Beyond COVID

The COVID-19 pandemic is the biggest crisis to hit American health care in a century, resulting in more than half a million deaths and millions of people postponing needed care, as well as jeopardizing the future of many medical practices, especially those in primary care.

But like every crisis, this one also brings opportunities for change. For medical practices, it could mean becoming nimbler in their operations, more accessible and affordable and less dependent on fee-for-service payments. The pandemic could also be a chance to reaffirm the physician’s vital role in health care delivery, especially primary care. And it might present an opening to address race- and income-based disparities in health outcomes.

So as COVID-19’s grip on the nation begins to ease, the question becomes: Will lawmakers, health care administrators and individual physicians use the pandemic as an inflection point for changing the direction of primary care? Or put another way, what might primary care after COVID-19 look like?

‘We need to evolve our patient models’

The answer, experts say, will depend almost entirely on two interrelated factors: whether the increased use of telehealth resulting from the pandemic continues after the pandemic has ended, and the availability of new payment models to support telehealth and other novel forms of care delivery.

“I think the pandemic has created some hopeful opportunities for meaningful change but it’s by no means a sure thing,” says Connie Hwang, M.D., MPH, chief medical officer and director of clinical innovation for the Alliance of Community Health Plans (ACHP). “We’ve seen some really interesting transitions into virtual care models but there are still a lot of questions around whether we can keep those gains and not fall back into business as usual when we reach the end of the pandemic.”

“We know that not all patient needs require a face-to-face doctor visit. There are many things that can easily be done over the phone or as a remote visit,” says Ann Greiner, president and chief executive officer of the Primary Care Collaborative, a nonprofit organization that advocates on behalf of primary care and the patient-centered medical home concept. “But we need to evolve our payment models so as to give patients and primary care clinicians flexibility in how they give and receive care.”

Payers respond to telehealth surge

Telehealth use, which had been extremely limited before the pandemic, surged after the Trump administration declared COVID-19 a public health emergency (PHE) in mid-March and in-person patient visits declined drastically. According to the most recent report of the Medicare Payment Advisory Commission, there were 8.4 million telehealth visits paid under the Medicare Physician Fee Schedule in April 2020, compared with 102,000 in February.

Similarly, a study from The Commonwealth Fund found that by early May 12.5% of ambulatory care visits were conducted via telehealth. They fell to about 6% in the fall before ticking up again late in the year.

Doctors were able to meet the surge in demand for virtual visits largely because Medicare more than doubled the number of telehealth-delivered services it would pay for, and increased payments for them, for the duration of the PHE. It also allowed clinicians to bill for some telephone-only visits (as opposed to visits that include a video component) and removed most site restrictions for remote visits. The Biden administration has indicated the PHE will continue through the end of 2021.

Absent another health crisis, no one expects telehealth visits to return to the levels seen at the height of the pandemic anytime soon. Still, many physicians and health care executives say the technology’s growth in 2020 use revealed intriguing possibilities for the future of care delivery.

“I think the pandemic gives us an opportunity to reimagine the ways we ensure that the care we’re delivering is high quality and easily accessible,” says Rachel Reid, M.D., a health care policy researcher with the RAND Corp. and practicing internist at Brigham and Women’s Hospital in Boston. “I don’t know that anyone’s nailed exactly what that transition looks like yet, but it’s exciting to think about what could be.”

Expanding access to care

One of telehealth’s biggest potential impacts, experts say, is to make care more widely accessible since it eliminates the need for travel to a doctor’s office. Indeed, with site restrictions on its use suspended, some doctors are already experiencing this.

“We’re able (through telehealth) to see folks who couldn’t come in whether because of transportation issues or because they couldn’t take time off from their jobs,” says Ada Stewart, M.D., president of the American Academy of Family Physicians (AAFP) and a practitioner at a federally qualified health xenter in Columbia, South Carolina “It’s really been a means to reach out to folks we were previously missing.”

Leon McDougle, M.D., a family physician with The Ohio State University Wexner Medical Center in Columbus and president of the National Medical Association, says that before the COVID-19 outbreak he rarely used telehealth, but now half of his clinic time is virtual. “It has provided opportunities for patients to overcome barriers like lack of transportation, and it gives me more options for virtual follow-ups if I have concerns about changes in a patient’s health status,” he says.

Most of McDougle’s and Stewart’s patients are Black and/or low income, and both view telehealth as a tool for providing more and better health care to people who traditionally have lacked it.But for that to happen, residents of those neighborhoods and communities will need the same access to broadband internet as residents of wealthier communities. Otherwise, Stewart says, “We risk creating more disparities.”

Altered space, staffing requirements

A future where telehealth is a routine form of care delivery could also change how practices use their space and personnel. “There’s no question if you’re doing significantly more telehealth visits it will change your space allocation,” says Jacqueline Fincher, M.D., an internist in Thomson, Georgia and president of the American College of Physicians. “You may find you need fewer rooms for face-to-face visits but more rooms where you can do telehealth visits and show patients ‘You and I are in this room together and it’s a safe space.’”

