Top 3 Reasons Primary Care Providers are More Important Now Than Ever

There is nothing new or innovative about assigning members to primary care doctors. What is new, however, is the coronavirus and how it is making the need for a primary care doctor more apparent than ever before. 

Here are the top three reasons to re-up efforts to get patients assigned to a primary care doctor — especially during the pandemic. 

1. Primary Care Providers Help Patients Boost Their Immunity

Overall health and immunity are intrinsically connected. Primary care doctors care for their patients’ overall health, and that includes encouraging behaviors that support a strong immune system, such as:

• Quitting Smoking

Primary care doctors can refer patients to smoking cessation programs, and in fact, patients are 1.6 times more likely to quit if they are advised to do so by their primary care doctor. 

• Good Nutrition

Eating wholesome foods and maintaining a healthy weight contribute to a healthy immune system. Conversely, being overweight has been shown to be a risk factor for COVID-19. Doctors play a role in helping patients who are struggling with diet and nutrition by providing counsel, referring patients to nutritionists, or encouraging participation in programs that support healthy eating.

• Regular Exercise

Like nutrition, exercise plays a key role in weight management, and doctors are increasingly writing prescriptions for exercise to encourage patients to be active.

• Getting Quality Sleep

When you don’t get enough sleep, your body doesn’t produce as many infection-fighting antibodies and cells. Coaching on good sleep practices can be helpful, and a referral to a mental health provider may be suggested if the problem is severe.

• Limiting Stress and Anxiety

In the early 1980s, researchers at The Ohio State University College of Medicine conducted research that showed a link between stress and immunity. Primary care doctors are often the first line of defense for screening patients and referring to mental and behavioral health providers. 

• Vaccines and Immunizations

Primary care providers keep patients up to date on important preventive measures — like the flu shot, childhood immunizations, and, eventually, a coronavirus vaccine — that prevent the spread of illness.

2. Primary Care Doctors are the First Line of Defense Against Chronic Conditions

Primary care providers work to identify chronic conditions early, and then play an essential role to coordinate care for their patients and help them manage their conditions. 

It is important right now:

According to the CDC, five chronic conditions are associated with a higher risk of severe illness from COVID-19. 

It is important all the time:

Six out of every ten adults have at least one chronic condition, making them more vulnerable to COVID-19 and putting them at greater general risk for morbidity and mortality. 

Most chronic diseases can be prevented through healthy lifestyle choices (like the ones listed above) and regular health screenings, putting the primary care provider in an important position to help patients prevent and manage these conditions.

3. Primary Care Doctors Make Care Personal

• They Answer Questions

Patients have a provider they can trust to answer their medical questions. 

• They Know Their Patients

Primary care providers know their patients’ overall health and baseline, making it easier for them to diagnose health conditions. 

• They Coordinate Care

Primary care doctors watch the overall health of patients and help coordinate care between specialists. 

• They Make Referrals

Patients get the referrals they need to see specialists when necessary.

Every member deserves to have a primary care provider they can trust, and health plans play a key role in ensuring members are assigned to the right provider. Even during the pandemic, members can be assigned to providers and begin to establish the important doctor-patient relationship. 

The pandemic had a direct impact on well-child visits. The American Academy of Pediatrics (AAP) reported that pediatric visits had dropped as much as 60 percent nationwide in the early phases of the pandemic.

The interruption in ongoing care is a concern. To adapt to the current environment pediatricians, like other providers, have integrated telehealth into their practices. However, some screenings simply require in-person appointments, especially for children.

During well-child visits, providers monitor the overall health of the child, including mental health, chronic conditions (e.g., asthma, allergies, and diabetes), and appropriate development. Vaccinations are also a critical component of well-child visits.

Of particular concern now, is the delay in vaccinations resulting from the reduction in well-child visits and the associated risk of outbreaks of vaccine-preventable illnesses, including measles, whooping cough, and the flu.

