Little or no protective equipment. No testing abilities. Fears of losing their practices. Staffing outages. Phone lines flooded with patients concerned about coronavirus.
Primary care practices are being hard hit by the coronavirus outbreak and many physicians describe desperate conditions, according to a new survey (PDF) of more than 500 primary care clinicians across 48 states.
Close to half of primary care practices (46%) lack testing capacity for COVID-19 and just over half (51%) lack adequate personal protective equipment (PPE), according to the survey from the Larry A. Green Center in partnership with the Primary Care Collaborative that was conducted March 13-16 to measure the impact of COVID-19 on practices.
The survey included clinicians in some of the hardest-hit states, including California and New York. Respondents to the survey largely represent family medicine (70%), followed by pediatrics (14%) and internal medicine (11%), and nearly three-quarters work in a practice with more than three clinicians. The five states with the highest number of responses were: Virginia, Colorado, California, Pennsylvania, and New York. Responses included 86 rural practices.
Over a fifth (21%) of respondents reported that the COVID-19 outbreak has had a “severe impact” on their practice; another 30% report the strain as “close to severe.”
Comments from many of the doctors paint a bleak picture as they face multiple clinical and operational challenges.
Lack of protective equipment
Close to half of respondents took the time to comment on their experiences and, of those, 85% said they lack access to PPE and testing.
“We have no face masks or respirators. They are on permanent backorder. I have no way to protect myself or my staff from infection. We reached out to the hospital and they have none to spare. We have no gowns or eye protection and no rapid test. We have been sending everyone to the ER. I need supplies yesterday,” said one survey respondent.
"I cannot get PPE. We have NO masks of any kind,” said another physician.
A total of 31% of respondents said they are running their offices without some employees, risk financial collapse as they are canceling face-to-face patient visits that generate the bulk of their revenue and expressed helplessness with their situation.
Staffing outages due to illness are already hitting clinicians (20%), nursing staff (17%) and front desk support (13%), according to the survey.
Practices report being overwhelmed by patients’ virtual questions, limiting routine primary care to address patients at risk for the virus, lack of supplies to meet the needs of patients who may have the virus and clinicians out due to illness or self-quarantine.
The financial impact on practices is real. Survey respondents report they have canceled well and chronic care visits to accommodate need (58%), lack enough available appointments (17%) and their phone lines are flooded with patient concerns (74%). They also report new workflows, extensive phone triage, care coordination and redesigned work areas and systems to limit exposure to the virus—largely unpaid activities.
“I am a solo practitioner. I am afraid we will get sick, have to close and I will lose my practice,” said one doctor.
“We are paid strictly on RVU [relative value unit] so we are going to have a dramatic financial risk. I have one N95 mask and no eye protection or gowns at all even before this thing has started. We can’t test but it is clearly here. Please help us,” another physician said.
Challenges caring for patients
Just after the survey closed, the Department of Health and Human Services (HHS) announced it is waiving certain Medicare telehealth payment requirements. It will allow doctors to treat patients in their homes via telehealth services and be paid under the Physician Fee Schedule at the same amount as in-person services.
And while the government has relaxed requirements for telehealth, some say that won’t help all patients.
“Telehealth for a technologically underserved population—a major problem,” commented one clinician. And 11% of respondents commented on health risks related to social inequities and fears routine preventive care is being ignored.
“Parents aren’t bringing children in for wellness visits. Babies are not being vaccinated—other illnesses still exist!!!,” wrote one clinician.
And coronavirus is creating health issues for patients beyond respiratory symptoms. “Right now, worried well and acutely increased mental health issues are our biggest patient-related problems,” said another clinician.
Shortage of testing kits
Survey respondents highlighted problems with the government’s early restriction on who should be tested for coronavirus and a lack of test kits. A third (34%) reported only having the capacity to test based on CDC guidelines and restrictions.
“Frustrated. Health department telling everyone to see primary care providers for testing. We don’t have tests,” said one respondent.
“It is appalling to me that we don't have broader testing capabilities,” a physician said. "I had a patient two days ago who absolutely should have been tested."
The patient tested negative for flu, but because she had not traveled internationally or had known contact with someone with coronavirus, the practice could not test her. “We know it's here in our area, and we aren't looking for it like we need to be. It's maddening,” the clinician said.
As coronavirus has spread, the government is now advising that anyone with symptoms be tested.
Over 30% of respondents expressed frustration with failed leadership and confusion in the face of constantly changing or conflicting guidelines.
“Enormous amounts of time and stress it takes to train, then re-train, then re-train, then re-train on the constantly changing protocols,” said one respondent.
A medical director at two nursing homes said staff have essentially no PPE and the facilities cannot get the hospital or public health department to test patients with respiratory infections before sending them to the nursing homes.
For many clinicians, the stress is showing.
“I may have already been exposed and have no way to know if I am an asymptomatic carrier to others,” said one clinician.
Another physician said, “Difficulty determining clinically which patients should be tested, running out of personal protective equipment, looming sense of doom that cases will spike suddenly and healthcare system will be overrun."