Fincher adds that reconfiguring office layouts for more telehealth visits could also be an opportunity to create spaces where physicians can work side by side with their support staff, thereby improving communication and care coordination.

Reed Tinsley, CHBC, a practice management consultant in Houston, says practices that continue providing significant numbers of telehealth visits will need to consider how to balance those against the needs of patients seeking face-to-face visits.

With business still down because of the pandemic, he says, many practices have been assigning telehealth care to clinicians whose schedules aren’t full. “What happens when patients start coming back and those people get busy? You’re left without anyone to service the telehealth side,” he says. “So the issue becomes whether a practice has the staffing capacity to handle both. That’s an unknown for most practices because they’re focused on rebuilding from the pandemic.”

Greiner says practices employing telehealth routinely may find they’re using support staff for pre-visit triaging to determine if a patient can be treated remotely or requires an in-person visit. “We’re just beginning to learn how this modality could affect the way primary care gets delivered,” she says.

Greater reliance on remote monitoring

Expanded use of telehealth in a post-pandemic environment could also mean more dependence on remote devices and health apps to monitor common indicators such as blood pressure, pulse, and A1C levels that clinicians routinely obtain during in-person visits. And while tracking and analyzing that data could require practices to change some aspects of their workflow, Reid sees possible clinical benefits to collecting information this way.

“It’s not necessarily a bad thing to have more measures of physiologic data come from outside the clinic setting and reflect more in real time how patients live their lives,” she says.

Stewart points out, however, that greater dependence on remote monitoring technology could widen care disparities unless the technology is made universally available. “You can do diabetes control and other things on apps, but many of my patients don’t have access to those,” she says. “So unless we find a way to provide it we’re still going to have inequities.”

Hurdles to meaningful change

Of course, the pandemic’s full potential to transform primary care won’t be realized unless the changes the government put into effect at the start of the pandemic—allowing Medicare to reimburse for remote visits at parity with in-person visits, and reducing or eliminating visit site restrictions—are allowed to continue after the PHE expires.

Doctors organizations and other groups are lobbying to make the PHE telehealth rules permanent. And CMS has launched a study exploring the possibility of doing that for at least some services, according to Shari Erickson, MPH, vice president of governmental affairs and medical practice for the American College of Physicians.

But the odds of those changes continuing after the PHE expires are slim, says Terry Fletcher, CPC, principal of Terry Fletcher Consulting Inc. in Laguna Niguel, California.

“The whole point of expanding telehealth under the PHE was so that people wouldn’t have to leave home in order to receive routine medical care,” she says. “That’s obviously going to change when the PHE is over unless Congress rewrites the law.”

Lawmakers would probably be reluctant to do that, she adds, given the vast increases in Medicare spending and greater opportunity for fraud that would likely result, particularly if telehealth visits occur in addition to rather than as a substitute for in-person visits.

Fletcher points to the actions of commercial payers, many of whom have reinstated the cost-sharing requirements for telehealth visits they suspended at the start of the pandemic. “A lot of them are saying spending (on telehealth) is out of control,” she says.

The need for new payment models

For primary care advocates and many health policy experts, the uncertainty over telehealth’s post-pandemic role is emblematic of the pandemic’s larger takeaway: the need to jettison, or at least significantly modify, fee-for-service payments in favor of models that provide doctors with more financial stability and greater flexibility in medical decision making.

Shawn Martin, MS, executive vice president and CEO of the AAFP, says the academy has been trying to persuade Congress and CMS to develop payment structures that are agnostic to the form of care delivery.

“We want to get to a point where a doctor can use any modality of care for any patient and we’re not incentivizing or disincentivizing them for it,” he says. “We just want them to be able to provide comprehensive, continuous care however they feel is best for their patients.”

“The pandemic has shown the importance of compensation models that offer primary care practices more financial predictability and the freedom to innovate and seize new opportunities,” says Melinda K. Abrams, MS, executive vice president for programs at The Commonwealth Fund.

Abrams points to the example of the Comprehensive Primary Care Plus model, which CMS has been developing since 2017. It combines traditional fee-for-service payments with upfront per-beneficiary per-month fees and performance-based incentive payments. If approved for use throughout the Medicare and Medicaid programs, “I think it has the potential to change the face of primary care payment in the U.S.,” she says.

But even COVID-19’s financial disruption hasn’t been enough to bring about a large-scale transition to value-based payments, Abrams notes. She cites results of a recent NEJM Catalyst poll showing that only 25% of its Insights Council members thought COVID-19 would be a “tipping point” for adopting value-based care.

“The pandemic hasn’t been a massive accelerator to value-based payment but more of a slow, steady march,” she says. “And I think it’s because making that transition requires a certain level of investment in information systems and staffing and changing workflows. And pursuing an innovation agenda in the midst of a pandemic is really hard.

“That said, I still believe the pandemic has demonstrated the importance of value-based payments, and we will continue the forward march.”