Exclusive survey: Physicians explain COVID-19 financial impact on practices

The COVID-19 pandemic has proved an unprecedented challenge for physician practices.

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Primary care is in the midst of a crisis. Many practices face the possibility of closure as they deal with fallout from the COVID-19 pandemic. So what can physicians do to save their practices and treat their patients effectively? Farzad Mostashari, M.D., says physicians should embrace risk.

And by risk, he means value-based care. Mostashari contends that the fee-for-service system has exacerbated these financial struggles and that the way forward is to accelerate the evolution of how physicians are paid for providing care. In a wide-ranging conversation, we discuss value-based care, telehealth and what the ideal primary care practice of the future should look like.

Mostashari is the former director of the Office of the National Coordinator for Health IT and current CEO of Aledade. Based in Bethesda, Maryland, Aledade assists small practices with transitioning to value-based care models. This interview has been edited for length and clarity.

Medical Economics®: What is the state of primary care right now? What are practices going through and how do we fix primary care so that they can succeed in the future, given the challenges?

Mostashari: Primary care has never been more needed. We have obviously a lot of need for primary care on the front lines of COVID-19. We all hear about hospital workers who are at risk of being infected with COVID-19, but those patients who end up in the hospital first went to their primary care practices. And those primary care doctors aren’t like you and me, who get to stay home and socially distance ourselves. Those primary care practices are exposed to every patient who walks in the door, and they care for them. They close the door, they’re in a room with them, often with inadequate personal protective equipment, because the supply chain for those small practices is broken, they could not order masks.

These primary care heroes have been caring for patients, helping patients stay home and healthy and telling them, “Don’t come in if you don’t need to.”

But that means under their current business model of primary care, they are struggling financially, because the only way they had been getting paid is by doing visits — not by answering phone calls or reaching out to patients. And so, at the very time we need primary care the most, we see more and more practices that were fee-for-service threatened with going out of business.

So it’s not a good time for primary care. They’re worried about themselves. They’re worried about their family members. They’re worried about their staff, and they’re worried about how to make payroll.

ME: What do you think needs to happen to save these practices from financial ruin?

Mostashari: This is quite topical. [Recently] BlueCross BlueShield of North Carolina announced a program that we’ve been working with them on for some time now, where they are leading the way on this issue for any health plans, in terms of thinking of what should be done to save these independent primary care practices. Quite simply, what they’re saying is, we will give you a lump sum payment to make up the loss of revenue that you had this year. There’s no clawback, if they miscalculated; there are no additional reporting requirements.

The one requirement is that you enter into a total cost-of-care accountability contract. Aledade is honored to be the partner helping support those practices and succeeding in these value-based contracts.

And guess what? If you’re in one of those value-based contracts now you’re less dependent on fee for service. Our North Carolina practices, like those in other parts of the country, are getting hundreds of thousands of dollars in payments — not for patients walking in the door, but for patients being healthy and at home and not having to go to the hospital. That is what we should be doing. We should be keeping independent primary care practices whole and using this as an opportunity to move toward value-based care.

How do you see value-based care approaches evolving, given this cataclysmic event?

Mostashari: It’s a cataclysmic event as far as fee for service goes, with hundreds of billions of dollars of bailouts required to compensate hospitals and others for lost revenue from people not walking in the door for fee for service. Value-based care is fine. It hasn’t needed a bailout. The ACO [accountable care organization] models are pretty robust. You have to say, “Can we be better than if we weren’t in an ACO? Can we respond faster to the needs of the patients? Can we educate the patients? Can we take care of their preventive care? Can we deal with care transitions? Can we deal with our medication issues?” All of the things that we are working on with our practices to do a good job on the value-based contract is exactly what you would want to do for your mother at the time of COVID-19. Right? You would want her primary care practice to reach out and let her know she can call us first, we’ll see her on video, we’ll talk to her on the phone. If she has any problems, we’ll send her a 90-day prescription so she doesn’t have to go to the pharmacy in person. It’s all the things that you would want done for her. And if she does end up in the emergency department, we’ll call to see how she’s doing and follow up. That’s what we should be doing anyway. It’s just that the current payment system didn’t support it.

ME: Telehealth utilization has skyrocketed. What is the link between telehealth and value-based care and how can we strengthen that link?

Mostashari: Telehealth has a long history of problems with reimbursement, because the concern on the part of the health plans and Medicare and others is it’s not going to substitute for face-to-face visits, that it’s just going to be additive, it’s going to increase costs, it’s going be harder to trace for fraud and abuse purposes. All of those issues are suspended now, because we can’t get any face-to-face visits, and this is a substitution for the loss of care. But when things go back to normal — and things 

 go back to normal — the question is whether this [telehealth surge] is just a blip or whether this is going to be the new way of delivering care. And I think people are being too optimistic to assume that all the flexibilities and parity that have come with telehealth during this period will continue.

I think the solution is to take risks. The solution is saying to the health plan, “Hey, we’re not going to run up the bill on telehealth because we have an incentive to care about the total cost of care.” More risk is more freedom, in that sense, because if you’re on the same side as the payer, then they’ll say, “You’ll deliver the care however you want to deliver it, I don’t care, because you have the same incentives to keep the person healthy and out of the hospital, as opposed to running up the bill.”

ME: Things are starting to open up in much of the country while there also is a surge in cases in many places. So you have to navigate this fine line of doing what’s right in terms of not seeing patients in person while keeping your business afloat. What are some ways to navigate these challenges?

Mostashari: The good thing about working with independent practices is that the north star is what’s best for the patient, sometimes to the detriment of their business, right? But if you work for an organization that has a big finance department, then the finance people can tell you how you should practice medicine. That’s not the case with these independent practices; they do what’s right for the patient.

What’s right for the patient in this case is: If we can deliver care to you remotely, we should do it that way. And if you have potential COVID-19, then we need to keep you and other people safe. So a lot of it has work done in terms of creating new workflows and protocols for how to do testing in the parking lot, how to keep separate entrances, how to put people behind [acrylic shields], how to keep the waiting room empty. We have to reopen the practices so that we can get primary care in person to the people who need in-person care, but we have to do it in a way that’s safe for the practice staff and safe for other patients.

ME: Let’s talk about the strain and mental toll this is taking on physicians. What do we need to do to take care of them?

