Family doctors face salary cuts, leave and supply shortages

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Dr. Greg Gulbransen performs a medical examination on a 72-year-old man with leukemia who is presumed to have coronavirus disease (COVID-19) while in his pediatric office in Oyster Bay, New York, United States, April 13, 2020.

Lucas Jackson | Reuters

Dr. Rafael Guillen spends a lot of time on the phone these days. His practice in the Bronx closed in mid-March to protect staff and patients as the coronavirus pandemic escalated in New York. He calls patients with the virus morning and evening to monitor their condition, about 60 people so far.

Guillen’s small internal medicine practice struggled not only to keep up with the virus, but also to make ends meet financially. Many primary care practices were already operating on tight budgets, and the pandemic is now threatening to drive some of them into bankruptcy.

Guillen said his office’s revenues were down about 50% from March to May compared to last year, as the volume of his patients fell during the pandemic. Many people simply avoid the doctor because they fear catching Covid-19 if they need treatment in the hospital, said Guillen. Insurers in the United States primarily pay medical offices per office visit – fewer appointments mean lower revenues. His transition to telemedicine could not make up for the deficit.

If a multitude of primary care physicians closed their doors permanently, communities would be ill-equipped to contain a second coronavirus outbreak that could occur in the fall, which would coincide with flu season. The shrinking and disappearance of medical offices could lead to future epidemics because sick patients are not treated and children do not receive important vaccines. Guillen warns of an impending mental health crisis as isolated patients express feelings of helplessness, anxiety and hopelessness.

And as millions of Americans have lost their jobs due to the pandemic, many no longer have health insurance. Guillen sees a number of patients who have lost their insurance, but said others are simply avoiding the doctor right now. Many in New York are likely to be covered by Medicaid, but it’s not automatic – you need to request it.

“I will not stop seeing a patient because he has no insurance,” said Guillen, but the cost is weighing on his practice. “Before the pandemic, we were in trouble, and what this pandemic revealed was all that was deficient,” he said.

“Small practices hardly succeed”

For many Americans, the family doctor is their primary entry point into the health care system. In 2016, primary care physicians made more than 480 million patient visits, or 54% of all visits to Canadian doctors’ offices, according to a survey by the Centers for Disease Control and Prevention. Primary care includes pediatricians, who treat children; internal medicine physicians who treat adults; general practitioners, who cover all age groups; and gynecologists, who specialize in women’s reproductive health.

Although primary care physicians play a huge role in the overall system, they receive a small portion of the overall expenses. From 2002 to 2016, primary care physicians received less than 7% of healthcare spending in the United States, according to a recent study published in the peer-reviewed journal JAMA Internal Medicine. Guillen said his overhead costs have continued to increase during his practice over the years, but his income did not keep pace even before the pandemic.

“The cost of living has gone up enormously, but our benefits have remained the same,” said Guillen. “There are small practices that barely succeed. There is so much to pay and it has all increased except your income. I am not interested in money, but the bottom line is, to keep my office open, I need money. “

The federal government created a $ 175 billion relief fund to support health care providers facing financial difficulties due to the pandemic, and $ 30 billion was automatically sent to providers on the basis of Medicare payments 2019. However, Guillen’s practice received only $ 397 because he did not have many Medicare patients, according to a beneficiary database maintained by the Department of Health and Social Services. Much of the relief money has gone to larger hospital networks.

No specific funding has been set aside for primary care physicians, many of them work in small practices in underserved areas. The Bronx, where Guillen practices medicine with a staff of only three, is one of the most affected boroughs in New York, which itself has the highest number of coronavirus cases of any city in the United States . More than 44,000 people tested positive for the virus in the Bronx and at least 3,492 people died, according to the New York Department of Health and Mental Hygiene.

The Bronx has the highest positive test rate in the city with 34% almost double the city average, according to antibody tests by Northwell Health. Guillen said there are hotspots in the Bronx where transmission of the virus is increasing, although much of New York City has passed the peak of infection.

Many Bronx residents, especially people of color, lacked insurance and did not have adequate access to health care before the pandemic, said Guillen. The borough has the highest poverty rate in the city and the worst health outcomes in New York State, with high rates of so-called morbidities that make patients more likely to die from the virus, including asthma and diabetes.

