Primary Care in Crisis

March 25, 2020

Photo via Canva

We’ve rightfully heard a lot about the stress the coronavirus is putting on our hospitals. But the pandemic is also straining our primary care system.

Listen to the full episode below or scroll down for the transcript and more information.

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Dan Gorenstein: We’re hearing a lot about the stress that the coronavirus is putting on our hospitals.

ABC News: Some hospitals reporting a 50% surge in coronavirus patients.
CBS News: Hospitals are overwhelmed with patients and alarmed that the supplies they have now will be gone in days.

What we’re hearing less about is what’s happening to the people you tend to call when you wonder if your kid has strep, you get a sharp pain, or now, if you’re running a high fever and have a cough.  

There are more than 200-thousand primary care doctors around the country, and they’re struggling to keep their doors open.

Farzad Mostashari: Two of our practices are already thinking about laying off their workers.

And the future doesn’t look much brighter.  

Chuck Jones: There’s not a light right now at the end of this tunnel that I can see.

Today, from the Annenberg Studio at the University of Pennsylvania, we look at the impact the coronavirus could have and is already having on our primary care system.

I’m Dan Gorenstein. This is Tradeoffs.

DG: Michaela Keller’s job these days is to take calls.

Michaela Keller: It has been just a constant flood of calls and emails and text messages. (laughs) Every form of communication.

DG: People on the other end of the line are freaked out.

MK: This is just another level that we are hearing in terms of the panic and the worry and the like, we need to fix this.

DG: Keller works for the National Association of Community Health Centers, the advocacy organization that represents 1,400 health centers, often called federally qualified health centers or FQHCs. 

The centers provide medical, dental and mental health services to 29 million patients, nearly half who live in poverty. 

Like most primary care practices, health centers get paid for each office visit and lab test. Basically every service they deliver to their patients. 

But with social distancing measures in place, fewer patients are seeking care for their diabetes, heart conditions and COPD.

Health centers got an additional $100 million in the first stimulus package passed by Congress earlier this month. 

But advocates said in a statement on Friday, that dropoff in service could result in losses exceeding $3 billion in the next 12 weeks.

MK: You know at the end of the day, I think while not every health center may be able to keep its door open, those that can will.

DG: One way to help make up that shortfall is telehealth, but for their 5 million Medicare patients, community health centers currently can’t get paid for virtual visits.

Congress is working on a fix as part of its latest coronavirus stimulus package, but the legislation would still reimburse at a lower rate than an in-person visit.

MK: This is not a time to be shortchanging health centers. You know, it’s essential that health centers, you know, have the ability to provide telehealth services and that they’re paid at their normal rate for doing so.

DG: While FQHCs wait for Congress, they’re hemorrhaging money.

Chuck Jones heads up Harbor Health, a group of six health centers serving more than 30,000 people annually in Boston and on Cape Cod.

I called Chuck Friday, March 20. The night before, Chuck had met with his board of directors. 

Chuck Jones: We’ve had to make a lot of difficult decisions recently, and at that meeting, I gave an update to the board about our financial situation. And we sought their approval to temporarily close Geiger Gibson Community Health Center, the very first community health center in the country

DG: Harbor Health could not afford to keep Geiger-Gibson open,  even after closing down its dental facilities and laying off more than 100 people earlier in the week.

CJ: And so they gave me that approval, understanding the situation that we’re facing right now. You know, what led to this decision and it’s… Every decision, you know, it affects… Every decision affects patients, staff, the organization’s financial situation… Excuse me.

DG: Are you OK?

CJ: Yeah. It’s a lot of… All right. Lemme start over. So this has really been sort of nonstop decisions, every one of which is a struggle between taking care of the people that built the organization and trying to ensure the survival of the organization itself.

DG: So help me understand your finances. How many people pre-COVID, typical day, how many people are coming through the door? How much are you guys billing?

CJ: So, on a typical day, 600 to 650 patients walk through the door. About a third of those are dental, two-thirds of them are medical. On a monthly basis our health centers have about $3 million of total revenue, about 60% to 70% of that is revenue that’s directly tied to the visits that are coming through the door. 

DG: Chuck says now with COVID-19, they’re only seeing about a third of their normal patient load which has real consequences for their bottom line.

CJ: That puts us on a sort of deficit track of about $1.5 million a month, and that’s that’s not that’s not something that can be sustained very long.

DG: When you say that, Chuck, do you mean that you might have to, like providing that care to all these people, you guys might just have to close, you can’t afford it anymore?

CJ: I try to stay positive, I try to stay optimistic. But without something really significant being introduced here, there’s not a light right now at the end of this tunnel that I can see. 

DG: Community health centers care for some of the country’s most vulnerable patients, but they are just one part of the primary care network that is feeling the strain of fewer patients walking in the door. 

The American Academy of Family Physicians says that many of its nearly 150,000members report seeing half as many patients as normal and just having 2 to 6 weeks worth of cash reserves in their practices.  

About a quarter of primary primary care docs work for a hospital, insurer or other corporate entity which, in theory, will help absorb this financial shock. 

But for independent practices, conditions are fast reaching a breaking point. 

Farzad Mostashari: These practices have razor thin margins. 

DG: Farzad Mostashari runs Aledade, which works with more than 500 independent primary care practices nationwide.

FM: We asked our physician practices what were their top concerns, and on that survey, the number one concern was they can’t get the masks. They can’t get personal protective equipment. They’re their supply chain is broken. The second biggest fear was this devastating their practice finances.

