I was on a socially distanced walk with my seventeen year old granddaughter this week, and we were talking about how quickly and unexpectedly life has changed. She and her parents usually come every summer for a quick visit. They fly into Logan Airport on a direct flight from Miami International Airport, and I drive down from New London to pick them up. Usually, the biggest challenge of the process is the traffic getting out of Boston. That world seems far away. Who in their right mind would fly now,especially out of Miami? Last week they drove from Miami to New London in two very long days stopping only for gas. They did not eat in a restaurant or use a public restroom. They spent one night on the road with a cousin in western North Carolina that had an apartment for them with a separate entrance. Even though they all scored negative tests for COVID-19 in the week before they traveled, they have been enduring a quarantine in a guest apartment that we have. Depending on how my granddaughter’s school decides to manage the return to school in the fall, they may be here for more than a month which will be great once we can be in the same room. It seems that everyday there is a reminder that the future is uncertain for everyone.

 

This is 2020, the era of COVID-19, and the world that we never questioned is gone, and the world that will replace it is still evolving. In a song that my songwriting son has just written, he referred to what we are experiencing as a “liminal” moment. Liminal is not a word that I use very often, but I was impressed that he was right because everything is in transition, and that includes such mundane things as how we work, how we travel, how we shop, and how we get medical care. In the introduction to his song he wrote:

 

The other day I was in the car listening to NPR, and somebody was talking about how we’re all inhabiting liminal space right now. I don’t know who she was, and I didn’t hear much of what she had to say, but I heard enough to agree with a lot of the broad strokes.

She spoke of our current existence as being situated profoundly in between what we knew, and the settled reality of what is coming, whatever that may be. God, that’s true. She had a pretty rosy outlook about what might come. We’ll be more patient, understanding, and community minded. Maybe or maybe not. That’s where she stopped reading the moment and started postulating. It’s also where I parted ways with her analysis.

I’m not saying we won’t arrive where the commentator hoped we might. I’m saying it’s not a foregone conclusion, and without a lot of deliberate effort it isn’t necessarily the likely outcome. We have to strive for a gentler world than the one we left. There’s a cost to be paid for that. For now, we’re still in between.

 

I don’t know about you, but my life is very different than it was when I attended “town meeting” with some trepidation back on March 11 or had my last haircut on March 13. That haircut was an interesting experience. While I was sitting in the chair I made the mistake of expressing some displeasure with the president. I did not know that the woman who was cutting my hair was an avid Trump enthusiast. She angrily stepped away and asked me to leave. It was a challenging moment. I reminded her that we had a professional relationship. I was her customer. I told her that I would keep my comments to myself as she finished the job she had started. 

 

At the moment of our “standoff” neither of us knew what lay ahead. As the economy has failed under the guidance of the president that she loved, she has sued our Republican governor because he will not allow her to run her full business. As she states in her suit, 90% of her revenue comes from coloring hair, and although she can now cut hair, the governor has not allowed resumption of her main activity.  I am following the suit in the newspapers and on television, but have no plans to get my haircut at her shop or anywhere else. My grey curls are approaching my shoulders. My hair hasn’t been this long since the early seventies, and my beard has never reached its current length. If the virus miraculously goes away, I have a good shot at getting employment in December as a realistic looking Santa Claus, but things will need to change before little children can sit on Santa’s knee. When I put a bandana around my head to keep the hair out of my eyes while walking or fishing, I am a Willie Nelson look alike. 

 

The silliness of the last paragraph was meant to underline how strange these times are, and some of the strangest and most unexpected events of our new era are occurring in helathcare. Ambulatory practice anywhere, and especially hospitals plus ambulatory practices in small towns and rural America are suddenly endangered enterprises. Life wasn’t so rosey for primary care and rural hospitals before the pandemic, and now, many practices and hospitals are in a death spiral. I am on the board of a rural health care system, The Guthrie Clinic, and the board of a large academic medical group, the Boston University Medical Group, which provides professional staff for the Boston Medical Center and many of the affiliated ambulatory practices. Both will survive the pandemic. Guthrie will survive because it had a very strong financial position going into the pandemic, and is the dominant provider in a large geographical area. I took the picture in today’s header during a visit last November to a new ambulatory specialty site that the Guthrie Clinic was opening in Big Flats in Horseheads, New York which is located on I 86 near Elmira, New York. This gorgeous facility was created with the use of Lean design for quality and efficiency from a very large repurposed trucking terminal and warehouse. BUMG will survive because of its leadership and the reality of the critical nature of its mission and its ability to draw support from many sources.

