Ambulatory care providers in California are emerging from the initial trauma of the COVID-19 pandemic to an uncertain future.
As the state-initiated shelter-in-place requirements in March, most ambulatory provider clinics and practices immediately experienced a massive drop in in-person patient visits and revenue. The CARES Act, alongside temporary policies that facilitated a rapid shift to telehealth services, helped improve access and provided some financial relief, but not enough to prevent many furloughs and layoffs of staff and the shuttering of many practice locations.
As the pandemic enters a new phase and the economy reopens, providers are preparing for additional challenges that lie ahead. These include handling the anticipated surge in demand for face-to-face encounters by patients who have delayed seeking treatment while simultaneously encouraging patients to come in for missed preventive care such as well child visits and associated vaccinations, adopting new virus-control workflow protocols that will reduce productivity and dealing with the anticipated significant shift of commercially insured patients to Medi-Cal or uninsured status.
Manatt spoke with the California Medical Association (CMA), two community clinic consortia and an academic health system’s ambulatory leaders to understand the implications of COVID-19 on California providers and their outlook for the future. This Industry Voices piece provides insights into their experiences and considers policies and regulatory changes that could help restore and improve access and services for California residents—and beyond—in the peri- and post-COVID-19 worlds.
Care delivery and workforce impact
The advent of COVID-19 triggered a meteoric adoption of telehealth, associated adjustments in clinical workflow and a scramble for personal protective equipment (PPE). Ambulatory providers rapidly switched to virtual contact modalities, initially focusing on serving patients by phone as they ramped up video visit capabilities and adjusted workflows. While many patients were receptive to virtual care, clinics reported that telehealth has been a game-changer for behavioral health, reducing historical in-person no-show rates from 30% to less than 5%. On the other hand, clinical leaders report that dental services, ophthalmology services and school-based clinics suffered tremendously, resulting in steep declines in revenue and in workforce reductions that threaten to undermine the delivery of these services in the future.
The pandemic has also required the adoption of new clinical protocols and workflows to change how providers triage and intake patients. Providers are developing medical necessity criteria to determine when patients should receive care by phone, by video visit or in person, and new protocols for screening patients for COVID-19 before they enter a facility. Protocols are being developed to define the roles of all care team members, including allied health professionals who support telehealth workflows by preparing patients and documenting conditions before the patients are “seen” by a doctor. Clinicians face longer-term questions about the nature of the care team, how the team functions as a unit virtually and whether their phone and telehealth capabilities are sufficiently robust to support seamless electronic health record integration.
The immediate and drastic shift in care delivery due to COVID-19 has taken a massive financial toll on providers. According to a CMA survey released in late April, practice revenue declined by nearly two-thirds starting March 1, with three-quarters of practices experiencing an immediate decline of 50% or greater. Between the shelter-in-place announcement in March to early May, 37% of primary care physicians (PCPs) surveyed by the California HealthCare Foundation (CHCF) furloughed or laid off staff, and 14% furloughed or laid off physicians. One-third of California PCPs worry that their practices will be shuttered due to the financial impact of the pandemic, according to the CHCF survey, and CMA estimates that over 13 million Californians are at risk of losing access to their physician absent decisive action to help medical practices.
Practices with fewer than 500 employees were eligible to receive paycheck protection support from the federal government while they waited for the return of pre-pandemic patient volumes. However, insurance coverage changes, including an anticipated significant shift to Medi-Cal coverage and a potential lag in care among those considering COBRA after a layoff, will likely amplify the strain on provider networks.
Preparing for Reopening
As capacity ramps back up, different challenges lie ahead for providers. A large anticipated surge in demand for face-to-face encounters by patients to address delayed health issues will require many providers to rehire and retrain staff and incorporate new virus-control workflow protocols that will slow productivity. As a lack of both evidence-based testing and quarantine protocols remain a concern for clinician, staff and patient safety, providers will need to encourage patients to come in for preventive care services, particularly to administer childhood immunizations, which have significantly declined since March.
Most providers scrambled to access PPE at the beginning of the crisis. And while some found creative ways to navigate the frothy supply chain—competing with other providers, governments and countries for dwindling supplies of PPE and testing equipment—over 30% of primary care physicians surveyed by CHCF in early May report still not having adequate PPE for clinicians to treat their patients. While PPE production volumes increase, accessing these supplies will likely remain challenging as more buyers, including a large number of retailers, restaurants and other businesses, seek them out.
Providers, particularly in those regions most significantly impacted by COVID-19, may face their own emotional struggles based on their earlier experiences caring for COVID-19 patients. In response to this, at least one clinic consortium is offering “emotional PPE” focused on anxiety reduction for clinic staff.
Policy and practice changes
As providers dig out from the pandemic, federal and state government agencies and payer partners can help providers recover by adapting and making permanent some of the temporary policies that were initiated as COVID-19 gripped the country.
The expansion of telehealth reimbursement and parity payment policies has been a lifeline for patients and providers that should be maintained beyond the COVID-19 era. However, additional guidance, including protocols regarding appropriateness, medical necessity and safety, is needed to ensure that telehealth is used in the right circumstances. Consistency of telehealth coverage across ERISA and non-self-insured plans would also help ease implementation at the practice level.
Federal and state governments can also advance technology, workforce and coverage eligibility policies to better support providers and their patients by acting on the following considerations:
- Expanding broadband services across California would help ensure patient access to vital services, particularly in rural communities but also in underserved urban areas.
- Health information exchange policy and infrastructure development is needed now more than ever to enable providers to remotely care for patients, quickly access test results and share them with the broader care team, avoid the costs and exposures associated with duplicative tests and in-person services, and enable closer coordination with public health to facilitate testing, reporting and contact tracing.
- Adopting policies to streamline eligibility and renewal processes for Medi-Cal and CalFresh for individuals who recently lost employment, including offering presumptive eligibility and a virtual option for CalFresh’s federal in-person interview requirement, will provide a consistent source of income for outpatient clinics serving these patients while relieving the administrative burden on their staff who must navigate the insurance fluctuations of their patients.
Despite the trauma that has been inflicted by the pandemic, there are some silver linings that may emerge if temporary state and federal policies can be meaningfully and thoughtfully adapted as we emerge from COVID-19. The early lessons drawn from the outbreak can serve as a catalyst to implement lasting reforms that could help the health system emerge more resilient and prepared than it was before the crisis.
Jonah P.B. Frohlich is a managing director at Manatt Health. Megan K. Ingraham is a director at Manatt Health.