As a practicing primary care physician, SPIA alumnus Dr. Deep Shah (AB ’08) is on the front lines of the COVID pandemic. He practices at Gwinnett Clinic, founded in 1983 in his hometown of Lawrenceville, with 18 metro Atlanta locations.

March 2020 introduced the well-regarded practice to a new era, as its longtime tradition of on-the-spot community care was challenged by COVID-related safety considerations and the practical and economic ramifications of the pandemic response.

“The pandemic is revealing that we’ve severely underinvested in primary care and public health––two sides of the same coin,” said Shah.

His office struggled to navigate conflicting COVID-19 protocols, changes to CDC recommendations, and a dearth of personal protective equipment (PPE), all while remaining responsive to the needs and fears of patients and staff. A July 2020 study in the Journal of the American Board of Family Medicine reported that primary care workers may face the highest risk of dying from COVID among medical personnel, as they have less access to proper PPE than frontline hospital staff.[1]

Shah’s practice remained open to patients throughout, though with reduced hours to allow for social distancing and cleaning. Patients are screened before entering, and those presenting with fever or respiratory complaints are seen virtually to ensure a sterile environment. Gwinnett Clinic partners with county health departments to coordinate testing and vaccination.

Meanwhile, primary care practices all over the nation have reported challenges to viability. Declining revenue caused financial stresses, school closures brought on staffing challenges, and the sudden vital nature of telehealth made technological equipment and training an immediate priority.

The COVID national public health emergency has vaulted the practice of telehealth to the forefront of the community response. To assist with these monumental changes, the HHS Office for Civil Rights (OCR) has issued guidance for providers and relaxed HIPAA regulations, so that physicians may, in good faith, provide telehealth services to patients using remote communication technologies, such as FaceTime, Facebook Messenger, Google Hangouts, Zoom, or Skype for telehealth services, even if the application itself does not fully comply with HIPAA rules.

“Like most groups,” said Shah, “we rapidly adopted and implemented telemedicine across our 18 clinics when leadership was trying to wrap its head around how to safely take care of patients in the office. At one point, we saw over 80% of patients using a telemedicine platform or the phone.”

Along with concerns over patient privacy, telemedicine comes with predictable drawbacks. “We’re still learning about the strengths and limitations of telemedicine. Some of the positives are obvious in terms of decreased exposure risk, but the downsides are also evident – we can’t examine the patient or perform any basic tests. But as things stand, at least in our patient population, patients still want to come into the office if we think it’s safe for them to do so.”

The pandemic, said Shah, has exposed weaknesses not just in the nation’s health system but in its primary care infrastructure. Shah joined two other primary care physicians in publishing “Preparing for Primary Care for COVID-20,” [2] an open letter in the Journal of General Internal Medicine, imploring policymakers to invest in pandemic preparedness, by standardizing protocols and data-sharing processes and providing more support to primary care physicians (PCPs) in the form of PPE and funding.

“The foundation of our health system is its primary care infrastructure,” said Shah. “Both government and private insurance have neglected primary care for decades, and unfortunately, the pandemic is exposing its fragility.”

Shah suggested three priorities for lawmakers looking to strengthen primary care practices.

“Primary care physicians and group practices vary across the country, but most of us will benefit from three types of support: ample personal protective equipment and testing supplies, strong partnerships with local and state public health entities, and a guarantee of financial stability through support payments.”

While the U.S. Department of Health and Human Services (HHS) has provided some relief money to primary care and other critical infrastructures through the CARES Act, and the U.S. Small Business Administration’s PPP program has helped a significant portion of practices stay afloat, this support was just a band-aid.

“We’re getting there, but we have a way to go,” said Shah. “Federal support is running out just as we round the curve into late winter with a potential surge in the Spring as variants pop up around the world. Hopefully, second round PPP funding comes through quickly and more support is offered, if needed. We don’t want primary care clinics or our community partners to limit access in anticipation of financial shortfalls.”

Improved partnerships in the medical community will also be vital to dealing with the pandemic. “We have received tremendous local support from our county health department and had good communication with the state, but we need better coordination with the entire medical neighborhood. Challenges with the vaccine rollout are exposing additional opportunity for better relationships.”

COVID testing procedures and reporting requirements introduce additional challenges. The CARES Act requires testing sites to report data for all diagnostic and screening testing completed, including molecular, antigen, and antibody testing. These data must be reported daily, within 24 hours of test completion. While HHS imposes and polices these basic requirements, each state or locality sets its own protocols and maintains its own channels for reporting.

“Each state has its own reporting requirements for the two types of nasal swabs (PCR / molecular and rapid / antigen) as well as serum antibody tests. Most labs and doctors’ offices are familiar with how to follow reporting requirements. It’s just up to each state to set its standards.”

Political pressure, uneven standards, and an evolving understanding of the virus have blurred best practices for testing and reporting. “There continue to be significant issues with testing and reporting,” said Shah. “We see overtesting, undertesting, and inappropriate testing. Reporting compliance also remains unclear. So, in short, we need to do better on reporting new cases and standardizing the process.”

As we enter the next phase of pandemic management with mass vaccination, the government is trying to roll it out as quickly as possible and they are toggling between creating a parallel health system through mega sites or investing in existing infrastructures. “PCPs are used to administering millions of vaccines annually and with minimal support we could be a significant contributor to the vaccine effort,” said Shah.

Shah finds lessons in the pandemic response for the overall state of healthcare in the country and the public health infrastructure.

“This is an opportunity for government payers (like Medicare and Medicaid) as well as private insurance companies to right the ship,” he said. “With appropriate resources, we are equipped to lead the community’s response, in partnership with community hospital and public health agencies.”

Shah’s time at SPIA and UGA, he continued, helped shape this holistic view of public health policy and multi-sector and collaboration issues, both those surrounding COVID-19 and more general challenges within the national healthcare landscape. He graduated summa cum laude with joint degrees in biology and international affairs, and won a Rhodes Scholarship to study at Oxford, before moving on to Harvard Medical School and a residency in internal medicine at Emory University.

“Learning how to dissect any policy issue––regardless of sector, scale, or scope––is an invaluable lesson that I learned while an undergraduate at SPIA,” he said. “COVID-19 has far-reaching policy implications for everyone in our country and around the world. I’m grateful for learning how to appraise each of these topics through a critical lens, a skill that professors like Dr. Loch Johnson and Dr. Gary Bertsch helped me to develop.”

Shah takes this mandate seriously, incorporating his health policy expertise to lead and advocate for high-value primary care at the state and national level. He currently serves on the board of Georgians for a Healthy Future and is active with the American College of Physicians and the Grady Health Foundation.

“Primary care offices, in partnership with hospitals and health departments, can emerge as local leaders. We. can help manage the pandemic and ensure every American has access to care – now and when COVID-19 is behind us. But we need support to take on that role,” he said. “We’re capable and willing to lead the fight.”

[1] Gouda, D., Mohinder Singh, P., Gouda, P. & Goudra, B. The Demography of Deaths in Healthcare Workers: An Overview of 1004 Reported COVID-19 Deaths. AMERICAN BOARD OF FAMILY MEDICINE (2020).

[2] Ali, M.K., Shah, D.J. & del Rio, C. Preparing Primary Care for COVID-20. J GEN INTERN MED (2020). https://doi.org/10.1007/s11606-020-05945-5