U.S. Health Reform – Monitoring and Impact Impact of the COVID-19 Pandemic on Primary Care Practices February 2021 By Sabrina Corlette, Robert Berenson, Erik Wengle, Kevin Lucia, and Tyler Thomas Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. With support from the Robert Wood Johnson Foundation (RWJF), the Urban Institute is undertaking a comprehensive monitoring and tracking project to examine the implementation and effects of health reform. The project began in May 2011 and will take place over several years. The Urban Institute will document changes to the implementation of national health reform to help states, researchers and policymakers learn from the process as it unfolds. Reports that have been prepared as part of this ongoing project can be found at www.rwjf.org and www.healthpolicycenter.org. INTRODUCTION The COVID-19 pandemic has brought enormous upheaval to on a wide range of health care issues. As such, these clinicians the United States, dramatically altering the way we live, work, have had a front row seat on the ravages of the virus that go to school, and, importantly, obtain health care services. causes COVID-19. They have also directly felt the financial That upheaval has been apparent in primary care, the impact of the pandemic’s economic fallout and responded in foundation of our health care system. Primary care physicians ways that could result in long-term changes to the delivery (PCPs), nurse practitioners, and physician assistants are often and financing of primary care. In this paper we discuss the first health care professionals individuals encounter when observations from interviews with practicing PCPs across the facing illness or injury, deliver the majority of preventive country on the ramifications of COVID-19 on their practices, and chronic disease services, and, particularly in rural and their patients, and the future of primary care. For example, we underserved areas, serve as experts and community leaders learned that: Early in the pandemic, many PCP practices were forced to close their doors or significantly reduce services, leading to financial shortfalls that threatened their viability. They also faced new expenses, such as acquiring personal protective equipment (PPE). Independent PCPs responded to the pandemic in a wide variety of ways, but all demonstrated nimbleness as small business owners, quickly implementing changes to their practice and modes of service delivery in order to survive. PCPs also received significant government and community support in the early phases of the public health emergency. PCPs reported significant challenges diagnosing and treating COVID-19 while also keeping themselves and their staff safe. Obtaining an adequate supply of PPE has been a challenge throughout the pandemic, and many practices determined they could not test symptomatic patients safely. Others noted that the unpredictable course of the virus, lags in testing results, and patient demands for unproven therapies have made it a difficult illness to treat, particularly when trying to do so remotely. PCPs expect that they will continue to deliver a significant proportion of their services via telehealth, so long as reimbursement remains adequate. Several also noted a new willingness to enter into capitated payment arrangements with payers, in order to avoid the financial uncertainties of fee-for-service should utilization once again be suppressed. Others, however, continue to resist any payment arrangements that require them to take on financial risk. PCPs reported rising levels of burnout for themselves and their staff, but none indicated they would leave the profession, retire, or seek acquisition by a larger practice or health system due to the pandemic. Indeed, for some, COVID-19 has only reinforced their commitment to the profession and to their patients. U.S. Health Reform – Monitoring and Impact 2 BACKGROUND In spite of serving as our health system’s front line of however, some of that volume bounced back, with physicians defense, primary care has typically been underfunded and reporting that adult primary care visits, both in-person and undervalued.1 As non-traditional providers of primary care via telehealth, were 13 percent above pre-pandemic levels. services have emerged, such as minute clinics, urgent care This uptick in services suggests many patients were making centers, and telehealth-only providers, many PCPs have up for appointments missed during the spring.14 struggled to remain financially viable.2 This has led many In March, the U.S. Congress enacted legislation to provide independent or small-group practice PCPs to be more COVID-19-related financial relief. The $1.8 trillion Coronavirus receptive to acquisition by larger groups, hospitals, or health Aid, Relief, and Economic Security (CARES) Act established systems. Indeed, by 2018, over half of U.S. physicians were the Paycheck Protection Program (PPP), which provided affiliated with a larger health system.3 Others have shifted $659 billion in forgivable loans to small businesses, and the to “concierge” financing models, serving primarily higher- Provider Relief Fund (PRF), a $175 billion fund to compensate income patients who can afford monthly or annual fees providers for lost revenue or treatment costs related to the for personalized attention and care.4 At the same time, the pandemic. Recipients of PPP loans who used the funds for number of U.S. medical students choosing to enter primary payroll, business mortgage interest payments, rent, or utilities care is far less than the number needed to support a growing can request loan forgiveness, relieving them of any obligation and aging population, although international medical school to pay back the funds. graduates have helped fill the gap. There is also a projected increase in the number of graduated advanced non-M.D. Of the PRF