EBLF Health+Benefits

The Future of Primary Care

A physician’s perspective on the coronavirus pandemic
By Katie King Posted on May 28, 2020

Shantanu Nundy, MD, serves as the chief medical officer at Accolade, an employee engagement and care navigation platform, where he oversees the company’s clinical strategy and solutions to improve health outcomes for individuals and families. Nundy also practices primary care at Mary’s Center, a federally qualified health center serving a large immigrant community in Washington, D.C.

What are the top two questions you’ve received from clients related to COVID-19?
The biggest questions we get are first, what should we being doing about COVID-19 now that we may not already be doing? And second, what should we be preparing for to address the next six or twelve months of the pandemic?

For the first question, we’re recommending that clients take a population health perspective and segment that population by varying levels and types of need. Nearly every client has members who are getting sick with COVID-19—how can clients support them with the physical, emotional, and financial impact of the condition on themselves and their families? But there are multiple other populations to think about as well: members with multiple chronic conditions that need to be actively managed but who can’t get in to see their usual doctor; members with behavioral health conditions that may get exacerbated by the emotional stress of sheltering in place; and part-time or contracting members who may not have health insurance and who may be at greater risk of getting sick and exposing others.

To answer the second question, experts tell us we will be dealing with COVID-19 for the next 12-18 months at a minimum. The challenges of mitigating COVID-19 when workplaces and the economy are back to near full swing will be different than they are today. In addition, there will be new testing and treatment options rapidly becoming available. Clients need a holistic strategy for engaging their workplaces with targeted information and simplifying the even more complex healthcare system that will soon be in front of us, so their members can be healthy and productive as well as have partners who are flexible and can adapt quickly.

Many health insurers offered free testing and waived cost-sharing around treatment and hospitalization related to the coronavirus, but it’s less clear what that means for self-insured employers who have been faced with a choice of whether or not to waive deductibles, coinsurance, and copays. How have you been working with self-insured clients to manage population health and increase benefits utilization since this virus started to spread?
Cost should not be a barrier to access, particularly for COVID-19. Barriers to care hurt individual members, but with a pandemic comes added harm to coworkers, customers, and society at large. It’s been powerful to see so many of our clients stepping up and not only waiving co-pays for testing but also going further to support telemedicine, behavioral health, and child care.
How do you think this pandemic will change employee expectations around their employer-sponsored benefits?
It’s such an important question. I think, by and large, employees are becoming more self-reliant. They have realized that the health system won’t always be there to serve their needs and they are increasingly turning to their employers and engaging more in their health and benefits than ever before. It is nice to see that employees are increasingly seeing themselves as agents in their own care journey. At Accolade, empowering members is at the core of our mission, and we couldn’t be more thrilled to see this shift happening.
CMS announced it would soften reporting requirements for the over one million clinicians participating in its Quality Payment Program for the time being. There are some who think efforts around value-based care will slow as a result of COVID-19. Tell us about one example specific to this pandemic where a value-based care payment model would succeed and one where you think it would fail.
A major driver of what I call the “second hit” of COVID-19 – health problems not from the virus itself but from worsening of acute and chronic conditions due to disruptions in the healthcare system – is primary care clinics going bankrupt. Because of physical distancing measures and general fears many Americans have of going to the doctor, primary care clinics like mine are seeing 50%+ decrease in visits. Because primary care is largely paid on a fee-for-service basis, and many clinics have only four to eight weeks of cash reserves, primary care clinics around the country are closing. If primary care clinics were paid on a capitated basis – monthly payment instead of fee for service payment – this wouldn’t be happening, and many more patients would have access to their doctor for their acute and chronic care needs that haven’t gone away now that the coronavirus pandemic is here.
Do you think your relationship with your patients will change post-coronavirus?
I don’t think my relationship with my patients will change, but I do think the way I interact with my patients has changed and will never be the same. From now on when I schedule a patient visit I’ll ask myself whether it would be better for the visit to be in person or virtual. I’ll also be more likely to prescribe digital therapies for my patients to follow up with. For example, if I want more family members to be part of the visit, I may prefer the visit to be virtual, to make it easier for family members in different places to participate. Similarly, if I want to better understand my patient’s home environment so that I can better coach them on their diabetes, I may prefer to do a video call with him or her from home.
As a physician, how have you embraced virtual care since coronavirus started to take hold in the U.S.?
I did my first phone-based televisits and my first video-based televisits last week! My very first patient was quite illuminating. She called about a flu-like illness, so my clinic scheduled her for a phone visit instead of an in-person visit in case she had COVID-19 to minimize risk to other patients and staff. After a brief phone assessment, I determined she needed testing for COVID-19. An hour later I saw her car drive up to our drive-thru testing site in our clinic’s parking lot. And today I’ll be calling her with her test results. All virtual, but still high quality and, I’d argue, more patient centered.
In light of COVID-19, what do you believe represents the network of the future, and what are the roles of new non-traditional care settings (i.e., telehealth or thinking about the home as the site of care)?
Right now, carrier networks are largely constructed around in-person care at fixed facilities. I think the future of care is to direct patients to whatever site of care will provide them the best outcomes based on their needs and preferences. That may be at a brick-and-mortar clinic or a traditional health system, or could be virtual care, or even home-based care.
What are lessons learned so far?
Uncertainty and complexity are part of the new normal. This pandemic is changing weekly as the virus spreads, clinical guidelines are updated, and testing and treatment options increase. What’s critical is to take a population health perspective and have a partner that can simplify the experience of care for your members and innovate to keep pace with the latest thinking and developments.

Katie King Vice President, Health Policy & Strategy, The Council Read More

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