The Centers for Disease Control and Prevention (CDC) recommends that everyone 6 months of age and older get a flu vaccine. This year, the flu vaccine is more important than ever. Preventing the flu will not only prevent sickness and the spread of the illness, but it will also reduce the burden on the healthcare system as we continue to require resources to fight coronavirus.

The flu is a risk for children. According to the AAP:

• Children consistently have the highest attack rates of influenza in the community.
• Kids play a pivotal role in the spread of the flu to others in their household and close contacts.
• Children can experience substantial morbidity, including severe or fatal complications from the flu, with children younger than 5 years being at increased risk of hospitalization and complications, and school-aged children being more likely to need medical care as a result of the flu than healthy adults.

The flu vaccine is effective for children.

• A 2020 study published in the AAP Journal, Pediatrics, found that flu vaccinations reduced flu-related emergency department visits by half among children.
• A 2017 CDC study found that the flu vaccine significantly reduces a child’s risk of dying from the flu.

The AAP released a statement regarding the flu vaccine for the 2020-2021 season, recommending, concurrent with the CDC, that all children 6 months of age an older (and without medical contraindications) be vaccinated. Here are some recommendations for increasing utilization of well-child visits.

Reach Out to Encourage Well-Child Visits

Pediatricians and/or health plans can identify children who have missed well-child visits and contact them to encourage them to schedule appointments.

Schedule In-Person Visits When Appropriate

Telehealth is an important part of care delivery; however, the AAP recommends that well-child visits should occur in person whenever possible, allowing pediatricians to provide vaccinations and immunizations, in addition to other care.

Reduce Fear and Anxiety

To make parents and guardians comfortable with scheduling in-person appointments, pediatricians can communicate the strategies they are using to prevent the spread of coronavirus and other illnesses within their offices.

The Centers for Medicare and Medicaid Services (CMS) recently announced that it added eleven new telehealth services to its reimbursement list effective immediately and through the remainder of the coronavirus public health emergency (PHE). Additionally, CMS is providing support to Medicaid and CHIP agencies to expand access to telehealth. There are now 144 services covered during the PHE. (See the full list at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.) The public health emergency was recently renewed for an additional 90 days from the renewal date of October 23.

That update comes as CMS also reported on telehealth utilization for Medicaid and CHIP beneficiaries. From March through June 2020, there was an astounding 2,632% increase compared to the same period in 2019, with a peak in mid-April. That equates to 34.5 million visits during those four months, with utilization being highest for working-age adults. CMS Administrator, Seema Verma, stated, “This revolutionary method of improving access to care is transforming healthcare delivery in America.”

Telehealth was pushed to the forefront when CMS relaxed requirements to ensure access to care during the pandemic. Initial indications are that both patients and providers are successfully integrating this method of care delivery. According to a report by Accenture, 60 percent of patients who have used telehealth during the pandemic want to continue doing so, and the vast majority of patients reported that the quality of care they received via telehealth was consistent with in-person care.

Telehealth enables providers to reach patients during the pandemic, and it also enables them to reach patients who generally face barriers to access, like rural residents. In fact, the Centers for Disease Control and Prevention has supported telehealth projects across the country, both before and during the pandemic, that are delivering chronic disease programs and specialty care to rural areas. The technology’s capabilities reach far beyond a check-up.

Stroke and Cardiac Rehabilitation

Doctors can monitor patients as they do rehabilitation exercises at home.

Diabetes Management and Prevention

The remote delivery of diabetes self-management education and support helps patients manage their condition through nutrition, physical activity, correctly checking blood sugar, taking medicine, and managing stress.

Vision Care

Providers can assess eye health and screen patients for eye disease.

Tobacco Cessation

Specialists can reach patients, especially those who have limited Internet access, with smoking cessation interventions via cell phone.

Epilepsy Management

Patients get access to self-management and telemonitoring programs to manage their condition.

Physical Therapy

Therapists can conduct assessments, prescribe strategies, manage exercises, and consult with patients remotely.

Dentistry

Dentists can conduct assessments via telemedicine, reducing unnecessary appointments and exposure during COVID-19.

