After more than two months into the COVID-19 pandemic, the overall picture for primary care practices remains tenuous as clinicians say they need a financial lifeline.
More than half of clinicians (55%) fear they are unprepared for the next wave of the pandemic due to high stress among clinicians, limited access to testing and adequate personal protective equipment (PPE), and patient struggles with technology, according to a survey of 730 primary care clinicians in 49 states and Washington, D.C.
The factors contributing to this fear include the 76% of clinicians who say they are under "severe" or "near-severe" stress; the 51% who say they continue to have no or severely limited access to testing; and the 59% who say they continue to have no PPE, according to the survey from the Larry A. Green Center in partnership with the Primary Care Collaborative that was conducted May 15-18.
"We are scheduled to open on [June 1] and have no PPE at all," a primary care provider in Connecticut said in a response to the survey. "Clinicians are required to find their own. Very frustrating to say the least. I am expected to see patients without the proper equipment putting myself and my family at risk."
The majority of clinicians (84%) also say they have patients who struggle with digital health platforms and 20% report they have patients who experience significant obstacles to using telehealth.
Primary care practices are beginning to report some modest improvements in key areas, such as an increase in testing capacity beyond CDC guidelines (29% to 35%) and reduction in the percentage of practices temporarily closed (19% to 12%).
But providers are continuing to feel the financial strain due to reduced patient volumes, with 53% saying they want "payment of any kind at this point," the survey found.
"I will sell my practice or shut it down. I don’t think I can break even and don’t want to go into debt at age 70," a primary care clinician in North Carolina said, according to the survey.
Patients are continuing to delay or postpone chronic and preventive health concerns due to stay-at-home orders, clinicians report.
Only 12% of clinicians say that routine check-ins with cancer survivors are happening as usual. And a majority report that follow-up for lung disease, hypertension, or diabetes is happening “very little” (58%) or “not at all” (2%). Instead, the most common care being performed as usual is the evaluation of new symptoms or acute injuries and accidents.
Preventive care is largely not happening. Only 5% of respondents say that routine cancer screenings are happening as usual; 28% say they’re not happening at all. Vaccinations are similarly down: Only 13% of clinicians report routine child immunizations are happening as usual, and 10% say so for adult immunizations. Screening for post-traumatic stress disorder (PTSD), depression, or anxiety is happening very little (50%) or not at all (8%).
"In this week’s survey, we see a growing concern among clinicians about preventive and chronic care that isn’t happening, either because patients are putting off anything but the most urgent health concerns during the pandemic or because some preventive and chronic care needs are not amenable to digital health platforms,” said Rebecca Etz, Ph.D., co-director of The Larry A. Green Center and associate professor of family medicine and population health at Virginia Commonwealth University.
“Front-line clinicians are in a double bind: They can take care of their patients without sufficient payment and without sufficient personal protection from COVID-19, or they can abandon their patients. They choose to continue to serve, despite the hardships. It’s inspiring," Etz said.
According to the latest survey, 40% of primary care clinicians continue to report laid off or furloughed staff, and 42% report staff out due to illness or quarantine.
A primary care provider in Maryland said, "As the least paid of the specialties (pediatrics), I am unsure that we will be able to weather a full summer/winter. If there is no school in the fall, there will be no incentive for parents to bring their children in and we will have to close our doors."
Clinicians have rapidly shifted to virtual care during the pandemic to care for patients remotely.
Beginning in March, the Centers for Medicare & Medicaid Services (CMS) made sweeping, but temporary, changes to telehealth reimbursement policies and agreed to pay for virtual visits at the same rate as in-person visits while the coronavirus emergency remains in effect. As of March 30, CMS is now allowing more than 80 additional services through telehealth.
For the past two months, survey data have shown that video visits were still slow to happen at many primary care practices and telephone visits were more common, but often these telephonic visits were not reimbursed.
But for the second week in a row, more clinicians (29%) reported using video for the majority of their visits as compared to telephone (25%). Yet challenges to telehealth remain. Eighty-four percent of surveyed clinicians report “patients who struggle with virtual health (internet or computer trouble)” as a stress on their practice.
Only 57% of respondents say that half or more of the care they provide is reimbursable. And 18% of clinicians report denied billing for virtual and telehealth.
"Congress and the administration need to provide immediate, targeted relief to primary care to stop the hemorrhaging and also address longer-term, system-wide financial issues that undervalue primary care," said Ann Greiner, president and CEO of the Primary Care Collaborative. “Getting all practices PPE and testing is way overdue, as is moving primary care to a prospective payment system that is resourced adequately to truly meet patients’ medical, behavioral and other needs.”
Respondents’ specialties were: family medicine (67%); pediatrics (7%); internal medicine (16%); geriatrics (4%); and other (7%). Nearly a quarter work in rural practices, 18% at a community health center, and 17% at school or offices. Among the respondents, about one-third of the practices were self-owned, 19% were independent and part of a larger group, and 40% were owned by a health system.