Every day, primary care providers are on the front lines of the COVID-19 pandemic, treating sick patients even as they worry about bringing the virus home to their families. Many still lack adequate protective gear, and many worry about the financial stability of their practices.
With the U.S. starting to reopen, we need our primary care practices to keep their lights on — not only to test and treat people with mild symptoms but also to address health concerns that people have neglected while staying home.
On this episode of The Dose podcast, health policy expert Farzad Mostashari, M.D., who advises and supports hundreds of primary care practices across the country, explains what it will take to ensure doctors can continue caring for Americans throughout the pandemic.
Editor’s note: On June 11, after we recorded this episode, the U.S. Department of Health and Human Services granted $6 million to primary care associations to conduct COVID-19 training and technical assistance activities.
Transcript
FARZAD MOSTASHARI: So I’m talking to you sitting in my basement in Bethesda, and that’s where I’ve been for the past couple of months. But our primary care doctors in all the practices across America, they actually have a very different situation. They are sitting and waiting for patients to come in. Patients with cough, patients with fever come into their office and they close the door and they sit in the room with a closed door with them, taking care of them, caring for them. And they do it patient after patient, day after day. Many of them have seen their own staff or other staff, people in the community get sick in those primary care practices. We’ve had spouses, they’re weird about taking it home to their families.
And while they’re doing all this, you know the other thing they’re worrying about? They’re worrying about how to make payroll and having to furlough their staff because they’re not meeting their practice finances. Oh, and plus they can’t find masks because their regular supplier will not honor a request for three boxes of masks from some small doc practice in rural Arkansas. That’s what it’s like being a small-practice primary care doctor today.
SHANOOR SEERVAI: Hi everyone, welcome to The Dose. You just heard from Farzad Mostashari about some of the challenges of being a primary care provider in times of coronavirus. Almost everyone has seen a primary care doctor in their lives for a routine checkup, a broken bone, everything in between. And it’s no secret that the entire U.S. health care system is reeling from trying to care for people with COVID-19. But I wanted to focus on primary care today because this is the lifeblood of our health system. And we need primary care doctors to keep their doors open as we figure out how we’re going to get out of this pandemic. Farzad is a health policy expert and through his company, Aledade, works with 550 primary care practices across the U.S.
Farzad, welcome to the show.
FARZAD MOSTASHARI: Thanks for having me.
SHANOOR SEERVAI: So tell me a little bit more, what are you hearing from the practices that you work with? You described a scene, but what’s it really like? It must be incredibly stressful.
FARZAD MOSTASHARI: These practices that we work with are the best case, because of a couple of things. One is they have actually embraced and moved away from pure fee-for-service and, let’s be clear, what’s broken here is how we pay for primary care by saying, in order to get paid, you got to have someone come in and spend X number of minutes and document X number of things to get paid. You’re getting paid for basically visits. You’re not being paid for taking longitudinal care of a human being, which is what they want to do.
So we figured out all of these workarounds in the fee-for-service system to keep these primary care practices afloat, even though it’s the wrong payment model. My company helps give them another alternative, a way to make money from value-based contracts, if they can keep people healthy and out of the hospital, which requires patient-centered care where you’re really worried about and thinking about the person, the human being. So many of our practices are in a very good situation because they have another source of income. We have practices getting checks for their savings that they’re creating. The other reason why they’re in a specially good position is because they have us.
SHANOOR SEERVAI: Yeah. What was your company doing before all this started?
FARZAD MOSTASHARI: I mean, before this started, we were using data and technology to help them manage the entire population of at-risk patients and help find ways and new habits for the practice to keep their patients healthy and out of the hospital. So we were training them and giving them tools for calling patients if any patient went to the emergency room, that they would get a call from their primary care doctor. We were helping them think through prevention.
SHANOOR SEERVAI: So specifically, what are you doing to help your practices provide? And I know that probably changes every week.
FARZAD MOSTASHARI: Well, we asked them, very early on in early March . . . I mean, one of the advantages for me of having been an epidemic intelligence service officer at the CDC was I understood exponential growth of epidemics. And on March 7th, when I saw what was happening in New York City, I realized this is going to be a major, major impact on every practice we have with that sort of rapidity of spread and morbidity. So we assembled an intimate command structure and we immediately shut off all practice visits. We did work from home that week, a hundred percent remote.
And we started asking our practices: What do you need? Are you ready? Can you get PPE, personal protective equipment? Can you see patients? Let’s send your patients notices to don’t come in, stay home and stay safe if you can, and protocols for testing, how to keep your staff and how to keep your other patients safe, how to do testing in the parking lot. And all of those, I think, helped.
SHANOOR SEERVAI: You said they’ve seen a huge reduction in the volume of patients coming in.
FARZAD MOSTASHARI: Yep.
