Primary Care Practices Struggle to Survive Despite Visit Rebound

Ken Terry

May 22, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Primary care practices are facing an existential threat, and they need government help now if they are to survive.

That was the main message at a news conference held on Wednesday to announce the results of a study showing that outpatient visits have rebounded across the United States. Having dropped 60% from their pre-pandemic level in early April, office visits are now significantly higher but are still 30% less than the baseline, on average, according to new data from the Commonwealth Fund, Harvard University, and Phreesia, a health information technology firm.

The outpatient visits study shows that most of the recovery was due to a rise in in-person visits, not telehealth encounters, which have plateaued. The rebound was more pronounced in some regions, like the South and Southwest, than in others, such as New England and the Mid-Atlantic.

Primary care practices are now experiencing 25% fewer visits than they did in early March, the study shows. While some other specialties have seen a greater dropoff in visits, speakers at the news conference drew reporters' attention to the financial plight of primary care.

"Primary care practices are in dire straits, and their ability to treat patients is under threat," said Melinda Abrams, MS, senior vice president of delivery system reform and international innovations for the Commonwealth Fund. "In the long term, an investment in primary care will ensure we have primary care, because we are concerned about its collapse."

Health policy experts from the Commonwealth Fund and other organizations, she said, propose that the next round of federal economic stimulus funding include recovery resources dedicated to primary care practices, especially small practices and those in underserved areas. She said the money should be distributed immediately through Medicare and Medicaid in supplemental monthly payments.

Up to now, Abrams said, no money in any of the federal rescue packages has been specifically earmarked for primary care.

Close Permanently?

Farzad Mostashari, MD, CEO of Aledade and former national coordinator for health information technology at the US Department of Health and Human Services, agreed primary care needs immediate help.

Aledade's customers for population health management services, he noted, are some of the most forward-looking and technologically savvy primary care groups. "Nevertheless, those practices are suffering," Mostashari said. "Many of them are at risk financially. There has been a massive 60% to 70% drop in face-to-face visits. About 40% of visits are telehealth, but the practices are still down 30% or more in visits. And they're losing ancillary revenues from procedures and labs."

The financial devastation of the pandemic is causing some physicians to question whether they will be able to stay in practice. A recent survey from the California Healthcare Foundation found that a third of California primary care doctors are worried their practices will be forced to close permanently because of the financial impact of COVID-19. Many doctors said their practices had furloughed or laid off staff or that they'd been forced to take pay cuts.

Similarly, a recent survey by the Patient-Centered Primary Care Collaborative found that 13% of practices predicted closure within the next month and that 20% have already had temporary closures. Forty-two percent of the practices have laid off or furloughed staff, and 51% are uncertain about their financial future through June.

Primary Care Is Essential

A pandemic-related reduction in the number of primary care physicians would exacerbate what many observers view as a nationwide shortage of primary care. Right now, the healthcare system badly needs all the primary care doctors it has, Abrams and Mostashari said.

Decades of research have shown that strong primary care is associated with better outcomes, lower per capita costs, and greater equity, Abrams noted. In addition, she said, dedicated support for primary care during the pandemic will help ensure that doctors meet the needs of patients with chronic diseases so they don't have to be hospitalized.

Moreover, with proper support, primary care physicians can expand COVID-19 testing "so we can reopen the economy and perhaps prevent or contain the second wave of the virus," she said.

Mostashari pointed out that primary care providers are on the front line of the pandemic. Although much attention has been rightfully given to those who treat COVID-19 patients in hospitals, he observed, "before those patients are admitted, they need to see primary care physicians.... We have to maintain the primary care first line of defense. When the CDC says if you're having symptoms, call your doctor, someone has to pick up the phone at the other end."

In addition, he said, "there's a hidden pandemic of untreated chronic conditions we should all be worried about. We know primary care is important because if you don't do prevention, you'll pay the price in heart attacks and strokes and kidney failure, and we've seen a dramatic decline in primary care services. In New York City, some people who have avoided necessary care have had bad outcomes, including in-home cardiac death."

Mostashari also argued that the negative financial impact of COVID-19 could lead to a further consolidation of the industry as health systems and private equity investors take over failing practices. Past experience suggests that that would result in "a lack of choice, a lack of competition, and a lack of access" in many cases, he said.

The best long-term solution, he said, is to pay primary care physicians capitation instead of on a fee-for-service basis so that they're not dependent on income from face-to-face visits.

In the short term, however, they need direct cash payments, Mostashari said. He called on Congress to allocate at least $15 billion to bolster the viability of primary care practices.

Telehealth Levels Off

One of the key findings of the outpatient visits study is that telehealth encounters, after soaring in the early days of the pandemic, have leveled off. After hitting a peak of 14% of all visits in mid-April, telehealth visits now make up about 12% of the total.

Study coauthor Ateev Mehrotra, MD, MPH, an associate professor of health policy and medicine at Harvard Medical School, said he'd expected the use of telehealth to continue rising. The fact that it hasn't, he told reporters at the news conference, may be related to the different ways in which practices conduct virtual encounters.

"Some practices are using HIPAA-compliant [telehealth] platforms and training their patients on how to use those platforms," Mehrotra noted. "Other clinics are mainly just phoning patients. You could envision those practices could easily revert back to in-person visits, because a phone call is going to be limited in many cases. Also, practices need to know whether payers will keep covering telehealth after the pandemic is over."

The study shows that in-person visits, which declined more than total visits in March and early April, are now increasing at about the same rate as total visits. However, in-person visits are still down by more than 40%.

Asked whether financially vulnerable practices will be able to afford the safeguards that medical societies recommend to resume in-person visits, Mostashari pointed out that Medicare is now paying $28 to collect a COVID-19 specimen from a patient.

"Just the cost of changing PPE, plus disinfecting the room or setting up a separate room or testing facility, those expenses are not included. We should have better accounting on what it actually costs to run a practice in the time of COVID. It's not the same as their earlier operating costs."

Mehrotra agreed. "You also can't have 20 people in your waiting room or the throughput you had previously. So the number of patients you'll be able to see will be lower because of appropriate restrictions."

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