Q&A: Failure to include primary care in initial COVID-19 response may have cost lives
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The toll of COVID-19 in the U.S. would have been less catastrophic if primary care had been more involved in the initial response efforts, according to a report by researchers at Johns Hopkins Bloomberg School of Public Health.
“One of the country’s biggest failures was to not look at primary care providers as frontline responders, and to build upon the trust and confidence that individuals have in their primary care provider,” Tener Goodwin Veenema, PhD, MPH, MS, RN, FAAN, a co-author of the report and contributing scholar at Johns Hopkins Bloomberg Center for Health Security, told Healio.
The report was based on information from more than 30 “key informant interviews” and nearly 100 publications, according to its authors. A substantial part of the report’s findings, recommendations and conclusions align with surveys that the Larry A. Green Center began conducting shortly after the public health emergency was declared, the authors added.
In an interview, Veenema discussed “missed opportunities” in the United States’ response to the COVID-19 pandemic, the challenges that primary care practices continue to face in providing care, and the changes that must be made to better equip and integrate primary care during future public health crises.
Healio Primary Care: What are some of the key “missed opportunities” that were identified in this report?
Veenema: Missed opportunities to provide better care included everything from doing faster testing, more effective contact tracing and counseling and education of individuals and their families in terms of appropriate protective actions to take to avoid transmission of the disease.
We could have seen greater early acceptance of vaccination and thus, higher vaccination rates, and overall, just a stronger communication pattern between primary care providers and their patients. Inclusion of primary care providers in the COVID-19 response could have helped alleviate the burden on public health. We also really missed on the opportunity to build upon people’s trust in primary care in order to reduce the confusion created by conflict or discordance in the guidance coming out from public health authorities. People trust their primary care providers and they could have been a terrific asset to our overall COVID-19 response.
Healio Primary Care: What resources did primary care practices lack that hindered their initial response to the pandemic?
The two biggest resources that primary care practices lacked were finances and personnel.
We know that primary care has been chronically underfunded, especially over the past 10 years, and that this has created a horrific burden, particularly on those independent primary care practices that are not affiliated with a larger hospital or integrated health care system. Therefore, they did not always have the finances to invest in better information technology and did not always have the resources to invest in telehealth.
Healio Primary Care: Do primary care practices still lack these resources?
Veenema: Primary care practices and health clinics did a phenomenal job of rendering health care services throughout the pandemic, even in the face of limited resources. We saw evidence of innovation and an unwavering commitment to their patients.
However, some primary care practices are still struggling, particularly in rural areas. We have witnessed a major shift in the primary care landscape over the course of the pandemic, with many independent practices being purchased by hospitals, large integrated health care systems or corporations.
There are major initiatives going on right now, such as pursuing payment reform in order to move away from the fee-for-service model, which has been very negative in terms of the financial health of primary care practices, to move towards a more value-based payment system. It is also important to mention that it is not just primary care that's been chronically underfunded, but public health has been chronically underfunded as well.
These are two critically important sectors of the health care system, and for them to be so underfunded resulted in misalignment and contributed to the poor COVID-19 response.
Healio Primary Care: Previous survey data showed that many primary care providers who wanted to participate in COVID-19 vaccine rollout efforts were excluded. What could have been done differently to better incorporate primary care in the initial rollout of the COVID-19 vaccine?
Veenema: Improved communication channels between public health departments and primary care practices and integrated technology systems would have been incredibly helpful to being able to include primary care providers as part of the response.
We did see some examples, particularly in some federally qualified health care centers and in some primary care practices that had preexisting relationships with their public health departments, where primary care providers were more involved in the vaccine rollout process than others. That preexisting relationship may have been based on personnel having had a personal relationship in a public health director or through shared disease management programs that had primary care collaborating with public health to manage the care of those individuals. In addition, primary care practices that had a strong preparedness plan linked to local and state public health tended to do much better in terms of making it through the COVID-19 response.
Healio Primary Care: What would the pandemic look like today had primary care been more involved in COVID-19 response efforts?
Veenema: I truly do believe that there would have been less severe illness and less mortality if we had effectively mobilized primary care as part of the initial U.S. response. We also would have done a much more effective job of the testing and contact tracing that was critical to a strong response to the pandemic. In terms of vaccination rates, and the overall implementation of the vaccination program, had primary care providers been provided supplies for testing and had been provided vaccines that they could have helped administer, all those initiatives would have saved lives.
Healio Primary Care: What efforts/resources are needed to address the communication barriers between primary care providers and public health officials?
Veenema: We list in our report several different recommendations that encourage federal and state agencies responsible for public health and primary care to review any existing policies and funding mechanisms and using them to support primary care and public health integration. The more we can integrate these systems, whether it is through increased interoperability of information technology systems or providing funding for programs that invest in innovations to help in this integration, these are things that would contribute to improving communications and then strengthening primary care and public health together.
One of the recommendations in our report is that we look at potentially establishing a federal public health–primary care collaboration and capacity partnership grant program that would foster the development of local coalitions of public health, primary care and community-based organizations. This is very similar to what HHS’ assistant secretary for Preparedness and Response Hospital Preparedness Program did years ago for hospitals and it resulted in improving bidirectional communication across participating member organizations.
Healio Primary Care: What should every primary care practice include in their preparedness plan that will allow them to better respond to future crises?
Veenema: This might vary across primary care practices in terms of how well-resourced they are and how connected they already are to their local public health department. At a minimum, there needs to be increased bidirectional communication channels and clear plans for how primary care and public health will work together when another event occurs.
