Strong Primary Care Could Help the US Prevent a Twindemic

Yul Ejnes is worried. A primary care doctor in Providence, Rhode Island, he and his team have done all they could in the wake of COVID: shutting down their office, gearing up telehealth, setting up respiratory clinics, and slowly opening back up on a reduced schedule. They have survived financially and are meeting the needs of their patients.

But the prospect of a “twindemic”—a resurgence of COVID coupled with the annual flu season—this fall fills him with dread.

Last flu season, the Centers for Disease Control and Prevention estimates that there were 56 to 59 million cases, with 740,000 hospitalizations and up to 62,000 flu-related deaths. Add that to a health care system already burdened with treating COVID 19, and one can understand why Ejnes and his fellow health care providers are so concerned.

As the gateways, navigators, and release valves for a complex health care system facing another surge in demand, primary care practitioners across the country can do their best to prepare possible arrival in the fall, but having barely survived the initial surge of COVID, they wonder if policymakers and payers have learned the hard lessons of neglecting primary care this spring.

In a face of a twindemic, the next best thing to a mask and a vaccine is strong primary care. How so? Primary care sites are critical for:

• Administering flu shots;
• Conducting COVID-19 testing;
• Diagnosing and caring for people with milder cases of the flu or COVID;
• Reaching out to help people with chronic conditions stay healthy and uninfected; and
• Helping with contact tracing to mitigate the spread of COVID-19.

But as emergency rooms buckled under the initial COVID onslaught all around the country, primary care practices starved. With routine visits declining by 60%, revenue dried up and practices were forced to lay off staff and limit access. Those that could stay open struggled to find the personal protective equipment needed to keep them safe.

The US health care system is reaping what it has sown. Primary care provides 55% of the health care services in the country, yet receives only 5% of its spending. Paid almost entirely on a per visit basis, primary practices do not have a stable revenue that allows them to invest in the staff, such as nurses, behavioral health specialists, and community health workers—who can help keep people healthy between visits.

In the wake of COVID, Medicare has shoveled federal CARES act dollars into hospitals and health systems, neglecting primary care and reinforcing current funding inequities that favor large institutions and rescue medicine. The health system’s rich have gotten richer, with some of the largest bailouts going to hospitals and health systems with the most cash on hand.

Commercial insurers have largely sat on their hands, benefitting financially from the reduced utilization of non-emergency care, while issuing vague warnings of the importance of reserves for future spikes.

There have been some bright spots. Early and aggressive action by Medicare to cover and pay for telehealth at rates approximating in-person visit rates was an important lifeline for primary care practices. Most state Medicaid programs and insurance regulators directed insurers to follow suit. And some regional non-profit insurers have actively looked for ways to support primary care practices, with advances of payments and simplified administration.

But with a twindemic bearing down, help for primary care will generate a healthier US population and a less burdened acute care system. That help can come from many directions:

• Each of us can get our flu vaccine—by the end of October—to keep us healthy and reduce demands on the health care system.
• Congress can pass stalled COVID-19 stimulus funding, with more explicit directions for health care spending going to support primary care.
• Medicare, Medicaid, and self-insured employers—the groups with the money—can make telehealth changes permanent and direct their contracted managed care organizations to prioritize primary care payments.
• Commercial insurers can keep money flowing to high-quality primary care, redirecting some of their current gains from reduced utilization.

Ejnes, his medical care team and thousands like them across the country will be ready to meet the needs of those with flu or COVID-19 this fall, before these twindemic victims have to be treated more intensively and the country has to endure more wrenching shutdowns. Will we help them keep us healthy and safe?