funds, the federal government distributed a primary care providers, including nurse practitioners and large portion automatically to providers who participate physician assistants in the coming years.5,6 Even so, the in Medicare, based on their total net patient revenue. This Association of American Medical Colleges projects a shortage resulted in large hospitals and health systems receiving of up to 55,200 PCPs by 2032, raising concerns about access the bulk of the money; small PCP practices have received a to care, particularly in rural and other underserved areas.7 relatively small proportion of these funds.15 These challenges existed well before January 2020, when In March 2020, the Centers for Medicare & Medicaid the U.S. health care system encountered a new and Services (CMS) began advancing Medicare payments to unprecedented test: COVID-19. By early March, the United providers under the Accelerated and Advance Payment States had the highest number of COVID-19 cases in the Program in order to help them through COVID-19-related world.8 Although rates of infection fluctuated throughout revenue shortfalls, and the CARES Act expanded the the summer, as of January 21, 2021, the U.S. has experienced program. These are essentially zero-interest loans from over 400,000 COVID-19-attributed deaths and over 24 million the federal government; CMS will reduce future Medicare total reported cases.9 As public health experts encouraged reimbursements to offset the amount providers received Americans to stay at home and practice “social distancing,” in advance payments. However, the vast majority of these governors declared temporary stay-at-home orders, and payments went to hospitals and other providers that hospitals cancelled non-essential services, many people participate in Medicare Part A.16 chose to delay or forego primary care services as well. At the In a broader change during March 2020, CMS increased same time, the pandemic forced many employers to lay off or flexibility around rules for the Medicare reimbursement of furlough workers, resulting in an estimated 3.1 million people telehealth visits, increased payment levels to provide parity in America losing their employer-sponsored insurance (ESI) with payment for in-office visits, and started covering audio- between March and September 2020, and millions of others only phone calls, with additional changes to reduce or waive experiencing a decline in income making it more difficult to cost sharing for telehealth visits.17,18 This was the model afford health care-related cost-sharing.10 for later changes in some state Medicaid plans and private These concurrent trends resulted in significant declines payers’ coverage of telehealth services, providing financial in PCP patient volume and practice revenue.11,12 As late as incentive for providers to begin delivering much, if not a July and August, an American Medical Association survey majority of their services remotely. of 3,500 physicians found that 81 percent reported lower revenue than they had before the pandemic.13 By October, U.S. Health Reform – Monitoring and Impact 3 RESEARCH APPROACH This study aims to capture the perspectives of PCPs as their providers including nurse practitioners and physician practices responded to the COVID-19 pandemic and its assistants. The smallest, a solo practitioner, has approximately attendant health and economic challenges. We focused on 3,000 patients. Practices were located in the following practicing internal or family medicine PCPs who are senior states: California, Florida, Georgia, Massachusetts, Michigan, or managing partners in independent, majority-primary Missouri, New Jersey, North Carolina, Texas, and Virginia. They care (>70 percent) practices, and who have knowledge serve rural, suburban, and urban areas. Patient demographics of their practice’s financials. We also sought a diversity of varied widely. Some practices served a relatively affluent practice sizes, locations, and patient demographics. To population, in which the majority of patients were privately identify interview subjects, we contacted national and insured; others had predominantly low-income patients state associations representing primary care physicians, who were either uninsured or on Medicaid. Most practices who in turn reached out to their members on our behalf. reported a mix of Medicare, Medicaid, and commercially This approach meant that, while we were able to interview insured patients, although a few limited the number of 16 PCPs in a short amount of time, they are not necessarily Medicaid patients due to the program’s low reimbursement representative of independent PCP practices nationwide. rates. Interviews were conducted between October 2 and November 10, 2020. In addition to a review of published data documenting physicians’ pandemic experiences, we conducted 16 interviews with PCPs. Practice sizes varied from solo practitioners to large, multi-specialty practices and federally qualified health centers (FQHCs). The largest practice employed 370 physicians and served approximately 500,000 patients. All practices employed a number of non-M.D. OBSERVATIONS The PCPs we interviewed provide a window on how the they offered. For many, that reduction was not entirely by COVID-19 pandemic has challenged our already-fragile choice, as patients were, in the words of one doctor, “too system of primary care. These have included threats to afraid to go to an office.” For example, a Miami-based practice their financial viability, particularly for smaller, independent reported a 60 percent decrease in patient volume during the PCP practices, and difficulties delivering quality care while initial weeks of the pandemic; another PCP in Florida put the ensuring safety for their patients, clinicians, and staff. At decline closer to 75 percent. The PCPs reported that demand the