We need a “Marshall Plan” to save primary care, public health infrastructure

Tags: Marshall Plan, primary care, COVID-19, coronavirus, public health

By Christopher Crow, MD, MBA, President of Catalyst Health network and Tom Banning, CEO of Texas Academy of Family Physicians

Following the devastation of World War II, the United States enacted the Marshall Plan to rebuild a heavily damaged Europe. Our war against this novel coronavirus is far from over, but it is already wreaking havoc on the nation’s primary care workforce. Our frontline health care providers are putting themselves at risk every day without proper personal protective equipment while community-based primary care clinics are facing economic disaster.

We need a Marshall Plan for our primary care and public health infrastructure.

For years health care experts have been warning of the dire consequences of persistently underfunding primary care and public health at the federal, state, and local levels. COVID-19 has vividly exposed gaping cracks in our siloed, fractured, and disconnected health care system. While it might be easy to point fingers and assign blame, this crisis is the result of system design failure.

Our medical supply chain has failed us. Our medical supply delivery distribution system has failed us. Our fee-for-service payment system has failed us, and our finance model -- health insurance, which leaves millions without coverage -- has failed us. The consolidation that has occurred in various segments of our health care market has only compounded the felony and exacerbated these system failures.

Our independent, community-based primary care physicians constitute the foundation of our health care system, a foundation that has been neglected and deteriorating for years. We now depend on them to serve on the front lines of the battle against COVID-19. But these practices are no different from other small businesses, and they are not immune to this sudden economic downturn. Many practices report visits are down 50% to 75% as patients stay at home, paralyzing revenue streams and hampering practices’ ability to make payroll, pay bills, and keep the lights on. These practices operate on a tight margin and often have only two to four weeks of cash reserves on hand.

Unlike other small employers, though, these independent practices can’t simply close up shop. People will continue to get sick. Patients with chronic disease still need ongoing care, and many more will seek mental health counseling as a result of isolation, job loss, and financial insecurities than ever before. We cannot afford to lose our primary care workforce.

We need action now. The first and most critical step in our Marshall Plan is to immediately change the way we pay for primary care, from transactional fee-for-service to prospective payment. This means health insurance companies, Medicare, Medicaid and all other payers would pay primary care providers a fixed monthly fee for a broad range of services rather than paying a claim for each service. To determine the amount of the monthly fee, payers could examine what they paid for primary care in the last year and then pay their primary care providers at a commensurate monthly rate for the coming year. Or it could be based on a percent of the premium cost.

It’s not a crazy idea. This is exactly how we pay providers in Medicare Advantage today and The Centers for Medicare & Medicaid Services has been testing this through other pilot projects. Under this payment model, patients could access primary care whenever they need it without racking up extra out-of-pocket costs. Primary care physicians would be released from the burden of mountains of paperwork and administrative hassles that keep them from spending more time with their patients. And in times of crisis like this, it would provide a predictable and manageable expense item for payers and a dependable income for primary care practices. Prospective payment is the future for primary care. Why not move forward with it now?

Next we need to implement regulatory and payment changes to accelerate the adoption and use of telemedicine. Patients want the convenience of telemedicine and when used appropriately, it boosts efficiency and productivity for medical clinics.

All public and private health insurance benefit packages should incorporate and financially facilitate innovative strategies that promote greater use of primary care physicians and their care teams in an effort to promote high-quality, efficient care and to assist patients in navigating an increasingly complex health care system.  This approach to benefit design will not only enhance the patient-physician relationship, but it will achieve better health and lower costs.

Our plan also includes a robust a national effort to procure and stockpile necessary items like personal protective equipment to prepare for future public health crises. If we’ve learned anything from COVID-19, it’s that our public health system was woefully unprepared for a pandemic of this magnitude. We can’t let that happen again.

Finally, we need to expand and tailor our primary care workforce by producing more primary care and public health workers, and by implementing strategies to encourage their appropriate geographic distribution. We could forgive medical school tuition for graduates who choose primary care specialties and provide further loan forgiveness for those who practice in underserved communities. We can also increase graduate medical education funding for primary care residency positions to incentivize academic institutions to invest more in those programs.

The Marshall Plan was initiated three years after the end of World War II. With the current crisis threatening our frontline primary care physicians, we don’t have the luxury of waiting that long. We need our federal, state and local elected officials, as well as business leaders and insurance company executives, working on this now, even as we continue the fight to contain this pandemic.