Chronic Pain

Providers can conduct virtual visits and monitor patients through devices that track and transmit data.

The future of telehealth continues to show promise as a means for delivering quality care both during the pandemic and beyond. While some services will always require in-person appointments, the availability of telehealth allows providers to limit the spread of disease during the pandemic, to provide innovative ways to deliver care, and to reach patients who otherwise experience a barrier to care.

Beneficiaries who are enrolled in both Medicare and Medicaid are referred to as “dually eligible.” The number of these members is increasing, and as health plans serve more dual-eligible members, they are challenged to find innovative ways to serve this population and address their unique needs.

The Needs of Dual Eligible

Many dual eligible have needs that are significantly more involved than the average health plan member, including complex medical issues, behavioral health concerns, and the need for additional support services. Consider these statistics: *

• 41 percent of dually eligible individuals have at least one mental health diagnosis
• 49 percent receive long-term care
• 60 percent have multiple chronic conditions
• 18 percent  report they have “poor” health

What Can Health Plans Do?

The Center for Health Care Strategies, with support from The Commonwealth Fund, created a learning collaborative called Promoting Integrated Care for Dual Eligible. Seven participating health plans collaborated to find ways to better deliver care to meet the unique needs of the dual eligible population. Following is a summary of their recommendations:

Meet the member’s immediate needs first.

While getting members access to health care is top of mind for plans, it may not be the most pressing concern for a dually eligible individual. Plans should focus on developing relationships with members to determine their most immediate needs – and then addressing them. That might mean fixing a broken wheelchair ramp or providing a meal. By addressing these concerns, plans can build trust and remove obstacles in the way of getting these members care.

Let the member set the pace.

Developing trust also comes into play as plans work to connect with members to complete initial health risk assessments. Plans should try offering multiple opportunities for connecting in a variety of settings, including in-home and offsite locations, that may make the member more comfortable.

Empower members to initiate contact.

When possible, allow the member to reach out to the plan instead of vice versa. Plans may need to consider creative strategies and communications that help the member feel empowered to take action to make contact.

Hire staff who can relate to members.

Hiring health care navigators from the community can facilitate connection for health plans. These employees can help plans build connections, identify needs, and overcome barriers, including language and culture.

Offer alternative settings for contact.

Members may not be comfortable meeting in their homes. Or some members may be struggling with homelessness. Offering a safe, convenient offsite location to meet with members can expedite contact.

Create connections to members through local organizations.

Community organizations are champions for their constituents. Consider how plans can develop relationships with organizations that will help build trust between the members of the community and the plan.

Identify unique preferences of cultural subpopulations.

Is your plan serving a population with unique cultural mores? Plans should consider how they can adapt to connect with members in a way that makes the member comfortable.

Help members obtain and/or maintain benefits.

Dually eligible members are often balancing multiple streams of support and maintaining benefits can present a challenge. When plans ensure members do not lose benefits, like food support or Social Security Income benefits, they help provide stability to the member that ultimately contributes to their wellness.

*According to the Centers for Medicaid and Medicare Services March 2020 Fact Sheet.

During COVID-19, we have seen a dramatic rise in the use of telehealth. While rushed into use to reduce the spread of the virus, especially to at-risk individuals, it is likely that telehealth will be here to stay, even post-pandemic.

When the Centers for Medicare and Medicaid Services responded to the pandemic with their guidance on telehealth, they specified that services could be delivered via telehealth to all Medicaid populations, including children, and pediatricians quickly moved to adapt. Telehealth provided a way for pediatricians to mitigate risks and meet the immediate needs of their patients, and it will continue to provide a means for them to deliver care.

However, some visits still require in-person visits. One of the impacts of the pandemic has been a significant drop in well-child visits and a corresponding reduction in vaccinations as families stayed home to reduce the spread of COVID-19. According to the American Academy of Pediatrics, pediatricians were only seeing 20 to 30 percent of the number of patients they typically see in the spring of this year. 

