The test of a system isn’t how it performs when times are good; it’s how well it works when responding to a crisis. By that measure, our health care providers deserve all our gratitude, but the way we pay them and ensure their livelihood is broken. If our primary care doctors do too many of the things we need them to do to keep people healthy, they don’t get paid. Keeping people out of their waiting rooms is exactly what we need them to do right now, but doing so threatens their very survival.
My local primary care practice serves about 10,000 people in the Upper Valley. It’s where I first heard my daughter’s heart beat, and where my family was cared for through many scrapes, checkups, and flu shots. And now, every day, these primary care providers put on their personal protective equipment and welcome patients who may have COVID-19, because that is what we need them to do.
In the past 3 weeks, my local primary care practice has done everything we all want our primary care providers to do. They have taken an unprecedented number of calls from anxious patients. They created a segregated space in their building to see patients with fevers and coughs—patients who would otherwise have to go to an Emergency Room— to reduce the risk of infection in other patients. They set aside separate time for parents with newborns, and they are using phones and Facetime to care for patients whenever that is possible, to keep people home and out of spaces where they might be exposed to COVID-19.
Again, this practice is doing everything the CDC, the VT Department of Health, and their patients want, so what’s the problem? My primary care practice has been so successful at keeping people at home where they are safer, that instead of seeing 70-80 patients per day, they only saw 15 on a recent day. And, in the current fee-for-service model of medicine, our providers don’t get paid when they don’t see patients. As the senior partner in this practice said: “That is a public health success, but for us, it’s certain financial ruin.” As a state, we are already struggling with critical shortages statewide of primary care practices and access, and we cannot afford to see these primary care practices close. To the extent that some of our doctors and nurses are close to retirement age, there is a real risk they may have no choice but to close, rather than go into debt.
If Vermont was further along in the transition from fee for service to paying practitioners to keep people healthy, primary care practices like mine would be receiving fixed payments every month to keep people healthy. Doctors would be kept financially whole by the consistent revenue stream, while being given greater flexibility to keep their patients safe and healthy.
Our primary care providers and hospitals provide invaluable service. Many are empty right now and hemorrhaging cash as they double down to prepare for the influx of COVID-19 patients. Primary care accounts for only about 5% of health care spending the state, but this front line service is critical to reducing costs across our entire shared health care system. Our providers need immediate help—cash, not loans—to survive the immediate COVID-19 crisis. Loans aren’t enough to close the gap in lost revenue. In the midst of this crisis, our current payment model puts patients’ lives in jeopardy.
The legislature has been working hard in the midst of a crisis to pass measures related to telemedicine, and that will be a big help. Similarly, insurance companies and the Department of Vermont Health Access have been working to quickly support fair payment for telehealth. However, telemedicine only works if practices and patients have good broadband and in some cases, cell phone access. In this, as with so many questions of opportunity, the state’s digital divide is exacerbated by crises like our current situation. The state must prioritize cell coverage and broadband not only to support economic development and the remote learning now facing our teachers and students, but also, to ensure better access to health care.
While federal legislation may help cover some COVID-19 expenses, we don’t know yet whether federal dollars will cover all losses, what the split will be between hospitals and primary care practices, and whether the help will come in time. Vermont’s Agency of Human Services recognizes the crisis, given our declining and limited tax base, is likely to overcome our resources.
Longer term, we need to double down on payment reform, so that primary care docs can be paid properly for the value they provide. There are a handful of primary care practices that have shifted over to Vermont’s accountable care organization, and are currently receiving “prospective payments”— cash payments up front instead of fees for service— to keep the patients in their practices healthy. We can evaluate these to understand how payment reform will protect most Vermonters’ first contact with health care. We can do better.
We should not kid ourselves about the unique and complicating challenge of doing this kind of work at the state level. State action cannot fully make up for the lack of leadership at the federal level, but as a state, we cannot afford to wait. As Governor, I will turn into the hard and knotty work of health care payment reform, and the investments in critical 21st century infrastructure and connectivity that ensure equity in access and opportunity. If we dedicate ourselves to doing the hard work necessary, we can keep our people safe in the present, and lay the foundation for a stronger and more resilient future.