Family Medicine and Global Payments: The Bridge to a Healthier Future
As I held her small body in my gloved hands, I tried to take in the preciousness of this moment. Despite standing in the grip of fear of the COVID-19 pandemic, my grin broadened beneath my surgical mask and shield. Standing at a distance was the child’s mother, a woman whose story I knew so well, as I had journeyed with her through the pain of a bad relationship, the loss of a pregnancy before this one, and the deep rivers of trauma in her past. I had treated her before, during, and after her pregnancy, and I would continue to care for her as many years as we remained in one another’s lives. And then there is her mother — this baby’s grandmother — who I started taking care of over a decade ago. Together with my pharmacy and behavioral health teams, we had treated her chronic conditions and marred relationships. The arrival of a granddaughter had provided hope and a way forward.
And so it is with family medicine during this time of national crisis. Family medicine physicians have continued to provide holistic care for the families who depend on us, while also working shoulder to shoulder with colleagues to build teams and solutions through the pandemic. At Boston Medical Center, for example, family medicine physicians have helped lead the charge on the inpatient response. They robustly staffed the influenza-like illness (ILI) tents. They strengthened and participated in the palliative care extender teams, provided steady support for the East Newton Pavilion COVID Recovery Unit (which housed homeless individuals while they were still COVID-19-positive but not in need of hospital-level care), tended to children and their families in tents outside the hospital, and helped lead the adoption of telehealth in primary care.
This kind of rapid and creative response to the needs of our community is not new.
In fact, family medicine was established as a specialty in 1969 in large part to respond to the fragmentation of medical care and subsequent healthcare disparities and delivery gaps that existed in our country. It is a specialty built upon the socio-ecological model of care, whereby providers recognize that the health of individuals is inherently tied to their relationships to family, community, and culture, as well as to broader political, social, and economic factors.
Without immediate and innovative interventions, the pandemic threatens an even wider gap of disparities
Nationally, the pandemic has stressed our healthcare system and tested our ability to provide equitable healthcare, threatening an even wider gap of disparities without immediate and innovative interventions. Family medicine providers, specializing in care at every age and through every stage, have been able to flex into patients’ and hospitals’ evolving needs in a time of crisis, and have the skills to continue to adapt care within a living, breathing system. Unfortunately, the future of primary care is uncertain. As health systems recover from the pandemic, a new way forward is needed to allow for both better access to care and more innovation, a model in which providers are able to consider care first and costs second.
Why does primary care matter?
Since its inception, the impact of family medicine has been enormous, especially for underserved rural and urban populations, for whom family medicine physicians provide the majority of care. The availability of robust primary care has consistently been linked to better health outcomes, lower spending, and more equitable distribution of health across sociodemographic dimensions. An analysis of epidemiological data demonstrated that every 10 additional primary care physicians per 100,000 people is associated with a 51.5-day increase in life expectancy.
But historically, investment in primary care in the United States has been low relative to other countries, which may contribute to our country’s higher costs and worse health outcomes routinely observed in international comparisons.
COVID-19 has wrought havoc on the population health consequences of this underinvestment in primary care. While reimbursement for telehealth has helped replace some lost revenue, it is not nearly enough. Revenue in many primary care practices has dropped significantly and in a recent national survey, more than 22% of family medicine clinics reported that they would be able to provide care for just two months or less under the current circumstances. Given that federal stimulus packages have not directly allocated funding to small or independent practices, it is projected that up to 60,000 primary care practices in the U.S. may close or scale back significantly. (This data is also supported by initial data that my colleagues and I collected with Mass Health through an IRB with Harvard, whose results will be published shortly.)
If family medicine practices shut down or even scale back significantly, the consequences would be devastating. Not only would it lead to increased deaths from chronic diseases but also increased costs and a further widening of existent healthcare disparities, which are largely due to barriers that family medicine practitioners are particularly well-equipped to breach. At a time when pivotal redesign is possible, family medicine and primary care cannot be an afterthought.
Global payments for primary care
Immediate and urgent funding is needed to support primary care, but we also need to rethink how that funding operates. Fee-for-service delivery models discourage innovative and effective primary care functions that don’t appear on the fee schedule. In our country’s urgency to respond to the virus, the fee-for-service delivery model was no longer the primary driver. We saw incredible demonstrations of the innovation that’s possible, and family medicine and primary care providers were easily able to respond to the needs of the community in the new paradigm.
As we build the bridge to a post-COVID future, we must consider moving towards a global payment for primary care, whereby a prospective, risk-adjusted amount for primary care services supplants the current fee schedule. And as we work towards improved payment and delivery models, family medicine can be counted on to continue to respond and deliver care in order to support the health of our patients and communities.