The Coronavirus Sparks a Feedback Loop

"We are learning that hospitals might be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients. Patients are transported by our regional system, which also contributes to spreading the disease as its ambulances and personnel rapidly become vectors. Health workers are asymptomatic carriers or sick without surveillance; some might die."

The insight is from a team of exhausted clinicians from a hospital at the epicenter of the Italian epidemic. Writing yesterday in NEJM Catalyst, they call for a new system vision, a shared point of reference on outcomes outside of the clinical setting as the organizing idea around which to understand and design new solutions:

"Western health care systems have been built around the concept of patient-centered care,” they conclude, “but an epidemic requires a change of perspective toward a concept of community-centered care."

The idea of positioning communities at the center of healthcare is not new or novel; it was first proposed in 1967 at a conference on medical costs organized by then President Lyndon B. Johnson. (More on the need to build a new narrative in healthcare in my article, “Isn’t Healthcare Already Fixed?”.)

“Every community is responsible for well-organized, effectively implemented planning— broad gauged and long-range — to achieve the best possible system for delivering the highest possible quality of healthcare to all its people at the most reasonable cost,” summarized the report’s authors nearly 50 years ago. “Through such planning, local priorities can be set up, duplication of services eliminated, and participation of all socio-economic groups encouraged.”

Except strategic success for community-based health assumes primary care is enabled with the economics to coordinate and sustain the production of health, at scale. They are not. And as hospitals across the country struggle with a surge of coronavirus infection patients, a second crisis is brewing in physicians’ offices, threatening to push the nation’s healthcare system further to the brink.

“Coronavirus Crisis Threatens to Shutter Doctors’ Offices Nationwide”

“Primary care physicians are being leaned on to keep patients out of hospitals, and to make do with limited protective equipment and other supplies. Yet they are seeing steep drop-offs in visits as patients stay away, fearful of getting ill,” writes Noam N. Levey, who covers national healthcare policy out of Washington, D.C., for the Los Angeles Times.

These doctors have seen a big uptick in telehealth visits — a move widely hailed by public health experts — but the fees for these services are sometimes lower. They also perpetuate the same economic orientation in healthcare: fee-for-service.

Nevertheless, there are already signs that the pandemic is taking a toll on an increasing number of the approximately 500,000 primary care physicians in the U.S., including internists, family doctors and pediatricians.

In Enterprise, Ala., a rural community in the state’s south where physicians and nurses rallied after a tornado swept through in 2007, killing nine people, the number of paying patients has dropped 75%, according to Dr. Beverly Jordan, a family doctor there.

“At a time when we are struggling physically and emotionally to treat our communities … it is horrifying that we’re having to consider how we’re going to keep our doors open,” Jordan said. “We are hurting.”

The California Medical Association reported that it is already seeing some practices shutter. Nationwide, widespread closures may be just four to six weeks away, said Shawn Martin, senior vice president of the American Academy of Family Physicians.

Like Driving in New Jersey, You Can’t Get There From Here

So why then are so many primary care practices struggling?

“It’s because of the unremitting stupidity of the current fee-for-service reimbursement system,” says Dave Chase, cofounder of the Health Rosetta. “Rather than paying primary care doctors a robust prospective, risk-adjusted fee per patient to care for a population of patients, the vast majority of health insurance offerings pay only for individual visits or tests (e.g., telehealth). Without patients, primary care practices are like the airlines operating ghost flights (except without the billions of profits the past few years, not to mention the huge federal dollars now flowing to the airlines from the recent Congressional legislation.”

He’s calling for a Primary Care Marshall Plan:

These practices need an immediate infusion of funding to implement a community-wide pandemic response. All insurers (including the 100 million people in self-insured employer plans) should pay primary care physicians / practices an upfront fee to care for patients for the duration of the Covid-19 pandemic, instead of having doctors bill for each service they provide. This would replace the severely flawed, fee-for-service model that has made our country more vulnerable to the pandemic.

In strategy, reacting matters more than planning.

Until we find a new orbit for innovation, a new narrative with new concepts to design a new strategic response, the unfolding system collapse triggered by the coronavirus will force growing numbers of physician practices to lay off staff, or even close their doors. And that’s stoked alarm that even more patients will end up in hospitals.

Feedback loops are powerful things.

/ jgs