SALT LAKE CITY — The coronavirus has put unprecedented pressure on U.S. medical providers as health care spending declined 18% in the first three months of the year. According to the U.S. Department of Commerce, that’s the largest reduction since the government started keeping records in 1959. But while physicians and administrators are still scrambling to pick up the pieces of a dismantled health care system, they are hoping to rebuild something better.
After weekslong restrictions on elective procedures, hospitals have found themselves strapped for cash. According to a list by Becker’s Hospital Review, about 250, including Boston Medical Center and Detroit Medical Center, have furloughed workers. Without being able to see patients, primary care facilities such as Autumn Road Family Practice in Little Rock, Arkansas, and Northampton Area Pediatrics in western Massachusetts laid off staff, and others have gone out of business.
All over the country, physicians have adapted quickly to try and get their patients the care they need without in-person visits. In many cases, they haven’t been paid for their work because it’s hard to bill insurance for consultations over the phone. The crisis has caused many medical professionals and other experts to take a careful look at the way the U.S. health care system is set up.
In a post-pandemic world, the expansion of telehealth options, a transition away from fee for service models to more value-based primary care, and an increased use of technology could help cut back on high costs and inefficiency in medicine, say experts like Elizabeth Mitchell, head of the Pacific Business Group on Health. The Pacific Business Group on Health represents large companies, including Boeing, Safeway, Walmart and Wells Fargo, that spend more than $100 million on health care for employees each year and are displeased with the quality and price, Mitchell said.
“I think the coronavirus is just exposing the preexisting failures of our system,” said Mitchell, who is particularly concerned by a report from the American Academy of Family Physicians that estimates more than 38,000 family physician practices will see closures or layoffs by the end of May.
Mitchell and other advocates for value-based care believe that primary care physicians should be paid prospectively based on the populations they treat and evaluated based on their ability to keep people healthy, rather the number of procedures they do or tests they order. Such a system would give physicians greater flexibility in how they treat their patients, including checking in virtually and integrating more mental health care, Mitchell said.
“Primary care really is the front line of public health, and people are realizing that’s something that we really need to invest in now,” said Christopher Crow, a primary care physician and the president of Catalyst Health Network, a company based in Plano, Texas, that helps doctors manage their patients.
Additionally, the coronavirus may encourage hospital systems to adopt new technologies, like using artificial intelligence to suggest diagnosis and treatment or building integrated systems for sharing data and coordinating emergency responses.
“The world of health care is going to be a ton better on the other side of this because we’re realizing that we’ve been over utilizing the system, it costs too much, we can do care in different ways, and we can use technology to support it,” said Crow.
Value-based care
The coronavirus has temporarily changed life as we know it, from the way we work, to the way we celebrate birthdays and weddings. But perhaps the most significant changes will be seen in the health care — specifically primary care.
Crow likened the way that health care is typically paid for to buying a hamburger — a singular transaction where a fee is exchanged for a service.
“That works pretty well given you only go to the hospital once in a while. When you need it, you just go pay for it,” Crow said.
But this fee for service or “hamburger” model doesn’t incentivize doctors to go beyond what happens in the office to keep the patients healthier long term, Crow said. In contrast, a value-based care system, which Crow advocates for, would be more like a monthly subscription, similar to the way people pay for phone service or a Netflix account. It would promote more personalized and consistent care that would ultimately keep them out of hospitals and lower costs.
“Prospective payment allows you the flexibility to use any modality possible to take care of that patient, including telehealth and follow-up phone calls,” said Crow. “Versus fee for service, where the only way I can get paid to take care of that patient has been for them to show up in my exam room.”
Salt Lake City-based primary care doctor Robert Corson is one of just a handful of physicians in the area that has a private practice that doesn’t bill to insurance at all. His growing business currently sees about 54 patients who each pay him a monthly fee of $60-$80 for unlimited access to care. At any time, Corson’s patients can call him or ask him questions via secure messaging.
Corson said his patients tend to be people with high-deductible insurance or no health insurance at all. They like knowing exactly how much they are going to pay each month and having a more personalized relationship with their doctor.
