Report from the Frontlines of US Primary Care on the Impact of Recent Federal Policy Changes

Primary care clinicians are the bellwether for the state of health care and health in the United States. One month after President Trump’s inauguration, we administered a rapid response survey to a diverse national sample of primary care clinicians.

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The General Public Vastly Overestimates Primary Care Spending in the United States

New study finds public perceptions of primary care spend is ten times greater than what is actually spent, highlighting the need for increased engagement of the public to support policies that affirm the foundational role of primary care in the US health care system.

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Why Clinicians Are Using More Gabapentin in Nursing Homes

April 11, 2024

Jonathan D. Winter MD,^a,b J. William Kerns MD,^a,b Danya M. Qato PharmD, MPH, PhD,^c Katherine M. Winter CFNP,^d Nicole Brandt PharmD, MBA,^c Linda Simoni-Wastila BSPharm, MSPH, PhD,^c Christopher Winter,^a Alex H. Krist MD MPH,^a Sarah Reves FNP-C,^a,e Rebecca Etz PhD.^a,e

Gabapentin is approved by the FDA for certain types of seizures and for the nerve pain caused by shingles. Curiously, its use in US nursing homes (NHs) has doubled in the last 10 years. Further, while common pain medications, as well as mood and anxiety drugs, are monitored by the Centers for Medicare and Medicaid Services (CMS), gabapentin use is not monitored.

Our investigators sought to clarify clinical reasons for gabapentin use and the factors spurring its prescribing gains in NHs by surveying US NH clinicians.

Results: 131 surveys were completed. Participants were 71% White, 52% female. Most had advanced training as well as over five years’ NH experience, and worked in for-profit facilities. Almost all NH gabapentin use was not for seizures or shingles pain. Most gabapentin prescribing was reported to be for other types of pain, including diabetic nerve pain, but it was also used for psychiatric symptoms like anxiety and patient behaviors like agitation. Indeed, gabapentin’s increased use was stated to be related to efforts by CMS and others to reduce NH prescriptions of monitored drugs, including pain medications, antipsychotics, and medications for anxiety. Clinicians stated that gabapentin may be a safer alternative to those medications. They also stated that NH gabapentin prescribing was related to the increasing frequency of residents coming to facilities already on gabapentin, and to the frequent lack of non- medication alternatives to manage resident behaviors.

Conclusions: Use of gabapentin for reasons not approved by the FDA, especially for all types of pain, is a key driver of NH gabapentin increases, and it is closely tied to CMS reduction policies in monitored pain medications, a finding substantiated in other studies. These results, however, showcase the impact of NH gabapentin prescribing for psychiatric symptoms, as well as motivations clinicians have to use it due to efforts to curtail antipsychotic, anxiolytic, and other psychotropic medications. Prescribers avow that gabapentin is at least as effective, and likely safer, than the medications it commonly replaces; but this assumption may not be accurate. Further work in this regard remains to be done.

a. Virginia Commonwealth University School of Medicine, Department of Family Medicine and Population Health, Richmond, Virginia. b. Shenandoah Valley Family Practice Residency, Front Royal, Virginia. c. University of Maryland School of Pharmacy; Peter Lamy Center on Drug Therapy and Aging, Baltimore, Maryland. d. Shenandoah University School of Nursing, Winchester, Virginia. e. Larry A. Green Center, Richmond, Virginia.

Management of Dementia Related Behaviors During COVID: Third Virginia Nursing Home Clinician Survey, June 2022

J. William Kerns, MD; Jonathan D. Winter, MD: Rebecca S. Etz, PhD; C. Christian Bergman, MD: Sarah Reves, FNP-C

This survey purposefully focused on current, June 2022, pandemic nursing home care of patients with dementia. Particularly concerning for this later stage of the pandemic, are that of the Virginia nursing home clinicians responding:

1)     Ninety-three percent reported that their facilities expect them to deliver the same level of care no matter what staffing is available to support that care,

2)     Only twenty-one percent stated that their facility offered supports for clinician stress and burnout, and

3)     Twenty-five percent recounted that they felt legally exposed because of their facility’s actions.

Compared to the other surveys:

1)     Vaccinations are not currently affirmed as helping dementia management as much, and

2)     Antidepressants and other medications are still used more often than pre-pandemic for management of dementia symptoms.

There were mixed responses to less PPE:

1)     Most stated that patients not wearing masks assisted dementia care, but others also noted that not wearing masks carried risks for infection/reinfection, and

2)     Responses were varied as to whether less glove wearing, directly touching patients, was beneficial for patient care.

These are preliminary findings from a June 2022 survey of Virginia nursing home clinicians funded by the Virginia Center on Aging, ARDRAF 22-2. Below please find a summary followed by a brief commentary.

PRELIMINARY QUANTITATIVE FINDINGS among respondents (n=28)

Reported helpful for dementia management during the pandemic:

·       71.4% Safe family/volunteer visits

·       28.6% Vaccinations

·       71.4% Residents socializing more with other residents

·       10.7% Technology enabled visits

Clinician Stressors:

·       92.9% reported ‘our facility expects us to provide the same level of care regardless of changes in staff’ in 2022

·       21.4% reported current support for clinicians to assist with pandemic stress and burnout

Contemporaneous use of medications for dementia behavioral symptoms in June 2022 compared to pre-pandemic:

·       14.3% reported increase in use of second-generation antipsychotics

·       53.6% reported increase in use of antidepressants

·       21.4% reported increase in use of sedating antidepressants

·       7.1% reported increase in use of mood stabilizers

Selected quotes from respondents who volunteered additional information: (n=14)

·       Facility staff burnout is taking a toll on providers who are trying to continue to provide good care

·       The feeling 'exposed' is particularly strong at this time.  Many of the new hires had no meaningful 'hands-on' training during their LPN training, and the trainers (4 LPNs) are not that senior or experienced.  Rehab practices have also changed and probably providing less intense therapy.

