A post-COVID-19 model of US primary care: Telehealth and a behaviorally enriched, expanded primary care team can tackle our chronic care challenge

The US healthcare system excels at many things. We lead in the development of new medical and digital technologies, medical devices, and drugs that benefit people worldwide. We are the world’s leader in complex and emergency medical care delivered in hospitals and emergency rooms. We train specialists to heroically diagnose, triage, and fix or stabilize people during grave health crises.

Our system is also incredibly efficient at managing less urgent, acute problems in primary care, such as allergies; bronchitis; asthma; fevers; minor pains and sprains; headaches and migraines; ear/sinus infections; conjunctivitis; heartburn; nausea; vomiting; constipation; diarrhea; urinary tract infections; and minor skin problems. Across clinics and community health centers, these important but less serious problems are adeptly managed by our primary care system in a cost-effective manner. But these “minor” problems can deteriorate into major problems when not well managed early on. And because these acute problems are usually addressed with treatments that do not require much effort or engagement from the patient – aside from taking prescribed medications and following short-term treatment plan instructions – patients typically have a passive role, while the medical team does the bulk of the work.

This is the world of acute primary care. It is made up of brief, individual visits; it is a place where we have underinvested. Only 5-7% of annual healthcare dollars are spent on primary care in the US. Most primary care clinics have fewer than 5-10 doctors supported by small teams of nurses, medical assistants, and admin staff as each doctor manages a heavy load of 2,000+ patients. Although our US system is very methodical in managing acute problems, it has mostly invested in building and expanding specialty care, not primary care, making the latter unnecessarily stressful environments for doctors and their teams to work in and less desirable for medical graduates to choose as a career.

“This is the world of acute primary care. It is made up of brief, individual visits; it is a place where we have underinvested.”

How does underinvestment in primary care specifically impact patients living with chronic diseases?

Our historical underfunding in primary care has direct consequences for our capacity to treat obesity and lifestyle-related diseases. It neglects patients living with chronic conditions who need long-term support to help them obtain the information, motivation, and behavior skills they need to succeed. Further, the US healthcare workforce is not well trained to manage or prioritize chronic conditions, nor is the medical billing code system designed to incentive clinicians to support patients between visits to the primary care clinic. And herein lies the major disconnect we face in our healthcare system: there are things that we have become good at, in part because the government, employers, and health plan systems will routinely pay for them, but now there is a serious national need to shift to a whole person, prevention model of care that will also create cost savings down the road.

Dr. Vivian Lee’s excellent analysis of the US healthcare system in her new book, The Long Fix, highlights the fact that when local healthcare systems fail to prevent chronic diseases from progressing, the dominant specialty end of the healthcare ecosystem perversely makes more money through more expensive tests, medical procedures, equipment, rehab sessions, and drugs.

Our financial reward system is moving slowly towards more effective treatment for chronic conditions, but it needs to move much faster and focus less on “fee for service” payments for clinicians and more on “value” –paying more for better patient care and outcomes. Employers, taxpayers, and patients now want this change.

The system of healthcare for chronic conditions in the US needs to change.

Currently, the extensive work to help patients receive tailored information and develop the lifelong motivation and behavior skills they need to manage their chronic condition is being delivered through a primary care system that is designed only to offer brief, 15-minute, disconnected visits. Our primary care model is thus not designed for the 21st Century challenge of chronic conditions. When common chronic conditions are not well managed, they often result in serious health issues for patients, including heart attacks, loss of limbs or vision, and kidney failure. Health statistics and medical guidelines get our attention but do not measure financial stress on families or human suffering.

System change is needed. To effectively manage our country’s chronic disease epidemic, clinical teams need to help patients become more effective and proactive at self-managing their chronic conditions. At Silver Fern Healthcare, we believe that being healthy while living with common conditions such as type 2 diabetes, hypertension, and heart disease, is influenced strongly not only by environment (see “Our modern food culture and the rising tide of type 2 diabetes”) but by what the patient does each day (personal lifestyle behavior and treatment choices), thinks (personal attitudes, preferences, coping, and biases), feels (stressors, emotions, and moods), and whether they believe they can fit their treatment plan into daily routines and life demands (see “Building a better behavior change model for chronic conditions). This personal focus is a key part of the strategy needed to improve our nation’s health. Care delivery for chronic conditions can be supported by evidence-based digital tools to help clinical teams better connect with their patients and empower them to better self-manage their own health.

Has COVID-19 provided an opportunity to disrupt the status quo in chronic disease treatment?

When COVID-19 spiked, patients became understandably fearful of in-person care. Since then, the number of visits to primary care clinics has plunged, and with them, normal revenue streams. But clinics and healthcare systems have jumped into action to offer treatment via telehealth visits. Many rules and regulations were adjusted to allow – at least during the crisis – more widespread use and payment of telehealth appointments.

