Letter: Rebuilding our primary care and public health infrastructure

Graphic by Lori Deaton

A recent survey of 295 primary care practices in the state conducted by the N.C. Department of Health and Human Services found that 34 practices already have closed (11.5%) and 121 practices (41%) have reduced hours due to the decline in patient visits caused by the COVID-19 pandemic.

This crisis has raised several painful questions for our region, the state and the nation as a whole. Yet the most important question we face is this: How long will we wait to fix what is broken so we’re better prepared the next time?

This crisis has exposed gaping cracks in our nation’s health care infrastructure. It is now all too easy to recognize the serious shortfalls of a disconnected, disorganized system focused on caring for the sick instead of preventing disease.

Nowhere are these problems more evident — and more dangerous — than in primary care. Local primary care is the foundation of any successful health care system, yet our country has long neglected it. Our system incentivizes expensive procedures rather than keeping people well. And the current crisis isn’t just weakening that foundation; it threatens to devastate it.

This is especially true for primary care practices that, like other small businesses, are suffering the economic effects of the pandemic. Primary care practices across the U.S. are seeing enormous decreases (some upwards of 80 %) in the number of patient visits. By June, an estimated 60,000 family practices could close or significantly scale back, reducing hours, furloughing or even firing hundreds of thousands of their employees.

The situation in Western North Carolina is no different. Potential closures here would mean 13 additional counties with family medicine shortages in our region alone and 50 more statewide. A recent survey of family physicians and pediatricians in the state reported more than 80% were experiencing “significant” or “extreme” financial losses because of COVID-19. That means the nurses, administrators, janitors and others who work at those practices will suffer financial losses as well. And because many independent and rural practices are already on the edge of the economic cliff, more are likely to consider selling or closing their practices altogether.

As a family physician in solo-independent practice, I have unfortunately seen the effects of this crisis on the health of my patients and the health of my practice. I have already had to reduce hours and salaries of employees. I struggle daily to make sure my office has enough personal protective equipment. Most of my local primary care colleagues are in the same position or worse. Many have already furloughed or eliminated staff positions.

The cruel irony is that those who are most able to treat the chronic diseases that put people at the greatest risk of COVID-19 are at the greatest risk themselves. Primary care physicians on the front lines of the battle against COVID-19 are poorly outfitted with insufficient COVID-19 tests, a lack of personal protective equipment and insufficient capital to weather this storm. Should practices close, the public health risk runs deep. People will still get sick; patients with chronic disease will still need ongoing care; children will still need immunizations; and even more people will seek mental health counseling as a result of isolation, job loss and financial insecurity.

We need a Marshall Plan for primary care. The Marshall Plan, enacted by the U.S. after World War II, provided billions to help rebuild heavily damaged cities, industries and infrastructure in Europe. What would a primary care Marshall Plan look like? Here are some ideas for state and federal leaders:

• Change primary care payment from fee-for-service to a system rewarding prevention and care management.
• Accelerate the use of telemedicine in primary care, rather than only incentivizing it during crises.
• Embrace new epidemiological strategies, like digital pandemic tracking, to detect global health threats sooner.
• Stockpile essential items like personal protective equipment and plan for efficient distribution.
• Expand the number of family physicians, pediatricians and public health workers by forgiving medical school tuition for graduates who choose primary care.
• Adopt strategies encouraging better geographic distribution of these professionals, including incentives for choosing underserved communities.

This pandemic is an unprecedented crisis, but it also provides an unprecedented opportunity for us to come together and fix our health care system and strengthen its foundation: primary care. If we don’t, then practices will fail, patients and communities will suffer, and we will have changed nothing. We will have let the virus win this war.

— S. Mark McNeill, M.D.
Board member, N.C. Academy of Family Physicians
Immediate past president, Western Carolina Medical Society
Trillium Family Medicine




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