What Does COVID-19 Tell Us About Primary Care in the U.S.?

Illustrated by Sophie Laye

September was a new and exciting month for many of us. More students returned to campus, clubs are no longer in hibernation, and we have in-person exams again. Yet the pandemic still lingers, as the Delta variant poses new challenges while vaccination progress has yet to reach a satisfyingly safe level. We are constantly reminded by the masks on our faces that this is an ongoing battle. In review of the past year and a half, a group of physicians were playing an especially important role during the pandemic: the primary care physicians.

Primary health care (PHC), according to the definition given by the World Health Organization (WHO), is “a whole-of-society approach to health.” It aims to address the comprehensive and interrelated aspects of physical, mental and social health and wellbeing [14]. Primary care physicians (PCPs) are often the first healthcare professionals that people see when having health problems. They are also responsible for vaccine distribution, COVID-19 testing and persuading those who are hesitant to receive vaccines during the pandemic [12].

Despite efforts made by PCPs, several groups are particularly vulnerable and find it challenging to access PHC during the pandemic. With the switch to telehealth, it can be difficult for those with chronic diseases, functional disabilities and other conditions that require frequent healthcare, as well as those who have trouble accessing the internet [8]. People who experience financial strain also report being hesitant about seeking healthcare services [6]. It is worth noting that financially, the pandemic has impacted different ethnic groups on different scales. According to a poll conducted in July and August of 2020, 72% of Latino, 60% of Black and 55% of Native American households report facing serious financial problems, compared to 36% of white households [6].

This uneven distribution is not an unfamiliar one. The aforementioned three minority groups are up to two times more likely than white people to develop major long-term conditions [5]. This means the pandemic has reinforced the existing disparities among different groups, forcing those who are already facing greater challenges to delay their visits. As of June 2020, 40.9% of U.S. adults avoided medical care during the pandemic out of fear for infection, inconvenient visits, and disabilities [3]. Yet as patients delay and cancel their healthcare visits, their conditions may gradually develop into something too severe to be treated in primary care facilities which often have limited resources. The deteriorating health conditions then force patients to visit the already crowded hospitals where treatments are more expensive and where the risk of virus transmission is higher.

However, issues in PHC had surfaced even before the pandemic started. Common problems include language barriers, geographic challenges, lack of health insurance and inflexible appointment hours [1]. For example, rural residents may spend extra time simply getting to the location of their PHPs because physicians tend to be dispersed in rural areas. It may lead patients in these areas to be more hesitant about getting vaccines or having regular check-ups. They also tend to have higher levels of poverty, a more elderly population and higher susceptibility to unemployment during the pandemic [1][11].

Nevertheless, the challenges are double-sided. For many PCPs, an ill-designed payment system, ever-changing formularies from the insurance companies and low reimbursement make it difficult to connect with patients [9]. The pandemic has only exacerbated the situation. During the second quarter of 2020, visits to PCPs experienced a 21% drop [13]. In a recent survey conducted by the Primary Care Collaborative, 52% of PCPs still report that “pandemic related strain is now severe/near severe” [12].

The root cause lies at the macro-level. The United States does spend a lot of money on healthcare: in 2019, healthcare-related spending reaches a total of $3.8 trillion, which accounts for 17.7% of gross domestic product [10]. However, only 5% to 7% of that expenditure goes into PHC despite it being the largest healthcare sector [4]. Moreover, most PCPs are still working under the fee-for-service system, in which healthcare providers are paid separately foreach time they provide a service to someone. This puts an emphasis on the quantity of care provided rather than the quality of service. Many PCPs recognize this dichotomy between income and personalized, detailed care and report a sense of frustration [9].

The problematic financial system in the field has also contributed to the decreasing number of people who choose to go into PHC, a trend that was obvious even before the pandemic and was projected to be getting worse [2]. By 2023, the U.S. could have a shortage of between 21,000 and 55,000 PCPs, according to the Association of American Medical Colleges [7].

It is vital to reflect on our healthcare from both perspectives and identify the real causes behind the scenes. These problems do not arise from the COVID-19 pandemic; rather, the pandemic serves as a magnifying glass that reveals these issues in our systems that have always been there.Seeing the pandemic as an opportunity for change rather than a complete disaster may prove helpful for both PCPs and patients.

Edited by: Darsh Singhania

Illustrated by: Sophie Laye

Comments restricted to single pageWriter: Rani HuoEmail: h.ran@wustl.eduEditor: Darsh SinghaniaEmail: d.singhania@wustl.eduIllustrator: Sophie LayeEmail: slaye@wustl.eduinflexible appointment hours [1]. For example, rural residents may spend extra time simply getting to the location of their PHPs because physicians tend to be dispersed in rural areas. It may leadpatients in these areas to be more hesitant about getting vaccines or havingregular check-ups. They also tend to have higher levels of poverty, a more elderly population and higher susceptibility to unemployment during the pandemic [1][11]. Nevertheless, the challenges are double-sided. For many PCPs, an ill-designed payment system, everchanging formularies from the insurance companies and low reimbursement make it difficult to connect with patients [9]. The pandemic has only exacerbated the situation. During the second quarter of 2020, visits to PCPs experienced a 21% drop [13]. In a recent survey conducted by the Primary Care Collaborative, 52%of PCPs still report that “pandemic related strain is now severe/near severe” [12]. The root cause lies at the macro-level. The United States does spend a lot of money on healthcare: in 2019, healthcare-related spending reaches a total of $3.8 trillion, which accounts for 17.7%of gross domestic product [10]. However, only 5% to 7%of that expenditure goes into PHC despite it being the largest healthcare sector [4]. Moreover, most PCPs are still working under the fee-for-service system, in which healthcare providers are paid separately foreach time they provide a service to someone. This puts an emphasis on the quantity of care provided rather than the quality of service. Many PCPs recognize this dichotomy between income and personalized, detailed care and report a sense of frustration [9]. The problematic financial system in the field has also contributed to the decreasing number of people who choose to go into PHC, a trend that was obvious even before the pandemic and was projected to be getting worse [2]. By 2023, the U.S. could have a shortage of between 21,000 and 55,000 PCPs, according to the Association of American Medical Colleges [7].It is vital to reflect on our healthcare from both perspectives and identify the real causes behind the scenes. These problems do not arise from the COVID-19 pandemic; rather, the pandemicserves as a magnifying glass that reveals these issues in our systems that have always been there.Seeing the pandemic as an opportunity for change rather than a complete disaster may prove helpful for both PCPsand patients.



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