The misalignment between this financial aid package and public health policy is most apparent in the pressure administrators' face to maintain their pre-COVID-19 outpatient practice norms, without a transition plan to adopt telemedicine and associated best practices. This disconnect between fiscal and public health strategies can result in inefficient interventions and limit improving health outcomes within the United States [25].

Changing financial incentives can foster behavioral change even in medical settings [26]. Hence, poor planning and program design by policymakers create the risk of producing poor outcomes and undermine progress by imposing greater disease burden on patients who are at the highest risk. Considering that the US Congress enacted the PPP program and the government implemented it rapidly—“14 years’ worth of loans in less than 14 days”—there was insufficient time to involve all stakeholders in the core discussions and the roll-out strategy [27].

In retrospect, the CARES Act, specifically the PPP, could have better addressed the needs of outpatient practices by including two minor provisions that would ensure employee safety and promote the adoption of telemedicine without unnecessarily complicating the program. As it stands, the policy forgives the borrowed amount if a business strictly adheres to employment requirements.

Safe working conditions Policymakers should have also required businesses, particularly health organizations, to provide safe working conditions for employees. That is, businesses should be required, where defined by national, state, and local policies, to stipulate that reasonable accommodations be made for employees to work from home if safety measures cannot be met. Similar to the current policy, any failure to follow such requirements could lead to loan repayment.

Expand ‘rent’ to include telehealth investment In the PPP’s current form, a portion of the borrowed amount can be dedicated to covering the cost of rent. The rent category could be expanded for medical practices to include investments in telehealth infrastructure and services. Just as a clinic’s walls provide a setting for the provision of health services, the infrastructure for telehealth allows clinicians to provide comparable, while safe, services throughout the pandemic.

Considering the PPP was set to expire at the end of June 2020, it is critical to identify important gaps and limitations to improve future iterations. Overall, the PPP is limited in the support and improvement it offers the healthcare system insofar as it addresses employment as both a process and an outcome. Future policymakers should consider employment as an outcome objective only. Financial assistance directed towards telemedicine and associated infrastructure should instead be considered as a process objective. If funding were dedicated to providing telemedicine, it would allow an office to continue practicing and generating revenue. This would incentivize administrators to adopt a new delivery model better suited to the challenges of COVID-19, and employees could redefine their roles while continuing to provide value—all while pushing patient care into a safer setting. This alternative fiscal program aligns the needs and values of all stakeholders—the general public, patients, clinical administrators, and their staff.