Mostashari: I’m very worried about burnout. I’m very worried about the pressures that are on our frontline primary care doctors and their staff. The worry that that we all feel — that uncertainty is compounded when you’re a small-business owner. You’re worrying about your finances, you’re worrying about your employees, you may have to do layoffs, you worry about their safety and you’re worried about bringing COVID-19 home to your family. I don’t think it’s appreciated enough the daily toll it takes to go in, expose yourself and then come home. I talked to one primary care provider who told me, “I come home and just scrub myself raw.” Living with that is taking a toll.

Caring for those who care for us, right now we need to do that. And we need to go beyond bumper stickers or signs that say thank you for the essential workers. We actually need to, as a country, follow through on providing them with the support they need.

ME: Let’s get more optimistic. What do the ideal primary care system and practice of the future look like?

Mostashari: I think the key is to really break the fallacy that fee for service is a good way to pay for primary care. We’ve kind of limped along and made it work based on compassion and professional ethos. And now I think we’re seeing this is just no way to run the zoo. We shouldn’t be basing primary care payments on that. It should be on the value created and we need to move toward more person-based rather than transactional [encounters]. Primary care is very much a person-based, longitudinal relationship kind of work, and we should be paying for it based on person-based longitudinal care and holding people accountable for total cost, total quality, total experience of care.

And I think that’s the optimistic view, that we will get to the point where we’re going to have more freedom for primary care to deliver care the way they see fit.

ME: What do you think the pandemic has revealed about our health care system?

Mostashari: We’ve talked a lot about how broken fee for service is and how we don’t have the systems to really support these independent smaller practices. The plus side is you never thought you’d see things move so quickly. We saw change within days on policy, regulations, payment models, technology adoption and telehealth. We saw a change in days that you would have thought would take years under the normal course. So that to me is the positive. We have responded. It’s shown that our health care system [is] getting up, sprinting and realizing, “Oh, I didn’t realize I could still sprint!” It is a good reminder that we can do it when we need to.

But even as we’re in the midst of an emergency, we need to be thinking around the bend.

Articles

The way forward is to accelerate the evolution of how physicians are paid for providing care

How value-based care  can save your practice

More Americans than ever are obese. The number of adults with obesity has skyrocketed 200% over the past 40 years, according to the Centers for Disease Control and Prevention. Obesity’s associated comorbidities and health care costs contribute to legitimate public health concerns in the face of novel health threats such as COVID-19.

However, as the number of Americans struggling to manage their weight continues to grow — 72% of Americans 20 or older are overweight or obese — our clinical understanding of this complex but treatable condition has increased. We know there are hormonal and metabolic differences between people who are obese and those who are not. We know that there is a range of effective treatment options for obesity, and, while it includes behavior modification and cognitive therapies, we also can explore pharmacological and surgical interventions. There are limitations to the effectiveness of physical activity on weight loss and obesity management.

Given all that we know about obesity, it is vital that clinicians and other health care professionals make it a priority to educate themselves on best practices for effectively integrating physical activity into obesity treatment plans.

We need to reexamine the role of physical activity in obesity management.

The notion that people can “win” the fight against obesity simply through dieting and exercise was taken to a new level with the introduction of television’s “The Biggest Loser.” Contestants experienced dramatic weight loss while appearing on the show — just as we might expect to happen when patients with obesity are prescribed high levels of physical activity along with around-the-clock monitoring — but maintaining highly intense exercise regimes is unsustainable for most people who are overweight or obese. Additionally, a key insight from a long-term study of “Biggest Loser” contestants tells us that physical activity plays a larger role in maintaining weight loss than it does in catalyzing it.

Certainly, that doesn’t mean physical activity plays no role in the weight loss journey. But it does mean that we should exercise caution in thinking about physical activity in terms of isolated exercise. Not only is it an ineffective weight loss treatment for patients with obesity, but it reflects an outdated understanding of the metabolic mechanisms behind weight loss.

We know that sitting for long periods of time can negatively affect insulin resistance, but breaking up those periods with short walks can reduce insulin and glucose responses. With that in mind, a more effective and sustainable approach would dispense with “eat less, move more” and instead encourage patients to “sit less, walk more.”

What health care professionals need to know about incorporating physical activity into obesity treatment.

Here’s what we do know about physical activity: It can power a number of positive health outcomes. Exercise can improve lipoprotein levels, blood pressure, insulin resistance, cardiovascular health and mood and brain function in patients with obesity.

Health care professionals should keep the following best practices in mind when collaborating with patients on obesity treatment plans:

 Create realistic expectations of weight loss results, if any, based on individual patient activity programs. Help patients start to take a longer-term view of the weight loss journey to stave off feelings of burnout or frustration with the process.

Patients often begin the treatment process with a great deal of enthusiasm, which can inspire positive behavior changes, but it can also create the risk of exercise-related injury from doing too much, too fast. Help patients learn their individual exercise level and collaborate on finding ways to support and gradually increase the intensity. Discuss the risk of sore muscles after starting a new exercise program.

Starting a new exercise program can be a major hurdle to overcome. Help patients make the first step by connecting them with an easy-to-follow, actionable regimen that incorporates physical activity into their everyday lives. An easy place to start is by advising patients to walk a certain number of steps each day and gradually increase that number over time.

 Keep the myriad positive outcomes of physical activity top of mind for patients and help them to understand that exercise is just one part of a broader plan of care to improve their overall health. This insight can make it easier for patients to prioritize physical activity every day.

Health care professionals can better meet the needs of this rapidly growing segment of Americans by deepening their understanding of obesity medicine. The Obesity Medicine Association (OMA) provides a number of resources to encourage this endeavor, including The Obesity Algorithm, Obesity Treatment Proficiency Badges, American Board of Obesity Medicine certification preparation materials and more. OMA hosts a series of virtual courses on the fundamentals of obesity treatment. The courses offer an informative primer on evidence-based approaches for evaluating, diagnosing and treating obesity.

Healthcare professionals who bring this knowledge into their practices can play a more active role in guiding patients with obesity to better health outcomes.

 is the associate director of the Massachusetts General Hospital Weight Center and faculty at the Harvard Medical School. She is board certified in obesity medicine, internal medicine and pediatrics. Fitch serves as vice president of the Obesity Medicine Association and previously served as secretary-treasurer. For more obesity medicine resources, or to become an OMA member, visit www.obesitymedicine.org.

There may be better ways to treat obesity that are more effective.

Why We Need to Rethink Treating Obesity With Physical Activity

It remains to be seen how the COVID-19 pandemic will affect medical liability, as so many aspects of health care are changing rapidly as a result of this world-shaking event. But there are steps physicians can take to protect themselves from new risks. 

 sat down recently with Sean P. Byrne, J.D., a medical malpractice defense lawyer in Richmond, Virginia, to talk through these strategies and learn how physicians can protect themselves from being sued in this new normal.

