COVID-19 Webinar Series Session 16 – The Changing Landscape of Primary Care

12:00 p.m. – 12:05 p.m.     Welcome and Introductions

Sarah J. Dash, MPH, President and CEO, Alliance for Health Policy

@allhealthpolicy

12:05 p.m. – 12:25 p.m.    Opening Remarks

Eric C. Schneider, M.D., M.Sc., Senior Vice President for Policy and Research, The Commonwealth Fund

@EricSchneiderMD

Caroline DeFilippo, M.D., MPH, FACP, Assistant Medical Director, CareMount Medical

@CareMountMed

Asaf Bitton, M.D., MPH, Executive Director, Ariadne Labs

@Asaf_Bitton

Sean Cavanaugh, MPH, Chief Administrative Officer, Aledade Inc.

@dc_cavanaugh

12:25 p.m. – 1:00 p.m.       Moderated Discussion

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)   0:06 Good afternoon, everybody or good morning to those of you on the west coast. I’m Sarah – president and CEO of the Alliance for Health policy. Welcome to week 10 of our covid-19 webinar series for those who are not familiar with the alliance welcome. We are a non partisan resource for the policy Community dedicated to advancing knowledge and understanding of Health policy issues. We launched this series to provide insight into the status of the covid-19 response and shed light on remaining gaps in the system that must be addressed. 0:36 Limit the severity in the United States The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation and the Commonwealth fund for supporting our covid-19 webinar series. You can join the conversation on Twitter using the hashtag all help live and follow us at all Health policy. We want you all to be active participants today. So please do get your questions ready. You can ask them through the speech bubble icon with a question mark that should appear in your web browser. You can ask that. 1:06 To submit questions at any time during the broadcast and we will collect them and address as many as we can during the QA you can also use that button to notify us. If you’re experiencing any technical issues visit our website, I’ll have policy dot-org for background materials and a recording of today’s webinar. 1:24 Primary care has played a key role in combating the covid-19 pandemic by delivering care to patients outside of the hospital, but the pandemic has also created a new Financial challenges for those providers and has disrupted care for patients elective procedures and preventive visits have been postponed to preserve social distancing measures and while some providers are leaning on Telehealth at an unprecedented scale to reach patients in their homes access to these Services is still Limited. 1:54 Today our panelists will discuss opportunities to support Primary Care Providers and preserve access to outpatient services as the pandemic progresses. I’m thrilled to be joined today by an All-Star lineup first, we will hear from dr. Eric Schneider who is senior vice president for policy and research at the Commonwealth fund next we will hear from dr. 2:15 Caroline Leaf Aleppo at practicing primary care physician and assistant medical director of Care Mount Medical in Mount Kisco, New York, then we will hear from Dr. Asaf baton executive director of ariadne labs. He also serves as associate professor at Brigham and Women’s Hospital and assistant professor of Health Care policy at Harvard Medical School. Finally. We’re pleased to have joining us today. Sean Cavanaugh who is the chief administrative officer for a Le dad corporated. Thank you all for joining us today. And I’m now going to turn it over to dr. Schneider for his opening remarks Eric. I don’t go ahead. 2:53 Thank you very much, sir, for the opportunity to share these updated results on outpatient Trends and outpatient visits since the beginning of the covid-19 pandemic next slide first. I want to just give you some background about the prop publication today. Today’s results are possible because of a special collaboration between researchers and analysts at Harvard University freesia. 3:17 And the Commonwealth fund freesia is a health care technology company that helps ambulatory practices with the all aspects of the patient intake process and because freesia technology is widely used in Outpatient Care the data Behind These analyses include 1600 provider organizations of varying sizes with 50,000 individual providers across 50 states and over all the data include more than 50 million outpatient visits in a typical year the 47% of these are in primary care and the remainder of the It’s are spread across more than 25 Specialties the citation below lists members of the Harvard freesia team who’ve done this excellent analytic work and these results are now posted on the Commonwealth fund website a next slide. Please last month. We reported a nearly 60 percent decline in weekly outpatient visits compared to February this slide shows the emergence of a rebound since then but visits are still approximately 30 percent below the pre-pandemic rate. 4:23 If you go to the next Slide the pandemic is affecting all regions of the United States, perhaps contrary to expectations though. This slide shows that the overall Trends are remarkably similar across regions. There are some subtle differences the New England and Mid-Atlantic regions in the bottom line saw a steeper decline compared to the mountain region that that’s the top grade line and the South Central Region including Texas, Oklahoma. 