Well-child visits are important to:

• Track a child’s growth and development
• Allow adults to discuss any concerns about a child’s health
• Get important vaccinations

And the vaccinations are of particular concern. While COVID-19 has thus far been shown to have less of an impact on children, diseases like measles and whooping cough, pose a greater threat.

Now, as communities have opened back up, how should it be determined when to utilize telehealth and when to schedule in-person appointments? The American Academy of Pediatrics suggested the following guidelines for well-child visits:

• Well-child care should occur in person whenever possible and within the child’s medical home where continuity of care may be established and maintained. For practices who have successfully implemented telehealth to provide appropriate elements of the well exam virtually, these telehealth visits should continue to be supported, followed by a timely in-person visit. 
• Pediatricians should identify children who have missed well-child visits and/or recommended vaccinations and contact them to schedule in-person appointments inclusive of newborns, infants, children, and adolescents. Pediatricians should work with families to bring children up to date as quickly as possible. 
• Pediatricians should inform families about the strategies already implemented in primary care medical home offices to assure safety. These strategies may include these examples:  

• Scheduling well visits and sick visits at different times of the day. 
• Separating patients spatially, such as by placing patients with sick visits in different areas of the primary care clinic or another location from patients with well visits. 
• Collaborating with providers in the community to identify separate locations for providing well visits for children.  

Health plans can make an effort to encourage the health of their youngest members through engagement efforts, including communicating the importance of well visits with parents and guardians; sending reminders to families that have missed appointments; sharing information on when and how to get vaccinations during the pandemic.

Chronic diseases are ongoing, generally incurable illnesses or conditions, such as heart disease, asthma, cancer, and diabetes. And in the United States, we have a growing problem with them.

Chronic diseases are the leading cause of death and disability in the US. It is estimated by 2025, nearly half of all Americans will struggle with a chronic disease.

In addition to the impact that these diseases have on quality of life and life expectancy itself, they also take a toll financially. Treatment for chronic disease accounts for the majority of health spending, resulting in:

81% of hospital admissions

91% of all prescriptions filled

76% of all physician visits

All told, the result of those numbers is that 99% of Medicare spending and 83% of Medicaid spending is for the treatment of chronic diseases.

That’s the bad news. The good news is that chronic diseases are often preventable or manageable through healthy lifestyle changes. The U.S. Centers for Disease Control and Prevention estimates that eliminating three risk factors – poor diet, inactivity, and smoking – would prevent 80% of heart disease and stroke; 80% of type 2 diabetes; and 40% of cancer.

Considering that obesity is a symptom of two of the three risk factors, an obvious question to raise is: What can health plans do to fight obesity?

Obesity is a Growing Problem

In the US, more than one third of the population is obese. That includes childhood obesity, which has been steadily on the rise for the past few decades. The National Center for Health Statistics reports that the prevalence of childhood obesity has tripled since the 1970s.

This information is not a surprise to anyone in the health care industry, but it is nonetheless striking to be reminded of the gravity of the problem. Of course, the solution is not dependent on any single entity, but health plans are in a unique position to consider their role and influence as our country looks for solutions.

What can health plans do to fight obesity?

Educate Providers

• Yes, providers record BMI information for their patients, but are they trained on how to prescribe physical activity and nutrition for members? Plans should consider how they can help providers prescribe behavior changes for their patients.
• If your plan offers benefits like gym memberships or enrollment in weight loss programs, are your providers aware so they can refer their patients?

Support Members

• Does your plan offer special benefits, like gym memberships, or enrollment in weight loss programs? How are you connecting with members to encourage their use of these benefits to improve their health?
• What role does care management take in supporting members who are trying to lose weight?

Advocate

• Consideringthemagnitude of obesity in the US, the solution will require a collaborative effort. What role should health plans take in raising awareness of the problem with other stakeholders in the community?
• What partnerships would help in this effort? Think about how the plan can work alongside parks, universities, K-12 schools, restaurants, community centers, etc. to fight obesity.