SHANOOR SEERVAI: Obviously people are staying home because they’re worried about getting sick. What about telehealth? Are people calling in?
FARZAD MOSTASHARI: Yeah. One of the ironies of this whole thing is that even as the practices are struggling with revenue, they have never been busier. They’re coming in earlier, they’re staying later, they’re spacing out the patients, they’re responding to hundreds of phone calls, and worried a patient . . . the CDC says, if you think you might be sick, call your doctor. And they’re picking up the phone and a lot of that they weren’t getting — there’s no reimbursement for that. Then CMS changed the rules and allowed much wider use of telehealth. There’s still all sorts of state regulations and stuff that we have to help with and picking a vendor and integrating it with their workflows and training how to do it. But for our practices, we’ve seen about 40 percent of all of their visits are actually telehealth now, which is great.
I really hope telehealth and I believe telehealth will be here to stay because it’s actually a superior form of primary care delivery for certain things. We’ve seen people responding super positively in all age groups. We actually ran this analysis recently and we found no evidence of groups, whether it’s by racial/ethnic group getting less care which, certainly at a time like this, we were particularly sensitive to, and want to make sure that we’re not seeing disparities emerge as a result of this in terms of primary care access. But even by age, there was very little drop-off in the older age groups in terms of use of telehealth. And as I said, for some things like transitional care visits, it’s fantastic — you even get a peek inside the patient’s home. And there’s a lot that you can do with telehealth.
SHANOOR SEERVAI: So let’s get really specific about that. What are the medical conditions that people go to their primary care doctor with that actually is fine if you just deal with via telehealth? And then what do you actually need to go and see the doctor for in person? And that’s why we need these practices to stay open.
FARZAD MOSTASHARI: Yeah, I think we’re still figuring that out. And I think the range of things that can be done through telehealth is only going to expand. If there’s one of the things that we gave our practices was some physical examination guides through telehealth. And some of it’s like have the person hop if they can. And then you see if they have a certain infection in the stomach. So I think there’s a lot more that we can do there. And a lot more that might actually come out with remote monitoring tools, integrated with telehealth, but for the time being much of what primary care does is talk to patients, and that’s been the problem with primary care reimbursement is we don’t pay very much for talking to people.
We pay you for sticking things into people. And that’s why even the primary care business, their highest-margin services and procedures are the ancillary procedures. It’s not the evaluation and management visits. So those ENM visits, a lot of it you can do through telehealth. When you went to the doctor and they put the cold stethoscope on your back, that’s kind of theater, that’s kind of establishing rapport, right? You don’t actually have to do that, take a deep breath before figuring out what’s going on with you. But one thing I worry a lot about is blood pressure and Medicare right now has a bright line policy around durable medical equipment, which says that we will pay for things that treat an existing condition like a stroke caused by high blood pressure.
So they’ll pay for your motorized wheelchair, but we’re not going to pay for the devices for prevention, like blood pressure monitoring, automated blood pressure monitoring cuffs. So that policy is just dumb. We’ve got to change that policy so that we can have much broader adoption of home blood pressure monitoring and making that something that could be done in the home as well. Then there’s fishhook in the finger, right? Literally like a fishhook in the finger that you don’t want everyone to have to go to the emergency room to deal with that stuff. Certainly not now. And so there’s a lot of that stuff that primary care does as well.
One of the big concerns during this time is keeping the people who might have COVID symptoms from infecting other people who don’t yet. And that’s the concern, right? Why people are hesitant to go to the doctor. And so you have to change the entire . . . Paul Farmers, four S’s — you got to look at your staff, you got to look at the stuff you need, you got to look at your space, you got to look at your systems. You got to change up all that so that you can safely segregate people and essentially take universal precautions now, because there are so many presymptomatic and asymptomatic infections that you have to assume that every staff member and every patient could have it.
And then for patients who do have symptoms, you got to be extra careful and ideally have separate entrances, or have people stay in their cars, go out to the parking lot to do nasal swabs, to disinfect rooms, to disinfect surfaces, to change up your gown in between visits. I mean, there’s a whole set of infection control practices that primary care has never had to do before on this scale. And that’s costly, it’s expensive, it’s time-consuming, and it’s not paid for. So at a time when they have lower revenue, they have higher costs. And something’s got to give.
SHANOOR SEERVAI: So in this situation where the revenue is going down because there aren’t as many patients going in and the costs are going up because you have to do all these additional things. Take additional precautions, do nasal swabs in cars. And the federal government is trying to provide funding for industries in crisis, right? So what’s the federal government doing for primary care?
FARZAD MOSTASHARI: Nothing special.
