For Dr. David Weinstock, Gov. Charlie Baker’s stay-at-home order this spring wiped out about 75% of his business.
“It was almost an overnight,” said Weinstock, a partner with Grove Medical Associates in Auburn. “Obviously, the volume [of patients] went down, so we had to eliminate some front desk staff and building staff, some medical records staff. We went from seeing … you know, a busy internist might see 18 patients a day, and that went from 18 to four, if that, early on.”
Out of about 29 employees, Weinstock said eight or nine were let go.
The coronavirus pandemic has put an enormous strain on private practice physicians like Weinstock. Some have estimated it could result in up to a third of small practices going out of business or merging with large consortiums.
But Weinstock says as difficult as the crisis has been for family physicians like him, it could have one positive result: a transformation in the way doctors are paid.
The change Weinstock and other medical experts are looking for would convert your relationship with your doctor into something like a membership or a subscription, instead of the current pay-per-procedure model.
From Challenge Comes Opportunity
“What the COVID-19 pandemic has illustrated is just how fragile the health care system really is in the current fee-for-service environment,” said Gary Plant, a fellow at the American Academy of Family Physicians and a doctor in private practice in Madras, OR.
Under the fee-for-service model, where doctors are paid for each appointment, test or procedure they do, physicians don’t get paid when they can’t work. But unlike restaurants or dry cleaners, even if a small doctor’s office can survive through the pandemic, the practice can’t ramp up its services when the pandemic is over to make up for lost revenue. Doctors will still be working with the same number of patients doing wellness exams, screening mammograms, providing routine follow-up to lab work and all the rest.
A recent national survey of primary care doctors by the Larry A. Green Center in Richmond, VA, shows that one in three are fearful about the future of their practices. Most of the respondents said because patients weren’t showing up due to COVID-19, they risked either bankruptcy or being incorporated into a larger health care network.
Dr. Maryanne Bombaugh, immediate past president of the Massachusetts Medical Society, said without changing the way independent doctors are paid, the pandemic could take a disastrous toll. For example, on Cape Cod, where she lives, patients would suffer if even a few private practices close their doors and doctors move away, she said.
“The patients here, what access will they have to take care?” Bombaugh asked. “I mean, they're not going to drive to Boston. There may be no one on the Cape who is able to open their practice to them. So, they will lose access. And it will be incredibly problematic.”
Pushing Aside 'Fee-For-Service'
Doctors have been trying to change the fee-for-service model for decades, but the pushback from insurance companies and the fear of change have been immense. Modifying fee-for-service was hotly debated during the push for Obamacare in 2015, but there was concern that it was too much of a change for consumers, companies and insurance providers.
There are different proposals, but the basic idea would be to give primary care providers a monthly fee, like a subscription, to cover the services they provide that keep people well. Most advocates for a new payment system are pushing for a “blended model,” involving both a subscription and fee for specialty services. One advocate compared it to joining a health club. You pay a monthly fee, and then there are add-ons for things like personal training or fruit smoothies. In this case, primary care would be covered with a regular monthly fee, and things like surgeries or trips to the emergency room would be covered by your standard insurance.
“We say you should pay us for the relationship, pay us essentially to keep people healthy, pay us for outcomes and not process, and let us get on with it,” said Rushika Fernandopulle, co-founder and CEO of Boston-based Iora Health, which has been around for 15 years.
Iora is one of the few providers that use a system called “global risk.” Iora bills Medicare, Medicaid or insurance companies a monthly fee for each patient, then takes care of all that patient’s health needs, beginning with primary care and including things like tests and surgeries. Fernandopulle said concentrating on primary care saves money, but it’s been hard over the past few decades to convince some insurance companies of this.
“Because you keep people out of the hospital, out of the emergency room, out of procedures they don't need, you prevent complications. And if we lower total health care costs, we get to keep that amount and get to invest it back in primary care,” he said.
Since Iora Health is paid up front, doctors aren’t “working for free” when they spend time emailing, texting or calling patients to check in on them. And, as Fernandopulle put it, visits don’t have to be limited to 15 minutes because practices aren’t incentivized to cram in as many patients as possible.
“This is not a little different,” he said. “This is completely different.”
A primary criticism about moving to a subscription model is that if doctors are paid the same amount whether they provide you a service or not, there’s a monetary incentive for them to limit the number of procedures they perform. But Fernandopulle said doctors would still be responsible for the patients’ health, so would have every incentive to provide complete care.
Telehealth On The Rise
One of the tools that Iora Health has been using for years is telemedicine, which, in the face of the COVID-19 crisis, has become a go-to method of delivering care. But until now, most family physicians couldn’t bill for telemedicine — there was no fee for that service.
That, too, is changing.
“You know,” said Ann Greiner, “we would hate to have a crisis go to waste.”
Greiner is president and CEO of the Primary Care Collaborative, a group of public and private health care organizations advocating on behalf of primary care clinicians. She said the pandemic has pushed telehealth into the mainstream. But, she said, while this new way of delivering care has proven to be well-liked by doctors and patients, it’s only sustainable if the payment system is changed.
