Publications

As of September 2021, mortality in the United States due to the SARS-CoV-2 virus had exceeded the death toll from the 1918 influenza pandemic. COVID-19 was the ultimate test of healthcare and public health capacity and capability across the United States. From its acute onset and throughout its extended duration, the COVID-19 pandemic has overwhelmed hospitals, disrupted businesses, and caused lasting economic harm. It has also illuminated and exploited major vulnerabilities within the US healthcare and public health systems. The impact of the pandemic on hospitals, and to a lesser extent on public health departments, has been explored elsewhere, but relatively little has been written about the impact on primary care services. Operating largely in silos and chronically underfunded disciplines, primary care providers and public health practitioners in the United States have struggled to respond to the numerous waves of the pandemic, which have caused high levels of morbidity and mortality and jeopardized health systems in communities across the country, especially those that are most vulnerable. It is crucial that the lessons learned from the COVID-19 pandemic must be shared.

To explore the degree of collaboration that has occurred among primary care and public health providers during the pandemic to date, we used a mixed-method, rapid-cycle approach, which included a literature review and key informant interviews. We interviewed primary care providers at family medicine and general internal medicine practices in integrated health systems and federally qualified health centers, personnel at the National Association of Community Health Centers, and state and local public health officials across several states about COVID-19 activities and lessons learned.

The findings of this study demonstrate that the failure to bring primary care providers into a frontline role as responders, alongside public health, resulted in many missed opportunities to provide better quality care, faster testing, more effective contact tracing, greater acceptance of vaccination, and better communication with patients. Participants in this study further indicated that better integration of primary care, public health, and community-based organizations could have provided greater support for the public health response, thereby easing the burden on overstretched public health personnel; and could have accessed primary care’s reach to amplify public health messaging. If these coordinated activities had been effectively implemented, they could have saved lives and reduced the health, economic, and societal impact of the pandemic in the United States.

This study reveals the extraordinary burden primary care and public health faced in meeting the demands created by a rapidly evolving severe pandemic, while simultaneously attempting to address the normal healthcare needs of existing patients and families. The level of preparedness to respond swiftly and effectively to the COVID-19 pandemic varied widely across public health and primary care organizations. In the key informant interviews, we found that the most productive collaborations during the COVID-19 response tended to be extensions of preexisting relationships between public health and primary care personnel or “test and treat” and other disease management models. Workforce flexibility and adaptability and the expansion of telehealth services were also central themes in these interviews. Federally qualified health centers played a critical role and pivoted quickly and effectively to provide both primary care and public health interventions during the COVID-19 pandemic, particularly those that serve higher-risk populations.

The data and themes described in this report clearly indicate that the COVID-19 pandemic must be a catalyst for change. The landscape of primary care in the United States is rapidly evolving; many traditional practices are being acquired by integrated health systems and for-profit companies and other practices are abandoning traditional fee-for-service reimbursement models in favor of various forms of capitation or prepayment. In light of these changes, now may be an opportune time to encourage better alignment and collaboration with public health.

Recognizing that high-quality primary care is the foundation of a healthcare system and that a robust public health system is the bedrock for healthy communities, we conclude that action is needed to address the barriers that exist between primary care and public health and to correct misalignment across systems. A new transformative vision is needed where public health is central to the delivery of healthcare in the US and where local primary care, public health, and community networks are strengthened and expanded. While payment reform is critical, action will be required by primary care and public health leadership and policymakers to build and sustain a thriving, resilient, integrated primary care, public health, and community sectors capable of optimizing health outcomes during future pandemics and large-scale public health emergencies. We make the following key recommendations:

• Colocate primary care and public health services to benefit population-level health and facilitate active collaboration.
• Primary care societies must align their efforts with public health in a unified voice to drive congressional action in order to ensure that the disastrous response to the COVID-19 pandemic is not repeated.
• Craft efforts to support, protect, and sustain the primary care and public health workforces to drive integration across disciplines.
• Public health “moves at the speed of trust” and people trust their primary care providers and community-based organizations; therefore, primary care and public health collaborative partnerships with strong ties to their community organizations should enhance health systems surge capacity, extend public health disease containment interventions, and position the United States for improved response to future pandemic.