We have an unprecedented opportunity to redesign our health care system so that it truly serves Americans and the professionals who care for them. We must save our frontline primary care and public health professionals and in so doing, set the foundation for a better way of delivering and paying for care.

If we ignore the primary care workforce crisis unfolding before us, the long-term consequences to our health care system will be dire.

For more on the Marshall Plan for Primary Care and Public Health, go to https://healthrosetta.org/marshall-plan/.


  • Gregory Fuller MD said Reply

    Please QUIT using the term provider. I'm a physician not a provider.

  • 9005675 said Reply

    How do we determine how much a month will cover a broad range of services? Overall this is an excellent article but we need it to be implemented. I believe we should start at the local and state level and then push it to the federal level.

  • Zohra Siddiqi said Reply

    Need Grants and not loans
    We don’t need debts

  • Michael Kirkpatrick said Reply

    I agree 100%. This is a system that needs radical change, which will be very difficult do you to the specialty hierarchies.

  • J. Robert Parkey, MD MTS HMDC CMD said Reply

    Sign me the heck up! I’m a solo FP who is mostly doing geriatric and palliative med these days. I don’t bill for follow up visits most of the time because I know my folks can’t afford it on a fixed income... Just give all of us the flexibility to take care of people the right way and we will show you even better outcomes and fewer hospitalizations!

  • Ashok Tripathy MD said Reply

    Agree that we need more primary care providers, increase residency slots in primary care and better pay assurance than currently offered

  • J J Carr MD said Reply

    Hell no. I will not give up liberty for security. This sounds like communism. No thanks.

  • Christopher Opella MD said Reply

    I agree with this 100%. I also agree we are not providers we are physicians. we need to take back health care and stop letting a third-party payer system dictate the quality of care in this country. It's about time our representing organization is addressing this problem.

  • David Walters MD said Reply

    If the Government doesn’t support “me “ better I will retire.

  • Chris S Ewin MD said Reply

    Agree with Greg Fuller. We are physicians. What is unfortunate is how they have changed the HSA Bill due to political reasons in my opinion.
    The original amendment was introduced in the family in retirement health investment active 2008 by Senator Orrin Hatch.
    It states

    (a) In General- Subsection (d) of section 213 of the Internal Revenue Code of 1986 (relating to medical, dental, etc., expenses) is amended by adding at the end the following new paragraph:
    `(14) PRE-PAID PHYSICIAN FEES- The term ‘medical care’ shall include amounts paid by patients to their primary physician in advance for the right to receive medical services on an as-needed basis.’.
    (b) Effective Date- The amendment made by this section shall apply to taxable years beginning after the date of the enactment of this Act.

    It took Roy Ramthun and I a long time crafting it with the advice of others. Note that this was a physician problem, not a provider problem. Also note that we were advised not to set a price on what our services are worth. Initially I was toying around with $1500 a year, but it makes it complicated.
    It irks me that the present Bill covers only $150 a month.
    It tells us that our services are worth $3 a day, or less if you want to charge that.. So why quit smoking at $7 a day.
    It would be rather hard for a physician in New York City to try and live off of $60,000 a month in revenue taking care of 400 patients.

  • Chris S Ewin said Reply

    The Family and Retirement Health Investment Act of 2008....

    Dr. Crow and Tom are correct...
    It is a fee for service PRIMARY CARE systems problem.

  • Chris S Ewin said Reply

    In terms of attracting primary care physicians, medical students on day 1 should be given a lecture about the rewards of direct primary care as family physicians and internists.
    They need to see the light at the end of the tunnel and the rewards of primary care, including the freedom of third parties and yes–financial freedom as well.
    IMO, that is how we attract our brightest minds into the practice of primary care.

  • Primary Care Physicians New Braunfels said Reply

    Agreed. Couldn't emphasize more the importance of implementing changes on our healthcare system especially now in this time of health crisis.

    <a href="https://healthtexas.org/our-providers/jose-ortiz/">Primary Care Physicians New Braunfels</a>

  • Rebecca Berens said Reply

    Direct primary care is already doing this. Were any DPC physicians involved in the creation of this plan? If we let payers get involved, we will be right back where we started. We need to have insurance companies start acting like insurance companies, cover the big stuff (without ridiculous networks) and stay out of primary care. This will increase access and reduce costs.

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