·       We as private practice physicians are being excluded from NH care

·       We encourage and give residents mask

·       Overall, the benefits are greater for this population than continued masking

·       Community exposure makes the covid rates go up

Commentary:

URGENT ACTION NEEDED

It is urgent that policy makers put procedures in place to support patient care by supporting clinicians, staff, and facilities in practical ways delineated by multiple published studies and editorials of how to improve nursing home care during the pandemic. Unfortunately, to date additional resources have not been forthcoming.

Wave after wave of Omicron sub-variants continues to stress Virginia nursing homes, and dementia management in particular. Risky drug use for dementia symptoms remains significantly increased.

Distressing for responding clinicians is the continued lack of physical, administrative, and emotional support offered by nursing facilities. Almost all facilities are said to expect the same level of care whether or not the facility has adequate nursing and other staff, and a quarter of clinicians responded that they feel legally exposed by their facility.

The findings above are from an ongoing study lead by Drs. Kerns and Winter to evaluate the impact of the pandemic on nursing home dementia care and outcomes. They hypothesized that the intense strain and pressure of the pandemic has functioned as a stress test on Commonwealth nursing facilities, unmasking and exacerbating existing dysfunctional processes and gaps in care. Since the start of the pandemic, they have described an increase in all dementia related behavioral symptoms along with functional losses that are likely to be irreversible

For the last decade, Drs J. William Kerns and Jonathan Winter, faculty at the VCU-Shenandoah Family Practice Residency in Front Royal Virginia, with the assistance of the VCU Department of Family Medicine and Population Health, have been investigating issues surrounding the use of risky psychiatric medications in nursing homes. Intriguing findings of their work include the description of significant barriers to the use of non-pharmacologic alternatives to medications that do not exist for drugs. They believe that optimal dementia care will not occur until non-pharmacologic therapies for dementia symptoms are as available, affordable, and accessible as drugs.

Management of Dementia Related Behaviors During COVID: Second Virginia Nursing Home Clinician Survey, March 2022

J. William Kerns, MD; Jonathan D. Winter, MD: Rebecca S. Etz, PhD; C. Christian Bergman, MD: Sarah Reves, FNP-C

Management of Dementia Related Behaviors During COVID: Second Virginia Nursing Home Clinician Survey, March 2022

J. William Kerns, MD; Jonathan D. Winter, MD: Rebecca S. Etz, PhD; C. Christian Bergman, MD: Sarah Reves, FNP-C

Thought-provoking trends from the second Virginia nursing home clinician survey included that rural clinicians reported increases in use of antipsychotics and sedating antidepressants more often than their urban and suburban colleagues (p=0.053 for both). Eighty-five percent of respondents stated that the lack of family and volunteers, as well as staffing changes, made dementia management more difficult. Of concern, only 19% of clinicians stated that their facilities offered support for their pandemic related stress, and only 12% reported reduced administrative burdens to help with the challenges of nursing home dementia care.

These are preliminary findings from a March 2022 survey of Virginia nursing home clinicians funded by the Virginia Center on Aging, ARDRAF 22-2. Below please find a summary followed by a brief commentary.

PRELIMINARY QUANTITATIVE FINDINGS among respondents (n=42)

For dementia behavioral symptoms:

·       26% (11/42) reported an increase in use of second generation antipsychotics

o   44% Rural (8/18)

o   12.5% Urban/suburban (3/24)

o   P=0.53

·       50% (21) reported an increase in use of antidepressants

o   50% Rural (9/18)

o   50% Urban/suburban (12/24)

·       28.6% (12) reported an increase in use of sedating antidepressants

o   44% Rural (8/18)

o   16.7% Urban/suburban (4/24)

o   P=0.53

·       14.3% (6) reported an increase in use of mood stabilizers

No significant differences in reported medication use between:

·       Geriatric and psychiatric subspecialists and clinicians without subspecialty

·       Facilities with low versus higher percentages of minority residents

*However, there may not have been enough respondents to show such differences.

Reported helpful for dementia management during the pandemic:

·       81% (34/42) Safe family/volunteer visits

·       71.4% (30/42) Vaccinating staff

·       71.4% (30/42) Residents socializing more with other residents

·       69.0% (29/42) Vaccinating residents

·       4.8% (2/42) None of the above

Other significant findings:

·       85.6% (36/42) reported periodic staff absences made dementia management more difficult

·       85.6% (36/42) reported family/volunteer absences made dementia management more difficult

·       19.0% (8/42) reported support for clinicians to assist with pandemic stress and burnout

·       11.9% (5/42) reported pandemic easing of administrative tasks to lessen work/stress for clinicians

Selected quotes from respondents who volunteered additional information: (n=17)

·       The pandemic created so many challenges that facilities struggled to manage, and in some cases left direct care staff on their own to "figure it out" while working under directive that pandemic could not have any impact on ability to provide care.

