Diagnosis for small family doctors: Less money, greater hardship, and patients on video

Government loans and a shift to telehealth have plugged holes, but deep worries plague independent practices

Michelle Forbes outside her practice in Flower Mound, Tex. (Allison V. Smith for The Washington Post)

By Christopher Rowland-SEPTEMBER 8, 2020

The wedding band is gone. So are his class ring, his wristwatch, the neckties he has worn for decades — even the white coat with his name embroidered in blue.

Since the onset of the coronavirus pandemic, James W. McNabb has switched to wearing just surgical scrubs. It’s a departure from the Norman Rockwell image of a small-town doctor, depicted in a print hanging at McNabb’s small-town practice in Mooresville, N.C. But the stripped-down look leaves fewer places for coronavirus to hide.

The staff disinfects the office five times a day. The waiting-room magazines have all been tossed out, eliminating another route of infection.

McNabb says these are just some of the permanent changes the coronavirus has wrought on his practice. For many solo practitioners, the virus has forced a stark choice — adapt or shut down.

Doctors who have been scrambling to stay afloat are changing the way they interact with patients and the way they run their businesses, and many changes are expected to be lasting.

Doctors are shifting large portions of their patients to virtual telehealth visits. They are being forced to make do with less revenue, some of which may never come back. Medical associations say some doctors are retiring early or joining larger groups as they seek strength in numbers.

And with the episodic, fee-for-service payment system magnifying economic pain for doctors as patients shun medical care amid the pandemic, the coronavirus crisis also may be accelerating long-overdue changes in the way doctors are paid, specialists said.

Like his colleagues across the country, many of whom operate like small businesses, McNabb is working with less pay and a shrinking staff, all while scrambling to connect with patients on the Internet and making diagnoses over laptops and smartphones.

“I sink or swim depending on my revenue,” he said. “There is no salary. You eat what you kill, and if you’re not bringing any money in, you’re not taking any money home.”

TOP: James W. McNabb with his staff this month in Mooresville, N.C. BOTTOM LEFT: McNabb performs a routine physical. These days he is seeing many patients via video. BOTTOM RIGHT: McNabb says his office is taking extra precautions against the coronavirus. He has switched to wearing surgical scrubs.

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National surveys have long shown that independent primary-care doctors already were squeezed financially. Compensation for family doctors is among the lowest in medicine, especially for independent physicians in rural areas who can barely afford to keep their exam rooms open to see patients they have treated for decades.

The virus forced a sudden and devastating cut in patient visits in March as people heeded public health warnings and stopped venturing out. That in turn led to an immediate cash crisis for doctors that has put the country’s entire health-care system under extreme financial pressure.

Predictably, many of the doctors at the bottom — the ones who form the backbone of front-line care — are barely hanging on.

For primary-care doctors, the coronavirus is “an extinction-level event” that requires a stronger policy response from government and insurance companies, said Rebecca Etz, co-director of the Larry A. Green Center, a nonprofit organization based at Virginia Commonwealth University that advocates for stronger supports for primary medicine.

“After covid, everything about health care is just going to be completely different,” Etz said. “We know the pandemic is not going to let us get back to normal for at least a year, and there is no normal to go back to.”

In addition to the fiscal crisis, doctors are juggling more work because of layoffs or staffers who quit, coping with chronic shortages of masks and other personal protective equipment, and struggling to keep track of chronically ill elderly people who are afraid to leave their homes. Crucial side revenue from things such as in-office tests and X-rays have completely dried up.

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Responses to a questionnaire in August circulated by the nonprofit Physicians Foundation suggested about 8 percent of U.S. doctors who reported shuttering their practice because of the coronavirus, or up to 4,000 practitioners, were primary-care physicians.

About 486,000 doctors work in all categories of primary care in the United States, including family doctors, internists, obstetricians and pediatricians, according to data compiled by the Kaiser Family Foundation.

Many doctors have stayed in business by skipping their own paychecks or reducing their salaries and furloughing members of their small teams. But critics say outdated methods of payment have compounded the crisis and heightened the urgency of moving away from episodic, fee-for-service contracts between providers and insurance companies and toward a more holistic billing approach.

“Covid, I think, has exposed everything that is wrong with the health-care system,” said Greg Griggs, executive vice president of the North Carolina Academy of Family Physicians. “You have these financial challenges, you have higher costs, and you have logistical challenges. All combined are pretty much a nightmare for primary-care practices.”

Family nurse practitioner Jackie Swope greets a patient with covid-19 symptoms outside McNabb's Mooresville practice. (Logan Cyrus for The Washington Post)

Paycheck Protection Program (PPP) loans approved by Congress and the Trump administration kept doctors afloat in the depths of the crisis from April through June. But the effect of that federal support is now evaporating, while patient visits and billings have yet to fully rebound. And those visits and billings may never return.

Responses to a questionnaire from the Green Center and another nonprofit, the Primary Care Collaborative, indicated that 4 out of 5 primary-care doctors were under greater levels of stress in July than they were in March. Forty-four percent of doctors who answered the questionnaire said in-person patient visits in July were 30 to 50 percent lower than normal.