 

Most ambulatory practices and rural hospitals were not as financially healthy as either of the organizations with which I have an affiliation.  Atrius Health, the ambulatory care organization that I once led, has temporarily shuttered many of its sites, and furloughed or layed off many of its employees while reducing the pay of remaining employees for an unspecified period of time. Guthrie, BUMG, Atrius, and I assume many other healthcare providers, have reduced benefits and salaries of employees that are doing more in a much more risky environment. The New Yorker published an article by a physician/ writer, Dhruv Khullar, in late June entitled “The Coronavirus Pandemic’s Wider Health-Care Crisis: COVID-19 has disrupted patient care and hospital finances—and the problems could deepen as the disease spreads.” In the articles Dr. Khullar writes:

 

The persistence of the pandemic is creating serious challenges, many of them unforeseen, for the health-care system. Even before the pandemic, many hospitals were in precarious financial condition: in 2018, the average hospital had a two-per-cent operating margin and less than two months of cash on hand; the situation was worse for rural hospitals, a fifth of which were already at risk of closing due to financial problems. Having lost billions of dollars in revenue, hospitals must now figure out how to reintroduce routine care while keeping patients safe and preparing for possible surges of covid-19. (As my colleague Atul Gawande has written, it is possible for hospitals to reopen without becoming vectors for the virus; doing so, however, requires time, resources, and personnel.) Hospitals in Massachusetts are losing $1.4 billion in revenue per month, and project total losses of five billion dollars by the end of July. The Mayo Clinic alone, which runs twenty-three hospitals nationwide, is set to lose three billion dollars this year. The American Hospital Association estimates that, altogether, U.S. hospitals are bleeding fifty billion dollars a month during the pandemic. The hundreds of thousands of doctors in independent practice have more limited capital reserves, and many may be forced to shutter their operations or merge them with others.

 

The picture would be much worse if it were not for the 175 billion dollars of support to hospitals coming from the CARES Act. Unfortunately for small practices and for rural hospitals most of the money went to our biggest institutions.  My dear old Dad used to say, “Thems that gots, gets!” An analysis done by the Kaiser Foundation shows that the relief money was distributed primarily by a methodology built on a hospital’s revenue from commercial payers prior to the pandemic. Those hospitals that serve the underserved and exist with a large share of their revenue from Medicaid or Medicare got substantially less money. This confirms my father’s bias about an essential fact of life. The Kaiser report sums it up:

 

Our analysis shows that hospitals with the highest share of private insurance revenue received a disproportionately high share of total funds. We would expect to see similar patterns for physicians and other entities that receive private insurance reimbursement. For example, community health centers that often see a relatively small share of patients with private insurance would have received less money than a private physician’s office that sees the same total patient volume but has more patients with private insurance. With HHS expected to release additional relief fund grants and Congress considering additional stimulus, this analysis demonstrates that the formula used to distribute funding has significant consequences for how funding is allocated among providers.

 

Maybe, the small hospitals and practices that serve the underserved should hire my hairdresser’s lawyer. More realistically, this November I hope that we might entrust the control of the House, Senate, and the executive branch to those who understand that beginning the long process that will improve the social determinants of health is a journey that is good for everyone in the country. It is not an issue of race.  Many of the practices that are at risk and hospitals that are likely to fail serve conservative voters in “red states.” Ironically, residents of Kentucky, the home state of Rand Paul and Mitch McConnell which voted for Trump by a margin of 63% to 33% for Clinton receive the second largest share of federal money per person. They are exceeded only by New Mexico. Of the 20 states receiving the highest government support per person, only one, New Mexico voted for Clinton. Poverty and inadequate healthcare for the poor are “red state” issues. 

