Telehealth is available, but no one’s calling

Not all insurers are paying what they should

BRUCE WEINRAUB, who works as a primary care physician in Northampton, came down with COVID-19 earlier this spring. He recovered from the disease, but his practice hasn’t been so resilient.

Like many primary care physicians across the state, Weinraub, who is my doctor, doesn’t see patients in person anymore. He goes to his office, shuts the door behind him, and connects with his roughly 1,000 patients over the phone or by video chat. If someone needs to be seen urgently, he sends them to an urgent care facility or the emergency room.  

What he’s finding is that most of his patients never reach out to him anymore and many of those that do don’t generate enough money to keep his practice afloat. Despite assurances that insurers will pay the same rates for all telehealth visits as they do for in-office visits, Weinraub says that’s not happening. 

In March, Gov. Charlie Baker ordered all forms of telehealth to be reimbursed at 80 percent of the cost of an in-person visit, with the patient’s 20 percent copay removed. Video calls have been reimbursed by payers in accordance with the order, but payment for phone calls has been inconsistent. Weinraub says he has been receiving an average of $30 per call over the past few months, a fraction of the reimbursement for a regular visit. 

The bigger problem is that patients just aren’t checking in as much. “They’re sitting on stuff, the usual aches and pains, they twisted their ankle, or something worse,” he says.”But they don’t want to see a doctor in a hospital or anywhere else. They’re fearful they’ll get infected.”

Their reluctance to interact with medical professionals seems to extend to calling  one on the phone. “I’m getting about half as many phone calls as I normally do,” he says. “My colleagues, whether they are working in small practices like mine or in the big groups, they’re all getting fewer calls.”  

As a result, the monthly revenue in his practice has plunged. “We’re down about 50-60 percent in receipts,” he says. Weinraub notes that roughly half of his revenue now pays overhead expenses such as rent and insurance, leaving little for personal income. “I can handle a 20 percent cut in my income to get through this crisis, but we’re running breakeven. This is not sustainable.” 

Weinraub is not alone. An analysis of medical practice appointment data indicated patient visits to 50,000 outpatient practices across the US declined nearly 60 percent between mid-March and mid-April. New England and the mid-Atlantic states saw the biggest reductions. While telehealth visits increased, the higher volume only partially made up for the dropoff in in-person visits. 

A recent survey of over 3,000 primary care doctors around the country found that 45 percent of them are unsure if they have enough cash on hand to stay open for the next month. Almost half have laid off or furloughed staff. The survey was conducted by Primary Care Collaborative, a non-profit organization based in Washington, DC. 

“I don’t know anyone whose [medical] practice isn’t affected,”says Dr. Maryanne Bombaugh, president of the Massachusetts Medical Society. “It’s not just primary care doctors, but specialists and hospitals, too. We’re all getting less calls and visits. We’re starting to see patients coming in who are sicker and whose problems are more acute because they delayed getting help for their problem. If there’s one message I want to get out to people, it’s that it’s safe to seek medical care.”

For now, Weinraub is keeping his practice afloat with COVID-19 assistance programs through the federal government. Through Medicare, he was able to get a three-month advance of what he would normally receive as reimbursements. The advance is like a no-interest, short-term loan that  will be subtracted from future reimbursements.  He is also getting federal assistance based on how many Medicare patients he typically has in a year. That funding will be forgiven as long as he uses it to pay for medical care expenses. 

In addition,  Weinraub landed a loan through the Small Business Administration’s Paycheck Protection Program, which covers salaries for himself and his employees. The PPP loan is also forgiven if he continues to use it for payroll. 

Getting the PPP loan took a bit of maneuvering. After wondering whether his application had settled to the bottom of the pile, he called an administrator he knew at the bank and lobbied for essential businesses like his to be prioritized. “That’s not how this should work,” he says. “But I know I wouldn’t have gotten the loan if I hadn’t made that call.”

Weinraub’s shingle is still hanging outside his office, but he is increasingly concerned about what will happen when the government assistance programs end in early summer. 

“I have a lifeline for two and a half months, but that’s it. Our economy is cratering  and  the health system is going down with it,” he says. 

If primary care and other medical practices don’t survive, Bombaugh says that will trigger another public health crisis in addition to the pandemic. “That would create a real issue of access, and when that occurs it will have all sorts of health ramifications. Our population’s health will worsen.” 

To prevent that, she says, doctors are going to need additional federal assistance like the PPP loan that Weinraub got. She also sees a role for private insurance companies to help out by advancing payments to doctors or paying immediately after billing, shortcutting an accounting process that can often drag on for months. 

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Weinraub has considered different options to practicing medicine if revenues continue to lag, such as going on unemployment or retiring early, none of which interest him. “I like being a doc and I think I’m pretty good at it, but I can’t wait until a couple weeks before the funding runs out on these programs to figure out what I’m going to do,” he says. “I have a commitment to my patients, and  an ethical responsibility to give them three months notice.”

Linda Enerson is a freelance writer in western Massachusetts.