same time, these PCPs have proven to be capable and was down not just for preventive and routine care services, nimble business owners, quickly shifting to new modes of but also for urgent care. care delivery. They have also taken advantage of government Several PCPs chose to discontinue offering “non-essential” and community support to sustain their ability to serve their services such as physicals and well-child visits, in part to patients. But these efforts have taken their toll, and many reduce the transmission risk for themselves and their staff. report a significant level of burnout that could have long- This was no small decision, one noted, as these are the term implications for our nation’s system of primary care. services that “pay the bills.” However, the downside of an Early Challenges: Empty Waiting Rooms, Revenue outbreak among the clinical or administrative staff was too Shortfalls great. One rural Texas practice was “crippled” after multiple In general, PCPs were committed to keeping their doors open physicians tested positive for COVID-19, requiring the clinic during the initial wave of the COVID-19 pandemic. Several to close its doors until the rest of the staff was able to receive respondents noted that they were an essential source of care testing results. Similarly, a small Michigan practice had to shut in communities facing a primary care shortage. For them, down when only one physician was left to treat patients, after shutting their doors was simply not an option. Others did the other doctor and staff fell ill. Other practices determined temporarily close shop, or significantly reduced the services that certain patients, such as the immunocompromised or U.S. Health Reform – Monitoring and Impact 4 elderly, would not be allowed to come into the office for in- along the way with government assistance and for many, person visits. local community support. Another key factor driving PCPs’ decisions to close or reduce PCPs are Nimble Small Business Owners their services was the lack of PPE, including masks, gloves, Practices Shifted Rapidly, and Relatively Seamlessly, to and gowns. Most reported that acquiring necessary PPE has Telemedicine been difficult, if not impossible, at multiple points during the pandemic. This was particularly true for the smaller practices, Almost every practice interviewed had shifted a significant which must compete with large health systems and hospitals portion of their services to telehealth, with the goal of for supplies. A Massachusetts doctor reported that they no protecting staff and patients. Many of the larger practices longer treat patients with symptoms of COVID-19 in-person, had begun to develop a telehealth infrastructure prior to due to inadequate PPE. After a Virginia hospital was overrun the pandemic, but even smaller practices that had not done with COVID-19 patients, its administrators asked local PCPs so found the transition to telehealth more seamless than to share the load. But without sufficient PPE, at least one they anticipated. Telehealth prior to the pandemic involved practice turned down the request, determining they did not purchasing the necessary hardware (webcams computers, have the necessary protection to be “frontline evaluators and etc.). It also required purchasing HIPAA-compliant software treaters of COVID-19.” (or a platform) from a vendor to conduct the actual visit. Emergency federal guidance, which allowed them to use Most PCP respondents reported dramatically reduced technology platforms that did not meet federal privacy and revenue in the early phases of the pandemic. For example, a security standards, helped in this regard. Several PCPs noted Massachusetts doctor reported that his practice experienced that the ability to interact with patients using noncompliant a 40 percent decline in revenue. These PCP practices generally technologies was critical to ensuring they could deliver timely did not have large financial reserves to sustain them during services, particularly to patients with limited technological this time. Several also reported that their monthly expenses access or ability. One rural doctor noted, “[Federal rules] allow were running higher than normal, thanks in large part to FaceTime which is excellent, because a lot of people have the high cost of PPE. As a result, several PCPs reported that iPhones and the quality is good. My first FaceTime patient was they reduced their own salaries, imposed staff furloughs, 99-years old; she already used it to talk to her kids.” pay cuts, or implemented a combination of these tactics. A Massachusetts doctor reported asking staff to take voluntary Respondents generally found that most of their patients furloughs, leading to a 15 percent reduction in payroll. A could navigate the technology relatively easily, but some Texas practice cut its hours by 20 percent, and a Florida PCP noted that those of lower socio-economic status often had reduced staff salaries by 25 percent. “no access and no idea” about telehealth options, producing a modest “digital divide.” A few respondents emphasized that It Takes a Village: PCPs are Finding Multiple Sources of audio-based telehealth (aka the telephone) has proved to be Support During the COVID-19 Crisis invaluable, and preferable to video-based telehealth in many In order to stay financially viable and maintain quality primary circumstances. care services during the pandemic, PCPs had to implement Nearly every practice reported that telehealth was a vital new and creative changes to the way they do business, and lifeline for their practice financially. “It’s been a lifesaver,” they did not take these steps without support. However, they reported one Florida physician. A Missouri doctor told us were operating without any standard blueprint or national- that, without telehealth, they would be under 50 percent level