With little direct federal support, doctors like Guillen apply for small business loans through the Paycheck Protection Program, which means they compete with other businesses – from restaurants to independent contractors to publicly traded companies. purse for money. Guillen’s request was approved and it was funded earlier this month, but said the loan was only enough to cover costs for about four weeks.

His firm’s financial outlook remains “uncertain,” said Guillen, because even when its doors reopen, patient volumes will remain below normal as he implements social distancing measures in his waiting room.

“Radically change our business model”

It’s not just the doctors’ offices in New York, the epicenter of the US coronavirus epidemic, who are struggling financially. About 51% of primary care providers are unsure about their financial future in the next four weeks, and 42% have laid off or laid off staff, according to a survey of 2,700 practices in the United States by Nonprofit Primary Care Collaborative and Larry A Green Center. In addition, 13% plan to close in the next month.

Dr. Conrad Flick said that the independent clinic where he practices medicine in Raleigh, North Carolina, saw a sudden 70% drop in patient volumes week-to-week at the end of March , people fearful of going to the doctor and being housed there. Her clinic, Family Medical Associates of Raleigh, is a small practice with five doctors and five nurses.

“We are a small business and our profit margin is 3% or 4%,” said Flick. “It doesn’t take a lot of business sense to know when the patient volume is down 70%, you’re in trouble. “

Even with fewer patients, Family Medical Associates had to adapt quickly to protect its staff and those who were still entering. They converted part of the building that had been used as a weight-loss clinic into a space for examining patients with Covid Symptoms19. The clinic also installed plexiglass screens in the check-in and check-out areas.

But as the demand for tests increased, practice decided that it was safer to see potential patients with coronavirus in their cars in the parking lot. Personal protective equipment for staff – especially N95 masks and gowns – began to run out. And within days, LabCorp’s inventory of nasal swab tests was about to run out. They decided to reserve what was left to test the staff in case they developed symptoms.

Dr. Conrad Flick and nurse practitioner Ryan Johnson of Family Medical Associates in Raleigh, North Carolina. Independent primary care clinics have been hit hard by the pandemic.

Source: Family Medical Associates

A handful of Flick’s patients tested positive for the coronavirus, and two were so sick that they had to stay in hospital for several days for follow-up, he said. Fortunately, they did not need to be placed on fans. The practice now directs most patients with symptoms to larger screening centers affiliated with hospitals.

In difficult financial situations, Family Medical Associates sought to compensate for the drop in office visits by quickly switching to telemedicine, but the volume of patients is overall still down by more than 25%. Flick and two doctors who owned the office were cut in wages by 45% while the other two doctors in the office were cut in wages by 25%. The mortgage was delayed for three months, and the practice nearly laid off a third of staff until she obtained a small business loan under the second cycle of the paycheck protection program.

Flick said the loan would only buy Family Medical Associates about six weeks of credit if the patient volume returned to its worst of the crisis. Many doctors are concerned about a second coronavirus outbreak in the fall or winter, new home support orders and new financial pressures.

Contrary to Guillen’s practice in the Bronx, Flick has more Medicare patients and has received about $ 31,000 from the federal government relief fund. It also helps his practice get out of the crisis as they look for ways to adapt to an uncertain post-pandemic reality. For the moment, the practice follows the evolution of patient volume and income.

“We are going to radically change our business model,” said Flick, “because I don’t think the number of patients we used to see will arrive soon. “

“Telehealth will not be enough”

As the pandemic transforms primary care, there is concern that future public health crises may loom. Many patients with chronic conditions are hospitalized and treatment with telemedicine can be difficult, especially when they have multiple conditions, said Dr. Robert Phillips of the American Board of Family Medicine.

“These people are going to come out of their hiding place and need help, and telehealth will not be enough,” said Phillips, “and if their practice disappears, we will see many more people die – not from Covid but from the effects of that. “

Not only is it difficult to treat patients with chronic conditions through telemedicine, but from an income perspective, it usually doesn’t pay as much as office visits. Medicare has agreed to cover telemedicine generally at the same level as office visits for the duration of the national emergency, but it is unclear if these changes will become permanent. State-based commercial and Medicaid insurers have a range of different policies on the matter.

