June 18, 2020 Rita Rubin, MA
Article Information JAMA. 2020;324(4):321-323. doi:10.1001/jama.2020.11254
Restaurants and retailers aren’t the only
small businesses that have taken a financial hit during the coronavirus disease
2019 (COVID-19) pandemic.
Physicians in small private practices around
the country have reported steep declines in revenues, drops so significant that
some of them and their supporters have turned to GoFundMe—the platform
best-known for helping patients pay their medical bills—to raise funds to help
pay their overhead. Telemedicine has helped pick up only a small portion of the
slack.
A few weeks into the pandemic, the Medical
Group Management Association found that COVID-19 had a negative financial
effect on 97% of the 724 medical practices it surveyed.
And in an online survey conducted in early May, the
Texas Medical Association found that 68% of practicing physicians in that state
had cut their work hours because of COVID-19, while 62% had their salaries
reduced. A concerned, long-time patient—with her physician’s blessing—set up
a GoFundMe page on April 20 for a Dallas
family medicine practice. In a month, it raised $96 766.
State medical associations in Indiana and New York have reported similar effects of
the pandemic on medical practices.
Meanwhile, in Georgia, “we dropped down to
seeing 20% or 30% of our practice,” said Fayetteville pediatrician Sally Goza,
MD, president of the American Academy of Pediatrics (AAP). “Unfortunately, we
had to furlough 3 of the employees just in our pediatric area, because we
really didn’t have the work.” Goza’s practice includes internists and family
practitioners as well as 4 pediatricians, 1 who works part time.
States and local jurisdictions have eased
stay-at-home orders, and the Centers for Medicare & Medicaid Services (CMS)
has lifted some restrictions on nonemergent, non–COVID-19
care, so business has recently picked up in physician practices. But physicians
report that it is still well below prepandemic levels and is expected to stay
that way, at least as long as social distancing is required.
On May 19, the Commonwealth Fund published
an analysis of
data from more than 50 000 physicians in all 50 states who use products from
Phreesia, a health technology company. An earlier study, published April 23,
found a nearly 60% drop in visits to ambulatory care practices early in the
pandemic. The more recent analysis found that practices had rebounded, but
visits were still roughly a third lower than before the pandemic.
In a survey of 558 US primary care physicians
fielded May 29 through June 1—nearly 3 months into the pandemic—6% of
respondents said their practices were closed, perhaps temporarily, and 35% said
they’ve furloughed staff, according to the nonprofit Primary Care Collaborative
(PCC) and the Larry A. Green Center.
“Unfortunately, I think this [pandemic] is
going to accelerate the closure of the smaller practices,” said Andrew
Kleinman, MD, a plastic surgeon with a solo practice in Rye Brook, New York.
“With a lot of practices, 40% or more of their revenue goes just to overhead.”
Staying Away
Although people packed beaches and boardwalks
after restrictions lifted and Black Lives Matter demonstrators flooded city
streets and parks, many patients, often older and in poor health, still seem
reluctant to visit physician offices.
The PCC and Green Center physician survey
found that 79% of respondents continued to report fewer patient visits compared
with before the pandemic.
“As a country, we did a very good job of
explaining there was this sudden, horrible virus going around,” said Ateev
Mehrotra, MD, MPH, a health policy researcher at Harvard Medical School and a
hospitalist at Beth Israel Deaconess Hospital.
But that message might have had an unintended
consequence, said Mehrotra, a coauthor of the Commonwealth Fund analysis. “We
got people scared of going to the doctor’s office or the hospital,” he said.
“They would rather die at home than get exposed to the coronavirus.”
The cause of some of the excess US deaths that have occurred since
mid-March might not be COVID-19 itself but the fear it generated, preventing
people from seeking medical care for symptoms that require immediate attention
such as chest pain, Mehrotra speculated.
“Patients are still fearful,” said Mildred
Frantz, MD, the sole physician in her Eatontown, New Jersey, family medicine
practice. Some days, she said, she’ll look at the next day’s schedule and
think, “Oh, that’s not bad, it’s three-quarters full.”
When the next day rolls around, though, maybe
half of the scheduled patients don’t show up, Frantz said. “That’s not good. We
run on small profit margins.”
Desperate to keep her practice afloat, Frantz
created a GoFundMe page on April 10. “I felt
conflicted about whether I should do it,” she said weeks later. She struggled
with the notion of holding out a hat to friends and patients and their
families, finally deciding not to, although she hadn’t yet taken the page down
as of mid-June.
Many people have lost their jobs and, as a
result, their health insurance because of the pandemic, noted Glynis Thakur, a
business consultant based in Bellevue, Washington, who works with physician
practices. “It’s not going back to normal any time soon,” she said. Thakur was
so concerned about the survival of the practices she works with that she
created a GoFundMe page to raise money for them.
