Another small business reeling from COVID-19: the doctor’s office

Erica Swegler is not just worried about her patients during the coronavirus pandemic; she’s also worried about her business, which she says has fallen into the red.

In normal times, the Austin family physician might see as many as 26 patients in a day. Recently, that number has fallen to 12 or six, as public officials urge people to stay home and delay non-urgent care to help slow the spread of COVID-19, the disease caused by the new coronavirus.

Swegler wants her patients to stay home if they can; about one-third of them are at high risk of bad outcomes if they contract the disease, she said. The problem is that lower patient volumes — and stingier reimbursement for caring for patients remotely via telemedicine — makes it tough to pay the bills. Swegler is trying to make payroll for her three employees on Tuesday. Her landlord has agreed to lower rent for March and April, but Swegler knows it’s not a long-term option.

“If I’m ill and have to leave the practice for up to two weeks, or God forbid I’m hospitalized where it may be a three- to six-week period of time, I’m bankrupt,” she said.

Primary care doctors and specialists are warning that, as financial constraints lead them to consider laying off staff or even go out of business, a greater number of patients might end up in Texas hospitals at a time when those facilities don’t have the capacity to handle them.

Nurse practitioners in doctors’ offices or outpatient clinics are already losing jobs or being furloughed, said Christy Blanco, president of the Texas Nurse Practitioners professional association.

One Houston-area nurse practitioner, who spoke on the condition of anonymity because her employer does not allow her to talk to reporters, said she'd had her hours cut this week by one-fifth because of low patient volumes.

"I have a home, I have my daughter’s daycare, I have student loans, obviously just food and living expenses just to keep things running," she said. "A 20 percent chunk is a big chunk."

Government mandates have required some health insurers to pay doctors the same amount for a telemedicine consultation as they would for an in-person visit, but many employer-based plans pay far lower rates for remote services, health workers said.

“What we’re seeing is an inadequate reimbursement” for telehealth, Blanco said. An insurer might pay a practice $70 for a primary care visit, she said, but if done via telehealth, the payment could be as low as $7.

Layoffs are “not just affecting restaurants and local businesses,” Blanco said. “In the specialty and the other clinics that aren’t acute care clinics, we’re seeing the same type of situations.”

Swegler spoke to The Texas Tribune late Thursday after finishing a telephone visit with a patient.

“It went well, it’s just that who knows how much I’ll be paid,” she said. “I don’t really look at what insurance they have, and the teleconsults without video, which I’m not currently set up for, could be paid as little as 10 to 30% of a regular office visit.”

Kevin Spencer, chief executive of Premier Family Physicians, a network of 42 primary care providers in Austin, said visits to his physicians were down about 30% because of the coronavirus. And that’s after seeing an uptick in virtual visits.

“To take away 30, 40% of your volume, the margins in your primary care business will run out in a matter of weeks or months,” he said.

Even with some insurance plans paying full rates for telemedicine visits, Spencer said the kinds of visits doctors can perform remotely don’t pay as well. For example, practices can’t run lab work, give vaccines or perform a complete physical exam over phone or video.

“Unlike other small employers who can furlough staff or close up shop, family physicians are essential to our health care system,” Tom Banning, president of the Texas Academy of Family Physicians, said. “People won’t stop getting sick, chronic care patients still need ongoing continuity of services and more folks will need mental health counseling for things like anxiety about job loss or losing the family savings.”

In the meantime, doctors are looking into small business loans guaranteed by the federal government and hoping for relief under a congressional bailout.

They’re also calling on insurance companies to help. They argue that many insurers are saving money as claims drop. Spencer would like to see insurers move to pay primary care physicians an upfront, regular fee for keeping patients healthy. Doing so would move away from the traditional fee-for-service system, which pays physicians for individual procedures.

Swegler backs that idea.

“I’m in a small, independent practice, and I just don’t hear much if any attention being paid to our peril, which is very real,” she said. “It’s going to happen very quickly that we just won’t have the resources to keep our doors open.”