4:52 The Arkansas Louisiana, Mississippi, Alabama, Tennessee, and Kentucky may have seen a slightly faster rebound than other regions, but I think the similarities are still the most striking feature of this analysis next slide. 5:09 Figure 3 here compares the trend for in-person visits in Orange with the trend for all types of visits Telehealth visits account for the gap between these two lines. The Striking result here. Is that after an initial increase in Telehealth visit shown by the diverging of the lines most of the rebound we’ve observed in the past month is due to return of in-person visits. 5:36 In fact in the last Month, you see the sort of steady gap between the two lines showing that Telehealth visits have plateaued during the past several weeks accounting for approximately 12 to 14 percent of the prior visit volume at this point. We don’t know how that Trend will continue next. 5:58 So on this next slide we examine differences between in rebound among Specialties the rebound and visits shows up as the difference between the orange bars and the turquoise bars on this slide. You can see that the rebounds and visits have occurred across all the Specialties the largest rebounds and visits have been seen in Rheumatology and among the procedural Specialties listed at the bottom of this graph such as off. 6:28 Balaji otolaryngology and dermatology Pediatrics and gastroenterology and the middle I’ve seen smaller rebounds. 6:40 And then in the next slide. 6:43 We’ve looked at the rebound related to the age of the patients being seen in examining those differences. We can see that larger rebounds in visits by adults who show up at the top of this graph 18 through 75 there in the top three bars and smaller rebounds and visits among children of all ages shown at the bottom of the graph. 7:07 And again that’s over a month period showing the rebound next slide and finally there have been questions about whether larger and smaller practices have been affected differently by the decline in outpatient visits. This graph shows that the initial declines and rebounds are fairly similar across provider organizations of different sizes, whether there are fewer than five providers or more than a hundred providers within the organization next slide. 7:40 So to summarize these results we’ve seen a rebound in outpatient visits emerging and it seems to be occurring broadly but outpatient visits even with the added use of Telehealth remain about 30% below what they were prior to the pandemic. We’re keenly interested in whether the rebound will continue or not and on behalf of the Commonwealth fund. I want to thank the freesia and Harvard University teams for their spectacular and Rapid efforts to produce these timely results. 8:10 And I’ll turn it back to you sir. Great. Thanks Eric. And so before we turn to two Caroline for her thoughts I wanted to ask you if you have kind of any early inclinations of why the rebound is different among children and forces older adults or some of the different special subspecialties of primary care that you that you outlined. 8:35 Yeah, it’s a little hard to get under the hood based on these results, but they they’re the anecdotes and hopefully others on the call will share some of these anecdotal observations are that there’s there’s a there’s a mix of sort of Fear Factor going on plus practices retooling to be able to bring patients into the office setting and that may account for the different some of the differential effects that we’re seeing. 9:06 Great. Well, thanks for presenting that data. So next we’re pleased to hear from dr. Caroline de Filippo and we’re looking forward to your perspectives. Go ahead. 9:16 Ed thank you. So if you could go ahead to the next slide, I’m happy to speak with you all today both as a primary care physician at caramel Medical Group where I also serve as an assistant medical director briefly caramel Medical Group is the largest independent Medical Group in New York state. We are in a multi-specialty Ambulatory Care Group we care for over half a million patients throughout the Hudson Valley region stretching both from Manhattan all the way up through Ulster County. Unfortunately this put us at the epicenter of the outbreak. 9:46 For covid so we have a really unique perspective on the changes that we have experienced throughout cross our group to go ahead to the next Slide the slide that Eric just presented. This gives you a little bit of a snapshot of the decline that we felt here in Westchester County. It really felt like we were seeing normal volume of patients and within 72 hours are practice almost shut down and we were forced to immediately pivot to a very large Telehealth base platform. 10:12 Thankfully we have had fantastic partners with us including freesia that have been about invaluable in helping us both pivot make this transition but also communicate with our patients and letting them know that we were still available to provide care for them during this time. Unfortunately, this transition did have a large Financial impact on us or had a financial impact on us and many other groups across the region as Eric showed as well. We did have to undergo office consolidation while maintaining access for our patients and communication in addition. We had various structures in place including well and sick hours. 10:46 All of which are impacting the patient’s access to care as we continue to push forward if you move to the next slide. 