Will covid-19 change US healthcare for the better?BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1784 (Published 30 April 2020) Cite this as: BMJ 2020;369:m1784
- Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, professor of family medicine at Georgetown University, and associate editor, The BMJ
The covid-19 pandemic has necessitated many changes in US healthcare. It has made me wonder which—if any—in three healthcare sectors will become permanent.
Firstly, in public health, we are finally seeing new investments to try to make up for tragic underfunding over the past decade.12 For some who have died, it is certainly too little, too late; whether we can catch up and adequately do the testing and tracing necessary to contain and end the pandemic remains to be seen. But after this is over, will we correct past mistakes and find the political will to adequately fund a robust public health sector?
Secondly, the payment systems for care in the US are varied and sometimes byzantine. Most are based on a fee-for-service model that rewards procedures and punishes chronic and preventive care. In this time of pandemic, most outpatient and inpatient care has been restricted to covid-19 and emergencies, essentially destroying primary care and some specialist practices that survive on payments for visits. We are hearing that many—20% or 30%—of practices will be forced to close, perhaps never to reopen.34 Other independent practices will be forced to sell to big, hospital based companies. This could have been largely avoided if the US used mainly prospective payments rather than fees for services. After this is over, will we correct past mistakes and turn to a primary care prospective payment system?5
Thirdly, there have been dramatic changes in how office based care is delivered. The most obvious difference is the almost total abandonment of face-to-face visits in favor of telemedicine, by video and by telephone. Family doctors tell me that they are shocked how quickly this change has occurred and amazed how comfortable doctors and patients are with it.
The dominance of telemedicine has led to many other changes: new requirements for what necessitates an in-person visit; less dependence on and a higher threshold for laboratory testing; a corresponding increase in the importance of history taking; increased reliance on patient reported clinical data from home monitors and wearable instruments; and others. Doctors have also reported increases in collegiality and cooperation within and between specialties as everyone works together on behalf of covid-19 patients.
Some of these changes are for the better, others not so much. Some benefit only patients with enough spare money to buy an Apple watch or a heart monitor, so they can report findings to their doctors. But one doctor told me that the pandemic changes have cut both ways economically, as she is now having video visits with patients whose resources didn’t allow them to make it across town to see her before, and she is gaining important insights into how they live and manage their health conditions from what is effectively a series of home visits.
After this is all over, will we correct past mistakes and harvest the best of these clinical changes for permanent adoption?
For what it’s worth, I believe that the obvious need for more public health funding will lead to an increased budget for this sector in coming years. I think we will see continued high use of (and continued payment for) telemedicine visits because they have been so successful. But I am less sanguine that we will have the political will to upend the fee-for-service tradition in favor of a universal prospective payment system for primary care. I hope I am wrong about this last one.