MedCity Influencers, Health IT, Hospitals

What would post-Covid value-based care look like?

As virtual care is only going to grow in the coming months as a solution to pent-up demand for care that has resulted from the pandemic, focused attention is needed to address these operational and reimbursement issues.

patient engagement

In only a matter of months, the global pandemic known as Covid-19 has had many victims. The people we have lost to its destructive power are the most visible, but beyond that are the ravages it has played across our economy, our livelihoods and, most of all, our healthcare system.

While providers around the United States have worked tirelessly in every environment possible to fight back against the coronavirus, its prolonged life cycle is destroying the livelihood of many physicians, nurses, medical assistants, and staff. Urgent care facilities and emergency rooms around the country are pushed past their maximum limits of patients and bed capacity while primary care physicians (PCPs) and community health centers have turned into ghost towns. Doctors and staff stand by ready to help, but their list of patients dwindles from a steady stream to barely a trickle. Elective procedures are for the most part canceled though they are now being restarted in some places.

The reasons are obvious, and somewhat ironic. Patients have stayed home from their regular doctors for months because they fear getting infected with Covid-19 in the provider’s office. The speed of transmission and lack of knowledge of the novel coronavirus and the risk of visiting a doctor in person has been deemed far too great for many. Likewise, in the first months of the national lockdown, doctors’ offices were actively encouraging patients to stay home if they weren’t desperately sick, and head to an emergency room if they felt particularly ill. Between mid-March when the reality of the coronavirus first hit and April 23, 60% fewer patients visited value-based care (VBC) facilities year-over-year according to data from the Commonwealth Fund. Until halfway through May, that number was still down 38% from the same time in 2019.

This has severely impacted the revenue of healthcare systems, especially primary care practices. Almost every primary care practice in the country qualifies as a small business, and even though they are deemed essential, they are still suffering to the point that thousands of them are facing imminent business closure. Even for larger health systems, things are not looking up. According to an estimate by the American Hospital Association, U.S. hospitals and health systems will have lost $202.6 billion from March 1 to June 30. As a result, many hospitals have had to find ways to reduce cost, including staff layoffs and furloughs.

Two issues now looming as we look forward: What does the future look like for VBC facilities and what happens when there aren’t enough primary care doctors to see all of the patients who need help beyond Covid-19?

How VBC Providers Can Help Themselves
When patients can’t or won’t come to the office, the best way forward for primary care doctors is to go to them — virtually. In the first eight weeks after the mid-March national shutdown, more than 85% of doctors were doing either video-based or telephone-based visits with patients. But reimbursements of telehealth and virtual visits are tricky. It didn’t help that Medicare was the only payer paying consistently during the first month or so while the big insurance companies were still deciding what counted and what did not.

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Additionally, about 20% of patients still face technical challenges when accessing virtual care. For many, technology is a huge barrier —particularly for the elderly or others who cannot afford a phone or other device that allows for streaming services. For patients that are unable to visit the office on a regular basis because of age, access, or mobility reasons, primary care providers can consider a small technology investment of a simply screened device that can be rented or purchased and used to schedule appointments and communicate with doctors and nurses from the patient’s home. The initial investment could be pricey yet a tax write-off is possible and would allow doctors to see more patients remotely and at their own convenience. As virtual care is only going to grow in the coming months as a solution to pent-up demand for care that has resulted from the pandemic, focused attention is needed to address these operational and reimbursement issues.

Government and Community Health Assistance
The U.S. government initiated the CARES Provider Relief Fund in response to COVID-19, which would provide $175 billion for the healthcare system, in addition to the $100 billion in advance and accelerated payments to Medicare providers. But the foundation for transformation in healthcare has to be a lot stronger. Over the last few years, the Centers for Medicare and Medicaid Services (CMS) have announced a number of opportunities to encourage primary care providers to participate in innovative payment models, which are designed to prioritize keeping patients healthy. These models have recently been adjusted to ensure that they are able to address the uniqueness of the situation like Covid-19. For some models, implementation deadlines and reporting requirements have been delayed, and for some, payment methodologies have been adjusted.

However, it’s the reduced reliance on primary care that burdens the U.S. healthcare system. Primary care only accounts for 6-8% of all healthcare expenditures. Even before the pandemic hit, visits to PCPs were on a decline, which is a major cause of poor health outcomes. For example, a patient diagnosed with Type-2 diabetes with regular visits to a PCP has lower chances of a sudden increase in their HbA1c levels, and can avoid the complications of serious symptoms such as numbness in body parts or blindness that require medical attention. Many patients without a PCP end up in emergency departments, which only puts an excessive load on an already overburdened system.

During this pandemic, PCPs can help decrease the burden by providing guidance to patients and answering their questions regarding the new virus. PCPs can triage patients with the symptoms which are common in a variety of conditions and make sure high-risk patients receive immediate care. Even community health centers can play an important role in reducing the burden on the healthcare system. Community health workers, who are also seeing far fewer patients at their community health centers, can be tasked with other assignments such as using data-collection technology to evaluate Covid-19 patients to perform vital tasks such as contact tracing to see whom they have been in close contact with to test those individuals and get them quarantined if necessary to stunt the disease’s transmission.

Hospitals should be an avenue for change
Hospitals are where changes can occur to truly aid primary care providers and patients. Primary care has long depended on people showing up.  Primary care should assume a more central role in delivering care to the population through the use of technology to keep PCPs engaged. Hospitals can add or transform spaces within their campuses for primary care facilities and employ PCP doctors who have lost their practices due to economic hardship. PCPs can also work hand in hand with the hospitals to determine quickly when a patient needs to be sent to the ER or be admitted into the hospital. A “check-in” station like an urgent care center can be provided for walk-ins to determine where best to send them while entering their data into the system so that it is readily accessible to all facilities on campus.

The healthcare industry might never look the same as it did in early March 2020. It’s a mission-critical industry that will need to be transformed and rebuilt. The future of a well-functioning system will need to focus on keeping people healthy, which will require dedication to a better primary care infrastructure. This will only be possible with support from the government and health systems. Covid-19 has claimed hundreds of thousands of victims – let’s not include primary care on that list.

Photo: Halfpoint, Getty Images 

Dr. Paul Grundy is the Chief Transformation Officer at Innovaccer. Affectionately known as the ‘Godfather’ of the Patient-Centered Medical Home model, he is the Founding President of the Patient-Centered Primary Care Collaborative (PCPCC) and a member of the National Academy of Medicine. Prior to Innovaccer Dr. Grundy enjoyed an esteemed career at IBM, as the Chief Medical Officer of the Healthcare Life Sciences division, and the Global Director of Healthcare Transformation. Previous to IBM he was the Minister Consular for the US Department of State. Dr. Grundy is a globally respected healthcare convener, storyteller, and visionary - a "Trusted Healer.” He holds numerous international honorary titles and awards, including an honorary lifetime member of the UK National Association of Primary Care, an Ambassador for Healthcare DENMARK and the first international member of the Irish National Association of General Practice. He was the recipient of the NCQA National Quality Award in 2012, and recipient of the prestigious Barbara Starfield Primary Care Leadership Award in 2016.

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