10:54 one of the things I really wanted to focus on today is how primary care has been so critically involved in this pandemic and when I think about that question particular, the initial wave that we experienced with covid was unlike something we had ever seen in primary care and that we were not only learning about this disease and trying to understand what the manifestations of covid were but we were rapidly triaging and managing the majority of patients who thankfully were not on well enough to go to the hospital, but did have serious Medical needs as I said earlier Telehealth was a game-changer for that. We quickly developed strategies criteria to help understand who needs monitoring at home with what frequency and what tools we can put in place to assess those patients safely and remotely we also learned that patience after hospitalization needed an additional level of care and so for so much time we’ve been so grateful watching people leave the hospital with great celebration, but that’s not the end of those patients story. So many patients have come home. 11:54 I’m with significant care needs that we are continuing to try to unravel with late stage effects of covid that we work with them regularly to try to understand one of the things I think about a lot with patients is the fear and how that has driven their behaviors during this time. 12:09 And we’ve seen the fear manifest in two ways cutely with covid patients who were frightened to go to the hospital for fear of being separated from loved ones and patients who are frightened to remain at home because they didn’t feel they had enough care provided to them in the first case that has Projected us into an area where we had to deal with a lot of Advance care planning almost overnight with these patients. We had difficult conversations about goals of care important conversations about goals of care and really had to create a structure to appropriately manage patients either at home or in the hospital as we started to emerge from that acute covid stage. 12:45 We then wound up in a new scenario where we were learning about screening for covid and the best way to provide screening as we started to reopen our practices we to be careful to do this in a way that made both providers and patients feel safe a private providing appropriate equipment for them and companies like freesia have been invaluable for us because we’ve been able to do pre-visit screening and even remote check-in for patients to try to minimize contact when they are back in the office. All of this has occurred though in the context of the three other pillars of primary care, which is acute non covid medical issues chronic disease management and preventive health. 13:21 So all of those issues still Named and we did continue to juggle those in this new landscape where we could patients had to be seen in the office. They were still seen in the office. But the majority of our patients elected to be seen via virtual platforms. We became quite creative and how we were managing patients virtually for chronic diseases and I have to tell you in many ways that has been a tremendous benefit from this the use of Telehealth. I hope is here to stay for Primary Care. The ability for are homebound patients who are chronically severely ill patients. 13:54 To receive Telehealth visits with their providers has absolutely been a game changer for all of us for the better and I talked about that briefly just to highlight The Human Side of medicine. I think about patients who I’ve known for decades who are really struggling at home with Advanced illnesses and seeing their dog seeing their art seeing their loved ones seeing the physical setup of their home has really helped me better understand who they are as a person and a patient so that has been a tremendous benefit in addition the advance care planning. 14:24 It has also helped us get a better idea of our patients goals and needs for them. Finally as we’ve been talking to patients about screening for covid that has been a great touch point to remind patients about all of their other Healthcare needs. So we have many patients who have come in requesting antibody testing to talk about covid screening and we have picked up on many other diagnoses overdue lab test mammograms that needed to be done and so it’s really provided us a platform to be able to meet all of the patient’s care needs. 14:51 So when I put all of this together, And I am so grateful for all of our colleagues in the hospital and all the work they have been doing there. But I also think another set of Heroes during this process has been the primary care Workforce who has been keeping as many patients safely out of the hospital as possible monitoring them and managing after the hospitalizations, but also maintaining all of their other care needs during this time with a new platform with unprecedented structures in their office and doing it around the clock. 15:20 And so I think as we move forward acknowledging the burden that this Placed on the outpatient practice is really important when we think about resource allocation acknowledging that there will be an impact of the delayed care that some people have received and we need to make sure our Primary Care Workforce is prepared for that and that we don’t prevent that. We work as hard as we can to prevent our providers from getting burnt out from all of this additional work. They have been providing. Thank you. 15:47 Thank you so much Carolyn, and just on that last note around provider burnout. I mean you have rapidly retooled so much and done so much. Is there anything you felt like you had to let go of the to make all of that change possible? 