Providers are especially excited about using telemedicine for mental health counseling, according to Greiner and others. In fact, they said, remote care is often a better way of providing services to people who might otherwise not work well with a counselor.
Perhaps the biggest booster of telehealth during the pandemic has been the federal government. The Centers for Medicare and Medicaid Services (CMS), the part of the Department of Health and Human Services that administers Medicare, agreed to dramatically expand payment for telehealth services, and the nation’s insurance companies followed suit — sometimes with an added nudge from state governments, as happened in Massachusetts. CMS has hinted it will make that change permanent.
Another factor that could lead to change in primary care is a rapidly growing health technology industry.
Companies are already producing relatively cheap ways for patients to gauge their own health, and to send readings to their primary care doctors. Patients can take most of their vital signs at home — weight, height, pulse, blood pressure — using devices that send the information directly to their doctors. And as more doctor visits are done at home, inventors are already scrambling for the next big thing.
Harry Glorikian, a venture capitalist with New Ventures Funds, said these devices could actually make health care better, if doctors can get a long-term picture of their patients’ health over time.
“Because I have an Apple watch,” Glorikian said, “all of a sudden [a doctor] gets to take a look at me over X number of months that I haven’t seen him rather than the one measurement when I’m in the waiting room.”
Dr. Robert Phillips is the director of the Center for Professionalism and Value in Health Care, a part of the American Board of Family Medicine. He said while patients really want trusted, healing relationships, the potential for technology is huge.
"For my patients who have high blood pressure in the office, if they have their own device at home and they're taking their blood pressure even sporadically, I can say, you know, 'Your pressures at home are fine, I think you're just anxious when you're here. Let's avoid medication and see how you do for the next six months.' That's really helpful. It would avoid medication — and potentially some tests," Phillips said.
This trend toward technology was happening already, but COVID is pushing it into high gear because people will continue to be fearful of waiting rooms and prefer doing appointments from home.
Speedbumps To Change
Despite advances with telehealth and technology, there are still a lot of kinks to work out before changing the way health care is paid for.
Girish Navani, who runs the Marlborough-based medical software company eClinicalWorks, said there are still arguments over whether in-person visits and telehealth should be considered the same thing. Of course, if fee-for-service is eliminated, it would end that debate.
Navani said some people consider telehealth visits “medical care lite,” which don’t demand the same rigor as in-person consultations. Navani said to get around that concern, telehealth or phone exams could be used as a preliminary screening tool. “That would allow me to make a determination on what your next course of action should be,” he said.
He said he believes using telehealth this way would let doctors know what to expect when patients arrive at their offices — or possibly to prevent an office or emergency room visit altogether. This could be a way of making telehealth more amenable to insurers and a first step toward changing the fee-for-service model.
Power Of The Marketplace
But there is no guarantee that insurance companies are ready — or willing — to change the way they pay for health care. They have spent decades figuring out how much to charge their customers and what to pay health care providers for different services.
“What's going to happen in the future, in my humble opinion, is the employer is going to become more directly involved in understanding the math and less reliant on the health plan to run the numbers,” said Jed Constantz, an independent health care consultant.
Constantz said advocates for primary care need to bypass insurance companies altogether and appeal directly to the ones who pay for most of America’s health care: Municipalities and businesses of all sizes. He said employers are increasingly realizing the benefits of preventive care, the kind of services that family physicians provide.
Employers are already paying for services like wellness programs, gym memberships, telehealth, Weight Watchers and other health services that are not generally a part of their standard health insurance plan. A subscription model of primary care would bundle those services together, and package them as part of a single health coverage plan.
For Dr. Weinstock, being paid a set fee to keep his patients healthy would be a huge help. He said it would eliminate reams of paperwork and other minutiae that must be done to appease companies like BlueCross BlueShield, which he works with. And it would keep people healthier.
“Someone who's got diabetes, hypertension, heart disease, those patients are high intensity, they’re labor intensive to take care of,” he said. “And they’re the ones who you can do the most with to keep out of the hospital. So fee-for-service for that higher risk group definitely is not ideal.”
For his part, Weinstock said he would love to see a blended model, where he collects a monthly subscription to care for his chronic patients that require much of his staff time, and then bill for services beyond primary care.
“Simply put,” he said, “I can’t envision a time when a company like Blue Cross Blue Shield reduces its grip.”
Blue Cross Blue Shield does offer a blended payment model, known as Alternative Quality Contract. Weinstock is part of the program that rewards doctors and hospitals for keeping patients healthy, rather than just doing procedures. But Weinstock said that for a small practice — with around 1000 patients — the program has been hard for him to implement.
Matthew Day, Senior Vice President for Network Payment Innovation at Blue Cross Blue Shield of Massachusetts, acknowledged that after decades of fee-for-service, it took the company a while to figure out the actuarial numbers, and that for years smaller practices were much harder to cover.
"Moving into our second decade of payment reform, we feel like we are at the cutting edge and can again lead the way and be an example for others in the state and even the country," Day said. “Doctors, especially in primary care, got in [to medicine] to have a relationship with their patients and to help them with their needs, and not to worry about every individual billing and what level of code needs to be attached to every interaction,” he added.
This story has been updated to include a comment from Blue Cross Blue Shield of Massachusetts.