Observing the evolution of the responses of governmental agencies, hospital advocates, and political lobbyists to the novel coronavirus from my vantage point within the medical system has raised my level of concern about its likely enduring legacy on American medical practice. The disruptions imposed by our current situation have the potential to dislodge obstructive barriers that prevent a humanistic realignment of healthcare, or to consolidate the ever-tightening grip of bureaucrats on medical practice.
I am a family physician in the academy whose teaching practice is sponsored by a large regional health system. Like every medical practice across the country, our neck of the woods has been touched by the Covid-19 pandemic. Our residency program’s inpatient service continues to care for hospitalized Covid patients, and our outpatient clinic diagnoses and triages a number of less-critically ill patients. Fortunately, the rate of admissions due to Covid have not overwhelmed our community’s ability to accommodate them. Our hospital bed and ICU capacity have remained open and ready to address the potential for a surge in critically ill coronavirus patients.
Also like many others, our hospital and health system have been impacted negatively—dramatically so—by the effects of the pandemic on the balance sheet. As federal and state stay-at-home orders have proscribed “elective” medical procedures and office visits, the outpatient visits, surgeries and scheduled admissions that comprise a large revenue source for health systems have dropped precipitously. In the midst of the health crisis, American healthcare is facing an astounding—and heretofore unforeseeable—financial crisis, which is resulting in the shuttering of economically tenuous hospitals and smaller medical practices. Even many larger, well-known hospital systems that are much more favorably endowed have announced salary cuts, furloughing of healthcare workers, and layoffs of frontline medical personnel.
Many Americans who are not intimately familiar with the healthcare sector question how it could be so negatively affected as a consequence of such a major public health event as this. As the news projects images of overwhelmed and overburdened emergency departments and ICUs struggling to provide care to legions of Covid patients, it seems unfathomable that hospitals would be facing such a deep cut in revenue, some to the verge of bankruptcy. Of course, the pandemic has not affected all geographic regions of our country equally; New York is not Tuscaloosa.
A fundamental structural flaw in our healthcare system that has been exposed by the pandemic and has had an oversized influence on the economic devastation has to do with the way medical services are funded. As self-quarantine orders went into effect across the country in March, outpatient medical practices such as the one where I work saw a rapid decrease in visits. Hospitals did not admit patients who otherwise would have come in for elective surgeries. Even emergency departments, which would be expected to receive runoff from closed outpatient practices, saw a marked decrease in visits. As the drop was observed across the spectrum of healthcare, health systems recognized the impending catastrophic losses and scrambled to provide some form of continuous care for patients that would also constitute a billable service. Offering a lifeline, the Centers for Medicare and Medicaid Services (CMS) launched a set of emergency rules that permitted practices to submit claims for remote patient visits that are conducted via telemedicine on two-way video platforms. Health systems seized this opportunity and began converting large numbers of outpatient services to telemedicine visits, rushing to enable technology and remote visit protocols. As an acknowledgement of the barriers faced by many patients in accessing the internet and using telemedicine technology, CMS modified the rules to allow billing of telephone-only services without video for discreet services ranging from annual wellness visits to obesity counseling.
The situation that many health systems and medical practices find themselves in is a paradox. While clinicians struggle to find workarounds to maintain ongoing care to meet the needs of established patients, their practices are starving financially as a result of government orders halting office visits—orders that were ostensibly issued to protect the health of the public. Additionally, many patients with chronic medical conditions have seen their routine care postponed indefinitely as an “elective service,” with adverse consequences to their overall health. It is the monolithic fee-for-service medical financing system, not the health crisis per se, that is mostly responsible for undermining the ongoing care of those with chronic conditions and depriving medical practices of the resources needed to survive this time of crisis. As government has assumed a larger role in the financing of the nation’s healthcare services over the past seven decades, it has been forced to legislate solutions to problems created by its own doing. What’s more, these solutions are created as one-size-fits-all, applying equally to all practitioners across the country, even though local conditions vary widely.
While it may be unwelcome to inject the language of Catholic social teaching into the secular discussion of this national dilemma, what has been sorely missing from American healthcare for a long time (never more so than now) is consideration of the vital principle of subsidiarity in determining how we meet such a great societal need as healthcare. This principle, famously elaborated by Leo XIII in his encyclical Rerum Novarum (1891), states that local problems are best solved at the grassroots level, leaving higher levels of government to address only those issues that are beyond the ability of local authorities. Adherence to subsidiarity is a societal good because it respects local communities’ authority to implement solutions that are best suited to their unique conditions and situations. This honors their collaborative and co-creative role in the societal ordering and governance that is directed toward human flourishing.