In addition, during the COVID-19 pandemic, practices that had a leg up in terms of their telehealth capacity tended to do much better than those that did not. They were able to pivot their service delivery model more quickly and maintain care services. Based on that, practices need to do some forward thinking in terms of what types of technological and information management systems could facilitate communication between patients and primary care providers and between primary care and public health. Additionally, primary care practices need a workforce plan that protects the health and well-being of their staff and provides back-up staff when needed. Those are all important components of a robust pandemic preparedness plan.
Healio Primary Care: Is there anything else you would like to add?
Veenema: There is some great work being done nationally regarding payment reform for primary care. These reforms are critically important and need to happen, since it will be the foundation of rebuilding strength and resilience in the primary care system.
However, we need more than just payment reform if we are going to rebuild, transform and integrate our health care system, particularly as it relates to primary care and public health. We need to make sure that preparedness and integration of services are the two threads that go through every policy and every funding mechanism.
Reference:
Integrating primary care and public health to save lives and improve practice during public health crises: Lessons from COVID-19. https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2021/211214-primaryhealthcare-publichealthcovidreport.pdf. Published Dec. 13, 2021. Accessed Dec. 16, 2021.
Perspective
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Yalda Jabbarpour, MD
Much attention during the COVID-19 pandemic has been paid to the health care response in emergency rooms and intensive care units. While these settings are critical to the survival of individuals with severe disease, most patients infected with COVID-19 will never require hospital-level care. In reality, many people with COVID-19 remain in the community and are managed by their primary care clinician.
While data is still emerging on the true impact of primary care during the COVID-19 response, historic data point to the capacity of primary care to meet the health needs of individuals during this pandemic. Research has shown that primary care offices are where a majority of Americans traditionally are treated for respiratory illnesses, including the common cold, bronchitis and pneumonia. Primary care clinicians also manage chronic disease and are the most common place patients with behavioral health needs seek care, both essential components of health care during this pandemic. Primary care clinicians are also responsible for the prevention of disease, and primary care offices have traditionally been where most Americans receive their immunizations. Although primary care is essential to the care of individuals and families, it cannot meet its full potential to care for communities without leveraging public health.
A new report by researchers at the Johns Hopkins Bloomberg School of Public Health explores the connections between public health and primary care during the COVID-19 pandemic. The overall message from the report is simple: public health and primary care are essential, and our underinvestment in both cost lives during the pandemic. The report highlights settings where primary care offices assumed the dual role of caring for their individual patients while also responding to the health needs of a community. Primary care offices provided testing for the entire community, they provided quarantine guidance and ensured access to food and housing for those in isolation. Primary care practices were agile in coming up with innovative ways to reach people in their communities, including the deployment of mobile units to provide COVID-19 testing as well as health care services unrelated to COVID-19. Not surprisingly, primary care offices shouldered the responsibility of meeting the health needs of their communities, and many were stretched to their breaking points trying to fulfill the dual primary care/public health role.
The question remains as to whether lives could have been saved had primary care and public health been more integrated prior to the pandemic. Previous work done by the Primary Care Collaborative and the Robert Graham Center for Policy Studies in Primary Care has quantified the benefit of having robust primary care and strong public health infrastructure in a community. Researchers found that individuals in counties with the best primary care and public health scores before the pandemic were 12% less likely to get infected with COVID-19 and 42% less likely to die with the disease. What remains to be measured is the impact that true integration of public health and primary care had in the COVID-19 response. Calls for the integration of primary care and public health are not new and research quantifying the impact of true collaboration during the pandemic are emerging. Studies from states like Maryland are showing early evidence that public health and primary care working together resulted in better COVID-19 associated outcomes. Yet, the level of integration has yet to be studied and likely also makes a difference. As the Johns Hopkins Bloomberg School of Public Health report points out, integration between public health and primary care ranged from intermittent communication to co-location and active daily collaboration. As we move forward it is essential that we continue to study the impact of these different levels of integration and create best practices for communities based on their diverse needs and resources.
The COVID-19 pandemic has highlighted the need for more investment in both primary care and public health. But it has also shown that these two entities cannot be siloed during a public health crisis. The Johns Hopkins Bloomberg School of Public Health report recommends steps that must be taken to bolster public health and primary care, but also to foster higher levels of integration. These include transitioning to value-based payment models to compensate practices for a wider spectrum of services; investing in federally qualified health centers, where primary care and public health have traditionally merged; empowering public health officials as opposed to political leaders in coordinating the response to large-scale health emergencies; co-locating public health departments and primary care offices to foster communication; and encouraging interdisciplinary training. Without action at the federal, state and local levels to support primary care and public health integration, we risk repeating the mistakes of the COVID-19 response in future public health emergencies.
References:
Improving COVID-19 Outcomes for Medicare Beneficiaries: A Public Health-Supported Advanced Primary Care Paradigm. https://www.milbank.org/publications/improving-covid-19-outcomes-for-medicare-beneficiaries-a-public-health-supported-advanced-primary-care-paradigm/. Accessed Dec. 23, 2021.
Integrating primary care and public health to save lives and improve practice during public health crises: Lessons from COVID-19. https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2021/211214-primaryhealthcare-publichealthcovidreport.pdf. Accessed Dec. 23, 2021.
Jetty A, et al. J Prim Care Community Health. 2021: doi:10.1177/21501327211023871.
Primary Care: It’s Complicated. https://www.pcpcc.org/sites/default/files/resources/PCC_Primary_Care_COVID-19_It’s_Complicated.pdf. Accessed Dec. 23, 2021.
Westfall JM, et al. J Am Board Fam Med. 2021;doi:10.3122/jabfm.2021.S1.200458.
Westfall JM, et al. J Am Board Fam Med. 2021;doi:10.3122/jabfm.2021.S1.200204.
Wilkinson E, et al. Ann Fam Med. 2021; doi:10.1370/afm.2679.
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