This transcript of the interview was edited for length and clarity.

 How has COVID-19, has affected medical malpractice liability?

Byrne: The diversion of health care resources into treating the pandemic has affected us in the medical liability world significantly. ... In medical liability cases, the test is always: Did you comply with the standard of care? Did you act like a reasonably prudent provider would act under the same or similar circumstances? But we’ve never faced the same or similar circumstances with a novel virus and a pandemic like this in the era of modern medicine. What the law will ultimately define as reasonable health care services that met the standard of care is going to be evolving.

We’ve seen a couple of responses across the country, state by state, to try to address it. A number of states, either by executive action or by legislative change, have put in place immunity provisions to protect health care professionals from liability claims that may arise in this era. A number of those state laws will say that you cannot be sued for simple negligence, which just means a mistake or careless error. You cannot be sued for simple negligence in this era for COVID-19-related claims. Those vary widely across the country in terms of how nimble and what the politics are and what people have done. A number of them are limited to: You can’t be sued for COVID-19-related claims that are caused by a lack of resources. And resources can mean [personal protective equipment], it can mean staffing, it can mean [intensive care unit] beds.

A number of states have also stated, “We’re going to give you some protection from lawsuits if you practice somewhat outside your scope of practice, but within your license.” So when we see resources being diverted from one area of a hospital to another to fight waves of pandemic patients, state laws have given some protection in those cases.

The big issue to think about is standard of care. Are you acting reasonably under the circumstances following directives? You should know you have some immunity protections, and it’s helpful to know what they are in your state as you make decisions at a health care professional level. And then another topic that’s coming up is what do we say to our patients and how can we deal with the disclosure of risk.

ME: What about disclosure of risk? What does that mean, specifically? And what do doctors need to communicate to their patients and in what way?

Byrne: Start with just the fundamentals, that we’ve always got an obligation to give our patients advice about risks, benefits, alternatives. So now that we’re facing the pandemic, folks have wondered, “What do I have to disclose to the patient? And can I protect myself from a lawsuit?”

We deal with that in a couple ways. A lot of providers have drafted, with the assistance of their lawyer and their risk management teams, COVID-19-specific programs. And so that will include protocols you have in place in your office for infection control, patient monitoring, screening employees and patients. It will also include some COVID-19-specific screening that goes into the patient’s medical chart about international travel, about symptoms, about exposure. And then a disclaimer or at least a discussion in your informed consent paperwork, where the patient has acknowledged that they’re aware that by being present in the health care environment, they’re assuming some risk of contracting the virus despite the best efforts of the provider. So we’re dealing with those on a number of fronts, and I’ve seen practices pivot really quickly to manage that risk.

ME: We’ve received questions from physicians along the lines of, “If I get a patient to sign something saying that they’re assuming risk, does that essentially wipe away my liability?” Is that true?

Byrne: It’s typically not that simple. I mean, most states have a public policy principle that says, “We ought not let people waive negligence.” [For instance], the back of your ticket to a ballgame or the documents you sign before an operation will have some broad language in there acknowledging the risk you’re undergoing, but you typically can’t waive negligence claims. So those disclaimers and informed consent documents are helpful; they can be damaging if you don’t do them. They can help you prove that you did disclose and discuss the risks with the patient.

Ultimately, though, the test is usually going to be: Did you act reasonably? I think it’s advisable to include some language about COVID-19 in your discussions with your patients and in your documentation, but it’s not a blanket protection against a lawsuit. Interestingly, we have those immunity provisions that have come into play in a number of states that do provide some protection.

What’s not crystal clear is: What about the downstream issues of preventative care screening for, say, breast cancer, for colon cancer, for other significant conditions? What about the other health care that’s being delayed? And from both lack of resources and patient reductions in seeking care, how will our immunity protections and the standard of care address that in the future? So those are going to be evolving considerations that, unfortunately, are going to keep lawyers like me busy in the years to come.

ME: Many physicians are now using telehealth to treat their patients. Are there any unique malpractice risks as a result

of telehealth or considerations that physicians need to take

Byrne: There are some really important considerations there. A lot of the medical malpractice insurance carriers who had very specific rules about telehealth have loosened those rules or adjusted them to accommodate the shift in delivery models and the prolific use of telehealth on such short notice during the pandemic. It’s a good idea for a provider or practice group to see what your insurance carrier is saying about that. And have they acknowledged that it’s within the scope of your malpractice policy?

Similarly, state regulations that impose some requirements on how you can do telehealth and when you can do telehealth, many of those have been broadened, and some of the regulatory hurdles have been set to the side so that providers have easier access to telehealth. This pandemic has fast forwarded the thinking both from a business perspective and also from a regulatory and insurance perspective.

ME: What should physicians be thinking about to proactively manage both pandemic risks and these downstream risks that you mentioned?

Byrne: The advice we give, oftentimes, as medical liability defense attorneys is that your documentation can be your best friend. If a claim or lawsuit develops a couple of years from now, we have to prove what you were thinking, your analysis, your careful reaction and your adjustment to the limitations that were being imposed on you and your practice by COVID-19. Good documentation of that in the chart is helpful. If patients are receiving routine follow-up or screening or maintenance care, and those appointments are being missed or discontinued or postponed, good documentation of your follow-up efforts will be really helpful. Some place I see people fall short is, you know, when they make phone calls to patients to follow up on abnormal lab results or abnormal imaging studies or missed appointments, but they don’t document those efforts, which makes it hard for me to prove you were doing it. Your documentation becomes really important to help you out in these uncertain times.

ME: Do we expect some policy situations to change going forward? Will there be new policy riders? Are there any ways that you should change your approach to coverage?

Byrne: Great question. There might be a couple things to think about, including when quarantine rules took effect. Everybody went into lockdown, businesses shut down, the courts shut down, too. And so the deadlines for filing lawsuits, which are usually matters of state law, where patient has a year or two years or five years to file a claim, and these are hard and fast deadlines, oftentimes insurance policies follow alongside those deadlines in terms of the scope and duration of your coverage. As a result of COVID-19, those deadlines have been extended in various states.

ME: What kinds of things are you hearing from your physician clients?