16:05 I think we had to let go of the old way of practicing medicine. I think we were all so accustomed to how we perceived a patient visit and this is both for the patient and the provider and allowing ourselves to be flexible and Innovative and how we practice medicine has actually made that work better. So removing the rigidity and allowing that creativity has actually worked very well. 16:30 Well, thank you. Well, so next we’re happy to hear from dr. Assaf beaten executive director of R&D Labs. Go ahead. Thanks so much for having me on and I really want to appreciate you know, all that’s all that’s been said. 16:48 You’re muted. Hi. Can you hear me? I hear you, but this is just a reminder that if there’s anybody not seeking to please mute your telephone. Thank you. Sorry there’s another conversation going on. 17:05 If I can just ask the people to please mute, I hear another conversation. 17:18 I am here. Can anybody hear me? 17:21 Except away. Yeah, I’m on sure. Can you hear me? Well? 17:30 So I tell you this is Ben Sarah. I’m just going to hand. 17:40 Ending. Okay. Sorry. I apologize that that I’m hearing another conversation between Russell and Sarah. So it’s are somebody. 17:52 So it’s a little hard to share. Let me just try to share with you even though there’s another conversation going on that. I don’t appreciate to be muted. Okay, my apologies Eric Schneider commute. Thank you. Okay, go ahead. So so I just wanted to really appreciate the commentary that was just made, you know, as a practicing primary care physician myself Brigham and Women’s Hospital. 18:18 We’ve gone through many of the same things that That were just discussed. You know, we’re here in Boston fourth-highest case rates in the country and and really an incredible Crush of patience and and similarly found the need to really reach pivot the way that we do medicine in the way that we do care over the course of days not weeks and move to 70 AD at one point over 90% virtual visits nearly overnight. 18:47 We also regionalized care within Raco where we had non-respiratory patients that needed a cute in page in-person visits get regionalized to one of the one of our 17 clinics, which was mine and in Jamaica Plain, Massachusetts, and then we had another clinic that was totally converted to a respiratory illness clinic and and was basically, you know, full PPE and essentially a sort of triage the emergency room and so you We were able to do that and we are finding the reopening is occurring as was discussed what I want to discuss both for my purview as a practicing primary care doctor and as executive director of Health Systems Innovation Center that sits between Brigham and Women’s Hospital and Harvard School of Public Health is really what what our work broadly on a policy landscape is showing us around the impact of covid-19 on Primary Care. 19:49 This this is Not business as usual. And in fact, this is a moment as most of you know, I believe of great Peril for much of primary care, especially primary care that occurs in small independent practices to that end. I want to share with you a few results that come out of a weekly survey that I’ve been advising and participating in that’s out of the Larry green center at Virginia Commonwealth University along with the primary care collaborative and and other collaborators from across the country. 20:20 This is Now it’s in its tenth week of collecting responses on the internet. And now we have responses from practices in all 50 states and I just want to share you the Top Line results from last week survey week 9 survey of 2774 Primary Care clinicians. And really what the picture is is a really difficult situation that even though visit volume is re-emerging the freesia data the data from New York our data. 20:51 In Massachusetts, that doesn’t tell the whole story what’s happening is that 19 percent of practices in our national survey are reporting that they’ve closed temporarily or for good nineteen percent. That’s nearly 500 practices. We have 42 percent of practices in this National survey all 50 states that report staff layoffs or furloughs 80% have report that their patients are struggling with virtual Health due to internet or technology. 21:21 Limitations and another eighty percent have had to limit chronic care and preventive care services due to the huge backlog of care needs testing remains really difficult for most practices a third of the practices in this National survey report. 21:40 No capacity for testing and only about 10% can test anyone so testing through Primary Care remains enormously challenged and finally PPE which was A tremendous challenge at the outset is still a huge problem in primary care. We’re looking at sixty percent of our respondents continuing to report that they have insufficient stock of PPE. So to me the Top Line messages are that most that many practices are struggling some are closing we even have, you know quotes from a physician in Indiana saying covid-19 is a pivotal moment for the Healthcare System. My practice will be included as a casualty of coronavirus. He right. 