guidance on how to manage through the pandemic. capacity. The practices also reported that purchasing the In large part, PCPs’ response to COVID-19 was a bottom-up necessary technology and engaging with telehealth vendors process, with PCP practices making mostly independent, was relatively affordable. Some vendors offered free trial rapid, and varied decisions to fundamentally shift the way periods or discounts during the initial outbreak. A rural Texas they deliver care. Every practice approached this with their doctor reported that his vendor had yet to charge him for own unique lens, often dictated by the number, age, and risk the service, noting, “They’re being gracious and letting us try factors for physicians and staff. Decisions also often hinged before we buy.” on whether the practice was located in an underserved area, or whether there were other providers in the community State and federal reimbursement mandates also helped. able to help diagnose and treat COVID-19 patients. In each The Medicare program is reimbursing for telehealth visits case, practices had to make difficult decisions about whether at parity with reimbursement for an in-person visit during and how to operate safely and continue to provide essential the public health emergency, and several PCPs practiced primary care services to their patients. They were helped in states that require private insurers to do the same. Some U.S. Health Reform – Monitoring and Impact 5 insurers in states that did not require they reimburse at PCPs Report Support from their Communities, but Less parity did so voluntarily, but can discontinue doing so from Payers at any time. PCPs noted that, without these government Many practices reported that they had received donations requirements, telehealth would not have been a viable from local residents, foundations, and non-profits. Some alternative to in-person services during the pandemic. donated PPE and provided financial assistance. One doctor Further, at least one state – Massachusetts – required insurers reported that patients were making them masks. At the same to waive consumer cost-sharing for telehealth visits during time, although many private insurers have touted19 their the COVID-19 emergency period. A PCP there reported efforts to support primary care during the pandemic, the that this requirement has been a financial boon for her physicians that we interviewed largely reported that insurers practice. “Deductibles are what has been killing our practice have done nothing to help them. A few have offered grants [financially],” she said. “This policy change enabled us to or loans, but those came with strings attached. For example, survive.” one insurer offered financial help to an independent practice in Virginia, but only on condition they refrain from being Practices Retooled In-person Service Delivery acquired by a hospital or larger physician group for a number Practices have been extraordinarily creative in adapting of years. However, in a few cases providers reported that their operations to provide a safer working environment and insurers were continuing to pay for telemedicine services continue delivering quality care. Many PCPs shut down indoor at parity with in-person services, even though the state waiting rooms, asking patients to wait in their cars or check in mandates to do so had lapsed. These providers found this to outdoors. “We’re at about 85 percent telehealth [visits],” one be very helpful to their ability to continue to deliver services PCP reported, with “10 percent in their cars, especially the and remain financially viable. elderly who don’t have devices. The rest – just 2-6 people per day – I see in the office.” Others have set up Plexiglass barriers Primary Care Providers: a Front Line against the in their waiting rooms, staggered patient appointment COVID-19 Pandemic times, and arranged for pre-visit screenings and post-visit To Test or Not to Test? Early and Ongoing Challenges with payments to be conducted over the phone or online. Many Diagnosing COVID-19 require temperature checks of patients, although there was Primary care clinicians were among the first providers to see skepticism over the effectiveness of this tactic. “Waving COVID-19 patients in this country and are often the first stop thermometers around, it’s stupid, but it’s a county regulation,” for patients experiencing COVID-19 symptoms. A critical early one said. “Half the people are asymptomatic.” question for PCPs was whether and how to offer their patients Government Funds Came to the Rescue COVID-19 tests. The decision whether to do so varied from CARES Act Relief Funds practice to practice. In some cases, despite a lack of PPE and personnel, practice leaders decided they had to offer testing The PCPs we spoke to consistently praised the CARES Act services, because there were few or no other options in their PPP funding as the most helpful form of financial assistance communities. “I don’t mean to sound overly pious, but that’s from the federal government. When asked about the impact, why we got into this [profession],” said one physician. “I didn’t a Texas physician said, “It was huge. I could actually keep my want to turn away any patients and [our community] doesn’t staff. They were wondering every day if they were going to be have a lot in the way of resources. The other clinics closed. It furloughed or fired....Having a PPP loan allowed us to breathe was really us, or no one.” easier.” A California practice reported that, without the PPP funds, “we couldn’t have continued our operations.” PCPs that chose not to offer testing services cited the lack of PPE and concerns about staff safety. Some also have The PRF was viewed as far less helpful. The amounts received had limited staff capacity, whether because personnel are in the initial, automatic payment from the government