Byrne: It varies widely by practice area. We get calls for risk management and compliance advice in all these areas. And people are thoughtful about when can I reopen. When the state governments imposed restrictions on elective procedures, there’s debate about whether a particular procedure is elective or medically necessary now, and it probably depends on your perspective, whether it’s you or your loved one, and it’s your practice or someone else’s practice. So we’ve had some debate about that. We’ve seen a few board of medicine complaints with unsatisfied patients saying, hey, my procedure was postponed as elective and it shouldn’t have been, and I want to move forward. I think the boards of medicine won’t have a lot of sympathy with patients who make those complaints when they know the providers are doing the best they can.

COVID has brought about new risks for physicians when it comes to malpractice. Make sure you know what they are.

New malpractice risks to watch for post-COVID-19

The sad truth is that many physicians are dissatisfied with their careers. They still enjoy helping their patients, but often feel beaten down by many challenges that overwhelm the reason they went into medicine in the first place. Survey results show that a lack of autonomy often is to blame for their frustration. But what does physician autonomy mean in today’s health care world?

 recently interviewed Wendy Dean, M.D., a psychiatrist and president and co-founder of Moral Injury of Healthcare, to discuss what physicians can do to take back control of their careers. This interview was edited for length and clarity.

 One of the things we hear about often from our audience is that they lack an autonomy they feel they should have as physicians. Can you talk a little bit about physician autonomy and what that means to you?

Dean: Physicians are trained from the time they go into medical school, and sometimes even before that, to be independent thinkers, to be critically analytical about the problems that they’re looking at that, that they’re investigating for their patients. And they’re also taught not to blindly follow algorithms because that may get them into trouble. And so, after a decade of that sort of training, to go out to practice and have to follow strict algorithms based on reimbursement policies, rather than on clinical best evidence, really goes against the grain of what we believe is good patient care.

ME: In a previous episode, we talked about moral injury. And I’m just wondering how much you feel there’s a relationship between moral injury and a lack of autonomy?

Dean: From my perspective, there’s quite a lot when we are not allowed, for reasons other than good patient care, to get patients what they need. That really goes against some deeply ingrained beliefs on our part and the promises that we made to our patients when we left medical school and went out into training. And the more we are constrained in what we can do for patients, the more frustrated, the more demoralized we become. So I think the two are linked.

ME: One of the things we often hear from our physician audience is that the solution to these systemic issues is just to get rid of the insurance companies, open a direct pay practice or concierge practice. What do you think about direct pay and concierge for simplifying a practice and are they solutions to physician autonomy concerns?

Dean: I think those are great solutions for some physicians. I’m not sure that it is a viable solution across all of health care in the U.S. I have practiced as a direct patient care psychiatrist, and it really did streamline my practice quite a bit. But ultimately, it wasn’t a solution for all of the patients that I wanted to see. So what I would like to get back to is a practice where we don’t have to make those machinations of direct patient care or not, that every patient comes through and can get the same attention, the same one-on-one care, the same undivided attention from their physician ... can walk out and get the prescription they need, the physical therapy they need, the imaging they need, without either the patient or the physician having to go through contortions to make that happen.

ME: What systemic changes do you think need to happen with health care in our country to allow physicians to have more autonomy to spend more time with their patients?

Dean: The biggest change that needs to happen is for the health care system to change the way it supports physicians. So, right now, when physicians are engaged with a patient, they’re reporting to their chief financial officer about how many patients they’ve seen, and this is all indirect, but they’re expected to make metrics on how many patients they see. They’re reporting to the insurer about what they think this patient needs. They’re making a case for why they need the imaging or why they need the medication. So the physician is actually responsible to report to a lot of different people. And really what would be great is if the administrative side of medicine would instead ask how they can support the physician and the physician-patient relationship and change the dynamic so that the physician is facilitated, and how they can get their patients what they need.

ME: The No. 1 reason physicians tell us they are losing autonomy is prior authorization, the insurance companies telling them how to practice medicine. And I’m just wondering, from your experience, what’s the link between the growth of prior authorization and how physicians feel about their careers?

Dean: I think the growth of prior authorization goes along with a lot of the other regulations that have come in and a lot of the other cost-saving measures that have been implemented in health care. So it’s one of a number but it is the most abrasive. The challenge for physicians is we’ve trained for 10 years or 15 years to know what our patient needs. We’re pretty clear that maybe another type of imaging isn’t going to yield us as much as we’d like. It’s going to cost the patient time, it’s going to cost them a copay. And all of that is a challenge, it’s a struggle. We don’t want to have to inflict those things on our patients. When we’re clear we could go right to a particular test, a particular medication, and to be asked to do that based on reimbursement rather than good care, it goes against the grain of our training. And it also doesn’t feel at times as though we’re talking to an equivalent specialist. We’re talking to a nurse who’s trying their best to do what’s right by their company, but not by the patient. We may be talking to a neurosurgeon, may be talking to an OB/GYN to get authorization. And so it just goes against what we believe is good care.

ME: I’m wondering what changes you think need to happen in medical school in the way physicians are trained, to prepare them for the realities of health care and to participate in changing health care?

Dean: Medical students are so fantastic because they are energetic, they’re idealist, which is great. It’s also a double-edged sword. Because if we don’t prepare them for what they’re coming out into as residents or as attendings, then they may become very disillusioned very quickly. So I would love to see us train medical students in what the economic realities are of medicine, how the money flows, how reimbursement works, how policy gets made, how legislation happens. Really train them to be activists in their own interest and in the interest of their patients, because that’s what’s going to be critical in the next 20 years.

ME: What recommendations do you have for physicians to reclaim autonomy in their own careers? Obviously, there are a lot of systemic issues, but I’m wondering what can physicians do for themselves to carve out a space where they feel they’re practicing medicine the best way?

Dean: The best thing that they can do is learn how the incentives are aligned in their own institution. Understand how reimbursement happens, what the incentives are at their entity. And whether they can negotiate to build bridges with the administration, build bridges with other licensees, so that everyone can work together to start fixing things at the local level.

ME: Even for individuals, what this sounds like is they need to talk to their fellow physicians and their fellow health care providers about how to really put the patients front and center and make this better for everybody.

Dean: Correct. In talking to all their fellow clinicians and other physicians, they’ll start to notice what the patterns are, where the stumbling blocks are. Each separate specialty may have its unique challenges, but there will be commonalities that happen. And as you start to look into that more and more, you can quickly become an expert and can have the tools available to you to change what that problem is.

Survey results show that a lack of autonomy often is to blame for their frustration. But what does physician autonomy mean in today’s health care world?