Today, there is tremendous, bipartisan support for virtual care, and strong stakeholders and major players are petitioning to keep the new telehealth provisions in place. Patient adoption of telehealth has skyrocketed from just 11 percent in 2019 to 46 percent now, largely comprised of telehealth visits that replaced cancelled in-person visits. Surveys show strong patient acceptance of telehealth.

COVID-19 has clearly accomplished something that seemed impossible until recently. In just a few months, it has forced more progress around the integration and adoption of telehealth and virtual care than we likely would have achieved in a decade without COVID-19. Doctors are being disrupted in a positive way to embrace not only virtual care but to begin to work with extended teams that have a wider range of expertise in chronic disease management and behavior change and that provide an extra layer of time and resources to help patients. With more options to reach their patients, perhaps this change will reduce the significant problem of professional burnout among clinicians and boost morale in front-line care.

When COVID-19 is finally contained, it has the potential to leave behind a new US primary care system – one that features both in-person and virtual care. We can now see a vision for primary care that includes routine remote monitoring of patient vital signs; care managers reaching out to patients regularly; brief video visits and telephone calls; busy patient portals successfully connecting patients to their doctors and nursing staff; and brief text messages and rapid responses to patient inbound queries.

“The expanded primary care team will have a dramatically improved ability to support the behavior and psychosocial needs of patients with chronic conditions by embracing a growing network of valuable new digital partnerships.”

What could the new primary care team look like? Below is a figure that shows Silver Fern’s vision of an emerging concept wherein both in-person and virtual care are part of a “behaviorally enriched” care delivery model for patients living with chronic conditions. Anchored in better access for patients and an increased availability of remote providers due to telehealth, patients will receive more continuous, higher touch support. Patients will be helped by a larger, seamless, extended team, led by MD “quarterbacks”. The team is enriched with clinical psychologists, dieticians, chronic care nurses, health coaches, and care coordinators without them needing to be physically present in the primary care clinic. Health plan nurses in call centers, who today treat the same patients as the primary care team, can also be integrated into this model as part of new business arrangements. The expanded primary care team will have a dramatically improved ability to support the behavior and psychosocial needs of patients with chronic conditions by embracing a growing network of valuable new digital partnerships.

If we bring the reimbursement system and staff training into alignment with this concept, primary care teams can lead a revitalized service valued for its ability to keep patients with chronic conditions healthier and happier.

Anticipating challenges and headwinds in this new primary care model.

Implementing this new vision will not be without challenges, including restrictive medical licensure rules; protection of professional status, roles, and traditional sources of revenues; unhelpful federal and state laws; backward medical billing and clinician reimbursement rules; technology barriers (including patient data security and interoperability among telehealth outreach technology and medical systems); inadequate research into telehealth’s effectiveness and utilization; COVID-19 continuing to dominate public attention; and extensive provider and hospital debt from reduced clinical revenues during the pandemic. Some of these issues are due to stubborn professional traditions or business model silos, rather than good medicine, and there will be some strong forces pushing to go back to the status quo.

However, bipartisan legislative support for telehealth and the noisy insistence of many US healthcare stakeholders to make recent telehealth improvements permanent means that we will not go back. It is highly encouraging for patients living with chronic conditions that we may have a new system of care that is truly patient-centered and geared for the 21st Century. At Silver Fern Healthcare, we have designed evidence-based digital health tools that support clinical teams to implement “whole person care,” and we can envision a future where our tools serve to strengthen this new model of primary care.

A timely opportunity to learn more about the power of lifestyle medicine.

In October 2020, our partners at the American College of Lifestyle Medicine will hold their annual conference – Lifestyle Medicine: Health Restored. In celebration of this excellent opportunity to expand our learning about the power of lifestyle medicine for chronic conditions, Silver Fern Healthcare will be giving away a ticket to the conference to one of our blog readers. We’ll include more details about how you can be entered to win this ticket on our social media pages and in our blogs. Keep an eye out for future posts and for more details about the ACLM conference giveaway.

In our next piece, we’ll offer a timely comparison of the traditional approach of taking pills to treat type 2 diabetes with the transformative power of lifestyle medicine to put type 2 diabetes into remission through aggressive weight loss and lifestyle changes. Both approaches are evidence-based and neither are easy for patients to follow for different reasons, but they represent two ends of the treatment continuum and have very different behavior and psychosocial journeys for patients.  

Garry Welch, PhD is an expert in the area of behavior medicine for chronic disease care. He has extensive experience leading clinical research on behavior change strategies for people with diabetes and other chronic diseases. Dr. Welch’s 30+ years of clinical research led to co-founding Silver Fern Healthcare. He leads research and development at Silver Fern.

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