22:21 my patients receive letters this month announcing the closure of a trusted friend of 22 years and on and on and on this is a major moment of inflection and risk for Primary Care, especially that which is not housed within large health systems or Hospital own health systems, but as we’ll talk about it’s not just being part of an IPA or a multi-specialty group that will protect practices we’ve seen in Massachusetts large multi-specialty groups furlough huge numbers of their Primary Care Workforce during this time because it underlines the point that I think many of us know which is that fee for service is simply not a system that is conducive or amenable to Primary Care being able to thrive and meet all of its opportunities and needs even in a normal day and certainly not in a covid day what primary care does under fee for services atomized payments into units of visits and when those visits get disrupted for Any reason whether it be Health shock or otherwise and combine that with the fact that the majority of primary care practices have low reserves or no reserves. They they often exist on a month-to-month basis and don’t have that perspective form of predictable population-based payment that really puts them at risk of not being able to make it through this tumultuous NE sand. 23:47 So I think one of the things as I end that we need to discuss is really what is the type of payment on the type of rescue quite frankly and I think I’d like to submit the idea that Primary Care is in fact a troubled crucial Health Asset in our system that needs to be rescued and that rescue may need to come in the form of short-term or even long-term perspective payments transitioning. I would argue to Global Payments or a form of risk-adjusted capitated payments for the majority. 24:21 Already of care for the majority of the defined population in order to make sure that Primary Care is role as acute chronic preventive promotive and surveillance as well as connections to Social and Community Resources are enabled through the storms of this help shock and Future Health shocks. 24:43 Thank you so much F Well, we are now going to turn to Sean Cavanaugh to for some remarks, but I will note that Allah dad co-founder Farzad mostashari co-authored a primary care Marshall Plan and your point a soft calls out the unremitting stupidity what he called the unremitting stupidity of fee-for-service and primary care. So I’m sure we’re going to get to that some more perhaps in Sean’s remarks and certainly in the Q and A as a reminder to everybody just go ahead and submit. 25:13 Questions and we will get to as many as we can and make you a all right, Sean. You’re next. 25:20 Thank you, sir. I first I should first introduce alidade, which is we are a company that works with independent Primary Care practices in 27 States across the country. So these are practices not owned by a hospital not owned by an insurer there the old-fashioned independent practices and their practices of all sizes. We’ve got you know, one doc practices 10 doc practices. We’ve got federally qualified Health Centers, and we’ve got large much larger practices, you know, honey. 25:50 Employee practices what’s common among? All of them is their primary care which means they’re the lowest paid specialty and because they’re independent. They’re getting the worst fee schedule that commercial insurers have and so typically these practices have little to no Financial reserves on their balance sheet and as will become important, they don’t have strong purchasing relationships. So covid-19 hits and suddenly you get these huge number of cancellations. 26:20 Ian’s the patients are disappearing which causes a financial catastrophe for them. But what also happens is a lot of the patients are coming depending on the area are actually sick meaning some of them have covid. So our practices are having to Pivot to a disease that’s new to them. They have PPE as you’ve heard that’s in very short supply. They don’t have a supply chain and a large relationship with a GPO that can help them and the staff are getting sick they’re doing layoffs. 26:51 It’s a real challenge like unlike any they’ve ever seen both clinically financially and operationally you’ve heard our practices did what many did around the country within days. 27:02 They stood up new Telehealth Solutions which helped clinically and help him steady the loss of visits many of our practices started doing parking lot visit so visiting patients out in the parking lot if they had respiratory illness to protect the practice segregating patient’s otherwise And as you’ve seen from the data there has been a rebound. But but if we’re you know if they went through a period at 40 60 percent loss of patients and now they’re leveling off at 30 percent loss patient’s as dr. Beaton says that’s still a catastrophe. If you’ve been following the policy responses in some ways the policy responses to try to help these practices have been unprecedented in scale and yet sadly they’re still insufficient. I was really pleased. 27:50 CMS one of the earliest actors providing Advanced payments to many practitioners. Unfortunately, those Advanced payments need to be paid back four months after they were given which really just pushes the financial crisis out a little bit. We had Great Hopes for some of the small business administration programs. But as you did hurt, dr. 28:14 the green survey that you were heard referenced up to A half of all Physicians that tried to get the paycheck protection loans were unable to do. So the emergency loans that SBA has long had Which is less of a solution because actually have to be paid back and creates debt hanging over the practice. Those were capped at a much lower amount than traditional and so really didn’t provide the permanent solution. 