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Has the Pandemic killed Primary Care?

This article is reprinted from VoxCare:

The coronavirus pandemic is creating yet another kind of health care crisis: America’s primary care practices are struggling financially as patient visits plummet, and patients themselves are missing out on vital routine care.

Doctors and other health care providers have seen a precipitous drop in the routine visits they depend on for revenue, and experts fear many offices will have to close. Meanwhile, patients with chronic conditions are facing hardships because they can’t see their regular physician to get routine care.

“That really creates a problem for those of us with chronic illnesses,” says Dania Palanker, an assistant research professor for the Center on Health Insurance Reforms at Georgetown’s Health Policy Institute. “Is maintaining your health … urgent care? Not something we usually put in the box of ‘urgent,’ but if we don’t take care of it, it’s going to get urgent or emergent.”

Palanker knows this because she is a patient herself. I talked to her while she was driving to Philadelphia from the Washington, DC, area to get a nerve block treatment for her chronic pain caused by a rare autoimmune disorder. Her regular clinic had stopped all outpatient services because of Covid-19.

For Palanker, and many other patients like her, her chronic condition is not something that can be put off. “I feel very intense pain pretty much everywhere in my body,” she says. “Yeah, it’s not life or death, but it’s not just quality of life. There’s pain that impedes on your quality of life and there’s pain that impedes your life.

“I’m not able to play with my daughter in the way that I would like to. I don’t have the energy, and I’m usually in too much pain to run around.”

Palanker was able to travel to Philadelphia for the treatment, but plenty of other people don’t have that flexibility. This likely won’t be a short-lived crisis, either. Primary care visits have dropped by nearly 50 percent during the Covid-19 pandemic in the United States, according to a new study from Harvard researchers; some specialists have seen even steeper declines. Independent physician practices might soon have no choice but to close or allow themselves to be bought out by insurance companies or a larger health system.

“I think many primary care practices are in critical condition because I don’t think they can survive much longer in the business model they’re currently in,” Bob Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, told me.

The stimulus bills passed by Congress have provided some relief, but it might not be enough. “The real worry is [if] eight weeks from now, hundreds of primary care physicians are shuttering their practices,” Doherty said.

Covid-19 has exposed many weaknesses in American life, including the vulnerabilities of the US health care system. In a nation that already trailed other rich countries in access to health care, America’s primary care is imperiled by this pandemic — now and in the future.

Doctor visits have fallen steeply during the coronavirus pandemic

Dr. Bill Fox has been part of a small independent primary care practice in Charlottesville, Virginia, for nearly 20 years. He says he’s never experienced anything like what he and his two partners are seeing now.

Their office is seeing half as many patients as they usually would, and the vast majority of their appointments are now being done by phone or video call. Revenues are way down.

“This is a completely unprecedented event I don’t think any of us could have imagined,” Fox told me. “I think even for those people who understood that pandemics could occur, I don’t think anyone gave thought to what that would mean to being a physician in a small independent practice.”

New data shows Fox and his colleagues are not alone. Researchers from Harvard University collaborated with Phreesia, a health care technology firm that works with more than 50,000 providers nationwide on patient registration and other administrative tasks, to measure the size of the coronavirus impact.

Their findings, published by the Commonwealth Fund, suggest an unparalleled crisis: Overall outpatient visits plummeted nearly 60 percent from the first week of March to the last. The numbers have stayed low through mid-April.

“Within my lifetime, I have not seen anything of this magnitude,” Ateev Mehrotra, a professor at Harvard Medical School who led the study, told me.

He also said that “our real concern is those patients who might have deferred a visit and they’re going to have a flare-up of their chronic illness.” In a worst-case scenario, that could lead to patients dying at home — a person with heart failure, for example — who might not have died if they’d been able to see their regular doctor. This will add to the death toll of Covid-19, but it will be hard to fully measure.

According to the study, some specialties have been hit harder than others. People have almost entirely stopped going to ophthalmologists for eye checkups and treatments (visits are down 79 percent). Dermatology (down 73 percent), urology (63 percent), and cardiology (61 percent) visits are also experiencing some of the sharpest declines. So are pediatric practices, where visits are down more than 60 percent.

But it’s all relative. The ostensibly less-affected fields have still endured dramatic drops in their business. Adult primary care visits have fallen by 49 percent. OB-GYN clinics are seeing half as many patients as usual. Even oncologists, who treat cancer patients, have seen their business cut almost in half during the coronavirus outbreak.

Increased telehealth visits have offset some but not most of those losses. Medicare and private insurers have increased eligibility and reimbursement for those virtual visits to allow patients to consult with their physicians and to help doctors recoup some of their losses from in-person visits. But even this surge in phone and video consultations, which accounted for a small percentage of all visits in early March and are up to nearly 30 percent of all visits now, has made only a small dent in the losses doctors are experiencing.

Doctors can only do so much over telehealth, too. Certain prescriptions can require an in-person consultation. And physicians often won’t accept new patients over phone or video calls.

Palanker says she worries about people recently diagnosed with diabetes or heart disease who won’t be able to get that critical first appointment with a new doctor. “You can’t delay those appointments for a few months,” she says.

