Over the past several decades, public health has seen a decline in its role in providing care to vulnerable populations. During this evolution, public health has embraced the 10 essential public health services—with activities to “strengthen, support, and mobilize communities and partnerships to improve health” deemed especially critical. This transition in the focus of public health was driven in large measure by the Affordable Care Act and its success in reducing the number of people without insurance. Yet another transitional incentive, reduced funding of public health agencies, was in play over the same time span. It was against this backdrop that the Maryland Primary Care Program (MDPCP) within Maryland’s Department of Health (MDH) was launched, with an eye toward emphasizing community health.
However, primary care clinicians continue to operate under the fee-for-service payment system that rewards quantity over quality without the promotion of population health. Moreover, increased patient volumes and a lack of relevant data and tools all but assure that primary care clinicians are unable to fully address the complex needs of the population they serve. The potential synergy of bringing together the tools of public health and the community resources of primary care has been recognized for many years.
The MDPCP set out to leverage the power of such a partnership. The program, launched in January 2019, is a key component of the 10-year (2019-2028) Maryland Total Cost of Care Model contract between the state of Maryland and the Centers for Medicare & Medicaid Services. By the beginning of 2020, 476 MDPCP practices were serving more than half of Maryland’s population, with the support of both the Centers for Medicare & Medicaid Services and the MDH public health administration (MDH Public Health). In addition to their fee-for-service compensation, MDPCP primary care practices receive visit-independent payments to facilitate their addressing the physical, behavioral, and social aspects of their patients’ health. These practices also receive guidance, technical support, and coaching support from MDH Public Health.
The value of the MDPCP concept became apparent in March 2020, when its primary care practices, with the support of MDH Public Health, mounted a powerful and coordinated response to the coronavirus disease 2019 (COVID-19) pandemic; MDH Public Health initiated a series of daily webinars to update MDPCP primary care practices on the pandemic’s status, COVID-19 testing, access to personal protective equipment, and modified workflows. During a time replete with misinformation, these webinars offered the practices trustworthy and up-to-date information and distilled complex information into a digestible, easy-to-follow narrative. The practices also received specialized reports designed to identify specific patients at high risk for contracting COVID-19 who could benefit from proactive outreach. One such tool, the COVID-19 Vulnerability Index, the product of administrative claims and social determinants of health data, ranks patients in order of risk and was incorporated into the dashboards of MDPCP primary care practices.
In addition, MDH Public Health provided MDPCP primary care practices with real-time clinical data on hospital admissions, emergency department visits, workflow guidance, and data analytics tools (such as the Pre-AH Model report) to help anticipate avoidable complications, with the pandemic in mind. At the pandemic’s earliest stages, the practices offered COVID-19 testing until Maryland was able to establish a system of outdoor and drive-through testing sites. Later on, once Maryland’s statewide stay-at-home order was issued, the practices received technical assistance, coaching, and support towards the establishment of telehealth services from MDH Public Health, which also partnered with the state medical society and a large commercial payer (CareFirst) to implement the telehealth platforms in the participating practices.
The first 6 months of the pandemic were marked by more than 100 COVID-19 health emergency orders and guidance changes from Maryland’s governor and its secretary of health, as well as from the Centers for Disease Control and Prevention. The program’s daily webinar series helped place these evolving COVID-19 policies in a clinical context and gave the MDPCP practices an opportunity to share innovations and best practices—including guidance on establishing drive-through testing sites and outdoor symptom screening to reduce the risk of COVID-19 transmission. Also, MDH Public Health developed resources, such as a guide to safely keeping practices open during the pandemic and a COVID-19 testing guide, and shared them with the practices in the spring of 2020.
The program’s integration of public health and primary care has produced some promising results. A survey of 474 MDPCP primary care practices in April 2020 indicated that 99.2% of them were providing telehealth care to their patients. The program is currently seeking to determine if patients served by these practices have experienced fewer COVID-19 hospital admissions compared with their non-MDPCP counterparts.
The role that the MDPCP has been playing during the pandemic offers an illustration of the value of integrating primary care and public health. With support and guidance from MDH Public Health, the program’s primary care practices have successfully advanced community health in Maryland during the COVID-19 pandemic and may serve as a blueprint for other states to follow.
Open Access: This is an open access article distributed under the terms of the CC-BY License.
Corresponding Author: Eli Y. Adashi, MD, MS, Warren Alpert Medical School, Brown University, Box G-M1, Providence, RI 02912 (eli_adashi@brown.edu).
Conflict of Interest Disclosures: Dr Adashi reported personal fees from Ohana Biosciences Inc outside the submitted work. No other disclosures were reported.