Peri-Pandemic Primary Care

By Laurie Gelb, MPH, BCPA

As pundits ponder a new digital health infrastructure under which reimbursement and federal regulation bring more of the hospital to the home [1], millions of vulnerable Americans continue isolation and avoid any face-to-face interaction, including medical care.

Providers report that presentations for cardiovascular events, uncontrolled asthma, and other important reasons for health care encounters have reached alarmingly low levels [2]. Vaccinations and other preventive care, along with ongoing chemotherapy and other treatment regimens, have been constrained by “non-essential care” provisions and capacity issues.[3]

New-onset heart failure and the return of communicable diseases such as measles have been identified as potential Covid consequences, and excess cancer deaths have been attributed to an overburdened health care system [4,5].

It is important to differentiate the motivation for seeking care, from the system’s ability to provide it without shortchanging other patients. For example, while public health messages urge parents to continue their children’s immunizations, options that might optimize access, such as one-at-a-time parking lot tents or drive-throughs, remain scarce.

Scheduling Could Be Key

Oncology patients and patients in specialty clinics that do not operate daily frequently have their clinic days arranged as a “one-stop shop” for tests, consultations, and exams.

Reducing serial visits to health care facilities can reduce risk for all, especially for patients who use public transportation. Therefore, primary care physicians, if/as affiliations and proximity permit, may consider trying to consolidate tests, therapy, and exams so as to reduce patient trips.

Likely requiring labor-intensive scheduling or online platforms better suited to this purpose, there might also be an incentive for patients to “show,” such as a credit card deposit.

Health care facilities are experiencing devastatingly high numbers of iatrogenic COVID-19 cases. In addition to scheduling changes for patients, scheduling for staff may also merit reconsideration.

One recent proposal suggests work cycles that alternate four days on-site with ten days in quarantine, to reduce transmission early in the disease course [6].

If/as clinicians trade off “onsite days,” back office and exam room space might be more often shared, for a smaller health system or practice footprint overall, to reduce fixed costs.

In this and many other possible scenarios, clinicians and staff could use “at home” days in a combination of pre-COVID and pandemic-related functions. So in addition to patient/pharmacy/payer/peer contact, completing documentation, and other typical clinical responsibilities, physicians in the pandemic era will likely more often:

• Evaluate, test and recommend leases or purchases of emerging biometrics devices, apps and platforms to improve the actionability of virtual exams
• Thinking creatively about how people at risk who need regular labs drawn or serial imaging, can do so more safely
• Manage disease and monitor physiologic parameters such as BP, glucose, and sats, with appropriate billing via remote monitoring CPT codes
• Leverage newer modalities such as point-of-care arrhythmia detection and patient app/physician portal platforms that support asynchronous communication, longitudinal data capture, and shared care plans
• Track medication adherence, exercise, and other important constructs via apps and wearables
• Follow up with personalized recommendations and advice, proactively seeking to help patients optimize individual outcomes

Whether or not new care models stimulate interoperable EHRs, inescapably, health systems will vary in the “safety and efficacy” of the policies, processes, and technologies brought to the pandemic. Thus, clinicians are advised to actively participate in this evolution, toward timely and patient-centered responses.

References:

1. Keesara S, Jonas A, Schulman K. Covid-19 and Health Care’s Digital Revolution. The New England Journal of Medicine, 10.1056/NEJMp2005835. Advance online publication. https://doi.org/10.1056/NEJMp2005835
2. McFarling UL. ‘Where are all our patients?’: Covid phobia is keeping people with serious heart symptoms away from ERs. STAT. https://www.statnews.com/2020/04/23/coronavirus-phobia-keeping-heart-patients-away-from-er/
3. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020. MMWR Morb Mortal Wkly Rep. ePub: 8 May 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6919e2external icon.
4. Grady D. The Pandemic’s Hidden Victims: Sick or Dying, but Not From the Virus. https://www.nytimes.com/2020/04/20/health/treatment-delays-coronavirus.html
5. Lai AG, Pasea L, Banerjee A, Denaxas S, Katsoulis M, et.al. Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency. (PDF preprint) https://www.researchgate.net/publication/340984562_Estimating_excess_mortality_in_people_with_cancer_and_multimorbidity_in_the_COVID-19_emergency, accessed May 12, 2020.
6. Alon U, Yashiv E. Exploiting a coronavirus weak-spot for an exit strategy. Centre for Economic Policy Research. https://voxeu.org/article/coronavirus-weak-spot-exit-strategy, accessed May 12, 2020.