immunocompromised or unable to come into work due to was relatively small for most practices. Several PCPs were childcare obligations. However, a few acknowledged that unaware they had received it at all. Others were aware of it finding local sites for their patients to receive timely testing but observed that the amount was too low to have an impact. can be a challenge. “It’s a full-time job just finding testing Along with the PRF many practices applied for and received locations [for our patients],” reported one PCP. Medicare advance payments, which were perceived as beneficial as a part of the larger relief package. Most viewed One practice decided only to test asymptomatic individuals, it as more impactful than the automatic payments of the PRF, and then only in their parking lot. “We decided we did not but not as helpful as the PPP. want our staff around people who were acutely ill,” the doctor said. Conversely, another practice has decided to test only U.S. Health Reform – Monitoring and Impact 6 symptomatic individuals, finding they did not have the staff 84-year-old who remained completely asymptomatic. Others capacity to also test those without symptoms. cited the humbling experience of treating a new disease they knew little about. For example, COVID-19’s unpredictable PCPs generally reported little difficulty receiving course of progression often made it difficult to identify when reimbursement for testing services, and one noted that a patient should be sent to the hospital. “I used to think I was her practice of requiring a telehealth visit prior to a test has a good doctor,” one said, “But now I know I just know how to brought in additional revenue for her practice. However, read a textbook.” another practice has found it burdensome to help uninsured patients obtain Medicaid eligibility for testing purposes, a For the most part, PCPs are treating COVID-19 patients benefit authorized by the federal CARES act, noting that there remotely, monitoring their symptoms via telemedicine. is a lot of back-office paperwork for her staff. “We made a decision not [to have COVID-19] patients in the office,” said one physician, noting that that in their small Results May Vary: Long Lag Times Lead to Limited office there was no way to do so and keep themselves and Clinical Utility of COVID-19 Tests their non-COVID-19 patients safe. However, providers serving Most PCPs reported that the turnaround time for test results predominantly low-income communities often did not have has improved since the initial surge of COVID-19 cases in this option. “Technological capacity has been a challenge, the spring. But others, particularly those interviewed later especially in the poorer communities with larger minority in the fall, observed that labs have started to take longer to populations,” observed a physician with a large urban FQHC. return results. For the PCR tests, the physician respondents Another PCP explained they had to work to stay on top of reported turnaround times between 2 and 14 days over the their COVID-19 patients’ conditions with follow up phone calls course of the pandemic. One referred to results received and emails. after a few days as “worthless” from a clinical or public health perspective. The slow results prompted one large practice Several PCPs expressed concerns about patients requesting to bring testing capacity in-house, which has reduced their unproven drugs or interventions that they had seen touted by turnaround time to 24 hours. politicians or online. “They all want hydroxychloroquine,” said one doctor, who has refused to prescribe it, noting that it was Some PCPs were also using the rapid antigen tests, but the drug of choice among patients who also refused to wear a several noted these have “significant limitations,” (with high mask. Another reported that he had patients yell at him when false negative rates). Some PCPs also observed that, when he denied them a hydroxychloroquine prescription. testing is done offsite, they rarely, if ever, have access to information on the type of test or the results. “I don’t know if Looking Ahead [the test] was a PCR, antigen, or antibody,” one noted. Preparing for a Second (or Third) Wave Several PCPs also observed that their patients of color have Many public health experts predicted the COVID-19 been disproportionately impacted by the pandemic and the pandemic would come with a summer lull in cases, followed inequities in access to health care services. “The first drive by a “second wave” in late fall, as colder weather initiated through testing locations were only in the affluent areas the annual flu season and people began to return to indoor [in our community],” reported one PCP. Another reported activities. However, as we began our interviews with PCPs in treating patients of color whose complaints had not been October, the pandemic was already raging in most parts of listened to by other doctors or emergency room staff, even the country. Indeed, some respondents reported that they when they complained of shortness of breath. Almost never experienced a COVID-19 “lull.” “It’s an ongoing tsunami,” universally, PCPs with a high prevalence of COVID-19 among one said. One Michigan practice had just closed their office their patients of color also reported that these individuals during the week of our interview, due to rising caseloads in tend to work in higher-risk settings, such as meatpacking, their area. service jobs, prisons, and other sectors requiring regular and That said, most PCPs felt they were better prepared to often close interaction with other people, and often live in weather a fall-winter spike in cases, having developed multi-generational housing. approaches to better assure safety for their patients and staff Treatment Challenges than they had in the spring. Respondents generally agreed Several of our respondents