While Emergency Departments, hospitals, and intensive care units are in the headlines for their battles against the growing wave of COVID-19 infections, a quieter, but just as dire, struggle unfolds in primary care offices all over the country. Primary care clinicians have been asked to keep our patients safe from COVID-19, screen them, tell them what medicines to use, when to stay home and when to go to the ER. And we are trying to maintain personalized delivery of acute, chronic and preventive services for all our patients. Everyone has been asked to practice social distancing, but we are trying to use our ongoing patient relationships to enable physical distancing with social connectedness.
Nearly overnight we have faced a dramatic reduction of in-person visits in our offices and have responded with attempts to stay in touch with our patients and provide quality primary care through telehealth. What used to be 20 in-person visits, is now 20 telehealth visits, and countless phone calls. But primary care clinicians and practices won’t get paid for much of the telehealth we do with our patients.
Most insurance, including Medicare and Medicaid prefer a live video feed between patients and their medical care provider. Many insurance companies won’t pay for telephone care. Live video is not readily available in many primary care practices. Many of our most vulnerable patients; the elderly, poor, and rural, may not have access to a video camera, the right computer or smart phone, enough internet access or the knowledge to make a live video connection.
Telehealth causes physicians to make huge sacrifices
Today, 100% of family physicians have the capacity to provide telephone care to their patients. Every practice has a phone, every clinician has a phone, every patient has a phone. Many of the issues facing our patients right now can be handled with a phone consult. Asking about symptoms and exposure, discussing COVID-19 testing decisions, providing medical advice, recommending treatments, and educating patients about prevention and safety can all be done by phone. Other medical conditions, like diabetes, asthma, and high blood pressure, can be managed on the phone for now. Yes, we want to see our patients in the practice sometimes, we want to interact with them personally and offer hands-on care and treatment, but telehealth may be a supplemental long-term solution, allowing patients to stay better connected to their own personal primary care physician.
To their detriment, primary care physicians can and will provide telephone care to our patients in this time of crisis, with or without payment. Until we can’t. Practices are already operating at reduced capacity due to shortages of personal protective equipment. We have reduced staff and are keeping staff at home for safety. Because we are not paid for much of the telehealth and telephone calls, many primary care practices may close in the next few months. The sacrifices made by small private practices should not be accepted as inevitable or the new normal.
We need to align the current technological capacity of millions of patients with the technological and clinical capacity of thousands of physicians immediately. We need the Center for Medicare and Medicaid Services (CMS) and commercial insurance companies to align their payment policies with this reality. Payers should pay for telephone care. Some states have started making the switch. Texas has issued an emergency rule that directs Medicaid and all state regulated insurance plans to reimburse clinicians for telephone care at the same rate as in-person visits. Medicare has started paying for some telephone care. Others should follow, even if it requires legislation mandating commercial insurance cover telephone care.
More must be done to protect physicians
In-person and video visits are important components of our COVID-19 pandemic response. They just aren’t enough. Our patients and communities without these options should not suffer. The reduction and closure of primary care practices from bankruptcy in rural and underserved communities will devastate these communities. At a time when primary care is already an endangered species, the dramatic decline in visit revenue could bring primary care to the brink of extinction.
It is certain COVID-19 will leave an indelible change in our health system. The benefits of primary care telehealth, once demonstrated, won’t disappear. Equally apparent is the poor fit of our current payment model that relies on antiquated fee-for-service, in-person, visits. Telehealth provides capacity to enhance and extend the four foundational dimensions of primary care — first contact, continuity, comprehensiveness and coordination. In short, while immediate action to ensure payment to primary care practices can be paid for telephone care, long-term solutions will require support of telehealth nested within population-based, whole-person, comprehensive care and prospective payment models
For today, the telephone visit, universally available for delivering high quality clinical care, should be paid for. The workforce is ready, patients need the care, now let’s align the payment policies.
Dr. John M Westfall, Dr. Kurt Stange, Dr. Jennifer DeVoe, Dr. Carlos Jaen, Dr. Andrew Bazemore, Dr. Christina Hester, Dr. Deborah Cohen, Dr. Robert Phillipser, Dr. Deborah Cohen and Dr. Robert Phillips are family physicians.
