Thousands of doctors’ offices buckle under financial stress of COVID

Cormay Caine misses a full day of work and drives more than 130 miles round trip to take five of her children to their pediatrician. The Sartell, Minnesota, clinic where their doctor used to work closed in August.

Caine is one of several parents who followed Dr. Heather Decker to her new location on the outskirts of Minneapolis, an hour and a half away. Many couldn’t get appointments for months with swamped nearby doctors.

“I was kind of devastated that she was leaving because I don’t like switching providers, and my kids were used to her. She’s just an awesome doctor,” said Caine, a postal worker who recently piled the kids into her car for back-to- back appointments. “I just wish she didn’t have to go that far away.”

So does Decker, who had hoped to settle in the Sartell area. She recently bought her four-bedroom “dream home” there.

T he Hea lthPa r tners Central Minnesota Clinic where Decker worked is part of a wave of COVIDrelated closures starting to wash across America, reducing access to care in areas already short on primary care doctors.

Although no one tracks medical closures, recent research suggests they number in the thousands. A survey by the Physicians Foundation estimated that 8% of all physician practices nationally — around 16,000 — have closed under the stress of the pandemic. That survey didn’t break them down by type, but another from the Virginia-based Larry A. Green Center and the Primary Care Collaborative found in late September that 7% of primary care practices were unsure they could stay open past December without financial assistance.

And many more teeter on the economic brink, experts say.

“The last few years have been difficult for primary care practices, especially independent ones,” said Dr. Karen Joynt Maddox, co- director of the Center for Health Economics and Policy at Washington University in St. Louis. “Putting on top of that COVID, that’s in many cases the proverbial straw. These practices are not operating with huge margins. They’re just getting by.”

When offices close, experts said, the biggest losers are patients, who may skip preventive care or regular appointments that help keep chronic diseases such as diabetes under control.

“This is especially poignant in the rural areas. There aren’t any good choices. What happens is people end up getting care in the emergency room,” said Dr. Michael LeFevre, head of the family and community medicine department at the University of Missouri and a practicing physician in Columbia. “If anything, what this pandemic has done is put a big spotlight on what was already a big crack in our health care system.”

Federal data shows that 82 million Americans live in primary care “health professional shortage areas,” and the nation needed more than 15,000 more primary care practitioners even before the pandemic began.

Once the coronavirus struck, some practices buckled when patients stayed away in droves for fear of catching it, said Dr. Gary Price, president of the Physicians Foundation, a nonprofit grantmaking and research organization. Its survey, based on 3,513 responses from emails to half a million doctors, found that 4 in 10 practices saw patient volumes drop by more than a quarter.

On the West Coast, a survey released in October by the California Medical Association found that one- quarter of practices in that state saw revenues drop by at least half. One respondent wrote: “We are closing next month.”

Decker’s experience at HealthPartners is typical. Before the pandemic, she saw about 18 patients a day. That quickly dropped to six or eight, “if that,” she said. “There were no well checks, which is the bread-and-butter of pediatrics.”

In an emailed statement, officials at HealthPartners, which has more than 50 primary care clinics around the Twin Cities and western Wisconsin, said closing the one in Sartell “was not an easy decision,” but the pandemic caused an immediate, significant drop in revenue. While continuing to provide dental care in Sartell, northwest of Minneapolis, the company encouraged employees to apply for open positions elsewhere in the organization. Decker got one of them. Officials also posted online information for patients on where more than 20 clinicians were moving.

The pandemic’s financial ripples rocked practices of all sizes, said LeFevre, the Missouri doctor. Before the pandemic, he said, the 10 clinics in his group saw a total of 3,500 patients a week. COVID-19 temporarily cut that number in half.

“We had fiscal reserves to weather the storm. Small practices don’t often have that. But it’s not like we went unscathed,” he said. “All staff had a oneweek furlough without pay. All providers took a 10% pay cut for three months.”

Federal figures show pediatricians earn an average of $184,400 a year, and doctors of general internal medicine $201,400, making primary care doctors among the lowest-paid physicians.

As revenues dropped in medical practices, overhead costs stayed the same. And practices faced new costs such as personal protec tive equipment, which grew more expensive as demand exceeded supply, especially for small practices without the bulk buying power of large ones.

Doctors also lost money in other ways, said Rebecca Etz, co- director of the Green Center research group. For example, she said, pediatricians paid for vaccines upfront, “then when no one came in, they expired.”

Some doctors took out loans or applied for Provider Relief Fund money under the federal CARES Act. Dr. Joseph Provenzano, who practices in Modesto, California, said his group of more than 300 physicians received $8.7 million in relief in the early days of the pandemic.

“We were about ready to go under,” he said. “That came in the nick of time.”

While the group’s patient loads have largely bounced back, it still had to permanently close three of 11 clinics.

“We’ve got to keep practice doors open so that we don’t lose access, especially now that people need it most,” said Dr. Ada Stewart, president of the American Academy of Family Physicians.

Caine, the Minnesota mom, said her own health care has suffered because she also saw providers at the now- closed Sartell clinic. While searching for new ones, she’s had to seek treatment in urgent care offices and the emergency room.

“I’m fortunate because I’m able to make it. I’m able to improvise. But what about the families that don’t have transportation?” she said. “Older people and the more sickly people really need these services, and they’ve been stripped away.”

“This is especially poignant in the rural areas. There aren’t any good choices. What happens is people end up getting care in the emergency room. If anything, what this pandemic has done is put a big spotlight on what was already a big crack in our health care system.”

— Dr. Michael LeFevre, head of the family and community medicine department at the University of Missouri and a practicing physician in Columbia