“They know they can call me whenever and get something addressed,” said Corson. “They don’t have to talk to the front desk, who leaves a message for the medical assistant, who leaves a message with the doctor who might return the call the next day.”
The coronavirus has hardly affected Corson’s practice at all, he said, although he now relies more on telehealth visits.
According to Mitchell, shifting from a fee for service to more subscription-like model is something that should have happened “decades ago,” but commercial insurers have been dragging their feet because they don’t have the proper channels in place to process payments this way.
The coronavirus may be just what the industry needs to spark more rapid change, Mitchell said. Blue Shield of California is an example of a progressive plan implementing changes, Mitchell said. Through Catalyst, Crow works with several small employers that pay for value-based primary care for their employees on top of regular insurance.
“There is a lot of interest in that continuing, and it’s proven to be effective,” Crow said. “The next step is to get it scaled out and adopted by big commercial insurers.”
The underlying concern is that if doctors are paid prospectively instead of by service, they will try and do as little as possible for their patients. Crow said this problem is addressed by measuring health outcomes and holding doctors accountable.
“You have to make sure the patients are staying healthy and you’re showing you’re keeping them out of the hospital and ER,” Crow said. “But you can put those metrics in place.”
Telehealth
When physicians had to stop seeing patients in person because of the coronavirus, doctors quickly transitioned to counseling patients via telehealth. While the Centers for Medicaire and Medicaid Services quickly approved billing for virtual visits, it has taken other insurers some time to catch up.
“No doubt telemedicine will be more important going forward,” said Shawn Martin, senior vice president for advocacy, practice advancement and policy at the American Academy of Family Physicians. Martin believes relying more on technology can help eliminate unnecessary in-patient appointments and increase the efficiency of health care overall.
In particular, preliminary evaluation and ongoing monitoring of a condition lend themselves well to telehealth services, Martin said. While physical examinations and other procedures will still need to take place in person, things like follow-up visits, medication management and mental health assessments could be carried out via video or telephone. He calls it, “the 21st century house call.”
“For physicians that have a longitudinal relationship with a patient who has known health conditions, you can do a comprehensive visit over telehealth,” said Martin.
In a preliminary evaluation, telehealth could also be used to advise patients on what course of action they should take — whether that’s going to an ER, making an appointment with a family doctor, or just waiting for the problem to go away.
Wyatt Decker, CEO of health services company OptumHealth, said in a video posted to the organization’s website, that telehealth could be particularly impactful for rural communities, where there is less access to resources.
“We have historically seen over the past five years, a gradual decrease in the number of health care services that are available over communities,” said Decker. “Through digital capabilities and technologies, I think a new era is coming upon us where those rural communities will be able to access not only primary care but potentially specialty medical care.”
Technology and integration
The coronavirus may accelerate a move toward computerized medicine as doctors care for patients without seeing them face to face, said Brian Whisenant, a cardiologist at Intermountain Healthcare. Instead of a person interviewing a patient, a computer questionnaire combined with artificial intelligence may eventually be used to evaluate a patient’s symptoms, medical records and sleep and activity data from personal health trackers. Ultimately, a technology-first approach could lead to earlier diagnosis and intervention, Whisenant said.
Hardeep Singh, a professor of medicine at Baylor College of Medicine in Houston said that one thing hospital systems have learned from the coronavirus crisis is that access to real-time and reliable patient-level data is essential to help prepare for emergencies. Sharing data across various health care organizations can help with that, Singh said. It’s just a matter of building the technological infrastructure at a national level.
“What I also hope we see is more coordination between primary care and public health. We need to know who’s been tested, what the test results are, if they’re positive, who’s going to follow up with contact tracing to make sure we know who’s been in contact — eventually we will want to know who has immunity, who has got the vaccine,” said Ann Greiner, head of the Primary Care Collaborative, an advocacy group. “Primary care plays an important role.”
The question is, will we actually have the motivation to actually make these changes? Or will our concern fade as the virus’s death toll wanes?
“I think it is easy to lapse back into complacency,” said Mitchell. “And I hope that what we are learning in this pandemic really spurs action. Because we have needed fundamental changes in our health care system for far too long. If this is the catalyst for making these changes, that might be something good that comes out of it.”