 

The road ahead in these liminal times will likely be more difficult than many of us have considered. There is much hype and hope about a vaccine, but a more realistic analysis suggests that our liminal phase will last for several years. The vaccine is only the beginning of the end as Sarah Zhang points out in an Atlantic article this week entitled “A Vaccine Reality Check: So much hope is riding on a breakthrough, but a vaccine is only the beginning of the end.” Even when the virus is vanquished we face the task of rebuilding an economy that is likely to look like “Berlin after the blitz,” or like Paradise, California looked the day after the “Camp” forest fire went through it. Rebuilding the economy and our healthcare system will be a multi year processes.  Like the debate in Congress now over further relief to the economy from the pandemic, how to invest as a nation in the rebuilding process could become a battle that will further divide us. The resistance to repairing economic inequality and racial inequality will not magically disappear just because there is a change of governmental control.

 

The pandemic has demonstrated that before the pandemic we were living on luck with many serious defects that we dismissed or were incapable of fixing because of our advanced state of political polarization coupled with the tremendous momentum of the status quo. We were “living” with racial inequities, worsening economic inequity, and a healthcare system that ignored at least ten percent of the population. We were investing in high tech management of dread diseases while failing to adequately focus on the reality that all healthcare rests on the presumption of controlling serious infectious disease and other public health issues. As my playground friends once said, “We were cruising for a bruising.” In hard times, it is the least among us that takes the most significant hit and in healthcare the “least” are public health and all forms of primary care. Thinking about how to effectively vaccinate a population, provide guidance on the nutritional management of diabetes to an underserved population, or treat elderly patients for their congestive heart failure don’t seem to be activities that are nearly as sexy or financially rewarding as face transplants, total joint replacements, or gastric bypass surgeries. We are drawn to dollars and hitech flash like moths to a light bulb on a summer evening. 

 

So what are the expectations of primary care in this liminal period? It’s a big question. The answer varies widely across the country. Some things seem to be true everywhere. It will be hard for every practice, but how hard it will be will vary by the income level of the community. One reality is that telehealth is here to stay. The New Yorker published an article this week by a physician, Clifford Marks entitled “America’s Looming Primary-Care Crisis” that tries to imagine what might happen. Marks begins with a little story from the real world that may coincide with what you have witnessed.

 

Beverly Jordan is a partner at a family-medicine clinic in Enterprise, Alabama. Enterprise is situated in “wiregrass country”—a largely rural region, encompassing southeastern Alabama and parts of Georgia and Florida, named for the ubiquitous vegetation that takes root in its sandy soil. Her clinic is one of a few offering primary care in the area; like many independent medical practices across the U.S., it has been gutted by the coronavirus pandemic. Even though her practice received a lifeline from the federal government’s Paycheck Protection Program (P.P.P.), Jordan had to take a pay cut, reduce staff hours, and lay off two new physicians who were about to start work. “For the first time in my career, we’re really just planning short-term,” she told me recently. “We’ve never had this level of insecurity.”

 

Marks goes on to describe what we all took mistakenly took for granted that set us up for the pain of these liminal times:

 

For decades, health care was America’s indomitable industry. While employment in other sectors—retail, manufacturing, construction—rose and fell with the business cycle, clinics, hospitals, and medical practices steadily added jobs. But the pandemic has changed health care’s trajectory. Hospitals now find themselves in dire financial straits as they forgo revenue from elective procedures, and a surge in unemployment is shifting patients from private insurance plans to Medicaid, which is less remunerative for doctors. Some rural hospitals, whose financial footing was already tenuous, are facing the prospect of closure.

 

He goes on to tell us what we know now and should have known before:

 

Among the most vulnerable parts of the nation’s health-care system are family-medicine, internal-medicine, pediatric, and obstetrics-and-gynecology clinics. With covid-19 precautions in place, in-person appointments have dropped precipitously. In May, a survey of primary-care doctors found that nearly a fifth had temporarily closed their practices, owing to the pandemic, and two in five had laid off or furloughed staff. Primary-care clinics are tasked with keeping people healthy, and decades of research have shown that the care they provide is associated with better outcomes and lower costs. …the health consequences of these clinics’ closures could be significant. Vaccination rates for children have already begun to fall; patients are missing screenings proven to save lives; prescriptions are going unfilled. Chronic conditions could worsen; life expectancies could drop.