But she abandoned that plan after raising $250 of a $50 000 goal because she’s
not on social media to promote it.
Affordability, cited by 40% of respondents,
was patients’ biggest obstacle to obtaining primary care, the PCC and Green
Center found in a survey fielded May 22 through May 25.
In the same survey, a quarter of respondents
said they stayed away from primary care practices “so as not to be a bother,”
because they assumed their physician was swamped due to the pandemic.
Crested Butte, Colorado, pediatrician Jennifer
Sanderford, MD, can attest to that. Sanderford is the only pediatrician in 3
counties, and, she said, patients and their parents figured she was busy taking
care of sick children. They could not have been more wrong. As noted in an
April AAP blog post, business in Sanderford’s practice
plummeted by 95% in the early weeks of the pandemic. She feared she would have
to shut down the practice she’d spent 20 years building.
Pediatric Patients Go AWOL
The AAP in May launched a social media
campaign, “#CallYourPediatrician,” to remind parents that
they should still make appointments for well-child checks and immunizations
during the pandemic.
Research supports pediatricians’ concerns that
children have been falling behind in their immunizations. Compared with the
same time period in 2019 and 2018, vaccination coverage of Michigan infants and
toddlers up to age 2 years declined in January through April of 2020, according
to a recent article in the Morbidity and
Mortality Weekly Report. Only coverage with the hepatitis B vaccine dose
given at birth, typically in the hospital, did not decrease.
“The observed declines in vaccination coverage
might leave young children and communities vulnerable to vaccine-preventable
diseases such as measles,” the authors noted.
When Sanderford finally received money from
the federal Payroll Protection Program in early May, she sent an email blast to
all her patients’ families. “We were very forthcoming,” she said, explaining
her practice’s financial straits and the need for vaccinations and well-child
checks. “We are slowly getting to the end of our list of patient well checks
that were due,” she said at the beginning of June, although business is still
well below prepandemic levels.
Pediatrics is among the specialties
particularly hurting during the pandemic, according to the Commonwealth Fund’s
recent analysis. One disadvantage they face is that very few of their patients
are Medicare beneficiaries, Goza, representing the AAP, noted in a letter April 16 to Alex Azar, secretary
of the US Department of Health and Human Services (HHS).
“Pediatricians have not been able to access
financial relief policies issued by HHS because of the focus on Medicare”
payments, she pointed out in the letter. “[T]hey have not been eligible for
Medicare advanced or accelerated payments, they have not been able to access
increased Medicare payments for care related to COVID-19.”
Shingles Replaced With “Closed” Signs
From the middle of March until the last week
of May, “I basically had no income,” said Kleinman, a solo practitioner who
closed his office for several weeks and laid off 5 full-time and part-time
staff members.
When pediatricians occasionally referred
patients with lacerated lips that needed stitches, he said, he’d check with his
wife, a nurse practitioner who works in occupational health, to see when she’d
be available to assist him.
Kleinman, a past president of the Medical Society
of the State of New York, said he reduced his malpractice coverage to
half-time, but he still had to pay two-thirds of his prepandemic premium. “For
a plastic surgeon, it’s still expensive when there’s no income.” And he still
had to pay other overhead costs—phones and electronic medical records, to name
2—for his temporarily closed practice.
“If this happened to me 20 years ago, I would
be bankrupt,” said Kleinman, who, at age 66 years, was able to draw on savings
to help his practice survive. “When this whole thing started, I strongly
considered just retiring now.” While he’s heard of physicians retiring early
rather than waiting out the pandemic, Kleinman said, he decided he’s not yet
ready to follow suit.
Joseph Valenti, MD, an obstetrician and gynecologist
in Denton, Texas, says he couldn’t perform surgery for 6 weeks, resuming only
in mid-May, because Medicare deemed his procedures nonemergent. “We just can’t
wait forever,” he said, noting that some of his patients needed to have
premalignant lesions removed.
“So many practices like ours were in trouble
before the COVID thing,” said Valenti, who had stopped practicing obstetrics
before the pandemic struck. “It’s now much worse.”
His office closed except for his associates’
obstetrics patients, and the practice, now comprising 5 physicians, 3 nurse
midwives, and 1 nurse practitioner, had to lay off its other nurse midwife and
temporarily reduce the nurse practitioner’s salary, he said.
“We did a lot of telehealth and were working
from home,” Valenti said, and his practice still is open only 4 days a
week—with shorter hours—instead of the usual 5.
