COVID-19 pandemic highlights need for primary care investments
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The COVID-19 pandemic has posed considerable challenges to primary care in the United States, highlighting shortages in workforce and resources that existed long before the pandemic.
In a recent survey of primary care providers in the U.S., 37% reported that their practices still had furloughs and layoffs and 4% reported that their practices closed entirely.
“Primary care isn’t about healthy people getting an annual physical, it’s about having a relationship with a particular primary care provider, so that when you do get sick that doctor knows something about you,” David Reichert, CCRA, president of the board of directors for the Academy of Allergy and Asthma in Primary Care, told Healio Primary Care. “Additionally, having a relationship with a PCP ensures that they have all of your records and can better assist you with health issues or diagnosis.”
Burdening health care system
Recently, a JAMA Internal Medicine study showed that the prevalence of people in the United States with an identified source of primary care decreased by 2% from 2002 to 2015, with a particularly large decrease among those aged 30 to 39 years.
“Reduced reliance on the primary health care in the [U.S.] really then burdens our health care system because it increases our costs, health care, and it makes health outcomes for both individuals and also as a population much worse,” David Duong, MD, MPH, director of the Program in Global Primary Care and Social Change and Healio Primary Care Peer Perspective Board member, said in an interview.
For example, he said a patient visiting a PCP during a regular visit might appear to be at risk to develop diabetes, prompting the PCP to test their HbA1c, determine that they are prediabetic or diabetic, and discuss lifestyle changes and appropriate treatments early on.
However, Duong said if the patient does not have a regular PCP, they may not present for medical care until they experience more severe symptoms, such as very high blood sugar, loss of sensation in their feet, numbness or even blindness.
“That’s where it’s a cost to both the patient, in terms of their overall well-being and function, and also it adds a significant cost to the overall health care system,” he said.
Reichert said other chronic conditions, including allergy and asthma, “can be handled by a properly trained PCP without the additional expense of being referred to an additional specialist practitioner.”
In addition to having poor health outcomes, Reichert said “many individuals without PCPs often utilize EDs, which are not only much higher in cost by nature, but also overburden the EDs, which are designed for real emergencies.”
With regard to the COVID-19 pandemic, Reichert said EDs are typically “not the ideal place to determine if your symptoms may be COVID-19.”
“The excessive load that these nonessential visits place on an already overtaxed system in addition to subjecting oneself to others who are infected is less than ideal,” he said.
Important roles of PCPs during COVID-19
Because the virus is completely new, Duong said patients have numerous questions and concerns about COVID-19, and a PCP “can help them answer those questions and calm their anxieties.”
In addition to providing reliable answers, he said PCPs can triage patients with symptoms that are common in a variety of conditions — including influenza and the common cold — to determine whether they have COVID-19 or another condition, whether they can treat themselves and whether they can visit the primary care office or present to the ED.
He said triaging by PCPs can “decrease the burden in EDs, and this can also decrease the burden in hospitals as well.”
In addition to aiding in the treatment of COVID-19 patients, Duong said PCPs will likely play a vital role in distributing a vaccine if one becomes available, as they have in previous vaccination campaigns.
The potential closure of more primary care practices could create an issue with distributing a COVID-19 vaccine, Duong said, noting that “if we don’t have primary care practices because they’re all closed, then even if we have a great vaccine, the question of how we’re going to deploy that vaccine is still up in the air.”
Equal access to a vaccine and potential treatments also could be challenging, Duong said, as only those with access to primary care may have the ability to get it.
Duong said if primary care centers and federally qualified community health centers — many of which provide care to “Black and brown communities” — begin to close, then in addition to typical concerns stemming from lack of primary health care, it also raises questions as to whether these patients will have equal access to a COVID-19 vaccine.
“The COVID-19 pandemic has already exposed so many racial and health inequities in our health care system in the United States,” he said.
He added that both older adults and communities of color have disproportionately been affected by the pandemic, and that “primary health care is poised to deliver quality health care services to both of these disadvantaged or marginalized populations.”
“What we need to do is build a primary health care workforce and invest in primary health care so that we can be better prepared and more resilient to address future pandemics and health threats — not just for some in the United States, but for all in the United States,” Duong said.
Increasing PCPs in US
To help keep practices open during the COVID-19 pandemic, Duong said additional stimulus payments specifically targeting primary care are needed.
For long-term support, he said payment reforms are needed, such as eliminating fee-for-service payment and making payments for telehealth services easier.
Global payments — payments made to physicians for each patient in their panel — may also benefit primary care practices, according to Duong.
Using global payments, physicians and patients can decide the best way to utilize the visits.
“Whether it’s all in-person visits, or a combination of in-person, virtual and/or home visits — that should be the choice of the physician and the patient, depending on their needs and circumstances,” Duong said.
To bring more PCPs, nurse practitioners and physician’s assistants into primary care, Duong said medical education should mandate more time spent in primary care settings, “because we know that students who are engaged in primary care practices tend to end up going into fields in primary care.”
In addition, loan forgiveness programs may provide medical students with incentives to enter the field. Duong said this is because primary care is a lower-paid specialty, and many physicians take on massive amounts of debt.
“For each year that they work in a primary care practice, there should be some loan repayment or loan forgiveness,” he said.