·       Poor management response to LTC staff stress

·       The way the residents were cut off from their families and isolated was in humane (sic). I have had more residents die from heartbreak or worsen clinically from such then any pandemic related illness. Their fear of our masked faces, again heartbreaking

·       Worsened staffing, especially those skilled in managing residents with dementia.

·       Observed global declines in patients with dementia not associated with personal COVID infection during isolation due to COVID facility outbreaks, also associated with weight loss, loss of ADL ability, and skin breakdown. Also a corresponding increase in hospice referrals.

·       Other residents (w/o dementia) were also negatively impacted by the increased symptoms of residents with dementia. Calling out/yelling while residents were confined to their rooms was a big problem.

To contribute your experience to this important work, the link to the most recent survey version is available here: Click Here for Survey!

Commentary

The findings above are from an ongoing study led by Drs. Kerns and Winter to evaluate the impact of the pandemic on nursing home dementia care and outcomes. They hypothesized that the intense strain and pressure of the pandemic have functioned as a stress test on Commonwealth nursing facilities, unmasking and exacerbating existing dysfunctional processes and gaps in care. Since the start of the pandemic, they have described an increase in all dementia related behavioral symptoms along with functional losses that are likely to be irreversible.

Decreased availability of employed and voluntary staffing, as well as family and community supports, has decreased the availability of all non-drug interventions for dementia. Conversely, the use of risky drugs for dementia symptoms has dramatically increased. Ominously, there appears to be an increasing separation of the ‘have’s and the have-nots,’ with the greatest negative pandemic impacts noted for resource-poor facilities in vulnerable communities, notably rural, with lower social determinants of health. On the other hand, this crisis has not been without its victories. Beyond the personal heroism of staff, families, and residents, pandemic stressors have forced innovation in the treatment of dementia symptoms with increased resident involvement in each other’s care, creative engagement strategies that are consistent with social-distancing protocols, and an increased reliance on family and community resources.

Alarming for clinicians as well as staff is the lack of physical, administrative, and emotional support offered by nursing facilities. As noted above, some facilities ‘…left direct care staff on their own to "figure it out" while working under directive that pandemic could not have any impact on ability to provide care.’ Many have published advice regarding steps to mitigate pandemics and similar crises in the future. Policy makers need to put procedures in place to support patient care by supporting clinicians, staff, and facilities in practical ways delineated by this and similar studies.

For the last decade, Drs. J. William Kerns and Jonathan Winter, faculty at the VCU-Shenandoah Family Practice Residency in Front Royal Virginia, with the assistance of the VCU Department of Family Medicine and Population Health, have been investigating issues surrounding the use of risky psychiatric medications in nursing homes. Intriguing findings of their work include the description of significant barriers to the use of non-pharmacologic alternatives to medications that do not exist for drugs. They believe that optimal dementia care will not occur until non-pharmacologic therapies for dementia symptoms are as available, affordable, and accessible as drugs.

Management of Dementia Related Behaviors During COVID: a Virginia Nursing Home Clinician Survey, November 2021

J. William Kerns, MD; Jonathan D. Winter, MD: Rebecca S. Etz, PhD; C. Christian Bergman, MD: Sarah Reves, FNP-C

New study finds that behavioral symptoms related to dementia sharply increased during the pandemic, along with an increase in the use of common medications and reduced use of non-medication management, possibly due to lost staffing and volunteer time. These are preliminary findings from a survey of Virginia nursing home clinicians funded by the Virginia Center on Aging, ARDRAF 22-2.

Below please find a summary of preliminary findings followed by a brief commentary.

PRELIMINARY QUANTITATIVE FINDINGS among respondents (n=23)

74% reported an increase in dementia symptoms, and when asked about the specific behavioral symptoms listed below they marked an increase in the following:

·       Depression 78%

·       Anxiety 78%

·       Apathy 65%

·       Irritability/aggression/disinhibition 65%

·       Delusions/hallucinations 39%

·       Mania 17%

Decreases in use of non-drug dementia management were seen, and said to be due to

·       Decreased availability of family and volunteers 43%

·       Changes in staffing 35%

Participants reported increases in use of the following medications for dementia symptoms:

·       Antidepressants 43%

·       Second generation antipsychotics 26%

·       Mood stabilizer 13%

·       Sedating antidepressants 13%

·       Benzodiazepines 9%

·       Other anxiety meds 9%

·       First generation antipsychotics 4%

PRELIMINARY QUALITATIVE FINDINGS among respondents (n=19)

Categorical findings among open text comments are found below. Each is reported as a percentage of total comments submitted, along with examples of how these were evidenced in the data:

·       Isolation from family, staff, other residents resulted in worsening outcomes (56%)

o   “When we finally opened back up it was tough. Many of the residents had no recognition of the person who was visiting them.”

o   “Some of the patients have lost ground without socialization, and will not regain.”

·       Increased dementia management was needed even as fewer resources were available (33%)

o   “Increased need for non-med management but decreased resources.”

o   “Management has mostly stayed the same, but far more patients are symptomatic.”

