Primary Care Perspective from OCHIN Chief Medical Officer Scott Fields, M.D.

With the COVID pandemic, our society is faced with both an economic and a medical crisis. The economic crisis stemming from a shutdown of the economy resulted in an unemployment rate that’s been above 10% nationally since April. The medical crisis involves the loss of life of more than 160,000 of Americans and deep disruption of the health care delivery system in our communities. Long-standing inequities and inefficiencies in the way our nation cares for its people have exacerbated both the economic and medical impacts. Fundamental long-term changes are required in our care delivery system, starting with primary care.

Below I outline changes that must occur to improve the overall health of our society. The 12 recommendations below prioritize the health of our patients, rather than the profits of providers, current health care systems, or payers.

Unemployment will increase demand for care in Community Health Centers, requiring change in how primary care services are provided.

With the COVID crisis, two major shifts have occurred: 1) people are becoming unemployed with decreasing access to care; and 2) care for patients shifted dramatically to comprise virtual care, including telemedicine (phone), video conferencing, patient portals (electronic-based care), and instant messaging as modes of care delivery.

The first shift will result in increased demand for primary care services to serve people who are on Medicaid, underinsured, or uninsured. This increase in demand for primary care services will lead to a shortage of access to these services, especially in Federally Qualified Health Centers (FQHC), if we do not permanently embrace the second shift of maintaining a significant volume of clinic visits virtually rather than face-to-face.

Many primary care clinical systems are now providing over 50% of their patient visits through virtual care modalities. As demand grows, we must maintain a large percentage of our care, perhaps 30-50% of encounters, with these non-face-to-face modalities. The movement to payment parity for virtual visits versus face-to-face visits will help solidify this change to a large percentage of visits via virtual care. By moving to virtual visits, we maintain physical capacity in our clinic buildings to see patients who need to be seen face-to-face, while expanding access using virtual care. If the overall number of patients increases by a significant amount (as much as 50% to 75%), the need for the current space will be maintained, and even challenged. The true shortage becomes the clinicians’ availability to care for the additional patients.

We must address an anticipated worsening shortage of primary care clinicians.

The shortage of clinicians needs to be addressed by 1) restructuring the roles in the clinical team to meet the health goals of the patient; and 2) restructuring, with increased oversight, the clinician supply process, including graduate medical education and medical assistant training.  There is already a known shortage of primary care clinicians, with a geographical and socioeconomic maldistribution of these clinicians. The COVID pandemic is bringing this problem to the forefront.  We need public policy to support increased supply of primary care clinicians. Without public policy driving the preferential growth in the supply of primary care clinicians, the mismatch between the needs of our communities and the availability of primary care services will continue.

Roles on the clinical team need to be restructured along with care delivery to embrace both face-to-face and virtual care delivery.

Assuming we obtain the clinicians and clinical team members needed to provide care, the role of each member must evolve. The face-to-face visit will become focused on acute medical problems, such as acute illness and procedures, as well as patients with complex medical needs. As primary care clinical teams are required to care for more complex patients, clinicians will be freed up to spend more time with these patients, while other team members care for patients with less pressing issues. Patients will have “summative” face-to-face visits for chronic disease management, but ongoing chronic disease management, and preventative care, should be provided through virtual care. This care may be provided by appropriate members of the team, but not always primary care clinicians. Registered nurses, medical assistants, and care coordinators all have important roles to play in the ongoing care of patients. Clinicians will expand their panel of patients and absorb the increased demand for services. This is important as clinical teams care for an increasingly complex population of patients.

Mental and dental health cannot be left behind in the shift to virtual care.

Currently, behavioral health services are effectively positioned to utilize a combination of face-to-face and virtual visits. There are important moments in the care of patients that will require a face-to-face appointment, such as with an acute change in mental health status, but much of the ongoing care and counseling may be provided virtually.  While dental services are generally face-to-face encounters, any care that can be provided virtually should be. In addition, all support services, such as patient scheduling, should be provided virtually.

Operations within clinics will be transformed, maximizing work at home.

To maximize use of existing space and maintain the maximum safety for clinic staff, restructuring will be required. Staff not requiring face-to-face interaction with patients should work from home. Clinics must support the staff by providing appropriate equipment in the home. This necessitates high-speed internet, computers and appropriate monitors, secure storage space, and ergonomic workspace support. Tax benefits for home offices should be reviewed and updated.

In addition to structural changes, scheduling of clinician and staff worktime will change. Clinicians must be able to efficiently provide both face-to-face and virtual care. They must also maintain continuity with their patients. One effective way of doing this is to schedule specific days for face-to-face interactions, and other days for virtual care. Nursing support, preferably with consistent team members, would be provided for either venue. Clinic support structures, such as patient scheduling, referral management, and billing support should all be done by staff working at home.

Patients have an important role in maintaining their own health.

