Much has been written about the response of the governmental agencies in the foreseeability of COVID-19 spread and management in the United States. Travel restriction from mainland China seemed to be a very timely intervention. However, instead of considering it as an initial step in a prolonged exercise of vigilance in preventing the disease from getting a foothold on the continent, it was considered the only one. Now it is well documented that majority index cases came from Europe.
Regardless, SARS-CoV-2 is here now, and states will follow a peak, trough, and likely multiple cycles of such in varying timelines. So what is the way forward? As states try to ease the economic pains of their residents, the incidence of new cases, hospitalizations, and mortality will depend upon many factors. These include population density, higher-risk groups, health literacy, political ideologies, state health care, and economic resources.
That, in turn, will determine the communities’ compliance towards maintaining the practice of social distancing, universal masking, and other strategies as we learn more about the pathogen.
Health care comprises 20 percent of the U.S. GDP. Therefore like other parts of the economy, health care has sustained a significant economic toll. However, a paradoxical phenomenon happened within health care. During these times of unprecedented economic downturn, triggered by the health care-related event, a significant part of health care infrastructure is shut down or reduced to crawling pace in terms of services and economic activity while the rest of the system, including E.R.s, inpatients and ICUs are on overdrive mode.
An ongoing survey by Primary Care Collaborative — a non-profit initiative showed that 49 percent of primary care practices report severe impact on their practices. Ninety percent of practices had to eliminate chronic care appointments (due to lack of personal protective equipment, among other things), and 82 percent of practices have not had any or limited testing capacity for SARS-CoV-2.
News of layoffs and furloughs are flooding the media. Health care providers from small outpatient practices to the mega health system are being forced to take a reduction in compensation. Latter is baffling since one of the reasons for their existence is the supposed financial sustainability and cushion in the face of such calamity.
The economic impact of this pandemic on health care will likely be in three phases.
1. Acute loss of revenue from the inability to provide services in both COVID (due to lack of testing capacity, among other things) and non-COVID settings, including elective procedures/surgeries, primary care, and other specialty services. Patients are being advised to either stay at home or seek care in E.R. for non-COVID related conditions.
2. As the unemployment rate will continue to grow, many patients will lose their health insurance. Hence, they likely will try to avoid seeking health care as long as they possibly can, which usually leads to worsening of conditions and outcomes both clinically and financially.
3. As states reopen their economies and patients rejoin the labor force, there is a significant lag between initiation of employment and reinstatement of health benefits (if at all offered by the employer in the first place). That will contribute to inertia in the economic recovery of health care, even when other parts of the economy will be getting up and running.
As with #1, many practices may qualify for relief under CARES Act. However, as for #2 and #3, there is no objective way to determine the depth and duration of the impact.
Among many things, this pandemic should make us realize that the health care system and its delivery in this country are too complex to navigate and too rigid to adapt to rapidly changing circumstances. As Julie Yoo wrote, “primary care was meant to be the front door to the health care system … to help us navigate the rest of the convoluted care delivery ecosystem. But as a front door, it’s pretty broken.”
According to the CDC, out of 883.7 million visits in 2016, 54.5 percent were to primary care providers. According to the Kaiser Family Foundation, 48 percent of practicing physicians are in primary care. Therefore any interventions to keep primary care practices on their footing will help mitigate the economic fallout and likely better clinical outcomes related to the current crisis.
At the same time, primary care in the U.S. is under-invested and undervalued. Primary care physicians are under-compensated and overworked (much so with non-clinical work). Nevertheless, considering the volume of patients these practices attend, it would be unwise not to utilize them in this ongoing pandemic.
As states’ economies plan to reopen, there should be the concern for not only a “second-wave” but multiple waves (hopefully each of lower magnitude) in the foreseeable future. Primary care infrastructure should be heavily invested in and utilized as the front line for the diagnosis, mass public education, contacts tracing as a matter of public health policy because these practices are usually situated within the communities impacted. Moreover, they usually have long standing relationships with their patients, their families, and, by extension, to those communities.
During the first wave, it is apparent that the primary care practices were completely overlooked as high-efficiency resources for the containment and mitigation process as they struggled and continued to do so to obtain guidance, protocols, and logistical resources. As we head to the next phase(s), technological tools offered by tech giants like Apple and Google and programs like Peace Corps and AmeriCorps will be valuable. However, primary care practices can play a paramount role in integrating these technologies and human resources to the communities and can potentially improve communities’ compliance significantly.
This pandemic provides a crucial window of opportunity to the movers and shakers of the U.S. health care system to provide much-needed support to the primary care infrastructure. So they can perform critical work on diagnostic tests, manage non-critical COVID-19 cases, and educate the communities they practice in. It will allow not only for an effective containment and mitigation strategy for SARS-CoV-2 but also provide economic support to hundreds of thousands of jobs in health care.
Ameer Ali Khowaja is an endocrinologist.
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