·       Success adaptations for dementia management were noted by 17% of respondents

o   “creativity to engage residents on a one to one level and social distancing socialization” (17% of respondents)

Respondent characteristics:

·       52% rural, 35% suburban, 13% urban

·       56% female

·       74% physician

·       35% geriatric specialists

·       52% with >20 years of experience; 8% with <5years

Nursing Home resident ethnic makeup:

·       <10% ethnic/minority 42%

·       10-49% Ethnic minority 46%

·       >49%ethnic minority 8%

·       Not sure 4%

The findings above are from an ongoing study lead by Drs. Kerns and Winter to evaluate the impact of the pandemic on nursing home dementia care and outcomes. They hypothesized that the intense strain and pressure of the pandemic has functioned as a stress test on Commonwealth nursing facilities, unmasking and exaggerating existing dysfunctional processes and gaps in care. Since the start of the pandemic, they have described an increase in all dementia related behavioral symptoms along with functional losses that are likely to be irreversible. Decreased availability of employed and voluntary staffing as well as family and community supports has decreased the availability of all non-drug interventions for dementia.  Conversely, the use of risky drugs for dementia symptoms has dramatically increased. Ominously, there appears to be an increasing separation of the ‘have’s and the have-nots,’ with the greatest negative pandemic impacts noted for resource-poor facilities in vulnerable communities, both rural and inner city, with lower social determinants of health. On the other hand, this crisis has not been without its victories. Beyond the personal heroism of staff, families, and residents, pandemic stressors have forced innovation in the treatment of dementia symptoms with increased resident involvement in each other’s care, creative engagement strategies that are consistent with social-distancing protocols, and an increased reliance on family and community resources. Drs Kerns and Winter have been distributing an online survey for ongoing nursing home provider feedback and insight.

For the last decade, Drs J. William Kerns and Jonathan Winter, faculty at the VCU-Shenandoah Family Practice Residency in Front Royal Virginia, with the assistance of the VCU Department of Family Medicine and Population Health, have been investigating issues surrounding the use of risky psychiatric medications in nursing homes. Intriguing findings of their work include the description of significant barriers to the use of non-pharmacologic alternatives to medications that do not exist for drugs. They believe that optimal dementia care will not occur until non-pharmacologic therapies for dementia symptoms are as available, affordable, and accessible as drugs.

A Resilient Primary Care Supported Patients During Summer Surge of COVID

WASHINGTON, October 11, 2021—Recently released data from a survey of primary care clinicians in mid-August by the Larry A. Green Center, in collaboration with the Primary Care Collaborative (PCC), shows that primary care remains resilient against increased demands, although the workforce is confronting myriad challenges. Responding clinicians reported that the needs of patients exceeded pre-pandemic levels, and for nearly two-thirds of clinicians (64%), telemedicine was a key way to maintain patients’ access to care.

Although primary care has continued to rely highly on telemedicine, the survey also showed that clinicians have concerns about its continued high use. If pre-pandemic payment regulations are restored, 41% of clinicians worry their practice will no longer be able to support telemedicine. The potential loss of this adaptive tool would be another challenge for a workforce in which more than half report mental exhaustion is a constant worry as both COVID-19 and patients’ needs surged during the summer.

Clinicians also cited growing pressures of providing care during the summer surge. More than 7 in 10 (71%) said patient visits were more complex and took more time, 54% said they were unable to hire staff for open positions in their practice, and 45% said they personally knew primary care clinicians who had retired early or left practice because of the pandemic.

On the COVID-19 vaccine front, 52% of clinicians said two to three conversations were needed to change the mind of vaccine-hesitant patients, and each conversation took several minutes. In addition, more than two-thirds (67%) said that for most of their vaccine-hesitant patients, it’s a gut or political opinion that cannot be changed.

“With no cash infusion and without regard to future payment concerns, primary care tended to the health needs of the nation during the pandemic and continues to do so,” said Rebecca Etz, PhD, co-director of The Larry A. Green
Center. “Despite poor resources, a shrinking workforce and the growing complexity of health burdens of patients, primary care expanded its services to provide the safety net so many were lacking. When will this nation – and its leaders – wake up to the fact that primary care is key to getting us out of this prolonged pandemic?”

Clinicians revealed moderate successes in administering COVID vaccines. Nearly 6 in 10 (59%) said they had patients who were asking for a third vaccine shot/booster, about one in three (34%) said they had found more patients requesting the vaccine because of fear of the delta variant, and more than half (51%) said their practice had received an adequate supply of vaccines for their patients. However, less than a third (31%) said vaccinating patients was common in their practice – part of routine care.

“We are calling upon public and private payers to step up to help meet patients’ needs and safeguard the primary care workforce,” said Ann Greiner, PCC’s President and CEO. “Left with the most difficult-to-vaccinate portion of the population, primary care clinicians must be adequately supported for the multiple conversations that are needed to

counter vaccine hesitancy and help meet our country’s vaccine goals.”

Since March 2020, the Larry A. Green Center and the PCC have collected and disseminated data from 30 surveys of primary care clinicians on their abilities and attitudes in responding to the COVID-19 pandemic.

The survey was conducted August 13-17, 2021. Responses came from 1,263 clinicians in 49 states, Washington, D.C., and two territories. Specialties: 72% family medicine, 13% internal medicine, 5% pediatrics, 3% geriatrics, 7% other. Type: 69% MDs, 8% DOs, 13% NPs, 3% PAs, 7% other. Settings: 26% community health centers or similar, 23% rural, 18% residencies. Practice size: 26% had 1-3 clinicians, 43% had more than 10 clinicians. Ownership: 26% self-owned, 43% system-owned, 6% government-owned, 3% membership-based.

