Let’s use the pandemic to change health care for the better

The COVID-19 pandemic should have us reflecting on the state of our health care system and beginning a national dialogue on what type of system we want for this country and what investments we need to attain it.

Why were we so ill-prepared to mount a national response, why are our health care costs still so high, why do we still have such poor access to basic care for much of the population with racial and economic disparities still so pronounced?What should be our focus going forward? Here are a few thoughts and observations as we start examining some of the issues and begin that dialogue.

Clearly, health care delivery has undergone massive shifts over the last decade, but has it brought us closer to a better system of care for our country? Looking back to 2000, it is interesting to note that only a handful of the Fortune 50 companies were involved in health care. Now 20 of them have health care as a line of business, including six of the top 10.

This massive shift of major corporate interest into health care clearly signals that there is big profit in health care. The question is whether that shift has resulted in better care at a lower price for the country as a whole or for the patients and businesses who pay the bills?

Many of the payment reforms implemented by the Centers for Medicare & Medicaid Services and now taken up by private payers promising to make providers more accountable and share more of the financial risk have hastened this massive consolidation of the health care industry. This consolidation has occurred mainly among health care systems and the insurance industry as they have added vertical integration to their strategic plans. How has that changed the delivery of health care? Is it now more accessible, higher quality and more affordable or has it reduced access and competition and made care more fragmented?

What about primary care?Not long ago there was a national recognition of the need for renewed investment in primary care. Movements such as the Patient-Centered Primary Care Collaborative and NCQA certification programs promised to bring improved and more consistent primary care delivery. This was to be followed by payment reform to better compensate primary care providers and attract more physicians into primary care.

Many primary care physicians jumped all in on the promise of such reforms, investing countless hours redesigning their practices, attaining new certifications and making the prescribed changes, all while caring for their patients and communities. Where are we now with the promise of payment reforms and renewed investment in primary care? While there are clearly some success stories, it has been far less than transformative. Has the movement just passed us by and given way to new interest and investment in retail services, internet-based services and venture-backed startups and primary care aggregators?What is our vision of a primary care system for the future?

As our nation fights its way out of this pandemic, we should examine how we can better prepare for future national health emergencies. Clearly a greater investment in public health and basic preparedness is needed. However, there are several aspects of our system that need to be separately examined. When the nation was facing massive COVID-19 spread and public fear, why were primary care providers seemingly sidelined without personal protective equipment and last in line to provide testing or vaccines? What effect has this had in exacerbating existing health care disparities and slowing our response? With so many states approaching vaccine distribution differently, what can we learn about successful models, such as in rural Alaska and West Virginia?

Common sense would tell us that mass vaccination events alone may not be the most effective way to reach the frail elderly, at-risk and rural populations. What approaches work best? Website appointments, travel and trust are all obstacles to the vulnerable. Maybe we should organize our primary care physicians as we do the National Guard, with periodic training and preparedness drills, along with adequate funding and coordination with local health departments. Then in a national emergency, we could respond quickly, mobilize an already trained and available professional workforce and reach our citizens quickly and effectively.

My last thought is about rural health care and other at-risk communities. Having practiced in a small community for decades, it is clear to me that the minimum level of health care required in any community is access to a caring and comprehensive primary care physician/provider, a local pharmacy and emergency medical services. These health care professionals can provide the vast majority of a community’s health care needs.

Health care, along with good schools, grocery stores and other locally operated basic services, is what sustains the economy of many small towns. This is evident from the Alaska frontier to many of our inner-city communities. It is the norm for other industrialized countries.

Much has been written about the closing of our rural hospitals, but it may be worth examining more closely the effect of the loss of independent primary care physicians and pharmacies as well, not just as health care providers, but as small businesses that contribute to the community as leaders and employers.

What is the effect of the purchase or consolidation of health care resources? Does it sustain or grow the local economy by bringing more jobs and services, or does it just slow the decline as leaders and decision-making move to a distant corporate location, services are streamlined and consolidated elsewhere while participation in local community activities is lost?Are we seeing the “Walmart effect” on locally owned health care businesses?

Now that COVID-19 has shown the effectiveness of working from home, the need to no longer live close to work may represent a new dawn for small towns, if we can reexamine how to make them viable communities again with the health care, education and services people need and want.

L. Allen Dobson Jr., M.D., FAAFP, is a family physician and Editor-in-Chief of Medical Economics®.