now, every bed, every mask and every minute of hospital staff time must be reserved for dealing with those who will become critically ill.
So why then are so many primary care practices struggling? It’s because of the unremitting stupidity of the current fee-for-service reimbursement system. Rather than paying primary care doctors a robust prospective, risk-adjusted fee per patient to care for a population of patients, the vast majority of health insurance offerings pay only for individual visits or tests. Without patients, primary care practices are like the airlines operating ghost flights (except without the billions of profits the past few years, not to mention the huge federal dollars now flowing to the airlines from the recent Congressional legislation).
These practices need an immediate infusion of funding to implement a community-wide pandemic response. All insurers (including the 100 million people in self-insured employer plans) should pay primary care physicians / practices an upfront fee to care for patients for the duration of the Covid-19 pandemic, instead of having doctors bill for each service they provide. This would replace the severely flawed, fee-for-service model that has made our country more vulnerable to the pandemic.
(As we drafted this, payments for Medicare patients we recommend here have been approved. It is time for private, ERISA, and Medicaid plans to join this decisive action.)
The quickest path to implementation would be for healthcare purchasers – public and private – to look back at what they paid each primary care physician last year and prospectively pay them each month for the next year. This can at least support them through this short-term crisis.
The federal government’s response with their Medicare decision is laudable and should be matched by their role as a large employer. The federal workforce, including the Postal Service, is over 2.5 million workers. The number of public sector workers is 22 million when including state and local governments. Mayors, county executives and governors should take immediate action to ensure the well-being of their citizens.
All public and private health insurance benefit packages should incorporate and financially facilitate innovative strategies that promote greater use of primary care physicians and their care teams in an effort to promote high-quality, efficient care and to assist patients in navigating an increasingly complex health care system. This approach to benefit design will not only enhance the patient-physician relationship, but it will achieve better health and lower costs.
Going forward, we simply must implement a new model of payment for primary care – and one that overall represents a much greater investment in primary care. Right now, we are seeing very different situations for those practices and primary care physicians operating under more stable, monthly-subscription-type revenue models. The City of Kirkland, Washington, was the epicenter of the crisis, but city employees have continued to have access to a free, full-service primary care clinic, funded by a stable stream of revenue.
Everyone should have the same access to care.
If your organization would like to support this initiative, please email firstname.lastname@example.org with your name and logo for your organization. In particular, we are looking for health plans, public sector employers (especially states, counties and cities), private sector employers, unions and TPAs that want to extend what CMS did for Medicare to the private sector. We also welcome your ideas and connections via this email to help us spread the word and address gaps.
Actions requested (email suggestions of other actions and we'll add to this list):
- Contact your regional health plans presidents to request that they do this
- Contact TPA CEO(s) to request they do this
- Contact your local/state elected officials (who are employers) to require their TPAs/carriers to do this
Government and Community Leaders: Mayors and governors are not only leaders and role models for the community, but you are also employers. If you’re on a self-insured plan, speak with your TPA to request they switch to a fee-per-patient model and start preventing the destruction of primary care. Stable, monthly-subscription-type revenue models not only offer better care for employees, but they reduce nonessential hospital visits and decrease potential virus exposure in overcrowded waiting rooms.
Employees/Citizens: Contact your local/state elected officials to request they make the switch to a fee-per-patient model. Every voice counts in this healthcare revolution.
Journalists: The primary care providers that make up the backbone of community healthcare are at serious risk. We implore you to use your media influence to recommend insurers move to a fee-per-patient model for the duration of the pandemic. We have advisors, employers, and our co-founder Dave Chase available to speak at any time - contact our PR department at email@example.com.
Benefits Advisors: Telehealth has become a large-scale solution to healthcare during quarantine. It works best when it's a core part of various value-based primary care models such as direct primary care (DPC). Fortunately, primary care practices who are using non-fee-for-service models (e.g., DPC) have shown the way and didn't skip a beat as Covid hit. This high quality, low cost option helps employees stay out of clogged ERs and get care remotely, without risking further infection.
Dave ChaseHealth Rosetta cofounder
Douglas E. Henley, MDExecutive VP and CEO of
American Academy of Family Physicians
R. Shawn MartinSenior VP, Advocacy, Practice Advancement and Policy Incoming of
American Academy of Family Physicians
Farzad MostashariFounder & CEO of
Christopher Crow, MDCEO of Catalyst Health Network
Brian Klepper, PhDPrincipal at Worksite Health Advisors and former CEO of the National Business Group on Health
Tom BanningCEO/EVP of Texas Academy of Family Physicians
Renee Crichlow, MD, FAAFPPresident of Minnesota Academy of Family Physicians
David Ehrenberger MDChief Medical Officer pf HealthTeamWorks
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