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Larry A. Green Center: www.green-center.org

About the Primary Care Collaborative:

Founded in 2006, the Primary Care Collaborative (PCC) is a nonprofit multi-stakeholder membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home. Representing a broad group of public and private organizations, PCC’s mission is to unify and engage diverse stakeholders in promoting policies and sharing best practices that support growth of high-performing primary care and achieve the “Quadruple Aim”: better care, better health, lower costs, and greater joy for clinicians and staff in delivery of care.

About The Green Center:

The Larry A. Green Center for the Advancement of Primary Health Care for the Public Good is a research group founded by Rebecca Etz, PhD at Virginia Commonwealth University and Kurt Stange, MD, PhD at Case Western Reserve University. The Green Center works to reclaim and reconstitute the intellectual foundations of primary care, to advance the science

of medicine learned and practiced within layered and competing social frameworks of meaning, and to deliver on a now 50 year old promise: better health and improved health care through a synergistic focus on both humanism and healing. We are nimble, inquisitive, curious, and open. We make personal doctoring and innovation visible.

About 3rd Conversation:

3rd Conversation is a national initiative reimagining the future of health care by reinventing the clinician-patient relationship for the modern era. Powered by X4 Health, 3rd Conversation works at both the local and national levels to address health professional burnout, improve patient experience and realize the promise of humanity and connection in our health care system. Funding support is provided by the Morris-Singer Foundation and the New York State Health Foundation.

White House Virtual Conversation

Health Systems, Providers, and the COVID-19 Vaccinations Effort

Dear Health System Leaders and Providers, 

On behalf of the White House COVID-19 Response Team, I am pleased to invite you to a White House Virtual Conversation on Health Systems, Providers, and the COVID-19 Vaccinations Effort. The event is on Wednesday, August 18, 2021, from 12:00 – 1:00 PM ET. 

The event will focus on the significant progress that has been made in activating providers in the vaccinations effort, as well as a number of best practices health systems and providers have committed to in order to further increase vaccine confidence and uptake. These include, for example, offering vaccinations at Emergency Departments, upon discharge from hospitals, and at all primary care offices in a health system; partnering with community and faith-based organizations to host pop-up clinics and educate communities about the vaccine; and proactively reaching out to unvaccinated patients about getting vaccinated. 

During the event, attendees will hear from health system leaders and providers on these and other best practices they are implementing to increase shots in arms, and to do so equitably. The event will also be an opportunity to thank health systems and providers for their continued service to their patients, state, and country throughout the COVID-19 response and vaccine rollout. 

Please see information for how to view the event below. We look forward to seeing you there. 

Thank you, 

Bechara Choucair, MD; Vaccinations Coordinator, White House COVID-19 Response Team 

**** 

Date: Wednesday, August 18, 2021

Watch Recording

A recording will also be available at this link after the event. 

Primary Care Stepping Up Involvement In COVID Vaccination Effort, But Future Of Primary Care Is Uncertain

4 in 10 Clinicians Worry That Primary Care Will Be Gone in 5 Years

WASHINGTON, August 2, 2021 — As the country experiences COVID surges again and struggles to reach the Biden administration’s vaccination goals, new data released today by the Larry A. Green Center, in collaboration with the Primary Care Collaborative (PCC) and 3rd Conversation, shows that primary care is playing a deeper role in vaccination efforts. And as new strategies are tried to convince significant numbers of unvaccinated Americans to get the shot, the importance of primary care using their trusted relationships with the public to provide outreach and education regarding the vaccine is becoming clearer, with President Biden and his administration stressing primary care’s role.

In a survey conducted July 9-13, 2021, more than half (52%) of practices reported receiving enough or more than enough vaccines for their patients, and 31% are partnering with local organizations or government to prioritize people for vaccination.

While the supply of vaccines is now flowing to primary care, clinicians are sometimes finding that getting shots in patients’ arms is challenging. More than half of the survey’s respondents – 53% – note that hesitancy among unvaccinated patients is high and hard to counter.

The survey also asked clinicians about their stress levels. Primary care practices have seen an easing of stress recently after the intense surges of COVID cases in 2020 and early 2021. A large majority of respondents – 76% – rank the strain on their practice from COVID-19-related changes and pressures on the low or moderate end of the scale (1, 2 or 3 on a 5-point scale). However, more than 1 in 3 (36%) say they are constantly lethargic, find it hard to find joy in anything, and/or struggle at times to maintain clear thinking.

The fatigue reflected in the survey data shows potential threats to the primary care workforce or the existence of the sector itself. 40% of respondents say they worry that primary care will be gone in five years, and 21% say they expect to leave primary care within three years.

“The administration has now recognized the key role primary care is able to play in reaching vaccination goals,” said Rebecca Etz, PhD, co-director of The Larry A. Green Center. “While the pressure is now on primary care to convert the most vaccine-hesitant, little has been done to support primary care to date. Policymakers need to bear witness to the quiet heroism of primary care – a workforce that suffered five times more COVID-related deaths than any other medical discipline.”

“As the federal government updates guidance to keep COVID-19 at bay, it also needs to implement strategies to support primary care, which is a vital ally in the vaccination effort,” said Ann Greiner, PCC’s President and CEO.

“Primary care is the front door to the healthcare system for most Americans, and the door is coming off its hinges,“ said Christine Bechtel, co-founder of 3rd Conversation, a community of patients and clinicians. “The fact that 40% of clinicians are worried about the future of primary care is of deep concern, and it’s time for new public policies that value primary care for the common good that it is. Policymakers need look no further than the recent National Academies of Sciences, Engineering, and Medicine report on primary care, which provides a road map to primary care’s future,” she said.

