Primary care has been under stress for years. It’s a medical field with high demands and relatively low incomes, at least among doctors.
When COVID-19 arrived, those practices took a huge hit. Despite measures to make up for lost revenue, many are still struggling.
On a recent morning, Amy Jewitt of Hadley, Massachusetts, brought her two-month-old baby Summer for a physical with physician assistant Sarah Vacca.
“Let me see you on your belly,” Vacca said to the baby, setting her on the exam table, over a few light gurgles. “Any diaper rashes?” she asked Jewitt.
This is one of the only times Jewitt has come into the office since the pandemic began. Most of her appointments have been on video.
“Just being in a space where a lot of sick people come is worrying,” Jewitt said, “especially with such a little one.”
For the past year and a half, many patients have been avoiding the doctor’s office — in varying waves.
“It was terrifying. I really thought I was going to lose my practice,” said Dr. Kate Atkinson, who runs primary care offices in Northampton and Amherst.
Early in the pandemic, when patient visits dropped off dramatically, Atkinson’s income dried up. So she laid off some staff, starting with those who wanted to reduce hours, and quickly ramped up televisits.
In March 2020, Governor Charlie Bakerordered insurers to reimburse telehealth at the same rate as office visits and to waive those copays, “which for Massachusetts was a godsend,” said Atkinson. “I mean, it really saved us. People actually wanted to keep their appointments.”
Atkinson said she got a $520,000 business loan — since forgiven — from COVID relief legislation. That helped for about a year.
“The problem for us financially has really just been recent,” she said.
'We have to think twice before ordering supplies'
Although in-person visits are up since the early days of COVID, many patients want to stick with telemedicine. But some insurance companies have cut back on reimbursement for telehealth.
Atkinson has also noticed that more of her patients have publicly funded insurance plans — such as MassHealth, the Medicaid program in Massachusetts — which typically pay less to doctors.
“We worry about how we're going to be able to keep plugging ahead,” she said. “We have to think twice before ordering supplies.”
Observers on a state and national level are worried too.
The data is sparse, but national surveys from the Primary Care Collaborative, an advocacy and research group, show high burnout and precarious finances among primary care doctors.
“The pivot to remote care did not make up for the revenue that primary care lost,” said Ann Greiner, president and CEO of the collaborative. “The field is still analyzing the data to understand what the implications are.”
The Center for Primary Care at Harvard University estimates private practices lost about $15 billion in 2020.
Many have rebounded through telemedicine and federal assistance, but some gave up.
'The practice has closed permanently'
Primary Care Associates in Springfield used to care for adults and geriatric patients. But after the pandemic began, the office couldn’t make up the lost income, according to nurse practitioner Julyvette Rodriguez, who worked there. The practice shut down in November.
Now when former patients call, they get a recording that says, “the practice has closed permanently” with no other information.
The former owner, Dr. Virginia Pamela Peters, did not return messages.
“I think you're going to see some real holes develop across the nation where access becomes very difficult,” said Dr. Robert Phillips, executive director of the Center for Professionalism and Value in Health Care of the American Board of Family Medicine.
Phillips oversees a national registry of 800 rural primary care offices. He says patient visits declined by about 40% in spring 2020 and haven’t totally recovered.
“That means that most practices remain financially underwater,” he said.
And, increasingly, primary care practices are being acquired by larger health systems, including the one Phillips works for in Northern Virginia, now owned by Inova.
“It was basically a survival issue for us,” Phillips said. “We were struggling before the pandemic, but when the pandemic hit, it was a saving throw.”
Phillips said joining a large health system provides more stability for struggling practices, but it also leads to higher costs for the overall health care economy, since large hospitals can negotiate higher payments with insurance companies.
From the perspective of doctors and patients, Phillips said when private practices lose their independence, there is less flexibility in how the office delivers care.
“Like my patients have a more difficult time scheduling appointments with me because the health system just wants to fill slots,” Phillips said. “And so it's disrupted relationships in some important ways.”
Atkinson, who once worked for a large health system, is hell-bent on avoiding that fate.
“I think we take much better care of patients and staff and each other, and we bring dogs and babies to work,” she said. “I don't want to go back to a corporate model. No, thank you.”
'You left unprotected an infrastructure ... that is very hard to get back'
But Atkinson is concerned about the future of her practice, including the emotional strain on staff during the pandemic.
“At the beginning, everybody was so sweet and appreciative and, ‘Yay, health care providers!’” she said. “And then it got to the point where people were just calling and yelling at my staff because they were just so stressed and worried.”
“I think that's taken the biggest toll from COVID,” Atkinson added, “just dealing with the stress of people who are demanding more than we're able to provide.”
Phillips is frustrated the federal government did not set aside more COVID-relief money to shore up primary care, beyond business loans and help for federally qualified health centers.
“You left unprotected an infrastructure that was critical and that is very hard to get back,” he said. “And now I fear that this delta surge is actually going to compound that.”
Phillips is part of an effort pushing federal health officials to focus more on primary care, but he said the process is slow.
Over the long term, some doctors want different payment models, outside the current fee-for-service system, so they don’t have to rely on the sheer number of office visits for their livelihood.
The Center for Primary Care wants to move Massachusetts toward what's called “global payment,” in which health plans allot a certain amount of money per patient, no matter how often they see the doctor. That could protect practices from sudden income loss during a pandemic.
But in the short term, many worry that physicians are fleeing primary care at a time when it’s already hard to find a doctor.
Atkinson’s practice has been full for years. She said the only way to get on her list is to marry an existing patient — or be born to one.