And moving from in-person visits to video examinations has been a stopgap, at best, the groups said.

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“Although telehealth has proven a useful care tool during the pandemic, lack of sufficient support has resulted in a downturn in use and a choke point for patient access,” the groups said of the questionnaire’s findings.

The Trump administration permitted Medicare to make full doctor payments for telehealth visits under the covid-19 public health emergency, and President Trump has proposed making the changes permanent for rural providers. Private insurance companies, while they have temporarily boosted payments to doctors to conduct remote examinations, have not committed to a permanent change.

In the short term, telehealth has been a vital link in the crisis, doctors said. Physicians turned on a dime and began seeing most of their patients via video link.

“In almost 40 years of practice, I’ve never had a situation where I told patients they couldn’t come in,” said Mitchell Miller, a solo practitioner in Virginia Beach. “Patients feel a bit more comfortable seeing us on the screen, as opposed to sitting one foot away.”

There was a learning curve initially. “It was pretty maddening at first, frankly,” he said. But most patients were able to adapt with coaching from the office staff. For those who couldn’t, Miller and his small team made do with telephone consultations.

Miller estimates he lost about $150,000 in patient revenue in the first five months of the pandemic. Patient revenue was about one-third of normal levels in March and April and rose to about 70 percent by July, he said. Much of his losses were plugged by a PPP loan of $130,000. But that federal assistance has been used up. The number of patients has bounced back somewhat but not to pre-outbreak levels, he said.

“One day, maybe a year from now, we will have life as it used to be,” he said, “but I’m not sure we’re going to see it.”

McNabb interviews a patient before her physical. (Logan Cyrus for The Washington Post)

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Independent practitioners have faced another crippling problem — an inability to purchase personal protective equipment. Without it, they have been unable to see patients with suspected covid-19 in person.

At Temescal Creek Medicine, a two-physician practice in Oakland, Calif., Michael Zimmerman said the office could not offer testing. Instead it spoke with patients via video or telephone to determine whether they were sick enough to go to an emergency room to seek a test.

“I literally had black paint on my N95 mask because I was using the one from my garage,” Zimmerman said. By last month, a California association of doctors had started a program to distribute boxes of 100 masks to independent doctors who lacked the purchasing power to get them on their own. Zimmerman pulled up to a pickup site, and young volunteers dropped the box in his trunk.

“I was almost tearful when I got this thing,” he said. “It was the first time I changed my mask since March 15th.”

The flow of patients coming in for primary-care visits has improved in the past two months, doctors said. But the crisis has driven some small independent family physicians to close up shop or join larger groups, a kind of strength-in-numbers approach that yields higher reimbursements because big groups have more negotiating leverage with insurance companies. For-profit companies backed by private-equity investors have been rolling up small practices in the most lucrative markets for years.

In Texas, a nonprofit physician group called Catalyst Health Network says it offers an alternative that permits physicians to retain their independence while getting the benefits of belonging to a large group, with large teams and plenty of administrative support.

Catalyst helped its doctors apply for PPP loans, and it set up drive-through coronavirus testing centers where doctors could send their patients. The group has added hundreds of doctors, growing to 1,000 since the pandemic began, and has a deep list of more ready to sign up, said Catalyst chief executive Christopher Crow.

Michelle Forbes, a pediatrician whose practice north of Dallas is part of Catalyst, helps recruit doctors to join the network. The muscle of 1,000 doctors is a huge part of the draw, she said, because it creates incentive for large insurance companies to compensate the group more fully for all of the work it does to keep patients healthy.

“Why don’t we recognize the value of primary care?” Forbes said. “Primary care is not sexy. It’s the gritty. It’s the granular. It’s what do I do to keep my patient healthy and address their chronic issues and social issues and housing security and education. And it can be hard work.”

TOP: McNabb greets longtime patient William F. Coleman. BOTTOM LEFT: McNabb examines Coleman this month. BOTTOM RIGHT: McNabb says the coronavirus has forced changes on his practice that will be permanent.

Advocates for overhauling payment practices in health care hope the crisis will steer contracts between insurance companies and doctors away from fee-for-service agreements that make the office visit the primary driver of payments for family doctors and pediatricians.

Instead, they argue, insurers should pay providers an upfront fee to manage a patient’s health for the duration of the coronavirus crisis. Providers would receive more money for people with chronic disease and would be financially incentivized to keep people healthy and out of the hospital.

The need to move toward such contracts — called prospective, or capitated, payments — has been debated for years.

“Family medicine has politely whispered for years that [fee-for-service] was an illogical payment construct for primary care,” Shawn Martin, chief executive of the American Academy of Family Physicians, wrote in an April blog post, “and the COVID-19 pandemic simply put a giant spotlight on this issue.”

“I sink or swim depending on my revenue,” he said. ” … If you’re not bringing any money in, you’re not taking any money home.” (Logan Cyrus for The Washington Post)