Since March 2020, the Larry A. Green Center, the PCC and 3rd Conversation have collected and disseminated data from Larry A. Green Center: www.green-center.org 29 surveys of primary care clinicians on their abilities and attitudes in responding to the COVID-19 pandemic.

Responses to the latest survey came from 702 respondents from 46 states and 3 territories. Specialization: 69% family medicine; 6% pediatrics; 14% internal medicine; 4% geriatrics; 7% other. Clinician type: 71% MD; 6% DO; 14% NP; 3% PA; 6% other. Settings: 22% community health centers or similar; 20% rural. Practice size: 29% had 1-3 clinicians; 44% had 10 or more clinicians. Ownership: 30% self-owned; 39% system-owned, 6% government; 5% membership-based.

###

About the Primary Care Collaborative:

Founded in 2006, the Primary Care Collaborative (PCC) is a nonprofit multi-stakeholder membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home. Representing a broad group of public and private organizations, PCC’s mission is to unify and engage diverse stakeholders in promoting policies and sharing best practices that support growth of high-performing primary care and achieve the “Quadruple Aim”: better care, better health, lower costs, and greater joy for clinicians and staff in delivery of care.

About The Green Center:

The Larry A. Green Center for the Advancement of Primary Health Care for the Public Good is a research group founded by Rebecca Etz, PhD at Virginia Commonwealth University and Kurt Stange, MD, PhD at Case Western Reserve University. The Green Center works to reclaim and reconstitute the intellectual foundations of primary care, to advance the science of medicine learned and practiced within layered and competing social frameworks of meaning, and to deliver on a now 50 year old promise: better health and improved health care through a synergistic focus on both humanism and healing. We are nimble, inquisitive, curious, and open. We make personal doctoring and innovation visible.

About 3rd Conversation:

3rd Conversation is a national initiative reimagining the future of health care by reinventing the clinician-patient relationship for the modern era. Powered by X4 Health, 3rd Conversation works at both the local and national levels to address health professional burnout, improve patient experience and realize the promise of humanity and connection in our health care system. Funding support is provided by the Morris-Singer Foundation and the New York State Health Foundation.

Primary Care Administering More Vaccines as Mass Immunizations Accelerate

WASHINGTON, April 22, 2021 — As more COVID-19 vaccines become available to Americans, new data released today by the Larry A. Green Center, in collaboration with the Primary Care Collaborative (PCC) and 3rd Conversation, shows that primary care is administering more vaccines, but this “front door” of the healthcare system can do more. In a survey conducted April 9-13, 2021, 38% of primary care clinicians reported that their practice is administering vaccines and they are increasingly partnering with public health (42%) and local organizations or government to prioritize people for vaccination.

While many leaders are expressing optimism about ending the pandemic through vaccinations and the Biden administration is turning to primary care to help target the most hard to reach populations, 7 in 10 primary care clinicians reported in the survey that mental exhaustion, both personally and in their practice, has reached all-time highs. Nearly 2 in 5 clinicians reported needing mental health support as a result of the pandemic.

“Primary care never hit the pause button. Without funding and without inclusion in pandemic-relief planning, primary care has extended hours and services, deferred salaries and waived co-pays in order to meet the health needs of the population, and yet we have failed to have its back,” said Rebecca Etz, PhD, co-director of The Larry A. Green Center. “How much data must we collect on its vulnerabilities, and how long before policymakers provide them with the support they’ve earned and deserve?”  

The survey data shows that primary care continues to perform beyond its available resources. Clinicians reported an increase of over 200% in health screening activities since May 2020, for example, even though significant percentages of practices have clinician positions they cannot fill (27%) and have seen COVID-19 cases increase in their community (39%).

“Primary care is now a key means for getting shots in Americans’ arms, just as practices are facing pent-up patient demand for care and worsening mental health and social vulnerabilities,” said Ann Greiner, president and CEO of PCC. “Public and private payers should continue providing relief from administrative burdens enacted under the public health emergency and dramatically increase fiscal relief for primary care. Strengthening primary care will pay dividends: getting the country more quickly to herd immunity and a return to some sense of normalcy.”

“We are proud of what primary care is doing to keep people actively engaged in their care and health. And now it’s time for us as a nation to care for our primary care practitioners and prevent an epidemic of burnout from spurring a mass exodus from the profession,“ said Christine Bechtel, co-founder of 3rd Conversation, a community patients and clinicians.

Since March 2020, the Larry A. Green Center and the PCC have collected and disseminated data from more than 25 regular surveys of primary care clinicians on their abilities and attitudes in responding to the COVID-19 pandemic.

Responses to the survey came from 657 clinicians across 48 states, the District of Columbia and Guam. 73% identified their practice as family medicine, 12% as internal medicine, 6% as pediatrics, 3% as geriatrics, and 6% as other. 75% identified as MDs and DOs, 15% as NPs, 3% as PAs, and 6% as other. 22% described their practice as rural; 11% work at a federally qualified health center (FQHC) or FQHC lookalike; 15% work in an academic or residency practice; another 6% work in a convenience care setting such as retail clinic or urgent care; and 5% practice in a direct primary care or membership-based setting. 29% work in a practice with 1-3 clinicians; 30% in a practice with 4-9 clinicians; and 41% in a practice with 10 or more clinicians.