How to restore physician autonomy

When considering the importance of medication adherence, former U.S. Surgeon General C. Everett Koop said it best: “Drugs don’t work in patients who don’t take them.” That was 35 years ago, and the issue remains a major area of concern for clinicians today.

One-fourth of new prescriptions are never filled — and even when filled, up to 50% of patients with chronic conditions fail to take their medications as prescribed. These statistics reflect the situation before COVID-19 led to social distancing and stay-at-home orders that may be making the situation worse.

Medication nonadherence can lead to serious health consequences and higher medical costs. Each year, medication nonadherence results in approximately 125,000 deaths and up to 25% of hospitalizations, which is estimated to cost the American health care system nearly $300 billion.

As the number of coronavirus cases continues to grow across the U.S., medication adherence has never been more critical, especially for elderly patients and those with chronic conditions who are the most susceptible to complications, including death, from COVID-19, according to the Centers for Disease Control and Prevention. To protect the most vulnerable patients, physicians and pharmacists must work together to identify the underlying reasons patients aren’t taking their medications as prescribed and to provide solutions that improve adherence.

There are three primary reasons why patients don’t fill new prescriptions or take their medications as directed: high cost, lack of symptoms and forgetfulness.

A major contributor to medication nonadherence is high out-of-pocket costs for prescription drugs, as shown by the results of a recent consumer survey. In the survey, 48% of respondents reported not filling a prescription within the last few years because of cost. The survey also found that even a $10 rise in copay increases the likelihood of prescription abandonment by as much as 19%.

 also found a direct correlation between the amount of a patient’s copay and the likelihood of prescription abandonment. Patients with $50 copays were nearly four times more likely to abandon a prescription at a pharmacy than patients paying $10.

Today, millions of Americans have lost their jobs, their health insurance and the incomes they used to pay for out-of-pocket health care costs. One in seven report they would avoid seeking care for potential COVID-19 symptoms because of cost concerns, according to a recent Gallup-West Health poll. Unless patients find some financial relief, medication nonadherence rates surely will rise.

Lack of symptoms and misunderstanding of disease

Patients often do not understand why they need certain medications. It’s not uncommon for a person to say they don’t feel their blood pressure is high or that they don’t have any symptoms from high cholesterol. If they don’t 

sick, people may stop taking their medications, which can have serious consequences over time. This situation often leads to unnecessary visits to the emergency department and, occasionally, hospital admissions that could have been avoided.

During the current health crisis, we have all been encouraged to stay at home, limit trips to the grocery store and pharmacy and postpone nonessential medical care. This means patients may have less interaction with physicians and pharmacists who can educate them about prescribed therapies. Now is the time for care team members to adopt proactive measures to make sure patients understand what their medications are for, how to take them and why doing so as prescribed is important.

Delaying or forgetting to pick up prescriptions

Even in our former everyday lives, it was easy enough to put off a trip to the pharmacy for a prescription. Now, as many of us remain sheltered at home, it’s a challenge to recall what day it is, much less remember to pick up a prescription.

Using reminder tools that notify patients when medications are prescribed and when they are ready for pickup, pharmacists and physicians can help reduce prescription abandonment. Many independent pharmacies and national chains are offering free delivery services for prescriptions, which is particularly beneficial for patients who feel leaving home could compromise their health. Additionally, health plans have eased restrictions on filling prescriptions in larger quantities, reducing trips to the pharmacy.

Improving medication adherence with technology

Care team members can improve medication adherence and health outcomes by leveraging technologies that provide price transparency, offer access to educational materials and send reminders directly to patients’ mobile devices. Technology also can facilitate secure communication between prescribers and pharmacists.

For example, when prescribers see patient-specific drug pricing detail

 at the point of encounter within prescribing workflows, it empowers them to discuss formulary options and out-of-pocket costs with patients and potentially review financial assistance options if cost is a barrier. Real-time price transparency tools let patients know exactly how much their medication will cost before going to the pharmacy. These tools eliminate the “sticker shock” experienced when the pharmacist accesses the patient’s health plan benefits to discover the medication is unaffordable for the patient.

Care providers also can reduce financial barriers with new technology that gives patients direct access to copay assistance options. Emerging solutions may link patients to educational content about prescribed medications, giving them a better understanding of the prescribed therapy.

Better communication between pharmacists and doctors

Physicians and pharmacists can further drive adherence by sending automatic reminders to patients’ smartphones, for example, to notify them when a prescription is sent to the pharmacy or when a prescription is ready. Such tools may allow patients to set reminder notices to pick up their medication. By committing to a specific time, patients are more likely to pick up their prescriptions and more likely to take them.

Sometimes, prescriptions are not filled in a timely manner because the pharmacist needs additional clarification from the physician or the payer. A pharmacist may place a call to the physician and leave a message, which starts a time-delaying game of phone tag. To increase efficiency, improve coordination and ultimately fill prescriptions more quickly, a patient’s care team can communicate directly using secure texting, email or videoconferencing technology.

COVID-19 has affected every aspect of our lives and created tremendous financial and emotional strain for many of the most vulnerable patients. Health care professionals must help patients overcome any hurdles standing in the way of medication adherence, including financial and safety concerns. With the right communication and educational tools, providers can help ensure patients take the medicines they need, especially those managing chronic conditions or at the highest risk of complications.

 is chief strategy officer and chief privacy officer for DrFirst. He is a board-certified cardiologist and internal medicine specialist with more than 40 years of clinical practice and is a past president of the Massachusetts Medical Society. Send your technology questions to medec@mjhlifesciences.com.

One-fourth of new prescriptions are never filled — and even when filled, up to 50% of patients with chronic conditions fail to take their medications as prescribed. 

Improve medication adherence with technology

The last thing I wanted to do was to write an article on racism. Not being an expert on the topic, any time I even contemplated writing something, I was crippled by self-doubt. But even more, I was paralyzed by fear. All I could think of were the buzzwords floating around social media. If I wrote against racism, would I be accused of “virtue signaling?” If I didn’t go far enough in condemning racism, would my words be perceived as insufficient, a mere “dog whistle?” What if I unintentionally wrote something that smacked of “white fragility?” Worse yet, I found myself avoiding the topic because of my own discomfort. What if in researching the issues of systemic racism I found myself unintentionally complicit in hurting people I cared about? How would I face this guilt and shame?

But the universe has a way of forcing us to face the unpleasantness that we dread, and when my editor specifically asked me to write an article for doctors on facing implicit bias in medicine, I knew that I had to answer the call. I’m glad I did. Because after speaking with multiple physician experts, I now have the tools to begin to identify and overcome my own implicit biases, and so can you.

