Changes in telehealth reimbursement and federal relief funding might not be enough to bolster many primary care practices during the COVID pandemic.
Low patient volume and inconsistent reimbursement are hampering cash flow, resulting in furloughs and layoffs, according to a survey of 1,000 primary care clinicians in 48 states and Washington D.C.
Most clinicians (89%) report large decreases in patient volume, and 57% say that less than half of their visits in the last week were reimbursable, according to the survey from the Larry A. Green Center in partnership with the Primary Care Collaborative that was conducted April 17-20 to measure the impact of COVID-19 on practices.
A majority of respondents are using video for less than 20% of their visits (43%) or not at all (14%). Instead, 44% of respondents are using the telephone for the majority of their visits. Two-thirds of clinicians (65%) report they have patients who can't use virtual health as they have no computer or Internet.
“The picture in primary care remains grim,” 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. “Clinicians are under siege, especially financially, and the burdens on patients are only getting heavier. Yet staff on the health care front lines continue to heroically respond to their patients.”
The Centers for Medicare and 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.
But physicians have complained that reimbursement is lower for audio-only telehealth visits compared to audio and visual telehealth visits. And, under current CMS rules, any diagnosis made during an audio-only visit with a patient cannot be used for risk adjustment purposes.
"Reimbursement rates for telehealth do not equal an in-person visit and should," a clinician practicing in Pennsylvania said.
"Older patients have no or limited access to the internet and devices. Reimbursement for visits low or non-existent to date," said another clinician in Arkansas, according to the survey.
Survey raises doubts on readiness to reopen
The survey results underscore that the country does not seem to have good information about the prevalence of COVID-19, raising questions about whether it is safe to resume the economy, according to the Primary Care Collaborative.
Despite some policymaker statements that testing is adequate, reports from frontline primary care clinicians indicate that one-third have no testing and 50% do not have adequate personal protective equipment (PPE) that makes testing possible.
Over half of respondents (54%) report the use of “used and homemade PPE."
The survey also found that many primary care offices, where testing of many Americans would take place, are on the brink of financial collapse; 42% say they need to lay off or furlough staff.
“The stimulus package just passed by Congress must direct at least some of the funds to primary care testing and PPE,” said Ann Greiner, president and CEO of the Primary Care Collaborative. “Policymakers also need to provide relief to primary care practices immediately to assure that the nation’s front door to health remains open to address patients with varied social, behavioral, and clinical needs and to help assure Americans that it is safe to return to work and school.”
The pandemic’s financial strain on practices is continuing, and current stopgaps are not enough, according to primary care leaders.
"Only a small amount utilizing telehealth. Office could potentially close. We have not been able to sign up for Cares due to bank site crashing," said one clinician in Pennsylvania, according to the survey.
Another clinician in Colorado said, "Large furloughs for front desk staff, all employees have lost their employer paying into retirement accounts, no clear path to reopening clinic for more in-patient visits—we are encouraging most patients to schedule by telehealth."
Practices also are serving patients with increasing COVID-19-related health burdens—particularly among those who have lost employment or have pre-existing mental health concerns.
Clinicians report that those patients, along with those who have weak social supports, including the elderly, are at a particularly high health risk.
Primary care physicians are increasingly concerned about patients deferring care due to COVID.
"I worry about chronic illness unattended as a result of lack of access to 'non-essential' care. I am imagining that next year we will be seeing increasing morbidity and mortality from cancers undetected, blood pressures out of control, etc.," a California clinician said, according to the survey.