Care will increasingly occur outside the walls of the clinic. Patients will have more tools at home to monitor their own health, such as blood pressure monitors and blood sugar monitors. Disease prevention and screening will also be part of their role. Treatments will be monitored by the clinical team, but follow-through will be the patients’ responsibility. Prior to both virtual and face-to-face visits, patients will be asked to complete electronic questionnaires to expedite the care and provide clinicians with an important foundation for the visit. While providing synchronous care through face-to-face and virtual modalities, clinicians and staff must become comfortable with the use of EHR patient portals to provide care. Patient portals allow asynchronous care, expand access, and enable increased efficiency in the provision of care. Patient portals and other technologies will play an important role in delivering automated reminders to patients.

Underserved, including minority populations and the elderly, will be at increased risk with these changes.

All patients will be impacted by these changes, but especially underserved populations and the elderly. Underserved populations, including minority populations, already have difficulty with access and trust of the health care system. These changes may make this even more difficult for them. The differences in care received by minority populations can be seen in the disparate outcomes experienced in minority communities with the COVID pandemic. Implicit racial bias leading to decrease in access to care and worsening of underlying health conditions must be addressed.

Access may be difficult due to the lack of technology to facilitate virtual care. Additionally, the personal connection with the clinicians may be decreased, thereby decreasing the trust that is so important to care. For the elderly, including nursing home patients, either lack of access or lack of capacity to access virtual care may be an impediment to care. We must actively address these risks and monitor the access and care outcomes very closely in these populations.

Broadband networks need expansion to assure easily accessible, medical quality high speed internet in all communities, including rural and inner-city areas.

To assure access to virtual care for all communities, expansion of the telecommunications network to support rural and inner-city communities is needed. These communities have less access to health care providers, and this access differential is increased by the lack of telecommunication support.

Public health departments need national coordination for the purpose of monitoring treatment and tracking of population health.

Central public health coordination must be improved. As we have learned with the COVID crisis, there is a need for rapid and transparent tracking and communication of data to concentrate public health resources in the places of greatest need. Only by having a national network of public health departments, backed up with infrastructure modernization across the country, will we be able to address ongoing communicable disease outbreaks and other nationwide health issues, such as the opioid crisis. National coordination is necessary to automate and optimize electronic case reporting directly from clinicians’ electronic health records to the U.S. Centers for Disease Control and Prevention and the local public agencies where the patient lives. This will streamline monitoring for disease identification, trends, and surveillance for early warning of outbreaks.

The payment structure for primary care must be transformed, combining capitation, value-based, and fee-for-service methods.

Changing the delivery system for primary care requires a change in the payment structure. That payment structure should focus on a capitation payment for primary care, and a value-based component focused on the quality of the care provided. The capitation payment should encourage the continuity of care required to monitor and maintain patient health.  Value-based care should be incentivized based on agreed-upon national metrics. A fee-for-service component can be reserved for care that is provided outside of the primary care bundle of services, including procedures. The fee-for-service component would incentivize providing a broad set of services within the clinic, decreasing the need for referral. Patient attribution, at least at the level of the clinic, but preferably at the clinician level, is critical to address responsibility and accountability for care and outcomes.

Changes in the payment system are different from the internal, personal compensation model for clinicians and others on the clinical team. The practice may wish to incentivize specific activities to reinforce the basic principles of comprehensiveness, coordination, accessibility, accountability, and compassion.

A research infrastructure is critical to assess these changes.

Dramatic changes in our primary care delivery system will require a research infrastructure to ascertain their effectiveness, impact on the health of the public, and their associated costs. It is important to standardize the metrics of evaluation and the process for obtaining the data. While maintaining individual patient confidentiality, the sharing of data for assessment should become more universal.

Every patient must have a Primary Care Medical Home with patient attribution to address responsibility and accountability.

Each patient having a Patient Centered Medical Home (PCMH) is reinforced by the transformation of the primary care delivery system. The attributes of a patient centered medical home include patient driven, comprehensive, accessible, coordinated, quality care. The PCMH will need to address social determinants of health, including food insecurity, housing instability, and social isolation. The administrative requirements, payment strategies, and public health policies must all be aligned to decrease costs and create the correct incentives for both the patient and the primary care clinical team. Patients must have a Patient Centered Medical Home to which they are attributed and have access, and with a clinical team that they know and trust. The Patient Centered Medical Home must use an updated system of care that supports this partnership between the patient and the clinical team.

In summary, the economic and medical crises created by the COVID-19 pandemic have placed a national spotlight on inequities that long have hindered the health of our nation. The medical system’s response, in rapidly redesigning health care delivery, provides a glimpse of what is possible. A vision for a new foundation of primary care—one rooted in the needs of patients, especially those with the greatest barriers to continuous care—is a historic opportunity to create a healthier future.