Every one of us has a certain degree of implicit bias, or subconscious automatic thoughts about others that stem from our upbringing and social framing. Having these thoughts does not mean we are inherently bad or evil. But if we fail to identify areas of implicit bias — blind spots in our knowledge and understanding of other groups of people — we risk inadvertently providing them with lower-quality care. Because this is the antithesis of what most doctors strive for, realizing that we have blind spots may be hard for us to admit.

Christina Girgis, M.D., a consultation-liaison psychiatrist in Chicago, Illinois, and founder of the Psychiatry Network, an educational group and advocacy resource for psychiatrists, says that one of the biggest challenges of acknowledging implicit bias is the cognitive dissonance that it creates. “We all want to think that we are good. Recognizing that we have automatic negative thoughts about certain groups of people does not fit with that belief. That’s why it can be so hard to recognize and accept this within ourselves.”

But everyone struggles with bias, including doctors of color. Brian Dixon, M.D., is a Fort Worth, Texas, psychiatrist, author and founder of Together Forward, a nonprofit think-tank focused on improving health and alleviating cultural disparities. Dixon discovered during a test of implicit bias that he, a black person, was biased against black people and in favor of white people. “I already knew it,” says Dixon, who grew up in a predominantly white area and attended medical school and residency with few other black people. “My biases, like those of anyone, are a result of my environment and the societal messaging I have received in my lifetime.”

Wamda Ahmed, M.D., a neurologist in Houston, Texas, with a special interest in racial disparities, agrees. “Even African American physicians face similar bias, because we receive the same messages and social framing that our white colleagues experience.” Ahmed notes that she sometimes even struggles to overcome automatic negative thoughts about herself that stem from her social conditioning. “I have to challenge my ‘imposter syndrome,’ and consciously transform the negative thoughts of ‘I am not good enough’ into ‘I can do better.’”

“Having bias doesn’t make you a bad person,” says Nicole Christian-Brathwaite, M.D., child adolescent and adult psychiatrist and CEO and founder of Well Minds Psychiatry & Consulting in Boston, Massachusetts. “Identifying bias is an opportunity to become aware and act.” To help recognize our inherent bias, psychiatrists like Christian-Brathwaite and Dixon suggest taking the Harvard University’s Implicit Associations test, which, although imperfect, can at least begin to raise our self-awareness. Another good way to avoid blind spots is to focus on patients as individuals. “Ask your patients about their cultural backgrounds. Listen to your patients’ stories. The more you individuate, the less likely you are to stereotype,” says Christian-Brathwaite.

Maiysha Clairborne, M.D., an integrative family physician, physician coach, neurolinguistic programming expert and founder of Stress Free Mom MD, says that one of the keys is to not only listen to patients but to watch their responses carefully when you talk with them. “Don’t dismiss patients’ reactions as sensitivity,” advises Clairborne. “If you see your patient react, ask them about it.” Clairborne uses the technique of emotional mirroring and validation, labeling the response that she sees the patient exhibit and asking for clarification. “Check in with your patient. If I see a patient flinch, I might say, ‘I just observed your face change, what happened there?’” She recommends asking specifically, “Was that a racially insensitive thing I just said? I’m sorry; I’m still learning.” This takes the pressure off and gives the patient space to respond.

One of the reasons that we fail to examine our biases is because of the emotions they can produce. These emotions can be immensely powerful, and without help in processing them, we may develop maladaptive coping mechanisms, including denial or anger. “Trauma begets trauma,” Dixon says. “If we are not careful in dealing with our emotions, we can risk traumatizing others. It becomes a vicious cycle unless we learn to break it.” Dixon believes that this trauma is one of the reasons it has been difficult to have a reasoned discussion about racial issues. “We cannot even begin to have a public debate or discourse about racism when tensions are high, because traumatized people can’t act in an even-keeled manner. When you feel afraid, you have a biological imperative to run away or lash out.”

To help examine your emotions, Dixon recommends finding a guide, usually a psychiatrist or psychologist. Another option is a physician coach, which may be ideal in states where the medical licensing board takes a punitive approach to mental health counseling. “It’s important to find someone to help you interpret areas of implicit bias and to remind you that having automatic thoughts doesn’t make you a racist. You may need help in overcoming the trauma of realizing that you’ve hurt someone. You have to learn to forgive yourself, and that takes work,” Dixon says.

Girgis says that physicians must work to change our thinking from “I’m a bad person” to “How can I change this type of thinking?” We can also transform our feelings from being about us to being about other people. “Reframing is one of the best tools that we can use. We need to see the realization that we are biased as a positive; now we can begin to deal with it,” Girgis says.

“The best way to deal with anxiety or fear is exposure therapy,” says Christian-Braithwaite. She compares the process to what physicians experience to M&M (morbidity and mortality) rounds during training. “We don’t go into medicine to hurt people, so when we do, it’s humiliating. We should discuss racism in medicine in the same way that we do medical errors, as both lead to negative patient outcomes. Although it’s difficult and uncomfortable, this is how we grow,” she says.

Once we have acknowledged that we have hidden bias, the next step is to develop a better understanding of the systemic issues that our patients face. We can do this by reading about social policies that have negatively affected black populations, such as redlining (the denial of mortgage loans in certain areas for people of color), wage inequality and unjust criminal justice policies. We must also research the effects of racism on medical outcomes. For example, Christian-Brathwaite notes that black patients are more likely to be improperly diagnosed with psychosis and schizophrenia and more likely to be restrained in an inpatient psychiatric unit than white patients. Ahmed points out that African American and female patients are less likely to be treated with tissue plasminogen activator for a stroke and more likely to have a stroke misdiagnosed as a psychiatric disorder or drug abuse reaction. African American patients are also less likely to undergo cardiac catheterization or receive a kidney transplant compared with white patients. African American and Latino patients have been found to receive less pain control in the emergency room than white patients.

Resources for learning about racial disparities include the Office of Minority Health’s Knowledge Center and the American Medical Society’s Health Disparities Toolkit. Dixon suggests checking to see if your hospital or university has a diversity officer. “Many organizations are hiring diversity officers who are trained in addressing racial disparities.”

“Physicians have a unique obligation to address racial disparities because our patients are vulnerable and trust us with their lives,” Ahmed says. However, she notes that this is not always easy, and she often must work at maintaining her objectivity. “Sometimes my first impression may be that a patient’s symptoms are psychiatric. But I remind myself to stop and follow my usual protocols for every patient until I have excluded the most serious neurologic causes,” she says.

