Primary care practices are projected to have combined revenue losses of $15.1 billion due to dramatic declines in office visits from March to May 2020 during COVID-19 shutdowns, a U.S. study suggests. Researchers used national data on utilization, staffing, expenditures, reimbursements including any fees for telemedicine visits to calculate how much revenue primary care practices would lose in 2020 due to the cancellation of in-person outpatient visits in response to the novel coronavirus. To determine potential losses, researchers projected expected 2020 gross revenue with and without COVID-19 shutdowns and determined that losses would amount to $67,774 in gross revenue per full-time physician. "We already knew that utilization of primary care practices during the pandemic had dipped dramatically during the month of April in particular, and that telemedicine visits - despite the hype - did not fully make up for the loss of regular in-person primary care visits," said lead study author Dr. Sanjay Basu, director of research and population health at Collective Health in San Francisco and a faculty member at the Center for Primary Care at Harvard Medical School in Boston. The biggest causes of financial losses have been decreased in-person visits leading to fewer payments to practices for those visits, Dr. Basu said by email. "This is primarily driven by shelter-in-place orders that were necessary to avoid spread of the virus within waiting rooms," Dr. Basu said. "To a lesser extent, people have also been postponing visits due to lost benefits or COVID concerns" Things could look a lot worse if there's a second wave of shelter-in-place orders during November and December that have half as much impact on visit volume as the spring shutdown, the study team writes in Health Affairs. If this scenario comes to pass, primary care practices would lose $46,157 if they furloughed staff and reduced salaries and benefits or $85,666 in gross revenue if practices maintained all of their pre-existing costs. Without furloughs, the total cost in primary care revenue losses would reach $19.1 billion under this scenario. In a separate scenario, researchers looked at what would occur if telemedicine payments returned to pre-COVID levels starting October 1, 2020. This would result in gross revenue losses for primary care practices of $173,453 over the 2020 calendar year, the study team calculated. And, this return to lower telemedicine reimbursement would lead to nationwide primary care losses of $38.7 billion, the study found. Subsidizing telemedicine during the pandemic also isn't a permanent fix to financial problems in primary care, said Dr. Kimberly Rask, chief data officer at Alliant Health Group in Atlanta. "Subsidizing telehealth is a band-aid that has helped practices stay open and provide some care," Dr. Rask, who wasn't involved in the study, said by email. "But many independent practices or practices caring for vulnerable populations do/did not have the technology to quickly transition to virtual care." Telemedicine is likely to have an ongoing place in primary care after the pandemic ends, but the current fee-for-service payment model doesn't make it easy for practices to transition to this model of delivering care, Dr. Rask added. The course of the COVID-19 pandemic is unpredictable, and this is a main limitation of the estimated revenue losses calculated in the study. "As with any model, this study relies on a number of assumptions that may or may not hold true — for example, that current policies will continue," said Dr. Ishani Ganguli, an assistant professor of medicine at Harvard Medical School and primary care physician at Brigham and Women's Hospital who wasn't involved in the study. Flattening the curve of the pandemic is also essential to financial recovery in primary care, Dr. Ganguli said by email. "We must make it as safe as possible for patients to see their primary care clinicians again - that is, we reverse the devastating surge in Covid-19 cases and deaths across the country through a multi-pronged effort that includes widespread social distancing, contact tracing, reliable testing, and eventually, hopefully, a vaccine," Dr. Ganguli said. Under the best case scenario, primary care practices manage to convert to capitated payments and move away from fee-for-service models to enable more flexibility to provide telephone or video-based care as needed instead of relying entirely on in-person visits, Dr. Basu said. A worst case scenario for financial losses might mean the pandemic continues to shutter practices, or that larger firms consolidate more independent practices and effectively limit access to care, Dr. Basu said. "This is made more likely if payments for telemedicine services are returned to their pre-COVID low levels, because social distancing and other important rules for reducing spread will necessarily cause in-person visits to be less in number over the coming months," Dr. Basu said. —Lisa Rappaport Source