Obesity is a daunting problem, but the promising result – better overall health, including a reduction in chronic disease – is worth the fight.

The United States has a much higher rate of chronic disease compared to other developed countries, according to The Commonwealth Fund. In fact, the US Centers for Disease Control and Prevention reports that 6 in 10 Americans have a chronic disease, and those conditions are the primary contributor to the nation’s $3.5 trillion in annual health care costs. A high percentage of people with chronic disease receive their health care coverage through Medicaid. 

Nearly 20 percent of Americans have their health care covered by Medicaid – the nation’s health care program for the low-income population. In 2014, Medicaid’s role in taking care of the poorest and sickest Americans grew when The Affordable Care Act empowered states to expand Medicaid to people with an income at or below 138 percent of the federal poverty level. Currently, 38 states and the District of Columbia have expanded their Medicaid coverage. That expansion of eligibility includes many who are sick and who have not previously had access to health care. And that includes many who have chronic medical conditions. 

Can Medicaid Make a Difference?

In 2012, The Kaiser Family Foundation conduced an analysis, reporting, “The relatively comprehensive Medicaid benefits package and improved care management could also foster more appropriate care patterns for the uninsured at a greatly reduced out-of-pocket cost, potentially improving both their health and personal economic security, as these individuals have quite limited incomes. For these reasons, Medicaid eligibility may have a substantial, positive impact on the quality of life for poor, uninsured adults with chronic conditions, especially those without children—a vulnerable population that has historically been excluded from health coverage.”

The same report also concluded, “If states can meet the challenges of effectively implementing the ACA Medicaid expansion, the results of this analysis suggest that enrollment in Medicaid may provide greater access to important services that would enable newly eligible adults with chronic conditions to better manage their conditions.”

Medicaid Managed Care brings with it the promise of member outreach and case management to improve care for members with chronic conditions. Here are two examples of how that has played out. 

· The report, Changes in Ambulatory Utilization After Switching from Medicaid Fee-for-Service to Managed Care, looked at Medicaid members in New York state. The researchers found that the transition from fee-for-service Medicaid to Medicaid Managed Care was associated with a significant decrease in ambulatory utilization, especially among beneficiaries with five or more chronic conditions.

· Molina Healthcare published a study on the outcomes from their Care Management programs, analyzing data on claims prior to enrollment in Care Management and 24 months of data post-enrollment in Care Management. The results show that Molina’s Care Management Programs successfully reduced all-cause inpatient admissions, emergency department visits, inpatient costs, emergency department costs, and total costs. Additionally, they saw improved adherence to medication regimens and the utilization of preventive care services.

As Medicaid continues to expand to cover more people, there is hope that a higher number of low-income individuals will get the care they need to prevent or manage chronic conditions. 

In response to COVID-19, The Centers for Medicare and Medicaid Services (CMS) offered rule flexibility and expanded payment for telehealth services so providers could continue to deliver care to their patients without the risk of exposing them to the virus at the root of the global pandemic.  

Those changes resulted in an astonishing increase in telehealth appointments. A CMS press release from August 3 reported, “Before the public health emergency, only 14,000 beneficiaries received a Medicare telehealth service in a week while over 10.1 million beneficiaries have received a Medicare telehealth service during the public health emergency from mid-March through early-July.”

In August, CMS proposed changes to expand telehealth permanently, consistent with the Executive Order on Improving Rural and Telehealth Access.

While some appointments still beg for an in-person visit, others, like annual wellness visits (AWV), maintain their effectiveness via telehealth and even hold the promise of increasing utilization for members who would have skipped an office visit because of transportation challenges, mobility issues, or other reasons.

The majority of the components of the AWV can successfully be conducted via telehealth, but a revised approach on the part of both the provider and the patient may be necessary to get the most value out of these appointments.