28:43 Really pleased by some of the money Congress appropriated to provide a relief fund though, you know, once again small independent Primary Care practices are competing with large health systems for those funds. These practices don’t have accounting and finance departments to pursue the money. They’re intimidated understandably. So by a lot of the legal language that accompanies the loans and a lot of the reporting that’s going to be required. 29:09 They don’t have the financial systems and other mechanisms to comply why so but so what you know, everybody’s having a rough time in covid who cares if primary care, you know Primary Care seem to be in the middle of the pack of the study that we saw rebounding about the average what’s special about primary care, but we need to worry particularly about primary care for three reasons one just as they were the front line of the beginning of covid. 29:36 They’re going to be the front line of the recovery, you know, if we don’t want patients crowding in the Those in nursing homes to get tested and so forth. They need a community-based place where they can go when they had mild symptoms. We already have that infrastructure. It’s all these Primary Care practices around the country, but the practice is need to exist. They need PPE to be able to operate safely and they need to be tied in a local public health and supported in those efforts. The other thing is if these practices go out of business as we’ve heard some are there likely to be gobbled up by larger Health Systems and we know there’s a significant amount of literature. 30:12 The consolidation and Health Care both vertical and horizontal leads to higher costs and possibly lower Quality Care finally before all this hit right? The greatest challenge. We were worried about was the management of multiple chronic diseases in our senior population and how it was driving healthcare costs nationally, but also particularly in Medicare. Well, there was developing a solution to that which were physician-based accountable care organizations the largest scale. 30:42 As for model in Medicare that was actually generating better care lower costs. Well if these practices are going out of business, they don’t have the ability to participate in these models then once we get past covid, we’re going to be in a worse shape than we were before and trying to manage that challenged the senior population with multiple chronic conditions. So like dr. Beaton, I really think we need to do something specific for Primary Care. We’ve been calling on Congress to segregate some of the funds. 31:12 They’ve been dating specifically / Primary Care cut some of the red tape make it easier for these small practices that don’t have sophisticated financial reporting and compliance departments make it easier for them and support them. So they’re there when we need them later this summer and going forward. Thank you, sir. Thank you so much John. All right. Well, we it is time for the Q&A. We have just over 20 minutes. So please do send in your questions. 31:42 We’ve already gotten View and not surprisingly they are about Telehealth. So why don’t we start there? So, you know, first of all couple of you mentioned that just practices have had to really stand up Telehealth within within days really really quickly. So can you just share a little more and maybe Caroline I’ll start with you and I mean, how did that work? How were you able to get it stood up as quickly as as you did. 32:12 Yeah. 32:20 Telling you might be muted. 32:23 Here we go now better. So honestly the way we brought it up for the way we brought it up. So quickly was you know, we are a larger multi-specialty group. So we did have some of the administrative infrastructure that we needed. But even with that said it was a tremendous effort on the part of our team internally to get the right Tools in place the workflows set up to work with our vendor to make sure we had everything working in the way we needed but the second thing was we had to get our patients on board. 32:53 Using Telehealth as well and getting a HIPAA compliant app to be used and teaching our patients had to use that was a second very large hurdle and to be honest the others alluded to it. It doesn’t work for every patient. There are patients who do have significant limitations with technology, whether it’s access to or ability to use that technology. 33:11 So the amount of Manpower that went into that process cannot be stated strongly enough and so our hope is that you know, as we move forward we cannot let this aspect of Of what’s come from covid disappear? Because it will be critical to continue some form of Medics Medical Care through Telehealth and I wouldn’t want to lose all the effort that’s been put into date. 33:35 Thanks and and a couple of couple of other Telehealth questions, so you be Sean will will will start with you and see if others want to join in. I mean, there’s obviously a lot of talk about what the future holds and just given the plateau of Telehealth is it said that Eric mentioned his data, you know, what do you all think? The future of Telehealth is going to look like after covid Sean? Why don’t we start with you? But I’ll welcome Eric and others to comment as well. 34:06 Sure. Than