What we saw was, rich hospital systems with tens of billions of dollars of extra money, some of them nonprofits, got hundreds of millions of dollars of payment. They don’t need that. And instead, we got kind of that peanut butter smear, if you’re lucky at best to have primary care get their 4.4 percent share, which they didn’t even get that much. And so it translates to, if you don’t do anything special and it translated — all the provider relief fund that they gave out — translated to one week’s worth of revenue for primary care.
That’s what happens if you say, well, I’m not going to treat anyone special, right? And I would say, we have to treat primary care special for three reasons. One is, it’s not you saving primary care. It’s primary care saving you, right? They’re the ones on the front lines of COVID early diagnosis and treatment. We got to get primary care to be able to survive so that when you have symptoms, you can go in and get tested and you can get advice on how to stay safe in isolation. And what if I have symptoms when I’m in isolation? What If I’m too sick? Should I go to the emergency room? You need those frontline workers. Like, yes, everyone’s hurting, right? The ophthalmologists are also really, really hurting, but they’re not on the front lines of helping get us the heck out of this problem. Primary care is, that’s number one.
Number two is, you know, what’s going to happen right on the heels of the COVID pandemic is a pandemic, a hidden pandemic of people with untreated chronic diseases. If more primary care is good and we’ve seen that in our work, then less primary care is axiomatically bad. We are seeing less primary care, less primary care for people with heart disease, lung disease, kidney disease, like all those people who are now staying at home, like my parents are going to have problems if we don’t keep primary care and strengthen their ability to deliver primary care to them. And we’re going to see, compounded across America, the problems of untreated chronic diseases. And who’s in charge of that primary care.
And then finally, and this may seem a little bit kind of cold in a time like this, but we’ve got to consider the long-term impact that consolidation is going to have on patient access in rural communities, on cost, on quality. It’s not good.
SHANOOR SEERVAI: I want to come back to the pandemic. We are by no means out of this pandemic, but we are seeing more and more people either they’re impatient, because they’ve been home for three months or they really want to get back to work. They’ve lost their jobs. They need their income. We are starting to talk about reopening. And as you pointed out, we really need our primary care practices to stay open. What do we need from them as we try to reopen, as we try to figure out what the new normal will be?
FARZAD MOSTASHARI: I think we need to enable them to be sites of much expanded testing. We have now fortunately much bigger ability to do testing, but the challenge now is actually the labs are saying we have capacity, but we’re not getting specimens in. So the challenge now is going to be actually empowering and enabling those primary care practices to be able to do what . . . we just massively ramp up their ability to test patients with symptoms or with exposures. And that work will require not only the swabs and devices and cartridges and so forth, as well as reimbursement, but also PPE because being the site where people go to get tested is a high-risk endeavor. And then the workflows and the staff training and hazard pay, as it were, for people who get infected or exposed. So that’s, I think, number one is, as we reopen, we need to be much more vigilant about making sure that a much larger portion of all those infected people are actually diagnosed and put into the public health contact-tracing programs.
SHANOOR SEERVAI: Farzad, when we first spoke, you mentioned that you had your own COVID scare. And so I was wondering if you would tell us a little bit more about that.
FARZAD MOSTASHARI: So I’ve been careful, I’ve been careful. And so Thursday night, I get shaking rigors where I can barely brush my teeth, my hand is shaking so bad. And fitful night and body ache and headache and feeling feverish, although I didn’t get out of bed to measure my temperature. And so I’m like, “Ah, crap. Did I somehow get this?” And so whereas early days in the epidemic, the advice would have been, “Stay home. Don’t go get tested, stay home, isolate yourself. Don’t risk spreading it.” At the place we are now in the outbreak, as an epidemiologist, my advice to others, and therefore to myself is, “Go get tested.”
So I was able to call and I actually looked at CVS and tried to see if I could get it done there. But then I got through to my primary care provider and they were super organized and I drove into the parking lot and I put my ID on the dash. They looked at it through the window. They said, “Okay, roll down your window just a little bit.” And her gloved arm reached in, swabbed my nose, and that was it. And the next day I had the test results, which were negative. They’re negative, don’t worry.
SHANOOR SEERVAI: That’s a relief.
FARZAD MOSTASHARI: Yeah. So that to me is a model of what it’s going to take.
SHANOOR SEERVAI: Before I let you go, Farzad, I wanted to ask: If you had a magic wand and you could wave it and just do one thing, make one change to make it easier for primary care doctors to do their jobs now and coming out of the pandemic, what would that be?
FARZAD MOSTASHARI: If I had a magic wand, I would change how we pay for care. And I would create equity in terms of the actual value created by primary care versus the value created by everybody else who deals with the failures of primary care. Don’t pay. Don’t make people rich if they deal with the consequences of a failure of prevention and make people struggle. If they’re focusing on talking to patients about how to stay healthy — I mean, that’s the fundamental of it. And so I would create a system where there is more parity there in terms of paying for the outcomes we want.