Patients with chronic conditions who cannot be treated with telemedicine often give up treatment because they fear they will get the virus when they visit their health care provider. Phillips recently urged an 82-year-old patient with a serious thyroid problem to go to the hospital, but the patient refused. “They are terrified,” he said.

Phillips practices medicine at a clinic in northern Virginia that is part of a group called Fairfax Family Practice Centers, which has 12 primary care offices and 500 employees. The pandemic has reduced patient volumes by 50%, resulting in a 60% drop in revenues. In response, the group put 50 people on leave and cut most other workers’ work hours by up to 50% while retaining their benefits. Doctors suffered 40% salary reductions and nurse practitioners 20%.

Fairfax family medicine centers received approximately $ 600,000 from the federal government’s relief fund. Crystal Mayers, the firm’s chief administrator, said the money was “extremely useful” but was still enough to cover a single pay cycle for staff at each firm. The Fairfax group is now entering its 10th week of vacation and salary cuts.

Vaccines cannot be administered by telemedicine either, and epidemics of infectious diseases other than the coronavirus are of growing concern. In the hard-hit city of New York, the number of vaccines given to children is down 63% from a year ago. The Centers for Disease Control and Prevention have warned of possible measles outbreaks after finding that vaccine coverage in Michigan has dropped 70% from last year.

“Primary care in general is in a very precarious state, and I fear that many practices will not reach the other side,” said Dr. Christoph Diasio, vice president of the North Carolina Pediatric Society. “I am concerned about what this means for children, as the bulk of vaccines for children take place in independent clinics. “

The Diasio practice, one hour south of Raleigh, reduced staff hours after a patient volume drop of more than 50%. He said applying for a paycheck protection loan was chaotic, but the office was eventually funded. Diasio’s office has not received money from the federal rescue fund because, as a pediatrician, he does not see Medicare patients. A third of primary care providers reported receiving a P3 loan while a fifth received support from the federal relief fund, according to the recent Larry A. Green Center survey.

Guillen, the Bronx doctor, expressed frustration with telemedicine. Not everyone has access to the best technology, and he says it takes longer to take notes when a patient describes symptoms over the phone than it does to face them face to face. Lonely and anxious patients often want to share their feelings about what is going on with the pandemic rather than talking about the main reason they are on the phone with the doctor, said Guillen.

“The most important thing that doctors will do will be mental health after Covid,” he said.

“Primary care could really collapse”

There are more and more calls for direct federal intervention that prioritizes primary care as doctors’ offices are forced to make difficult choices to make ends meet financially in the midst of the worst public health crisis in a century.

The American College of Physicians, which represents internal medicine physicians in the United States, calls on the Trump administration and Congress to provide dedicated financial support for struggling primary care practices, similar to the $ 10 billion earmarked for rural hospitals by the Ministry of Health. and human services.

Phillips estimates that it would cost less than $ 30 billion to consolidate the entire primary care system in the United States until the end of the year. His research will soon be published in Health Affairs peer-reviewed journal. The price would be lower if the government takes a targeted approach that helps practices in rural areas or underserved communities, he said.

“It’s a lot of money, but in terms of total recovery packages, it’s relatively small,” said Phillips.

The consequences of failing to provide direct assistance may prove more costly in the long run. Rebecca Etz, a health policy specialist and co-director of the Larry A. Green Center, warns that “primary care could really collapse” as the pandemic puts pressure on a system that was already suffering from decades of underinvestment. Flick, Raleigh’s doctor, hopes the crisis will give Americans a new appreciation for their family doctor.

“I hope this pandemic will show the United States what the problem is with their health care system – that they have to reinvest in primary care because they need independent primary care as their first line of defense,” said Flick.

Guillen, for his part, plans to reopen his practice in the Bronx on Thursday using CDC guidelines, but there are many unknowns. He is concerned about lacking personal protective equipment, which is expensive, and he is unsure whether he can take tests in his office or not. Finance is the least of his concerns in many ways – for now.

“If I can make enough money just to keep it open, that’s fine with me because I’m a heart doctor,” he said.

– Graphics by CNBC John Schoen.

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