Primary care—including family medicine, general internal medicine, and pediatrics—is the first place that people go for preventive health care, urgent health concerns, and management of chronic illnesses. Excellent primary care constitutes the foundation of a health care system that is high quality, low cost, and equitable. But as a result of the COVID-19 pandemic, many primary care practices across the United States are on the brink of collapse.
Lack of access to necessary personal protective equipment (PPE) combined with shelter-in-place orders led to an unpredictable and unprecedented drop in in-person visits. By some estimates, ambulatory care visits have decreased more than 50 percent since the start of the U.S. pandemic, and more than 80 percent of primary care clinicians report that they have limited the provision of routine care. Because primary care physicians are mainly reimbursed for in-person visits, a dramatic decline in in-person visits resulted in a similar decline in practice revenue—leading to widespread furloughs, layoffs, practice closures, and even bankruptcies. And although many primary care practices have turned to phone and video visits where possible to continue caring for their patients, too often, this care has been delivered for free because of lack of insurance payment for telehealth. Under pressure to stay in business and provide the care their patients need, primary care clinicians and staff are suffering unprecedented levels of exhaustion and burnout.
The collapse of primary care is happening in the larger context of an economic crisis with levels of unemployment not seen in the United States since the Great Depression. Unfortunately, the policies put in place to respond to the crisis are not reaching primary care providers. Despite being eligible, few primary care practices were successful in obtaining federal loans through the Paycheck Protection Act, and less than 1 percent of dedicated funding in the CARES Act went to primary care practices.
As a nation, we are at a crossroads. If, like other developed nations, we want to have a stable and sound infrastructure that addresses inequities in health and health care and that continues offering childhood immunizations, COVID diagnosis and treatment, and care for chronic illnesses such as diabetes and heart disease, now is the time for bold action to save and strengthen primary care practices in communities across the United States.
A national Primary Care Service Corps (PCSC) could provide needed emphasis and resources for primary care. Modeled on the federal Works Progress Administration (WPA) and the Civilian Conservation Corps (CCC), which were established in the wake of the Great Depression, PCSC could serve to strengthen and improve the nation’s primary care infrastructure while boosting regional economies. The PCSC could provide primary care practices with the money, technical assistance, personnel, and other direct support they need to survive the COVID-19 pandemic.
- First, practices that commit to participating in the PCSC for a minimum of two years could receive new, designated federal disaster funding to help them cover basic operating expenses, including salaries and rent, and practice personnel would serve as members of the PCSC. This support would remove the immediate financial threat to practices’ survival and provide a foundation for other immediate actions as infection rates continue to rise and we prepare for ongoing transmission and potential future waves. In return, while participating in the PCSC, practices would agree to provide care to members of their communities regardless of insurance coverage or ability to pay, and they would agree to engage with practice improvement consultants (described below).
- Second, as part of the PCSC, the Primary Care Extension Program (PCEP) could be fully funded and implemented. The PCEP, a federal program that has been authorized but not funded, is modeled on the U.S. Department of Agriculture’s Cooperative Extension Service that has successfully spread agricultural innovations to farmers throughout the country over the past 100 years. Similarly, the PCEP could employ regional practice improvement consultants who understand the local needs of primary care practices and can help practices respond successfully to the extreme challenges they are facing as the result of the pandemic and economic crisis. Consultants, who also would serve as members of the PCSC, would support and coach practices as they implement telehealth and learn to function under new payment methodologies. Consultants would also provide tailored assistance to help practices improve essential services, such as building enduring partnerships with local public health departments, integrating behavioral health care, and connecting and coordinating care with community services.
- The PCSC could coordinate with the National Health Service Corps, established to provide loan repayment and scholarships to individual primary care physicians to address regional doctor shortages across the United States in the 1950s and 1960s. All primary care practices enlisted in the PCSC could be automatically designated as facilities in health professional shortage areas, helping draw National Health Service Corps primary care clinicians to high-need areas.
- Finally, the PCSC could be chartered and organized in a way that would enable it to meet other pressing needs of participating practices. This could include contracting for innovative services to meet the urgent mental health needs of frontline primary care personnel and serving as a purchasing and distribution agent for the PPE that individual practices cannot currently procure themselves.
Almost 90 years ago, the federal government acted boldly to create the WPA and the CCC. These national service programs and others provided not only jobs and critical short-term economic relief but also created long-lasting infrastructure—from roads, libraries, and hospitals to parks, forests, and public art—that we continue to use, rely on, and enjoy today. Likewise, taking bold action now isn’t just about helping primary care practices recover. Shoring up this vital component of our health care system will not only prevent the collapse of primary care but also help our nation get in front of subsequent waves of the COVID-19 pandemic and contribute to better health at lower costs for the future. The WPA and the CCC provide a road map. It’s time to act to save and strengthen primary care, a critical national resource that we, and future generations, can’t afford to lose.