More information about the survey

Survey Shows Patients and Clinicians Want Primary Care More Involved in Mass Vaccination Efforts

WASHINGTON, March 29, 2021 — The Larry A. Green Center, in collaboration with the Primary Care Collaborative (PCC), today released new data showing that patients want to receive their COVID-19 vaccinations from primary care and that practices want to be involved in vaccination administration. In a survey of primary care clinicians conducted in mid-March, nearly half (46%) reported that patients are calling their practice and demanding to be vaccinated, and 74% said they are willing to administer the vaccine. The reality, however, is different. Over half (54%) of clinicians said their local health department has not actively engaged primary care to help with vaccine distribution, and only 9% have a reliable vendor and know when they will receive the vaccine, according to the survey.

Meanwhile, primary care continues to address the growing non-medical needs of patients, with 4 in 10 clinicians increasing their support for patients with food, housing, or financial insecurities during the pandemic. Practices are also expanding their capacity to provide mental health support, even while eight in 10 report practice revenue is more than 10% below pre-pandemic levels.

“Primary care has been ready to help in our country’s massive vaccination effort,” said Rebecca Etz, PhD, co-director of The Larry A. Green Center. “It has been able to offer more support to patients as the pandemic drags on and as families struggle with food, housing and finances. For 40 years, primary care has annually managed the majority of U.S. population vaccinations. Yet during the greatest vaccination effort of our lifetimes, national planning has proceeded without primary care. How does that make sense?"

“This survey suggests that primary care is more than doing its part, yet is not receiving needed support. One in 3 clinicians – the front line of the pandemic – plans to leave an already shrinking primary care workforce in the coming years,” said Ann Greiner, president and CEO of PCC. “The administration must immediately help to financially stabilize primary care in the same manner it seeks to stabilize the national economy.”

Since March 2020, the Larry A. Green Center, in collaboration with the PCC, has collected and disseminated data from more than 25 regular surveys of primary care clinicians on their abilities and attitudes in responding to the COVID-19 pandemic.

The survey of clinicians was fielded March 12-17, 2021, and received 765 responses from clinicians in 48 states and Guam. 69% of respondents identified their practice as family medicine, 14% as internal medicine, 7% as pediatrics, 3% as geriatrics, and 7% as other. 73% identified as MDs, 4% as DOs, 14% as NPs, and 9% other. 10% work in community health clinics or similar and 22% in rural settings. 31% work in a practice with 1-3 clinicians and 39% had more than 10 clinicians. 32% work in a practice that is self-owned, 38% are system-owned, 5% are government-owned, and 5% are membership-based. 

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Visit the PCC’s website for:

• more details on the survey findings

• executive summary of the survey

Experts are available to provide insight and comment on the survey. If you would like to speak with them, please contact: Stephen Padre, spadre@thepcc.org, 202-417-3911

The surveys are conducted regularly with an aim to measure the impact of COVID-19 on primary care practices, clinicians and patients. Results are reported on the websites of PCC and the Larry A. Green Center. 

Download the full press release

Survey Shows Primary Care is Willing to Distribute Vaccines Widely and Equitably

WASHINGTON, February 24, 2021—The Larry A. Green Center, in collaboration with the Primary Care Collaborative (PCC) and 3rd Conversation, today released new data showing that primary care is willing to help meet the nation’s COVID-19 vaccine goals through outreach, education, advocacy and administration of the vaccine. However, primary care is not yet being leveraged for these purposes, despite the rapid ramping up of the vaccines’ distribution.

According to a survey of more than 900 primary care clinicians fielded in mid-February, 89% of clinicians want their practices to be a vaccination site, but only 22% are considered one by their health department, local hospital or health system. Targeting groups that are most vulnerable and in need of the vaccine is a key strategy for addressing vaccine equity, and the survey shows that primary care can assist with this. Over 60% of clinicians surveyed have created eligibility groups and carried out proactive outreach to educate their patients.

“Primary care is the largest platform in our country’s healthcare system,” said Rebecca Etz, PhD, co-director of The Larry A. Green Center. “It has the experience and expertise in administering vaccines as well as established relationships with communities and patients. These are all things we need right now. Americans are desperate to get vaccinated, and primary care is willing, so what are we waiting for?”

Read the full press release

Primary Care Remains Untapped as U.S. Struggles to Administer COVID-19 Vaccines

WASHINGTON, February 10, 2021—The Larry A. Green Center, in collaboration with the Primary Care Collaborative (PCC) and 3rd Conversation, today released new data showing that 8 in 10 primary care practices are ready and willing to assist with COVID-19 vaccine distribution, despite ongoing staffing shortages caused or exacerbated by pandemic-related financial issues. With 20% of respondents practicing in rural communities and a vast majority with access to patients with chronic conditions, primary care could be an untapped yet key avenue for reaching vulnerable communities.

This data comes during a critical time when millions of Americans face months-long waits for their first dose of the COVID-19 vaccine, even as the new administration aims to issue 150 million doses in its first 100 days. As the largest healthcare platform in the United States, primary care has the potential to turbo-charge distribution if resources are put in place to enable practices to join the effort.

“The science of innovation adoption tells us that vaccinating the population at scale will necessitate focusing on people who are worried and have questions – which, let’s be honest, is the majority of us,” said Christine Bechtel, co-founder of 3rd Conversation. “When it comes to health questions, the first place patients think to go is their primary care doctor’s office. It will be another tragedy in a long line of missteps if we don’t equip these trusted doctors with the vaccine and resources they need to reach so many individuals in our communities.”

