Doctors’ offices are slowly reopening as California loosens restrictions put in place to halt the spread of the coronavirus, but the patient experience may never be the same even after the virus is under control.
Although health care was deemed essential and most medical practices remained open, California doctors had to cancel or delay all elective surgeries and non-urgent health care starting in mid-March when Gov. Gavin Newsom put the stay-at-home order in place.
Patient volume declined 60% to 70% statewide during the COVID-19 shutdown, leaving private physicians with high overhead costs, including rent, employee salaries and health insurance, malpractice coverage, supplies and electronic health records.
With reduced revenue from patients or their insurance, nearly half of the doctors in California laid off or furloughed workers, and some practices were left on the verge of closing, according to the California Healthcare Foundation.
The survivors are now trying to pick up the pieces of a badly damaged private health care system.
“I would say this is the most consequential thing many of our members have faced in their lifetime,” said Conrad Amenta, executive director of the San Francisco Marin Medical Society, which represents almost 3,000 physicians in San Francisco and Marin counties, about 10% of which are solo or small practices with four physicians or fewer.
“Just like any business, there are fewer customers, and like any other business, it is hurting revenue,” he said. “Any provider of preventative health care and anybody who specializes in procedures that are elective in nature, like a knee replacement, those types of practices are encountering a lot of issues right now.”
Newsom lifted a statewide hold on hospital elective procedures on April 22, allowing doctors to again schedule non-emergency medical appointments as long as they meet certain protocols, including wearing masks and social distancing.
Physicians throughout the state are now ramping up their practices, resuming surgeries, preventive care and procedures like colonoscopies, but office visits won’t be happening like they used to, at least not anytime soon.
First, doctor’s offices will be limiting visits, requiring staff and patients to wear personal protective equipment and rearranging work areas to maximize social distancing in accordance with protocols laid out by state and local governments to prevent the spread of the virus. Physicians will do risk assessment screenings by telephone to determine whether patients have COVID-19 symptoms.
The coronavirus scare forced most offices to begin using telemedicine to screen for respiratory problems, look at patients’ skin for signs of cancer or other ailments, and test their limbs for range of motion. Video examinations are likely to remain a big part of medicine, even when the virus is no longer a threat.
“Most of the work is done by telemedicine. It has worked better than I would have expected,” said Michael Schrader, an internal medicine physician who shares his practice on Bush Street in San Francisco with four other doctors. “There are things that you can examine on the video screen and things you can’t do. You can’t listen to hearts or lungs, and you can’t do abdominal examinations, so the trick during a telemedicine exam is to determine whether there are problems where patients need to be seen.”
Schrader has reduced the number of chairs in his waiting room from 10 to four and now schedules appointments far enough apart so that there is never more than one person waiting. There is hand sanitizer in all the rooms, all staff wear gloves and face masks, and the doctors wear face shields during exams, he said.
It is the same for Dr. Sharon Drager, a surgeon who has had a small private practice in San Pablo for more than 35 years.
“There have been a variety of experiences, but all have been characterized by stress and just trying to get back to normal as best we can, both for our patients and ourselves,” Drager said. “We want it to be as safe as it can be for everybody.”
Coming back from a downturn like this one is hard, especially given that another wave of COVID-19 cases could sweep through the populace at any time. It is why doctors, public health officers and epidemiologists say testing is so important, including diagnostic swabs that can be used to isolate exposed individuals and antibody tests to determine immunity.
Although testing has increased in the Bay Area and throughout California, infectious disease specialists say there still is not enough to confidently determine the full dimensions of the crisis.
“I have a number of patients in care homes waiting for surgeries. We’re trying to figure out how to get them tested before we see them, and we’re trying to figure out what facilities are doing about testing,” Drager said, referring to nursing homes, which have proved to be spreaders of the virus. “Testing, testing, testing is ultimately a big part of the solution, but we aren’t anywhere near where we should be yet.”
The lack of testing means that, for the time being, many small practices have to be operated at a loss. A lot of physicians with smaller practices have obtained small business loans from the Paycheck Protection Program, a key provision of the Cares Act that Congress passed in response to the coronavirus pandemic.
The Centers for Medicare and Medicaid Services, which administers health coverage programs for more than 130 million Americans, agreed for the first time this year to allow doctors to charge patients the same for video appointments using Zoom, Skype, FaceTime and other platforms as they bill for office visits, which has also helped build revenue.
But the transition back isn’t easy, especially for small operations.
“This has been financially devastating for a lot of physicians,” said Joe Greaves, executive director of the Alameda-Contra Costa Medical Association, whose 5,000 members include about 500 small doctor’s offices not affiliated with universities or medical centers. “Many of them have had a difficult time financially keeping their businesses running. We have a high level of concern that some of our small solo providers may not come back the way they were before.”
Dr. Steven Una, who has a small practice in Castro Valley, is among many community doctors who have struggled. He now sees only about a third of the number of patients he was seeing this time last year. One of the internists in his medical group decided to retire as a result of the financial burden, he said.
It isn’t a new problem. Small family doctors like Una have long been losing patients to large group medical centers, like Kaiser Permanente. And most young doctors don’t want to risk starting their own practice when they have hefty student loans to pay back.
Una, a 72-year-old specialist in infectious disease and internal medicine, thinks the coronavirus may have put the nail in the coffin of the community doctor.
“Most of the owners of solo small practices are in their 60s and above, and as they age out they are not being replaced, and I think the COVID virus has certainly facilitated this,” Una said. “You are losing these old-style, mom-and-pop doctor operations, and when you lose that, you lose the relationships formed over many years between the practitioners and the patients and their families.”
While some struggling doctors have chosen to retire, others are purging their waiting rooms of toys and magazines, rearranging the furniture, stocking up on masks, and preparing for the next phase of doctoring.
“I’ve been in the medical association world my entire professional life, and the thing that I’m struck by is the fact that, no matter how difficult things get, the thing that doctors care about more than anything else is their patients,” Greaves said. “This crisis is no different. They are doing what’s best for their patients, and they are sacrificing in the process.”