The Stakes for Primary Care - Opening Presentation of a Capitol Hill Briefing

Two PCC Executive Members, the Pacific Business Group on Health and American Academy of Family Physicians, along with the Partnership to Empower Physician Led Care, hosted an online Capitol Hill briefing on April 30 titled The Stakes for Primary Care: Impact of COVID-19 on Primary Care Access and the Urgent Need for Action.

Among those who presented at the briefing was Rebecca S. Etz, PhD, Co-Director of The Larry A. Green Center and Associate Professor of Family Medicine and Population Health at Virginia Commonwealth University. Dr. Etz is leading the Green Center's work on a weekly survey of primary care clinicians that PCC is involved with. 

Dr. Etz's presentation was the first at the briefing, and it set the scene for the state of primary care during the pandemic and for other experts to provide their perspectives. Among her evidence on the precarious state of primary care amid COVID-19 were the results of the latest Green Center-PCC survey.

Following is the verbal part of her presentation. The emphases (capital and bold letters) in the following text are hers.

My name is Rebecca Etz. I’m an associate professor of family medicine and population health at Virginia Commonwealth University and Co-Director of the Larry Green Center.

Now I know this CONVERSATION is just another in a long line of meetings FOR YOU, BUT WE NEED TO TALK.

I’m asking you to hit the pause button,
put aside your other work
and focus.

We need your full attention
because primary care is dying.

The US has systematically starved it more than 30 years. The American public deserves better.

The data informing this presentation were collected 2 days ago. It’s a stark view of what primary care looks like on the ground – and one that you STILL have a chance to fix.

I only have time for highlights but would be happy to follow up on questions later. My comments are my own. I represent no particular specialty or organization. These data were collected across all primary care specialties and clinician types.

For most people, primary care is the first point of contact with the health care system. The literal front line. It is a relationship with a person and team who take into consideration your full social and medical history when participating in your care.

Primary care is over half of ALL medical visits ACROSS the US. That’s over 500 million PATIENT visits. It does this with one-third of the healthcare workforce and less than 7% of the national health budget. That bar for funding support is not a typo. Primary care receives zero-point two percent of NIH funding. This is an epic fail.

On March 13, the Green Center, in conjunction with the Primary Care Collaborative, launched a weekly survey of primary care clinicians. It is the first and only survey of its kind. We are seven weeks in with close to ten thousand responses collected.

The survey is distributed with the help of over 50 organizational partners across all primary care groups. This is no time to fight among the professional guilds – this isn’t a disciplinary crisis, it’s a humanitarian one. All of these first responders are battling the front line of a health crisis like none we have ever seen.

Primary care has a new normal: it is corrosive, debilitating, and constant.

Three quarters of clinicians work under continuous and severe stress. Regardless of governance or structure, primary care is STILL the FIRST on the scene and the LAST to receive support.

They have limited testing capacity and not nearly enough personal protective equipment but show up every day to help their patients fight a virus with no vaccine and no treatment.

When the pandemic hit, primary care moved swiftly and with clarity of purpose.

OVERNIGHT, they adopted virtual care systems to prevent unnecessary coronavirus exposures and to expand avenues of access that served the public. Despite the anticipated financial hit, clinicians adjusted to caring for patients at a distance. Despite significant decreases in patient volume, clinicians continue to work harder and longer, at great personal risk.

And yet seven weeks in, over two-thirds report the majority of their work is not covered by payment of any type. And almost 50% have had to furlough or lay off staff.

11% of primary care clinicians say they will close in the next 4 weeks while two thirds are uncertain about their
sustainability 4 weeks out.
One third are applying for loans.

Think about that.

11% of an industry will be shuttered and over 60% of that industry struggles to picture their future one month ahead.

There will be no easy fix when this happens. Fewer than 20% of medical graduates are entering primary care. Our failure to figure out how to hold up this critical resource means that the largest public health crisis of our lifetimes could be an extinction-level event for primary care.

What about virtual care? Care delivered through video, secure messaging, and phone has exponentially expanded in the past 7 weeks.
It is necessary and it is good, but it is not sufficient.

Payment for virtual health is not yet at parity. Among those payers who have expanded payment, the new coding requirements are dizzying and cumbersome. Virtual health offered is not the same as virtual health received. Broadband access is currently not sufficient to support the country’s needs. Many patients struggle with technical literacy and internet access. Over two-thirds of clinicians report patient obstacles to virtual
health.

And this modality of care cannot replace the need for tests, vaccines, procedures, or touch.

In the immediate and necessary response to COVID, many usual activities have been pushed aside. 80% of clinicians report limited well and chronic care visits. Delayed usual care and avoidance of medical settings is starting to cause greater harm among segments of the population. Clinicians express grave concerns about chronic conditions that continue unchecked and cancer screenings or vaccinations that pass unaddressed.

We are bearing witness to a now tenuous and fragile contract.

The contract goes something like this – as your primary care clinician, I will be there for you when and where you need me.

I will be worthy of your trust.
I will treat you with fullness of dignity and personhood.
And I will put your interests above my own.

In exchange, we as a society agree to invest in this highly effective public good.

COVID-19 has caused a final blow to this social contract that has been eroding through decades of neglect. Quality measures are misaligned. Documentation is burdensome. And for too long, we have enacted piecemeal payment and delivery solutions.

I find it fascinating that many of these challenges have been completely set aside during the pandemic. To get done what needed to get done, primary care blew by these obstacles to accelerate the pace of change.

The next action lies with you.
The opportunity to restore this social contract is now.
The window is immediate.