The main issue, which predates the pandemic,
has been that small practices have no money in reserves, he said, noting that
his salary is lower than it was when he started practicing in Denton in 1998.
“I have a stack of paperwork here for debts owed to pharmaceutical companies
for birth control,” Valenti said. “Hopefully, they’re willing to work with us.”
Turning to Telehealth
In the early days of the pandemic, CMS expanded coverage of and access to
telehealth services to minimize Medicare beneficiaries’ need to seek care at a
physician’s office or a hospital.
“There’s been this tremendous, tremendous rise
in the use of telemedicine,” Mehrotra said. “A change that I would have
expected over a decade happened in a month.” About 14% to 15% of all patient
visits are now telemedicine, he said.
Telemedicine has helped make up for some of
the decline in office visits, but far from all of it. While his office was
closed, Valenti said, “I was doing maybe 3, 4, or 5 telehealth visits a day.”
But prepandemic, he’d typically see 13 to 15 gynecology patients each day.
As many as 40% of patient visits could be
handled via telemedicine, Mehrotra said. However, many practices are reluctant
to commit the necessary resources because it’s not clear whether they’ll
continue to be reimbursed for telemedicine visits after the pandemic ends, he
said.
On June 11, the American College of
Physicians sent letters to the presidents and CEOs
of the Blue Cross Blue Shield Association, UnitedHealth Group, the National
Association of Insurance Commissioners, and America’s Health Insurance Plans,
that, among other recommendations, urged them to continue paying for
telehealth, no matter the platform, at the same rate as in-person services
after the public health emergency ends.
“It’s not a thing that you can flip on a
switch that easily,” said Mehrotra, who coauthored a recent article outlining
the strategies for implementing regular use of telemedicine. Practices need to
figure out the logistics—the when and where of telemedicine visits—and “we need
to train the patients,” he said.
All the training in the world won’t help
patients if they don’t feel comfortable using the technology or don’t have
access to it, he said. While that probably isn’t much of an issue in obstetrics
practices because a high percentage of pregnant women have cell phones, it
could be a huge stumbling block for geriatricians, Mehrotra said.
The CMS recently expanded telemedicine coverage again to
include services delivered by audio-only telephone calls, which likely would
help patients who lack Wi-Fi and a computer. For some families receiving
Medicaid, though, even telemedicine by telephone is out of reach, Sanderford
said. They might have only 1 cell phone, and it goes to work with the father,
she explained.
Practices Trying to Make Perfect
The COVID-19 pandemic has forced practices to
take the wait out of waiting rooms, as physicians struggle to see as many
patients as possible while maintaining social distancing in their offices.
“The same physical footprint cannot be used
for the same number of patients,” Mehrotra noted.
Before the pandemic, Frantz said, her waiting
room seated a dozen people. Now, it contains only 3 chairs, each placed against
a different wall. Particularly high-risk patients skip the waiting room
altogether and remain in their car until their appointment. When patients
simply need to drop off a urine sample, they wait in their car until a member
of Frantz’s staff comes out to retrieve it.
For now, Kleinman said, he is scheduling only
1 patient per hour, even though he has 3 examination rooms. “I really want to
minimize the overlap.”
One of his staff calls patients the day before
their appointment to ask whether they have any possible COVID-19 symptoms. If
so, they are rescheduled for a later date. When patients arrive for an
appointment, they call from their car to make sure the coast is clear for them
to come up to the office.
Kleinman, who performs surgical procedures in
his office, not in a hospital, feels lucky that he was able to obtain two
20-count boxes of N95 respirators, albeit “at an outrageous price.” And he was
able to buy an extra gallon of the sanitizer—“a higher level than a Clorox
wipe”—he uses to disinfect surfaces.
Soon, Kleinman said in late May, he planned to
begin scheduling 2 patients per hour, seating 1 in his waiting area and 1 in an
examination room. “I expect my income to be down by 50% for the next month or
2,” he said. “I don’t think it will get back to normal before there is a
vaccine.”
Article Information
Accompanying this article is the JAMA Medical
News Summary, an audio review of news content appearing in this month’s issues
of JAMA. To listen to this episode and more, visit the JAMA Medical News Podcast.
June 21, 2020
Retirement Communities Preventing or
Restricting Visits to Physician Offices
Stephen Sinclair, MD | Private Practice
in Ophthalmology
In Philadelphia, "elder care"
communities and centers are preventing or severely limiting their residents and
participants taking family transportation or the facility's transportation from
the facility to physician offices for other than "life-threatening"
problems. Beyond the policies' effects on medical practice activity, this has
resulted in physicians dealing with progression of sight-threatening ocular
disease problems.
CONFLICT OF INTEREST: None Reported
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