Once she has confirmed that a patient is not suffering from a neurological condition, she takes the next step to try to determine the root of their problems. “I ask myself: ‘If this is not a stroke, what is it?’ Often, I discover that patients have had a recent traumatic life experience or an underlying socioeconomic cause for their symptoms,” Ahmed says.

Although many physicians worry they won’t have time to address racial disparities or socioeconomic pressures, Ahmed says that even taking a moment to connect with your patients on a human level can make an impact. “Take a few minutes to be kind, give encouragement or a hug, just to show that you care.” She notes that developing emotional connections with patients also has been found to decrease physician burnout.

Christian-Brathwaite, who specializes in helping physicians fight racial disparities, suggests that doctors take time to reflect on the care that we provide. “Consider doing a chart audit to look at your plan and your goals for different patients,” she says. “Ask yourself: ‘Are my treatments consistent?’”

She notes that implicit bias increases when we are tired, rushed or stressed. “Medicine is often not conducive to being unbiased because when we are under stress, we often find ourselves resorting to shortcuts, including stereotyping our patient,” Christian-Brathwaite says.

Developing anti-racist thoughts and behaviors

I hesitated to write this article because I was afraid of saying the wrong thing. I’ve also avoided discussing racial issues on social media for the same reason. Girgis told me that this is a common concern. “Discomfort can be the worst feeling, and most of us try our best to avoid it. Sometimes you just have to acknowledge your fear and just jump in,” she says.

Girgis notes that if we stay silent, our colleagues won’t know about our support. “Most of the time, our efforts are appreciated, even if they are clunky or imperfect.” She recommends using an accountability partner such as a friend or colleague to help us evaluate our objectivity.

One of the things we can all do, Girgis says, is to analyze what advantages and resources we have as physicians to help mitigate racial disparities.

“I may not be able to go out and protest, but I can take steps to make my patients feel more comfortable, to talk with my colleagues and to mentor trainees,” Girgis says. The public pays attention to doctors, and our words and actions carry weight. “We can educate the public by writing and speaking out, or we can just be a good example in our interactions with others outside of work,” she says.

“We have to keep trying,” Ahmed says. “I see the process of developing as a physician to like that of a parent. I’m not going to be perfect every day, but I’m going to keep trying, because the stakes are too high.”

Rebekah Bernard, M.D., is a family physician and author of “Physician Wellness: The Rock Star Doctor’s Guide” and “Change Your Thinking, Improve Your Life.” She can be reached at rebekahbernard.com.

Analyze what advantages and resources we have as physicians to help mitigate racial disparities.

Overcome your bias blind spots to better help patients

Six months into the COVID-19 pandemic, its impact on medical practices is becoming clear: fewer in-person visits, more care provided via telehealth and, for many, lower revenue.

But even as doctors struggle with the day-to-day challenges of practicing under radically new circumstances, some health care policy makers, academics and payers are asking another question: What do the changes brought about by the pandemic mean for accountable care organizations (ACOs) and other value-based care models, under which doctors and practices are rewarded for keeping patients healthy while holding costs down?

The consensus among experts who spoke with 

 is that the pandemic will, in the long run, benefit ACOs and other value-based programs, as practices lessen their dependency on fee-for-service medicine as the sole source of their income.

“If you’re a small practice living on fee-for-service, and suddenly all your patients disappear, you realize how much risk you’re under, as opposed to those who have moved to some sort of capitation or bonus for quality arrangement covering at least part of their patient base,” says J.B. Silvers, Ph.D., a professor of health care finance at Case Western Reserve University’s Weatherhead School of Management in Cleveland, Ohio.

“What many thought was the less risky approach of just practicing fee-for-service turns out to be more risky when you have these unexpected ‘black swan’ events,” he says.

Early in the pandemic, as practices’ patient visits and incomes plummeted, value-based programs seemed anything but appealing, especially if they involved financial risk. A mid-April survey by the National Association of Accountable Care Organizations (NAACOS) found that 56% of ACOs in a two-sided risk program — i.e., one that requires sharing losses as well as gains — said they were “very likely,” “likely” or “somewhat likely” to leave the program due to fear of having to repay losses incurred as a result of treating patients with COVID-19.

Partly as a result of this sentiment, the Centers for Medicare & Medicaid Services (CMS) moved quickly to shore up its main value-based initiative, the Medicare Shared Savings Program (MSSP).

According to Silvers, CMS had little choice but to act quickly to ensure that ACOs remain in the MSSP program. “This [MSSP] is a big bet they’ve made, and if practices start to bail on them, the whole program goes down the tubes,” he says. “Having practices stay in it for the long run is really important, so they want to make it as stable and predictable as they can.”

Allison Brennan, MPP, senior vice president of government affairs for NAACOS, says the steps CMS has taken have helped allay members’ initial fears over the effects of the pandemic.

“The main reason they are taking these actions is to prevent ACOs from unfairly shouldering the burden of a pandemic over which they have no control, and so far it seems to be working,“ she says, adding that “we still have to wait and see what the net effect will be in some of the hardest-hit areas.”

How value-based programs are responding to pandemic

Despite their initial fears, practices in value-based programs appear to be better positioned to survive the COVID-19 crisis, says Keely Macmillan, M.S., senior vice president of policy and solutions management at consulting firm Archway Health, which helps practices shift to bundled payments and other types of value-based models.

“The providers who had put infrastructure in place to achieve success in these models, like care coordination, patient tracking and telehealth, are able to respond more quickly and continue providing high-quality care to patients in the midst of this health emergency,” she says.

That has proven true for CareMount, an ACO based in Mount Kisco, New York, with more than 600 providers in five counties and parts of New York City. It began participating in MSSP in 2013, and since 2018 it has been part of the Next Generation ACO program, where it shares in losses as well as cost savings. It also has performance-based contracts with many of its commercial payers.

Because of its long experience with value-based programs, CareMount understood the importance of population data in improving patient care, says Kevin Conroy, M.S., the group’s chief financial officer and chief population health officer. It had built an in-house data analytics department that performed functions such as alerting doctors when a Medicare patient was due for an annual wellness visit.

Once the severity of the pandemic became apparent, Conroy says, CareMount was able to use the data it had accumulated to quickly identify and contact its most vulnerable patients. “We already had a robust care coordination team, but we became more targeted with it,” he explains. “We looked at things like who was deferring care or missing a screening and who we needed to reach out to telephonically to make sure there’s no deterioration in their condition.”

