“We’re a small office and are working by ourselves and are figuring things out as we go. We are still continuing to care for our patients. We’re on our own.” This quote, from our April 2020 survey of New York City (NYC) primary care practices, epitomizes the COVID-19 experience for small independent practice owners. Over the last two months the nation’s attention has been laser focused on how to support hospitals faced with unparalleled patient care demands and the economic fallout among small businesses. This is particularly true in NYC, the epicenter of the US COVID-19 pandemic.
Missing from state and national briefings is concern about the impact on smaller independent primary care practices. Despite recent trends towards the acquisition and consolidation of these practices into larger health care systems, they continue to play a major role in US health care delivery; more than half of primary care visits occur in these practice settings.
In NYC, 40 percent of primary care providers are independent practices with four or fewer health care providers. These practices provide access to care for many of the city’s poorest communities, including large numbers of minority and immigrant populations. In a recent study of 257 small independent practices that are members of the NYC Department of Health and Mental Hygiene’s practice network, 47 percent were located in areas considered Medically Underserved; for practices in Medically Underserved areas on average, 27 percent of patients were covered by Medicaid, 33 percent were Hispanic, 29 percent black, and 32 percent Asian.
As both small businesses and front-line health care delivery settings, small primary care practices are experiencing COVID-related disruptions similar to other small businesses and acute care settings. Patient volume has dropped by 50-80 percent, and shortages of personal protective equipment (PPE) preclude in-person visits. At the same time, these practices have pivoted to virtual care without training, appropriate infrastructure, or guarantees of commensurate reimbursement that would avoid untenable revenue losses. Cash flow disruptions coupled with low-financial reserves increase the risk of permanent closures.
What Is The Impact Of COVID On Small Independent Primary Care Practices?
The crisis has hit small, independent primary care practices hard. In an April 2020 survey (survey instruments found here) among NYC Health Department member practices, 85 percent reported that COVID-19 was having a severe impact on their practice. The most common sources of stress included shortage of PPE (53 percent), large volume of patient calls (47 percent), the need to reduce visits (36 percent), and ill staff (42 percent). Only 13 percent remained open as usual; 73 percent had reduced hours or were closed for in person visits, and 15 percent were temporarily or permanently closed completely. The main reasons for changes to care delivery were lack of PPE, insufficient staff, lack of revenue, and lack of space for social distancing. The most commonly cited reasons for closures were safety concerns because of the lack of PPE, insufficient staff, and a lack of revenue.
Practices remaining open reported that in the past week, over 50 percent of visits were via video or telephone. Although most believed they would be reimbursed by Medicaid/Medicare and commercial insurers, a little over 30 percent responded, “don’t know”. In 2018, 32 percent of these practices were already reporting that they “worried about meeting monthly expenses.” Uncertain revenue streams combined with small margin for staff losses are threatening further reductions in service and closures during this pandemic.
What Is The Impact On Access To Primary Care?
Primary care practices across the country were at different levels of readiness to move patient care to virtual interactions. However, without a large system’s infrastructure to support a rapid transformation to telehealth, small independent practices in NYC and in other parts of the US, are forced to reduce access to care for their most vulnerable populations. NYC providers reported that the main barriers to using telehealth are their patients’ lack of reliable internet access or devices and discomfort using video technology, particularly among elderly patients. Even with the right telehealth platform and appropriate reimbursement, disparities in access to care will widen without additional resources to support patient engagement in virtual options.
What Are The Policy Implications?
As demand for hospital services peaks, attention must shift to policies that prevent permanent practice closures in primary care. This includes harnessing existing support infrastructure like independent practice associations (IPA), primary care associations and organizations, and practice-based research networks. Small independent primary care practices need support to take full advantage of available help. This includes understanding eligibility criteria for CMS waivers and the documentation needed to bill for telehealth, and how to access the new federal funding through new stimulus packages.
The $2 trillion Coronavirus Aid, Relief, and Economic Securities (CARES) Act includes three potential provisions that may support these practices. First, the Act adds $100 billion to the “Public Health and Social Services Emergency Fund” for expenses and losses due to COVID-19. However, none of the funds have been specifically earmarked for primary care practices. Second, the CARES Act established a $349 billion “Paycheck Protection Program” for small businesses financially suffering from the COVID-19 crisis. While this program may be particularly helpful for small physician practices, the fund was depleted as of April 16, although Congress added $320 billion through a law signed by President Trump on April 24.
Third, the CARES Act also appropriates $200 million to the Federal Communications Commission’s COVID-19 Telehealth Program to help health care providers ramp up their virtual health services. However, this program is limited to nonprofit and public eligible health care providers and would exclude many independent practices. Such caveats complicate the ability of small independent practices to reap the benefits intended to keep them afloat, illustrating why they may need additional support to navigate this complicated terrain.
As the federal government rolls out a new $100 billion in federal funding for hospitals, there is still no mention of primary care. In the short term, legislators should provide equivalent funding for independent practices to prevent closures. In the long term, we need to avoid the impulse to invest even more in acute care settings. On the contrary, COVID-19 has shined a light on the pressing need to invest additional resources in the primary care infrastructure, as well as the need for payment models that may provider greater financial security for small practices over time.
Finally, when planning for the next health care crisis, federal agencies must take a broader view of frontline health care providers and include small primary care practices in their estimate of resource stockpiling and distribution plans. As one provider noted, “The primary care physicians, including myself, do not have PPE, and we are not considered priority for these.” Independent practices form a key social safety net in underserved communities. Leaving out these practices is shortsighted and adversely impacts the most vulnerable practices and patients whom they serve.