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In March, Jason Goldman, MD, couldn't find a supplier to sell him personal protective equipment (PPE) for his independent general practice in Coral Springs, Florida. As he watched COVID-19 cases pop up, he resorted to begging family and friends to share their personal supplies of N95s: "You're not a doctor," he'd say, "so can I please use them to see my patients?"
He made those supplies last for months, reusing masks and wearing goggles instead of face shields. Finally, in July, he received his first shipment of PPE — part of a bulk order placed in June through a pilot program from the American College of Physicians (ACP) and the nonprofit Project N95.
"We had to ration our supplies, but it wasn't good for us — it's like breathing through a dirty CPAP mask," Goldman said. "It was like practicing in a third-world country."
The PPE supply at the Fort Worth, Texas practice of allergist Susan Bailey, MD, was equally dire: It consisted of gloves and one box of N95s from 2010, stashed away in a cupboard after the H1N1 pandemic.
As an independent practice with only three physicians, Bailey couldn't find any PPE to buy, other than a few vendors that required expensive minimum orders of more masks than she needed. So her practice doled out their 10 respirators to the 10 employees and instructed everyone to take good care of them.
Such problems for small, independent practices have not improved as the pandemic wears on, causing delays in reopening and putting healthcare providers at risk. But nonprofits and medical associations have started stepping in to fill the gap. Project N95 has partnered with ACP and the American Medical Association (AMA), of which Bailey is president, to pool physicians' orders so they can buy PPE in bulk. The medical associations collect orders from their members during a 1-week period; Project N95 buys the supplies and distributes them. The demand has been greater than the organizers anticipated.
"This is not a long-term solution," said Bailey, who began her tenure as AMA president in June. "We're just trying to fill the gap and urge the administration to pull every lever it can to ramp up PPE production."
Small Practice Struggles
Practices like Bailey's that didn't previously need N95 respirators or gowns had no relationships with vendors in PPE supply chains, and found themselves competing with hospitals and large health systems in the scramble to buy equipment.
"I was searching Amazon, trying to find any place online to find some," Bailey said. "A few vendors whose names I wasn't familiar with wanted a minimum order of 5000 masks, which we couldn't afford, and we didn't need that many."
Even some practices that did have previous relationships with suppliers had issues, said ACP President Jacqueline W. Fincher, MD,: "Some [PPE] got hijacked by the government to go where the needs were biggest, and some orders would get canceled."
In Florida, Goldman remembers a conference call in March in which the governor promised him and other independent physicians that they would provide PPE. But when he called the Florida Division of Emergency Management to follow up, he was told they weren't allowed to supply PPE for doctors in private practice.
On the rare occasion when a provider did find PPE, a single surgical mask—typically less than a dollar— often cost more than $5.
"The price becomes too great to make sense," said Ali Raja, MD, MPH, MBA, executive vice chair of the Department of Emergency Medicine at Massachusetts General Hospital in Boston.
And the quality was often suspect, Bailey said. "There's been counterfeit merchandise, companies that are there one day and gone the next. If you're taking care of COVID-19 patients, protecting yourself with a counterfeit mask is not going to help."
Medical organizations and nonprofits hear about the prevalence of such struggles every day, and the ACP approached Project N95 in May about organizing a bulk order for its members, Fincher said. The two organizations decided to pilot a new approach with the group purchase program in June.
"While the market usually requires organizations to purchase PPE in the hundreds if not thousands of units, our pilot program has created a way for smaller practices to purchase the exact amount of equipment needed at competitive market prices," Andrew Stroup, executive director of Project N95, said in a press release. "By doing so, we're promoting equitable distribution of supplies and helping these organizations support their communities — many of which consist of underserved populations."
Through the pilot program with the ACP, 2000 members across all 50 states placed orders for 145,400 N95 respirators, surpassing the organizers' predictions by about 10-fold. Project N95 bought a total of about 70,000 gowns and delivered them to the physicians at smaller practices and frontline workers who'd requested them. The average physician's order was for just four boxes of 20 N95 respirators and two bags of 15 gowns. Totals from the AMA's sale in late July are still being tallied.
Another pooled bulk order with multiple medical organizations is already in the works. The date hasn't been nailed down yet, but organizers are hoping it will happen in the next several weeks, Project N95 spokesperson Mickey Hyun said.
Nonprofits Still Needed
When health care providers and entrepreneurs founded nonprofits such as Project N95 and GetUsPPE in March out of desperation, they expected to serve a short-term need. Five months later, they're still going strong.
"The environment has shifted, but there is no doubt that there is an ongoing need," Hyun said. "We're not really seeing a decline at all in requests."
Back in March, GetUsPPE figured they'd be around for a month or two until there was a federally organized replacement — a large stockpile or a centralized distribution system, noted Raja, a cofounder. "That never happened," he said. "But we would love to be put out of business."
It won't happen unless the government makes domestic PPE production mandatory, possibly through invoking the Defense Production Act, said every doctor Medscape Medical News spoke with.
"We need to do all we can to take care of patients safely. And if providers are willing to put themselves on the frontline then, just like we treat the military, we ought to be providing them with the best protective equipment," Fincher said. "If we need to manufacture it in the US, we need to be doing that."
A central distribution system might also alleviate some of the disparities that PPE shortages reveal, Raja has previously told Medscape, by ensuring that everyone has equal opportunity to buy supplies.
Although people of all means have been affected by the PPE shortage in smaller medical practices, lower-income patients disproportionately may feel the impact, Raja said. Often, he said, the clinics that people working lower wage jobs rely on for care were the ones having a particularly hard time getting PPE.
GetUsPPE has established a separate fund for getting PPE to protestors for Black Lives Matter and masks and gowns to the street medics taking care of protestors.
Long-Term Ramifications for Small Practices
While it may be impossible to predict what independent practices will look like after the stresses of COVID-19, some doctors say they've already seen changes specifically revolving around PPE. Goldman, the general practitioner in Florida, says several of his colleagues have opted to retire early.
"We merged our practice with a larger private practice so we could get a little more market buying power — although even with eight clinics, we still could not get enough masks," said Fincher, who works in a primary care practice in Thomson, Georgia.
And the budget for PPE has soared: "We quintupled our budget for masks, gowns and gloves," Fincher said. She predicts buying PPE will be a mainstay.
"Right now, I can't imagine a time when I'm not using a mask even to see a routine patient," Bailey said. Prior to the pandemic, she hadn't worn a mask since she was a resident, over 30 years ago.
Sheila Eldred is a freelance health journalist in Minneapolis. Find her on Twitter @MilepostMedia.
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Cite this: Small Practices, Struggling With PPE, Band Together to Buy in Bulk - Medscape - Aug 07, 2020.