CareMount also had a telehealth platform, Conroy says, although before the arrival of the pandemic it was rarely used. Beginning in mid-March, however, telehealth visits escalated rapidly, peaking at 1,500 per day, and they have been an important tool in enabling CareMount’s providers to stay in touch with patients and monitor their health.

In addition, Conroy says, CareMount is in the early stages of developing a home health program to augment telehealth visits. The goal is to send medical assistants to patients’ homes for tasks that can’t be done by phone, such as blood pressure screenings and checking on prescription adherence.

Conroy predicts that the pandemic will heighten the appeal of value-based care models such as ACOs. “Groups that are using value models are positioned to create a more predictable revenue flow,” he says.

Another effect of COVID-19 on value-based programs is the increase in telehealth visits. A Commonwealth Fund study released in mid-June found that while telehealth visits were down from their mid-April peak, they were still about 8% higher compared with four months earlier. Meanwhile, numerous surveys have shown high levels of patient satisfaction with telehealth and a desire to continue using it, even post-pandemic.

The growth has been fueled in part by CMS’s decisions to allow Medicare to pay for more types of telehealth visits and raise reimbursements to match what it pays for in-person visits, and Congress’s loosening of restrictions on how and where telehealth visits can take place. And while it’s not known if these changes will be permanent, they will likely remain in effect at least for the duration of the public health emergency, according to Travis Broome, MBA, MPH, senior vice president for policy and economics at Aledade, a consulting firm that helps practices form and join ACOs.

Broome notes that ACOs and other value-based programs are a good environment for testing whether more telehealth visits improve patients’ health, and, if so, under what circumstances. “Under these models, the providers are incentivized to find and do just the parts of telehealth that really add value, because they’re on the hook for the total cost of care,” he says. In other words, practices will incur financial penalties if telehealth leads to more visits without improved outcomes.

Mark Fendrick, M.D., director of the Value-Based Insurance Design Center at the University of Michigan and a professor of health management and policy at the university’s School of Public Health, echoes Broome’s prediction and thinks it will also extend to fee-for-service medicine.

“I’m certain that, across populations, patients seen virtually will have lower rates of unnecessary services than those seen in person,” he says, adding that too many primary care doctors routinely order electrocardiograms, blood work-ups and other tests at every patient visit.

“I’m hopeful [with telemedicine] that the volume of these low-value services will fall and free up funds to invest in the areas where we really need to be spending money,” he says.

Another significant question for practices in value-based models, especially those that are part of the MSSP, is the effect of the steep decline in health care spending due to patients delaying or foregoing care, both elective and necessary. Results of a study from the insurance and consulting firm Milliman, released in April, estimate that health care spending in 2020 will be down by at least $75 billion, and possibly as much as $575 billion, due to deferral or elimination of care related to COVID-19.

The spending drop-off has both short- and long-term implications for ACOs in the MSSP, according to Archway’s Macmillan. In the short term, it has caused CMS to adjust the formulas it uses to set spending benchmarks for some shared savings programs.

Looking ahead, Macmillan says, the big question for ACOs and other value-based programs concerns medically necessary care that has been deferred because of the pandemic. “A lot of patients with chronic conditions haven’t been well managed in the past few months because they’ve stayed home, which means their diseases may have progressed more quickly than normal,” she says. The result would be more severe acuity when these patients do finally venture out, leading to higher costs of care.

“CMS is going to have to figure out how to address that issue fairly, and I don’t think there’s enough data yet to measure the impact this [deferred care] has had,” Macmillan says. “But going forward they have to make sure their benchmarking methodologies reflect the circumstances of COVID-19.”

Fendrick says the changes in care delivery wrought by the pandemic could result in a wholesale rethinking of spending priorities. “Everyone agrees we have enough money in the health care system to take care of everyone, we’ve just been spending it in the wrong things and in the wrong places,” he says. “My hope is that payment reforms, combined with changes to benefit designs, will better align around high-value services and make it harder to use low-value services. I think that outcome would be a win-win.”

If you’re a small practice living on fee-for-service, and suddenly all your patients disappear, you realize how much risk you’re under, as opposed to those who have moved to some sort of capitation or bonus for quality.

What will COVID-19 mean for value-based models?

COVID-19 has created a global public health disaster. As world leaders struggle to contain the spread of the virus, they are also trying to figure out how to balance public health needs with economic stability.

For practice owners, especially those who have been hard-hit by the economic impact of the virus, making decisions to keep their business viable may not be easy. This could mean cutting jobs or furloughing staff. The question becomes how to balance the needs of the practice and staff and avoid legal fallout.

In the U.S. alone, unemployment rates jumped by 10.3 percentage points in April to 14.7%, the highest monthly unemployment increase since the Bureau of Labor Statistics (BLS) started tracking the data in 1948. More than 23 million Americans were out of work in April, a one-month increase of 15.9 million people, with 1.4 million job losses in the health care industry.

While some of these job losses may be temporary, others are not. Dentists, physicians and other health care practitioners have had their livelihoods hit hardest in the health care sector. About 243,000 jobs were lost in physician offices and another 205,000 in other health care provider offices. The number of unemployed people in the education and health care sectors increased by nearly fivefold in the last year, according to the BLS, from about 512,000 to more than 2.5 million.

While the hope is that business will at some point return to normal, that still may be a long way off. In the meantime, the number of outpatient visits and elective procedures has dropped sharply, along with the revenue for these office-based services.

Richard G. Roberts, M.D., J.D., FAAFP, FCLM, is a professor of family medicine at the University of Wisconsin School of Medicine & Public Health in Madison and a practicing family doctor in a small, rural area. He says the pandemic has cast a spotlight on inequalities in health care, among patients and even among different types of practices. He pointed out the irony of some states pleading for help and more health care workers even as other states were forced to furlough health care workers.

While virtual visits have surged as a way to meet outpatient care needs during the COVID-19 pandemic, primary care visit volume is down 50%, and some practices were forced to cut costs right away, he says. “Patients are afraid to come in, and we are telling them not to come in,” Roberts says.

Although the majority of physicians are employed in health systems, there are still many physicians in small practices or groups who own or have a stake in their practice and have to make tough financial decisions.

Large systems have been able to move employees around and repurpose them instead of furloughing them, but this also presents challenges.

“Say you have been working as a nursing assistant in primary care, and now you are bedside with COVID-19 patients,” he says. “It’s sort of like asking someone to move into a position with great risk to them without adequate protection or preparation.”

Medical Economics August 2020

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