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Dr. Michael Lyons used to count on a steady 70 patients a day at the White River Family Practice that he runs with four other doctors.
No longer. Even as hospitals prepare to treat a surge of people with coronavirus, patients avoiding routine care have left small independent practices with empty waiting rooms and a dwindling flow of cash. At a low point on March 27, practitioners at Lyons’ office in White River Junction saw just eight patients.
“Independent primary care practices in Vermont will collapse if you do not provide relief and payment reform immediately,” Lyons wrote in a March 21 letter to legislators and state officials. “We will soon run out of CASH to pay our staff!”
The shortage of patients in the midst of a public health crisis is a predicament faced by small practices nationally — part of the lopsided strain placed on the health care system by the coronavirus. Vermont has reported 543 cases of Covid-19 and 23 deaths, as of Monday afternoon. Hospitals are preparing to be inundated with sick patients, setting up temporary hospitals in gyms and tents.
But after the first coronavirus cases were reported in Vermont in mid-March, physicians started telling patients to stay out of the doctor’s office, to protect doctors and patients alike. Most offices have postponed annual checkups and preventive visits. They’ve told patients to call before they come in, and they’ve started seeing patients online.
The decreased traffic has been costly to doctors, who have as little as a week — and no more than two months — of cash on hand, said Susan Ridzon, executive director of Health First, an organization that represents about 70 independent providers across Vermont.
Some surgical practices have reported losing as much as 95% of their revenue. “Every day that goes by, it gets more tenuous,” Ridzon said.
At White River Family Practice, Lyons and the other four physician-owners have stopped taking a salary. Doctors shifted their patients to telemedicine and are now seeing about 45 people a day online — about 60% of the pre-Covid-19 total. Lyons estimated the practice has enough cash on hand to pay staff salaries for four weeks. After that, the company’s survival will depend on how much and how quickly money in the form of grants and loans comes through.
Evergreen Family Health in Williston has laid off seven administrative and clinical support staff as well as a nurse practitioner and a physician’s assistant, said Paul Reiss, a physician partner at the practice. “There are not enough patients for them to see,” he said. The 10 employees who work at Richmond Family Medicine will likely all work fewer hours to reduce overhead costs, said co-owner and doctor Dan Goodyear.
Meanwhile, they’re scrambling to change the way they practice medicine. Some doctors are seeing patients with Covid-like symptoms in the parking lot; some are only seeing them online. They’re fielding hundreds of phone calls, and navigating new insurance policies and testing protocols.
Goodyear said he’s wearing full personal protective gear, including a gown, mask, and gloves when he ushers patients into the office one-by-one. Doctors from every practice say they worry they may face a shortage of protective gear.
Joe Haddock, a doctor at Thomas Chittenden Health Clinic in Williston, has reluctantly adjusted to caring for patients from his basement at his home in Jericho. The 73-year-old bemoaned the shift to online appointments as a less effective way to practice medicine. “You can’t listen to their murmur, you can’t feel their abdomen for a mass. You can’t listen to their lungs,” he said.
Still, he added, “In this situation, it’s what we have, it’s the best we can do.”
Private insurance companies as well as the federal government have agreed to reimburse doctors for telehealth visits at the same rate they pay for in-person exams.
Sara Teachout, spokesperson for BlueCross BlueShield of Vermont, said the company will cover doctors visits conducted by phone as well. On March 17, the federal Centers for Medicare & Medicaid Services also loosened rules to allow doctors to use common platforms such as FaceTime or Skype for telemedicine, which don’t technically comply with the privacy mandates of HIPAA.
Doctors praised insurance companies for the rapid response to the crisis. But they say the changes won’t fully compensate for the lost revenue; some patients have no interest in seeing their doctor virtually and cancel their appointments; some procedures simply can’t be done online or by phone; the ones that can be done tend to be simpler, so generate less revenue for the practice.
“It’s lower volume, and lower value to those [visits],” said Goodyear.
The financial impacts of Covid-19 aren’t unique to private primary care practices. Dental practices have closed, as have other speciality practices such as chiropractic offices, eye doctors, or surgery centers.
The Green Mountain Care Board reported on Wednesday that the crisis has posed a hardship for hospitals across the state; hospitals are seeing between 50% and 70% decline in net patient revenue. Costs are “mounting”; revenues are “seriously compromised,” said Alena Berube, director of value based programs and ACO regulation for the board. The University of Vermont Medical Center laid off a portion of its health care workers, and other hospitals are considering similar measures.
The anticipated surge of Covid-19 patients, including expensive procedures such as in the intensive care unit, will help recoup hospital losses. Most independent practices will see no such rebound.
Instead, doctors are counting on the state and federal government to provide an injection of money that will keep them afloat. On Friday, the Department of Vermont Health Access opened grant applications for a variety of health care providers enrolled in Medicaid, including primary care practices. The department did not detail how much money practices could request, or how much was available.
The federal CARES Act, which Congress signed into law last week, includes funds for at least two months of operating expenses for practices. The money doesn’t need to be repaid — as long as practices adhere to some stipulations, including retaining all employees. There will also be other state and federal loans, grants, and advanced payment available. For practices, it can’t come soon enough. “People need a quick infusion of cash — like now,” Ridzon said.
Until then, doctors said they’ll continue caring for patients as usual. Joe Nasca, a pediatrician in Georgia, Vt. has been seeing the patients who can come in, and offering medical guidance to parents by phone. Nasca has already stopped taking a salary, and he likely wouldn’t be reimbursed for many of the phone calls and follow-up conversations, he said. But he’s reconciled to that reality — it’s what he signed up for when he launched his own practice in 2006.
Caring for the sick is “a doctor’s privilege,” he said. “And the risk is part of the deal.”
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