expressed frustration over the that access to PPE had improved, as well as their protocols to many inexplicable aspects of the virus, particularly the minimize contact with possible COVID-19 patients. Increasing variance in how different patients respond. For example, one comfort with and use of telehealth was also a factor. PCPs cited his experience with an otherwise healthy 22-year-old further felt they had become more proficient at diagnosing who barely survived, and still suffers effects, versus a frail U.S. Health Reform – Monitoring and Impact 7 and treating COVID-19 patients, improving outcomes and reimbursement for telehealth services. However, some helping to reduce transmission. PCPs reported that insurers had begun cutting back on the generosity of telehealth reimbursement and re-imposing However, many PCPs appeared resigned to their lack of patient cost-sharing for telehealth visits. Most respondents control over the course of the pandemic, which some thought that if telehealth payments were to return to at observed had been worsened by the lack of trust in their or near pre-pandemic levels, it would not be financially communities in government recommendations on mask sustainable. However, research demonstrates that the cost of wearing and social distancing. Indeed, in spite of their best delivering services via telehealth is significantly lower than an efforts, some practices informed us they were once again in-person visit, so payers may seek to discontinue full parity experiencing staff and clinician shortages, due to their age or for telehealth services once the public health emergency is risk status, as well as, for many, childcare challenges. lower.21 Several also raised concerns about lack of trust in the safety PCPs were uniformly critical of telehealth-only vendors that or efficacy of a COVID-19 vaccine. A PCP working in a FQHC consult with patients outside any established relationship noted that this lack of trust was a particular problem among with a PCP or other clinician. Many of these have been the “disenfranchised, poverty-stricken” population served by developed and encouraged by insurers. As one PCP pointed her clinic. out, insurers “undermine us and send ads that there will be The Future of Telehealth no co-pays with a ‘teledoc’ doctor compared to your regular Our PCP respondents agreed that expanded use of telehealth doctor.” In his view, these telehealth-only providers are not has become an integral part of primary care but differed invested in the long-term health of the patient, leading somewhat on the proportion of their services that can be to fractured care and inappropriate treatment, such as effectively provided through this modality over the long overuse of antibiotics for minor upper respiratory infections. term. Estimates ranged from 20 percent to as high as 70 Universally, PCPs felt that “if you don’t have an established percent. PCPs reported they now have a clearer idea of the relationship with the patient, you can’t provide the same clinical conditions for which telehealth is appropriate, as level of care.” That said, at least one respondent admitted that well as those where it falls short. For example, video-based many primary care practices are not always as responsive telehealth can be good for diagnosing rashes, but not for to patients as they could be, especially outside business delivering pediatric or gynecological care, which require hours. This physician thought that telehealth could help his physical examinations and/or immunizations. Some pointed practice improve access for their patients, but only as long as to telehealth’s particularly useful role delivering behavioral reimbursement remained favorable. health services but noted that confidentiality can be a COVID-19’s Impact on Patients and the Community problem. PCPs serving patients in more affluent areas reported little Several respondents observed that telehealth has become first-hand experience with patients losing their jobs or very popular among their patients due to its convenience and insurance coverage in the wake of the pandemic. However, safety. “Most of my patients absolutely love it, particularly my those serving more low-income patients discussed several working population,” one said. However, in some cases PCPs examples of individuals losing employer-sponsored insurance felt that patients loved it too much. One practice established or having their hours cut because they worked for hotels, a rule that no patient could have more than three consecutive restaurants, or other businesses affected by COVID-19 social telehealth visits without an in-person visit. Another distancing strictures. A Florida physician reported that he has commented that patients, once acclimated to telehealth, had more patients sleeping in their cars or having to choose were demanding immediate appointments, placing between buying food or medicine. Other PCPs suggested unexpected demands on his practice’s ability to respond. their communities had not yet seen the full impact of job loss. Such patient behavior raises policy concerns that expanded “I think it is a slow burn,” one said. use of telehealth could lead to overutilization, particularly Although perception of the economic impact of the if reimbursement remains at parity with reimbursement for pandemic varies across practices, PCPs uniformly agreed that in-person care.20 COVID-19 has produced markedly increased levels of anxiety Respondents generally felt that their shift to telehealth as and depression among their patients. A Virginia physician a significant portion of their interaction with patients was observed, “It’s taken a toll on a lot of people; even those who only viable because of altered payment rules and increased are mentally quite healthy are tired, anxious, and depressed.” U.S. Health Reform – Monitoring and Impact 8 Some