Even before the pandemic, the healthcare system’s reliance on a gargantuan set of federal rules that regulate the delivery and financing of medical care has long contravened the principle of subsidiarity. The issuing of rules outlining the conditions that govern how clinicians interact with their patients, that dictate specific documentation requirements for care in cumbersome and inefficient electronic records, that create billing rules and non-negotiable government-created fee schedules, all serve to suppress local autonomy and control over the practice of medicine. As the federal government has assumed a larger financial and regulatory role, individual practices and physicians have found the burdens of adherence to CMS demands harder to maintain. Consequently, many practitioners have been forced to sell their practices and their autonomy to health systems in order to survive. Many observers predict that hard times brought on by the coronavirus pandemic will only serve to accelerate this trend in practice consolidation as smaller independent practices either sell out to large corporate health systems or close completely.
In the eye of the Covid storm, the government’s one-size-fits-all payment scheme has left many independent medical practices and smaller hospitals in ruins. Practices are seeing how a fee-for-service payment model collapses when patients do not come through the door, either due to government decree or out of fear for their own safety. CMS proclamations that temporarily permit practices to submit charges for remote services are a perfect example of a government-created solution to a problem created by government. Now Medicare and even commercial health insurers who traditionally follow the CMS lead on billing rules are forced to offer some sort of life line to medical practitioners, at the risk of losing participating service providers. From their perspective, the loss of too many providers threatens the viability of their networks in the same way a parasite might be at risk of perishing as a result of the death of its host.
As the financial fallout of Covid continues to roil U.S. healthcare, there are a few possible outcomes that may affect the future financial viability of medical care. One is the realization that fee-for-service financing of all healthcare services—especially primary care—is inadequate to ensure a stable supply of practitioners and to maintain their availability to provide ongoing care. The idea of stable per capita payments to primary care was popular during the HMO boom of the 1990s, but was wildly unpopular as payors sought to reduce costs by placing primary care physicians in the role of “gatekeepers” to limit use of more expensive specialty and diagnostic services. A version of the theme of subscription payment has found favor with independent practices that charge member patients recurring fees in the direct primary care model. These direct care practices contract directly with patients, or with self-insured small employers on behalf of their employees, to provide ease of access to a personal physician at predictable and reduced costs.
More progressive elements of society view the current crisis as an opportunity to agitate for an even larger role of government in healthcare financing and delivery. Activists for a single-payer healthcare system claim that only such a system can guarantee that all Americans will have access to care, and that a monolithic system can more comprehensively coordinate the national health response to a crisis of this magnitude. What this argument fails to acknowledge is that much of the ire of those critical of the national response to the coronavirus blame large governmental bodies such as the Federal Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), and Federal Emergency Management Administration (FEMA) for inefficiency and ineffectiveness. Using the Covid crisis to invoke the need for another gargantuan governmental administrative body overlooks the abysmal track record of mammoth administrative bodies in managing similar crises at home and globally, and it dismisses the nimble role of local agencies to address the granular differences in disease incidence, spread, and transmission patterns in communities across the United States.
A more likely outcome of the coronavirus pandemic on American medicine is that, as outpatient offices and hospital ORs gradually open and resume their practice, health systems will see a return of their regular operations and associated sources of revenue. They will work with CMS to permanently adopt and institutionalize changes in practice and payment models that have arisen during the crisis and that have demonstrated economic and scalable efficiency, such as the widespread implementation of telemedicine for everything from outpatient visits to hospitalist rounding. While such technologies are a tool that can be wielded effectively in certain clinical scenarios and situations, they are a far cry from a panacea for our national healthcare woes. Many physicians, myself included, worry that an overemphasis on technology and its attendant economic savings and efficiencies will come at the expense of aspects of doctoring such as the physical exam and flesh-and-blood human interaction, especially in high-touch disciplines such as primary care, which will further serve to degrade and commodify medicine into a purely transactional practice. An over-reliance on the telemedicine delivery model, and the expanded scope of independent practice of non-physicians that has been implemented as a stopgap measure during the crisis, will further erode the quality of medical care and reduce the traditional practice of medicine to an outdated and antiquated exercise. Only time will tell which of these outcomes will be medicine’s fate, and whether such changes will bring us closer to, or remove us farther from, the principle of subsidiarity in American healthcare.
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