 

One of my main themes of the past 12 years of writing has been our impending primary care catastrophe. The pandemic has made what was already bad much worse. A few telehealth appointments will not fix things. The decline of primary care and rural hospitals, like our Internet insufficiencies, antiquated plumbing in may cities, dangerous bridges, deteriorating schools, borderline electrical grid, and worsening climate problems, are derivative of an intentional resistance to invest in the common good. We prefer to lower taxes while never expecting that we are choosing to live on the edge of multiple disasters. Limiting the scope to primary care Marks writes:

 

Even before the pandemic, primary care was in crisis. Primary-care doctors were already among the most poorly compensated physicians in the country; for medical students burdened with debt, those smaller salaries lessened the specialty’s allure. Experts have long warned of a shortage of doctors providing foundational forms of outpatient care, especially in rural areas. Last year, the Kaiser Family Foundation estimated that more than fourteen thousand primary-care physicians were needed to eliminate existing shortages.

..“This is taking us down,” Jacqueline Fincher, an internist and the president of the American College of Physicians, told me. “We’re not going to have a vaccine and herd immunity for probably a year—so, is this sustainable for a year? The reality is, it’s probably not, certainly not for most small practices.” If many of them go out of business, the consequences for Americans’ health could be profound and enduring. What’s at stake is not just a pattern of health outcomes but the shape of the health-care system as a whole.

 

That sounds like a pretty disturbing liminal analysis. We know where we are, but we are clueless about where we are going.  From no quarter do we hear a clear and total vision of what we should be building in healthcare as we “Build Back Better.” The recovery will be a “brown field” project. Perhaps the first step is to change how we finance care as we expand care to everyone within our borders. Marks gives us an overview of some of the problem that needs fixing:

 

The challenges facing primary care are rooted in the structure of the American health-care system. This system wasn’t designed at any one moment; instead, it has accreted over time, with each new layer seeking to compensate for the deficiencies of what came before. One of the most consequential layers is fee-for-service payment, which was codified as part of the Social Security Amendments of 1965—the law that created Medicare and Medicaid. In a fee-for-service setup, the payer, usually a health insurer or government agency, pays the health-care provider a set fee for any given service. …It encourages health-care providers to offer more services, in order to earn more revenue, without necessarily controlling for quality…“In a fee-for-service payment system,” Atul Gawande has written, “we are actually penalized for making the effort to organize and deliver care with the best service, quality, and efficiency we can.”

…The fee-for-service principle reverberates through the whole health-care system, but it has especially dire consequences for primary care, because it favors discrete medical episodes over ongoing and preventative treatment. 

 

Dr. Marks builds from there reviewing the unfairness and dysfunction of the RVU system for payment, and the specialty “cabal,” the “RUC,” that controls it to their advantage. These are not new issues. You can use the search function of this site to discover my previous rants about the unfairness and dysfunction of the system including RVUs and the RUC. 

 

There is much to do as we sit waiting for tomorrow in this liminal period. I will end with the words of my son’s songs which offer a little generalized perspective. Click on the title to hear the song.

 

Liminal Space

 

Home

The horizon is further than it looks

Know all of this will change

All of this is heading somewhere

Gone is the comet

Got swallowed by the dawn

Know all of us will change

All of us are headed someplace

And all the way

Our thoughts are fixed on silence

And all the way

We pray we’re being drawn somewhere

Gone all the pretense

We’ll utter what we mean

Though all the waves will crest

All trials cost us something

And all the way

Our path will follow questions

And all the way

We’ll pray we’re being drawn somewhere

 

I hope that the “somewhere” we are being drawn is toward a healthier nation with more equitable care. Wouldn’t it be nice to discover that what follows this liminal period looks a lot like the Triple Aim? That is not going to just happen. “Being drawn” toward a better place seems very passive and much less certain of becoming a reality than intentionally moving in the direction of a desired goal. It is time for us to be intentional when it comes to primary care and the stability of all of the resources that support primary care for all of us, and especially the underserved everywhere and the hospitals and practices that serve the poor in urban and rural America.