described increases in alcohol and other substance replacing fee-for-service with capitated payments. Some abuse. of these physicians have hopes that the financial swings associated with COVID-19 could persuade more providers to Most respondents could also point to patients who had embrace capitation. foregone care because of COVID-19, including needed preventive care and chronic disease management. An Atlanta Indeed, a few PCPs told us that they were newly interested in doctor reported a recent patient with stage 4-breast cancer, capitated payments. “It might just be a means of survival at which would have been caught at an earlier stage if she this point,” said one. Another suggested that COVID-19 had hadn’t deferred her appointment due to COVID-19. A Dallas opened his eyes to capitation because “I would not have to physician reported concerns about missed immunizations: argue [with an insurer] about what gets paid.” “Our biggest fear is that we finish with COVID and wind up Despite this new openness to capitation, several PCPs with a measles outbreak.” expressed concern about the lack of transparency in how New Receptiveness to Payment Reform? insurers would calculate the payments. Small, independent For most of our respondents, their significant shortfalls in practices noted that they lacked the leverage and expertise revenue during the early weeks and months of the pandemic to assure payment levels would be “fair.” One expressed was a result of their reliance on a fee-for-service method of concern that insurers would reduce the level of payments payment. In theory, if insurers paid them on a per-person, per- over time, essentially shifting more financial risk onto their month basis (often called capitation), these providers would practice. On the other hand, capitation could give practices have been insulated from the financial effects of a sudden more flexibility to manage the mix of telehealth vs. in-person drop in services. However, in our interviews with PCPs, there visits, potentially disciplining unwarranted patient demand. was wide disagreement over the benefits of capitation as a And the practices, rather than payers, could determine the basic payment method. A few view capitation as “unethical” appropriateness of audio-only versus video-based telehealth because they believe it gives clinicians a financial incentive modalities. to limit services, particularly for higher need patients. On the other hand, some respondents said they have long supported CONCLUSION The COVID-19 pandemic continues unabated, with surges capable businesspeople, making tough decisions to cut in cases, hospitalizations, and deaths in most parts of the expenses, pursue new financial opportunities, and make country. Although federal financial assistance and the necessary changes to their workflow and procedures. The increased use of telehealth helped many practices stay afloat unrelenting nature of the pandemic has and is continuing to in 2020, current trends in virus transmission will continue to exercise a steep toll, with PCPs noting rising levels of burnout put financial and safety pressures on primary care practices. and exhaustion for both themselves and their staff. Even Additional federal support is likely needed, at least in the so, not one suggested to us that they intended to quit the short-term, to ensure continued access to sufficient PPE and profession or retire because of COVID-19. Indeed, for at least adequate reimbursement for services delivered via audio and one the pandemic has reinforced her commitment to this video technology. Many practices may also need support work: “COVID made me realize I can’t retire. I’m like the glue for general operating expenses due to depressed patient that keeps it all together.” demand for well visits and other elective services. Future outlays from the PRF should ideally be better targeted than past payments, in order to support those providers most in need. Young medical students do not choose to enter primary care to become rich. It is among the lower-paid physician specialties. Our interviews with PCPs bore this out, as they universally demonstrated that their first priority is to serve their patients and communities and deliver quality services. At the same time, many have proven themselves to be U.S. Health Reform – Monitoring and Impact 9 ENDNOTES 1. Reiff J, Brennan N, Fuglesten Biniek J. Primary Care Spending in the Commercially 12. Barnett ML, Mehrotra A, Landon BE. Covid-19 and the Upcoming Financial Crisis in Insured Population. JAMA. 2019; 322(22): 2244-2245. https://jamanetwork.com/ Health Care. NEJM Catalyst. 2020; 1(2). https://catalyst.nejm.org/doi/full/10.1056/ journals/jama/fullarticle/2757218. Accessed November 25, 2020. CAT.20.0153. Accessed November 25, 2020. 2. Johnson CY. What Happens When It’s Easier to Visit the Doctor: We Do. The 13. COVID-19 Physician Practice Financial Impact Survey Results. American Medical Washington Post. 2016. https://www.washingtonpost.com/news/wonk/ Association. 2020. https://www.ama-assn.org/practice-management/ wp/2016/03/10/the-major-downside-to-the-cheap-health-clinics-popping-up-all- sustainability/covid-19-physician-practice-financial-impact-survey-results. over-the-place/?arc404=true. Accessed November 25, 2020. Accessed November 25, 2020. 3. Furukawa, MF, Kimmey L, Jones DJ, Machta RM, Guo J,Rich EC. Consolidation of 14. Mehrotra A, Chernew M, Linetsky D, Hatch H, Cutler D, Schneider EC. The Impact Providers Into Health Systems Increased Substantially, 2016–18: Study Examines of the COVID-19 Pandemic on Outpatient Care: Visits Return to Prepandemic Levels, Provider Consolidation into Vertically-Integrated Health Systems. Health Affairs. but Not for All Providers and Patients. Commonwealth Fund. 2020. https://doi. 2020; 39(8): 1321–25. https://doi.org/10.1377/hlthaff.2020.00017. Accessed org/10.26099/41xy-9m57. Accessed November 25, 2020. November 25, 2020. 