Annual Wellness Visit Components

• Review and update the patient’s Health Risk Assessment (completed during their initial appointment)
• Update the beneficiary’s medical/family history
• Update the list of current providers and suppliers
• Measure weight, blood pressure, and other measures appropriate to the patient
• Assess for any cognitive impairment
• Update the written screening schedule for preventive services and vaccines
• Update the list of risk factors and conditions that require intervention
• Update the Personalized Prevention Plan Services
• If necessary, furnish advanced care planning services

For a successful visit, both the provider and the patient may need to consider how to prepare for a telehealth appointment differently.

Preparing Providers for Telehealth Visits

• Establish a secure and stable connection in an appropriate office setting for telehealth visits.
• Remind providers of the components of the AWV and appropriate billing codes (see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf)
• Educate providers about best practices for developing rapport via video and phone calls, including considering the camera angle, lighting, and chat functions.
• Review any questions submitted by patients in advance of the appointment.
• Have ready any documents or educational materials to screen share with patients.

Preparing Patients for Telehealth Visits

• Create communications to ensure patients are prepared with the information they need to have a successful AWV. Let them know what to expect and ease any concerns they may have.
• Create an intake form so patients can submit questions to the provider prior to the call.
• Ensure members are prepared with any vital information, like weight, blood pressure, or a list of current medications.
• Create easy-to-follow instructions to help patients connect to the appointment.
• Direct members who need help accessing a reliable Internet connection to community services that can help.

Maintaining patients’ consistency with AWVs via telehealth will contribute to the important preventive care they need to stay their healthiest.

Chronic diseases are ongoing conditions, such as heart disease, asthma, cancer, and diabetes. These diseases are often preventable and can be managed through care like early detection, a healthy diet, regular exercise, and other preventative treatments.

Despite the preventable nature of most of these conditions, chronic diseases represent a significant percentage of total spending for plans serving Medicare and Medicaid members:

• more than 99% of the spending in Medicare
• about 83% of spending in Medicaid

But there is great potential for improvement. According to the Centers for Disease Control and Prevention (CDC), there would be a reduction of 80% of cases of heart disease and stroke, 80% of cases of type 2 diabetes, and 40% of cases of cancer by simply eliminating three risk factors:

1. Obesity
2. Smoking
3. Inactivity

Finding a solution to the root cause for those risk factors is not easy, and sometimes it helps to derive inspiration from others. The Centers for Medicare and Medicaid Services issues grants to incentivize Medicaid members to participate in programs to improve health outcomes. Here are summaries of how some plans are using incentives to reduce risk factors for chronic disease.

Obesity Solution Spotlight

The Montana Medicaid Incentives to Prevent Chronic Diseases Program promoted healthy diet and regular physical activity for adult Medicaid beneficiaries at risk of developing cardiovascular disease and diabetes to achieve weight loss. The program used certified diabetes educators, registered dieticians, registered nurses, exercise physiologists, and physical therapists to support participants to achieve a seven percent weight loss in 10 months and maintain that success over time. Participants were incentivized with up to $320 in debit card funds.

Smoking Solution Spotlight

Medi-Cal engaged beneficiaries to help them quit smoking and manage their diabetes through telephone counseling. Members were offered an incentive to call the helpline, complete the intake protocol, and participate in counseling sessions. The helpline also supported members who wanted to obtain nicotine replacement therapy. An incentive was offered for every relapse-prevention call that members completed to encourage their smoking cessation efforts.

Inactivity Solution Spotlight

The New Hampshire Wellness Incentive Program created a Supported Fitness and Weight Management program which could include a health club membership; participation in a motivational health promotion program; participation in Weight Watchers, or a combination of both. In addition, participants who expressed interest in quitting smoking could receive vouchers for memberships to community fitness centers and formal weight loss programs.

Full descriptions of these and other incentive programs can be found at https://innovation.cms.gov/innovation-models/mipcd/mipcd-the-states-awarded.

An emphasis on smoking cessation, healthy weight management, and physical activity has the potential to have significant impact on member health. But the common denominator in all strategies to reduce the risk of chronic disease is this: successfully engaging the member to be an active participant in taking care of their health.

How is your health plan helping members to improve in these areas?