Read the full press release

Saving Primary Care: Is it Time for A New National Service Corps for Primary Care Practices?

Diane Rittenhouse
Senior Fellow

Rebecca Etz
Associate Professor, Co-Director

Janice Genevro
Senior Researcher

By: Diane Rittenhouse, Rebecca Etz, and Janice Genevro

Original place of publication can be found here.

Primary care—including family medicine, general internal medicine, and pediatrics—is the first place that people go for preventive health care, urgent health concerns, and management of chronic illnesses. Excellent primary care constitutes the foundation of a health care system that is high quality, low cost, and equitable. But as a result of the COVID-19 pandemic, many primary care practices across the United States are on the brink of collapse.

Lack of access to necessary personal protective equipment (PPE) combined with shelter-in-place orders led to an unpredictable and unprecedented drop in in-person visits. By some estimates, ambulatory care visits have decreased more than 50 percent since the start of the U.S. pandemic, and more than 80 percent of primary care clinicians report that they have limited the provision of routine care. Because primary care physicians are mainly reimbursed for in-person visits, a dramatic decline in in-person visits resulted in a similar decline in practice revenue—leading to widespread furloughs, layoffs, practice closures, and even bankruptcies. And although many primary care practices have turned to phone and video visits where possible to continue caring for their patients, too often, this care has been delivered for free because of lack of insurance payment for telehealth. Under pressure to stay in business and provide the care their patients need, primary care clinicians and staff are suffering unprecedented levels of exhaustion and burnout.

The collapse of primary care is happening in the larger context of an economic crisis with levels of unemployment not seen in the United States since the Great Depression. Unfortunately, the policies put in place to respond to the crisis are not reaching primary care providers. Despite being eligible, few primary care practices were successful in obtaining federal loans through the Paycheck Protection Act, and less than 1 percent of dedicated funding in the CARES Act went to primary care practices.

As a nation, we are at a crossroads. If, like other developed nations, we want to have a stable and sound infrastructure that addresses inequities in health and health care and that continues offering childhood immunizations, COVID diagnosis and treatment, and care for chronic illnesses such as diabetes and heart disease, now is the time for bold action to save and strengthen primary care practices in communities across the United States.

A national Primary Care Service Corps (PCSC) could provide needed emphasis and resources for primary care. Modeled on the federal Works Progress Administration (WPA) and the Civilian Conservation Corps (CCC), which were established in the wake of the Great Depression, PCSC could serve to strengthen and improve the nation’s primary care infrastructure while boosting regional economies. The PCSC could provide primary care practices with the money, technical assistance, personnel, and other direct support they need to survive the COVID-19 pandemic.

• First, practices that commit to participating in the PCSC for a minimum of two years could receive new, designated federal disaster funding to help them cover basic operating expenses, including salaries and rent, and practice personnel would serve as members of the PCSC. This support would remove the immediate financial threat to practices’ survival and provide a foundation for other immediate actions as infection rates continue to rise and we prepare for ongoing transmission and potential future waves. In return, while participating in the PCSC, practices would agree to provide care to members of their communities regardless of insurance coverage or ability to pay, and they would agree to engage with practice improvement consultants (described below).

• Second, as part of the PCSC, the Primary Care Extension Program (PCEP) could be fully funded and implemented. The PCEP, a federal program that has been authorized but not funded, is modeled on the U.S. Department of Agriculture’s Cooperative Extension Service that has successfully spread agricultural innovations to farmers throughout the country over the past 100 years. Similarly, the PCEP could employ regional practice improvement consultants who understand the local needs of primary care practices and can help practices respond successfully to the extreme challenges they are facing as the result of the pandemic and economic crisis. Consultants, who also would serve as members of the PCSC, would support and coach practices as they implement telehealth and learn to function under new payment methodologies. Consultants would also provide tailored assistance to help practices improve essential services, such as building enduring partnerships with local public health departments, integrating behavioral health care, and connecting and coordinating care with community services.

• The PCSC could coordinate with the National Health Service Corps, established to provide loan repayment and scholarships to individual primary care physicians to address regional doctor shortages across the United States in the 1950s and 1960s. All primary care practices enlisted in the PCSC could be automatically designated as facilities in health professional shortage areas, helping draw National Health Service Corps primary care clinicians to high-need areas.

• Finally, the PCSC could be chartered and organized in a way that would enable it to meet other pressing needs of participating practices. This could include contracting for innovative services to meet the urgent mental health needs of frontline primary care personnel and serving as a purchasing and distribution agent for the PPE that individual practices cannot currently procure themselves.

Almost 90 years ago, the federal government acted boldly to create the WPA and the CCC. These national service programs and others provided not only jobs and critical short-term economic relief but also created long-lasting infrastructure—from roads, libraries, and hospitals to parks, forests, and public art—that we continue to use, rely on, and enjoy today. Likewise, taking bold action now isn’t just about helping primary care practices recover. Shoring up this vital component of our health care system will not only prevent the collapse of primary care but also help our nation get in front of subsequent waves of the COVID-19 pandemic and contribute to better health at lower costs for the future. The WPA and the CCC provide a road map. It’s time to act to save and strengthen primary care, a critical national resource that we, and future generations, can’t afford to lose.