15. Schwartz K, Damico A. Distribution of CARES Act Funding Among Hospitals” Kaiser 4. Daily L. Before you pay extra to join a concierge medical practice, consider these Family Foundation. 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/ questions. The Washington Post. 2019. https://www.washingtonpost.com/lifestyle/ distribution-of-cares-act-funding-among-hospitals/. Accessed November 25, home/before-you-pay-extra-to-join-a-concierge-medical-practice-consider-these- 2020. questions/2019/10/21/90d8206a-ef8b-11e9-b648-76bcf86eb67e_story.html. 16. Cubanski J, Schwartz K, Biniek JF, Neuman T. Medicare Accelerated and Advance Accessed December 1, 2020. Payments for COVID-19 Revenue Loss: More Time to Repay. Kaiser Family Foundation. 5. Knight V. American Medical Students Less Likely To Choose To Become Primary Care 2020. https://www.kff.org/medicare/issue-brief/medicare-accelerated-and- Doctors. Kaiser Health News. 2019. https://khn.org/news/american-medical- advance-payments-for-covid-19-revenue-loss-more-time-to-repay/. Accessed students-less-likely-to-choose-to-become-primary-care-doctors/. Accessed November 25, 2020. December 8, 2020. 17. Telehealth: Delivering Care Safely During COVID-19. U.S. Department of Health and 6. Thousands of Medical Students And Graduates Celebrate NRMP Match Results. Human Services. 2020. https://www.hhs.gov/coronavirus/telehealth/index.html. The National Resident Matching Program. 2020. https://www.nrmp.org/2020- Accessed December 8, 2020. press-release-thousands-resident-physician-applicants-celebrate-nrmp-match- 18. Adams K. A timeline of telehealth support from the federal government during the results/#:~:text=The%20number%20of%20U.S.%20citizen,highest%20match%20 pandemic. Becker’s Hospital Review. 2020. https://www.beckershospitalreview. rate%20since%201991. Accessed December 8, 2020. com/telehealth/a-timeline-of-telehealth-support-from-the-federal-government- 7. New Findings Confirm Predictions on Physician Shortage. AAMC. 2019. https:// during-the-pandemic.html. Accessed December 8, 2020. www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions- 19. Lucia K, Blumberg LJ, Curran E et al. The COVID-19 Pandemic: Insurer Insights into physician-shortage. Accessed November 25, 2020. Challenges, Implications, and Lessons Learned. Urban Institute and Robert Wood 8. Hauck G, et. al. Five Months In: A Timeline of How COVID-19 Has Unfolded in the US. Johnson Foundation. 2020. https://www.rwjf.org/en/library/research/2020/06/ USA Today. 2020. https://www.usatoday.com/in-depth/news/nation/2020/04/21/ the-covid-19-pandemic-insurer-insights-into-challenges-implications- coronavirus-updates-how-covid-19-unfolded-u-s-timeline/2990956001/. Accessed and-lessons-learned.html?cid=xem_other_unpd_ini:moni_dte:20200629_ November 25, 2020. des:insurer%20insight. Accessed November 25, 2020. 9. COVID-19 Cases, Deaths, and Trends in the US | CDC COVID Data Tracker. Centers for 20. Berenson R, Shartzer A. The Mismatch of Telehealth and Fee-for-Service Payment. Disease Control and Prevention. 2020. https://covid.cdc.gov/covid-data-tracker. JAMA Health Forum. 2020. https://jamanetwork.com/channels/health-forum/ Accessed January 21, 2021. fullarticle/2771509. Accessed December 1, 2020. 10. Karpman M, Zuckerman S. ACA Offers Protection as the COVID-19 Pandemic Erodes 21. Ashwood JS, Mehrotra A, Cowling D, Uscher-Pines L. Direct-to-consumer Employer Health Insurance Coverage. Urban Institute. 2020. https://www.rwjf.org/ telehealth may increase access to care but does not decrease spending. Health en/library/research/2020/11/aca-offers-protection-as-the-covid-19-pandemic- Affairs. 2017; 36(3): 485-491. https://www.healthaffairs.org/doi/full/10.1377/ erodes-employer-health-insurance-coverage.html. Accessed November 25, 2020. hlthaff.2016.1130. Accessed December 1, 2020. 11. Gonzalez D, Zuckerman S, Kenney GM, Karpman M. Almost Half of Adults in Families Losing Work during the Pandemic Avoided Health Care Because of Costs or COVID-19 Concerns. Urban Institute. 2020. https://www.urban.org/research/publication/ almost-half-adults-families-losing-work-during-pandemic-avoided-health-care- because-costs-or-covid-19-concerns. Accessed November 25, 2020. U.S. Health Reform – Monitoring and Impact 10 Copyright© February 2021. The Urban Institute. Permission is granted for reproduction of this file, with attribution to the Urban Institute. About the Authors and Acknowledgments Sabrina Corlette and Kevin Lucia are Research Professors at Georgetown University’s Center on Health Insurance Reforms (CHIR). Robert Berenson is an Institute Fellow in the Urban Institute’s Health Policy Center and Erik Wengle and Tyler Thomas are Research Analysts with the Health Policy Center. The authors thank Megan Houston for her research support, Camille Ahearn for copyediting, and John Holahan for his editorial review. We also thank the American Medical Association, American Academy of Family Physicians, National Association of Community Health Centers, and the National Medical Association for their assistance identifying PCPs to interview, as well as the many sources who took the time to discuss these issues with us. About the Robert Wood Johnson Foundation For more than 45 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working alongside others to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and well-being. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook. About the Urban Institute The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector. For more information, visit www.urban.org. Follow the Urban Institute on Twitter or Facebook. More information specific to the Urban Institute’s Health Policy Center, its staff, and its recent research can be found at www.healthpolicycenter.org. U.S. Health Reform – Monitoring and Impact 11