Guest Opinion: If not now, when? Rebuilding our primary care and public health infrastructure

Published 5:47 pm Friday, April 24, 2020

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By David A. Rinehart, MD, FAAFP and Conrad L. Flick, MD, FAAFP

A recent survey of 295 primary care practices in the state conducted by the N.C. Department of Health and Human Services found that 34 practices already have closed (11.5 percent) and 121 practices (41%) have reduced hours due to the decline in patient visits caused by the COVID-19 pandemic.

This crisis has raised several painful questions for our state and the nation, as a whole. Yet the most important question we face is this: How long will we wait to fix what is broken so we’re better prepared the next time? 

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This crisis has exposed gaping cracks in our nation’s healthcare infrastructure. It is now all too easy to recognize the serious shortfalls of a disconnected, disorganized system focused on caring for the sick instead of preventing disease.

Nowhere are these problems more evident — and more dangerous — than in primary care. Local primary care is the foundation of any successful healthcare system, yet our country has long neglected it. Our system incentivizes expensive procedures rather than keeping people well. And the current crisis isn’t just weakening that foundation; it threatens to devastate it.

This is especially true for primary care practices that, like other small businesses, are suffering the economic effects of the pandemic. Primary care practices across the U.S. are seeing enormous decreases (some upwards of 80 percent) in the number of patient visits. By June, an estimated 60,000 family practices could close or significantly scale back, reducing hours, furloughing or even firing hundreds of thousands of their employees.

The situation in our state is no different. Potential closures here would mean 50 additional counties with family medicine shortages. A recent survey of family physicians and pediatricians in the state reported more than 80 percent were experiencing “significant” or “extreme” financial losses because of COVID-19. That means the nurses, administrators, janitors, and others who work at those practices will suffer financial losses, as well. And because many independent and rural practices are already on the edge of the economic cliff, more are likely to consider selling or closing their practices altogether.

The cruel irony is that those who are most able to treat the chronic diseases that put people at the greatest risk of COVID-19 are at the greatest risk themselves. Primary care physicians on the front lines of the battle against COVID-19 are poorly outfitted with insufficient COVID-19 tests, a lack of personal protective equipment; and insufficient capital to weather this storm. Should practices close, the public health risk runs deep. People will still get sick; patients with chronic disease will still need ongoing care; children will still need immunizations; and even more people will seek mental health counseling as a result of isolation, job loss, and financial insecurity.

We need a Marshall Plan for primary care. The Marshall Plan, enacted by the U.S. after World War II, provided billions to help rebuild heavily damaged cities, industries and infrastructure in Europe. What would a primary care Marshall Plan look like? Here are some ideas for state and federal leaders:

  • Change primary care payment from fee-for-service to a system rewarding prevention and care management.
  • Accelerate the use of telemedicine in primary care, rather than only incentivizing it during crises.
  • Embrace new epidemiological strategies, like digital pandemic tracking, to detect global health threats sooner.
  • Stockpile essential items like personal protective equipment and plan for efficient distribution.
  • Expand the number of family physicians, pediatricians and public health workers by forgiving medical school tuition for graduates who choose primary care.
  • Adopt strategies encouraging better geographic distribution of these professionals including incentives for choosing underserved communities.

This pandemic is an unprecedented crisis, but it also provides an unprecedented opportunity for us to come together and fix our healthcare system and strengthen Its foundation: primary care. If we don’t, then practices will fail, patients and communities will suffer, and we will have changed nothing. We will have let the virus win this war.

David A. Rinehart, MD, FAAFP is president of the N.C. Academy of Family Physicians and Conrad L. Flick, MD, FAAFP is co-president of Community Care Physicians Network.