Independent practices are the most at risk of closing or being bought out

The threat to independent practices is a matter of simple economics: They do not have the same amount of capital or reserve funds to fall back on that hospitals and large systems do. It’s the same reason that solitary rural hospitals are more threatened during the coronavirus crisis than academic institutions or systems composed of several facilities.

America’s doctors have gradually been shifting from independent practitioners to employees of larger health systems, often owned by hospitals, over the decades. In 2018, the number of doctors who were employed by a health system narrowly surpassed, for the first time, those who owned their own practice, the culmination of that long-running trend.

Experts expect the toll of the coronavirus pandemic to cause even more consolidation. The only other option might be to go out of business.

“What happens to the structure of primary care? I fear you could end up with a very different-looking structure, with many [practices] shuttered. Many of them could be bought by insurance companies,” said Andy Slavitt, who oversaw Medicare and Medicaid during the Obama administration. “I could see a real decimating of independent primary care, and specialists impacted as well.”

The funding provided by the CARES Act will help, but it only goes so far. Doherty told me the first payout from the emergency fund set up by that legislation probably covers a couple of weeks of lost revenue for most practices. Federal assistance could run out before business returns to normal.

Fox, the Charlottesville physician, told me that if he and his partners continue to see the volume of patients they’re seeing right now, they could probably pay most of their overhead but wouldn’t be able to afford to pay themselves a salary.

The Paycheck Protection Program should help them for a couple of months. But beyond that, the future is uncertain. Fox said he and his partners haven’t started planning for what they’ll do if they can’t afford to keep the practice open, but with all of them in the middle of their careers, retiring isn’t an option. They’ll have to find a way to work.

“Physicians who go into independent practice and stay there for as long as we have believe in the ethos of independent practice,” he said. “But we all recognize in the back of our minds, there’s a possibility we might not make it through this disruption to our practice.”

Telehealth visits are expected to stay up, but Doherty worries patients will be reluctant to visit a doctor’s office anytime soon unless absolutely necessary.

“Under almost any circumstances, practices are not bringing back the volume of in-person visits anytime soon,” he says. “It just becomes a simple question of math. They’ve gotta pay payrolls, and they don’t have the revenue to support it.”

That leaves closures, retirement, or mergers as options. Palanker told me her greatest fear for herself is that her neurologist, whom she’s seen for nearly a decade, will decide to retire because of the economic shock of the pandemic.

“He’s gotta be hemorrhaging money right now,” she said. “I keep waiting for that email that he’s retiring.”

US health care access could get even worse

With every doctor’s office that closes or every physician who gets bought out by a bigger company, health care access in the US will only get worse. America already has fewer doctors and nurses per capita than other wealthy countries.

And those losses are likely to be disproportionately felt in rural America (80 percent of which was already found to be medically underserved, according to 2019 federal estimates) and by black or Latino patients, who have historically had less access to primary care than white Americans.

Even if physicians survive by joining a larger system, that might not mitigate all the damage to health care access. Doctors could be asked to move as a result of their mergers, Palanker told me, drawing them farther away from their patients.

“The aftershocks on primary care will be huge. I’m terrified what we’ll see is left of our independent practices,” she says. “I fear a lot of provider deserts are going to be worsened.”

And then there is the problem of prices.

Health care concentration of any kind, whether hospitals merging with one another or primary care and specialty practices merging into hospital systems, has been found to drive up health care costs.

Brent Fulton, an adjunct professor at the University of California Berkeley, summarized the existing research in Health Affairs in 2017:

Overall, these studies have found that higher concentration was associated with higher physician prices across a range of services, including three types of commonly billed office visits, office visits across ten prominent specialties, orthopedics, cardiology and orthopedics, and common outpatient procedures.

Already, doctors in the US are far more likely to say their patients have cost-related access problems (33 percent) than physicians in other wealthy countries (the average was 13 percent across 10 other wealthy nations, per a 2016 Commonwealth Fund survey). One in three Americans said last year they had skipped medical treatment because of the cost.

Millions more Americans now are uninsured because they lost their jobs during the coronavirus recession, and, when the dust settles, the physician market will probably be more concentrated. That will drive medical prices, and therefore insurance premiums, even higher. Out-of-pocket costs could rise as insurers shift more of those excess costs to their customers. It will be that much harder for many Americans to access and afford health care.

The US could have made policy changes that would have prevented such a deleterious impact on doctors just because in-person visits are down. Right now, many primary care doctors are paid on a fee-for-service basis, which means they bill insurers and patients for every visit and service. So when those numbers drop off, so does revenue.

There are other ways to pay doctors. Many other developed countries use global budgeting, which sets the income for hospitals and doctors at the beginning of the year based on the services they are expected to provide. There are other variations, but the core principle — doctors can expect a set amount of income and don’t have to tally up visits and services to make their revenue goals — is largely the same.

But, as Doherty put it, changing how American doctors get paid would be “a very long bridge to get across.” A crisis like the coronavirus could lead to such fundamental changes to US health care, but the odds are against it. The history of US health reform is generally one of more marginal changes, with many of the more ambitious plans falling short.

Instead, Doherty is worrying about two or three months from now, when doctors might decide they have no choice but to shut down their practices. His thoughts drifted to chronic-care patients like Palanker, who depend on having easy access to their doctors to manage their conditions.

“Who’s going to provide that care?”