DG: Compared to other independent practices, Farzad’s members may actually be more insulated from the financial sting of seeing fewer patients. These practices sign contracts that reward doctors for keeping patients healthy and controlling costs, rather than for the volume of services they provide like every shot, test and exam. But Farzad says volume-based contracts still reign supreme, and that leaves his practices vulnerable.

FM: Because fee for service still pays the bills. In terms of cash flow, they need to be able to bill fee for service in order to keep the doors open. 

DG: Farzad says one of his practices already had to lay off 12 staff members. Others are seeing more than half of their appointments cancelled. Not to mention staffing shortages due to the outbreak.

FM: I mean, we had one one practice where the doc is the one who’s the revenue generator for the whole practice, and she was exposed and is in quarantine and the whole practice is shut down, and they may need to lay people off. It’s literally that degree of fragility to some of these practices.

DG: If these practices close down, Farzad, what is that going to mean for the country’s larger efforts to contain coronavirus and keep people as healthy as possible?

FM: We’re going to have people at home who still have high blood pressure and are still at risk for stroke and heart attack and kidney failure. And a real concern is that if we snap that thread of primary care, that the actual death toll could end up being far higher, not just the direct impact, but also the indirect costs that it’s incurred into our nation’s ability to care for the most vulnerable.

DG: How many independent primary care practices are there in the country, do you know?

FM: 21,299.

DG: Do you expect all of them to survive this?

FM: No.

DG: If primary care practices are forced to close their doors, the evidence suggests it won’t just hurt patients and staff.

Meredith Rosenthal: Most health economists and health policy researchers I know would agree with the statement that the strength of our primary care system is critical for the health system overall.

DG: Meredith Rosenthal is a health economist at Harvard who studies primary care.

When we think about the infrastructure of our primary care providers, particularly independent physician practices that are not affiliated with large hospitals, if these practices end up going under, long term what sort of impact will that have on our health care system?

MR: If we lose primary care capacity, almost surely that will have a detrimental effect on patient health and on the cost of care overall. The published evidence is not so robust to be able to make it easy to quantify this, but almost surely a loss of primary care capacity will have negative outcomes for the system as a whole and certainly for those patients who have a loss of access. 

DG: We’ve heard from folks, even just in this episode talking about how financially strapped they are, particularly with some of our FQHCs, the federally qualified health centers around the country that serve 29 million people. If these primary care providers close down in the coming weeks, what will that do, Meredith, to the flow of work for ERs and hospitals?

MR: If FQHCs were to close that would be really catastrophic, and it would tip their patients into local emergency departments almost surely. For the most part, that is the only other place that some of these people can get care.

DG: And Meredith, what needs to happen to support primary care providers during this pandemic? Does there need to be some sort of emergency funding relief for primary care providers?

MR: What needs to happen for those practices may be some cash flow support, may be some additional flexibility in terms of payments for telemedicine — emails, phone calls, even text. I think what happens in the scenario in which there is no additional financial support, we’ll see more and more small independent practices get rolled into larger health care systems.

DG: What ultimately do you see being the consequence of primary care providers becoming employed by our large health systems, by the hospitals?

MR: If independent primary care practices are bought up by health systems, almost surely the cost of care will increase with no additional benefits in terms of health. So it’s something that policymakers can do something about now that may prevent consolidation from being the inevitable consequence of the financial strain that is happening now.

As of this recording on Tuesday evening, Congress was still debating a third stimulus package, expected to hit nearly $2 trillion.

There’s money in there for airlines, small business owners and everyday Americans.

Primary care providers say they need a bailout too — from wonky fixes on telemedicine reimbursement rates to interest-free loans to straight up cash infusions.

Research shows that having more primary care doctors is associated with better outcomes and lower costs.

These providers, the people we call first when we’re sick, say that if they don’t get help now, some of them will not survive this pandemic.

I’m Dan Gorenstein. This is Tradeoffs.

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Episode Resources

Select Research and Reports on Primary Care:

Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015 (Sanjay Basu, Seth Berkowitz, Robert Phillips, et al; JAMA Internal Medicine; 2019)

The State of Primary Care in the United States (Robert Graham Center, 2018)

Association Between Temporal Changes in Primary Care Workforce and Patient Outcomes (Chiang‐Hua Chang, A. James O’Malley and David C. Goodman; Health Services Research; 2016)

Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care (Katherine Baicker and Amitabh Chandra, Health Affairs, 2004)

Federally Qualified Health Centers:

Health Center Fact Sheet (HRSA, National Association of Community Health Centers)

Under Financial Strain, Community Health Centers Ramp Up For Coronavirus Response (Will Stone, NPR, 2020)

Cash-Strapped Community Health Centers Fear Impending Funding Will Fall Short (Ysura Murad, Morning Consult, 2020)

Episode Credits


Michaela Keller, Manager, Federal Affairs, National Association of Community Health Centers

Chuck Jones, President and CEO, Harbor Health Services

Farzad Mostashari, MD, Co-founder and CEO, Aledade

Meredith Rosenthal, PhD, Professor of Health Economics and Policy, Harvard T.H. Chan School of Public Health

Music composed by Ty Citerman, with additional music this week from Whitewolf and Blue Dot Sessions

This episode was reported by Dan Gorenstein and produced and mixed by Ryan Levi.

Additional thanks to:

Amy Richardson, Ishani Ganguli, Bob Marsalli, Susan Sumrell, Amy Simmons, Brian Chiglinsky, Kerin O’Toole, Shawn Martin, the Tradeoffs Advisory Board…

…and our stellar staff!