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Primary care practices may lose about $68k per physician this year


Primary care practices stand to lose almost $68,000 per full-time physician this year as COVID-19 causes care delays and cancellations, researchers estimate. And while some outpatient care has started to rebound to near baseline appointment levels, other ambulatory specialties remain dramatically down from prepandemic rates.

For primary care practices, Sanjay Basu, MD, and colleagues calculated the losses at $67,774 in gross revenue per physician (interquartile range, $80,577-$54,990), with a national toll of $15.1 billion this year.

That’s without a potential second wave of COVID-19, noted Dr. Basu, director of research and population health at Collective Health in San Francisco, and colleagues.

When they added a theoretical stay-at-home order for November and December, the estimated loss climbed to $85,666 in gross revenue per full-time physician, with a loss of $19.1 billion nationally. The findings were published online in Health Affairs.

Meanwhile, clinical losses from canceled outpatient care are piling up as well, according to a study by Ateev Mehrotra, MD, associate professor of health care policy and medicine at Harvard Medical School in Boston, and colleagues, which calculated the clinical losses in outpatient care.

“The ‘cumulative deficit’ in visits over the last 3 months (March 15 to June 20) is nearly 40%,” the authors wrote. They reported their findings in an article published online June 25 by the Commonwealth Fund.

When examined by specialty, Dr. Mehrotra and colleagues found that appointment rebound rates have been uneven. Whereas dermatology and rheumatology visits have already recovered, a couple of specialties have cumulative deficits that are particularly concerning. For example, pediatric visits were down by 47% in the 3 months since March 15 and pulmonology visits were down 45% in that time.

Much depends on the future of telehealth

Closing the financial and care gaps will depend largely on changing payment models for outpatient care and assuring adequate and enduring reimbursement for telehealth, according to experts.

COVID-19 has put a spotlight on the fragility of a fee-for-service system that depends on in-person visits for stability, Daniel Horn, MD, director of population health and quality at Massachusetts General Hospital in Boston, said in an interview.

Several things need to happen to change the outlook for outpatient care, he said.

A need mentioned in both studies is that the COVID-19 waivers that make it possible for telehealth visits to be reimbursed like other visits must continue after the pandemic. Those assurances are critical as practices decide whether to invest in telemedicine.

If U.S. practices revert as of Oct. 1, 2020, to the pre–COVID-19 payment system for telehealth, national losses for the year would be more than double the current estimates.

“Given the number of active primary care physicians (n = 223,125), we estimated that the cost would be $38.7 billion (IQR, $31.1 billion-$48.3 billion) at a national level to neutralize the gross revenue losses caused by COVID-19 among primary care practices, without subjecting staff to furloughs,” Dr. Basu and colleagues wrote.

In addition to stabilizing telehealth payment models, another need to improve the outlook for outpatient care is more effective communication that in-person care is safe again in regions with protocols in place, Dr. Horn said.

However, the most important change, Dr. Horn said, is a switch to prospective lump-sum payments – payments made in advance to physicians to treat each patient in the way they and the patient deem best with the most appropriate appointment type – whether by in-person visit, phone call, text reminders, or video session.

Prospective payments would take multipayer coalitions working in conjunction with leadership on the federal level from the Centers for Medicare & Medicaid Services, Dr. Horn said. Commercial payers and states (through Medicaid funds) should already have that money available with the cancellations of nonessential procedures, he said.

“We expect ongoing turbulent times, so having a prospective payment could unleash the capacity for primary care practices to be creative in the way they care for their patients,” Dr. Horn said.


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