The COVID-19 Tsunami: The Tide Goes Out Before It Comes In

Most people in the US have withdrawn from their daily routines unless their jobs are essential. Quiet streets, shuttered stores, silent schools. More than 400,000 live with the knowledge that they have the disease, but the slowness of our testing means that multiples of that number are likely to be infected. In pockets around the country, hospitals feel the earliest surges from those most vulnerable to COVID-19, but countrywide, the tsunami is still out at sea.

The devastating effects of a tsunami are usually preceded by an abnormally fast and long low tide, as water is actually pulled away from shore toward the epicenter of the underwater earthquake. Most of the US currently sits in that temporary equipoise. Most Americans who receive any health care in a given year do so in a primary care setting, (CLICK THIS LINK) to see where primary care fits into health care. where they generally have the relationships that they count on most when they are sick—or scared that they might be. In 2016, primary care provided 54.5 percent of all patient care visits and despite representing only 30.0 percent of the physician workforce, primary care physicians manage the majority of the care of people with the same high-risk conditions that put them at risk for the coronavirus. Research published in 2016 reminded us that the “Ecology” of care-seeking and receiving behavior in the US has not changed in 60 years. In a given month, 113 people in 1,000 visited primary care clinicians, while only eight were hospitalized and less than one was cared for in any of the university hospitals that dominate the US health care landscape and conversation. Primary care clinicians are the predominant providers of health care in small towns and rural areas where they often also staff many of the rural and critical access hospitals that those communities depend on. And although the relationship between the US population and its primary care workforce should, therefore, serve as protective breakers in the face of an unprecedented pandemic tsunami, the outgoing tide may actually be undermining the defensive wall before the surge arrives.  

Most primary care practices are seeing a 30-70 percent reduction in visit volume due to the pandemic. Simultaneously, many are being asked to self-finance a total transformation to telemedicine to provide needed care while reducing patient exposure to COVID-19. Most practices still live on fee-for-service contracts and will struggle to bear that loss of revenue. Nearly one in three family medicine practices remain independent and are not only financially hemorrhaging but cannot even afford the jump to telemedicine, meaning that they either choose to stop seeing patients or to put themselves and their patients at risk by continuing face-to-face visits. Many practices are facing difficult decisions about laying off staff or closing due to the likelihood that operating margins will run out in a matter of a few weeks to a few months. These vulnerable family medicine practices are just a subset of the wider group of practices facing these difficult choices. We estimate that a 50 percent reduction in visits will mean a $700 million loss for independent practices across the country over the next three months, more if they are unable to implement telemedicine. The rest of the primary care workforce will lose much more, and we estimate the total loss in primary care to range from $10 billion to $15 billion.

Although CMS (Medicare/Medicaid) and private payers have quickly authorized reimbursement for telehealth visits this requires acquiring available telehealth solutions as well as training how to adapt it to a practice setting. It is unknown whether the loss of income due to reduced in-person visits will be offset by telehealth reimbursement.  Telehealth function is available by subscription service to a cloud provider such as one of these

Nevertheless here is some of the bad news..The National Rural Health Association has reported that more than half of rural hospitals were already operating in the red, and deep losses in their traditional fee-for-service functions mean many will run out of cash in the next month. Federally qualified health centers (FQHC), which provide care to 1 in 12 people in the US and are mostly staffed by primary care, are projected to lose more than $3 billion over the next three months and more than one-quarter becoming bankrupted. All frontline primary care practices also face unplanned costs related to the epidemic beyond implementing telemedicine. These include stocking up on protective equipment and working with public health and hospitals to figure out how to manage the waves of people needing triage or intensive care that are about to crash down on our health system. The third and most recent stimulus package related to the pandemic offers $100 billion for health care providers, most of which is likely to go to hospitals. While $1.3 billion was appropriately allocated for the sustenance of FQHCs, nothing was specifically directed toward other frontline clinicians. While independent and small practices may be able to eventually apply for support created for small businesses, they have no special standing and little idle time to queue for this funding.

Many frontline primary care physicians are displaying tremendous professionalism as bulwarks for their patients and the public at great personal cost. They are fulfilling their commitment to the social contract, and it is on stark display. The government should respect this contract and help keep them whole in ways that directly reach this workforce. It would be a potent signal that they can focus on serving their patients and the public with faith that their practices will survive.

Understanding the tide of the COVID wave is already out, and a giant wave is visible on the horizon, but without more help, the primary care bulwark against the tsunami and its aftermath is in real jeopardy.  And like a tsunami wave the first is not the largest.