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As the Pandemic Evolves, So Do Ambulatory Care Practices

The Commonwealth Fund has been collaborating with researchers at Harvard University and Phreesia, a health care technology company, to document the dramatic changes to ambulatory care practices wrought by COVID-19. The first snapshot revealed a staggering 58 percent drop in outpatient visits in late March. Since then, there’s been a rebound in visits as medical offices reopened and patients began to return.

Still, things are far from normal. Our interviews with physicians at six medical groups of various sizes and specialties across the country, all using Phreesia’s technology, demonstrate that the evolving nature of the pandemic continues to roil their operations. It has necessitated changes in office procedures to protect patients and staff at the same time clinicians scramble to make up deferred care, help patients cope with the fear and uncertainty triggered by a new disease, and adjust to staff furloughs and lost revenue that some may never recoup.

Patients Return to Offices That Look Very Different

The physicians we spoke to are working harder but at a slower pace, as once straightforward procedures like pulmonary function and stress tests now require more steps to mitigate the risk of viral transmission. Many are sequencing visits in new ways to reassure patients it’s safe to return: one provider was offering treatment, including lab work, to high-risk patients in their cars while another has been asking patients to remain in the parking lot until their appointment time. “I don’t know what we’re going to do in the winter,” says Gregory Adams, M.D., a pediatrician at Blue Ridge Pediatrics and Adolescent Medicine in Boone, N.C., where 40 percent of families are covered by Medicaid.  “Some of our families don’t have cars.”

Fears of returning to medical offices and delivering in hospitals run high among pregnant women, says Gem Ashby, M.D., the owner of Gentle Hands, a two-physician OB/GYN practice in an affluent Tampa suburb. Her practice saw office visits plummet to 20 percent of pre-COVID-19 volume in the early days of the pandemic. Ashby offers the most anxious patients the first visit of the day and a promise not to schedule another patient for at least one hour. She also fields questions outside of her specialty — like how to manage depression or blood pressure — from patients who can’t reach their primary care providers, either because their offices are closed or they are too overwhelmed to respond. “So even though patients weren’t physically in the office, our phones were ringing off the hook,” she says. “I’ve tried my best to help, sometimes by texting primary care colleagues for answers to their questions.”

CareMount Medical, a multispecialty practice serving 665,000 patients in urban, suburban, and rural communities of New York, some hard hit by the coronavirus, created a video to help patients understand the precautions clinicians were taking. Explaining the disease itself remains a challenge, says Caroline DeFilippo, M.D., M.P.H., CareMount’s assistant medical director. This is especially true for patients who contracted coronavirus and didn’t require hospitalization, yet suffer debilitating symptoms weeks later and require consults with multiple specialists. “Some of their symptoms are very frightening,” DeFilippo says. “Consulting with colleagues and figuring out whether they are better served in an emergency room, an urgent care, a primary care office, or by a cardiologist, and triaging them and supporting them takes a lot of resources. Many times we are trying to assuage their anxiety. That is hard to do given the uncertainties of this disease.”

Recent Disruptions in Care May Have Pernicious Downstream Effects

Many of the clinicians we spoke with are also worried about a secondary pandemic: large numbers of patients missing or deferring treatment for non-COVID conditions. Proliance Surgeons, with 400 providers across 32 sites in western Washington State, postponed more than 10,000 surgeries between mid-March and mid-May — only venturing into operating rooms to handle urgent and emergent conditions such as ruptured appendices and fractures. After resuming many nonemergency surgeries with enhanced safety protocols and reduced daily volumes, they are at nearly 80 percent of their preshutdown case level.

But, in accordance with guidelines they developed in concert with the state, Proliance surgeons are still cautious about undertaking elective procedures on patients who are morbidly obese, have severe diabetes or cardiac conditions, or are otherwise at high risk should they contract the coronavirus. And some patients who are not at high risk are still putting off surgery out of fear. “We worry some patients who are delaying surgery and in severe pain might start taking prescription opioids, or self-medicating with alcohol, cannabis, or other means,” says Charles Peterson, M.D., an orthopedic surgeon and chair of Proliance’s board of directors.

Adams, along with other pediatricians across the country, is concerned that missed vaccinations could lead to infectious disease outbreaks that could be worse than COVID-19 for children. Asheville, N.C., just a couple hours away from his practice, saw a measles outbreak last year. “If there’s a real drop off in the MMR vaccine this year, we run the risk of having measles make a significant comeback,” he says. Infants who miss the vaccination for Haemophilus influenza type B could also face long-terms problems, including seizure disorder and blindness, should they become sick.

Blue Ridge’s clinicians leveraged a database created by Community Care of North Carolina, the state’s medical home network, to identify 500 kids in the Medicaid program who were behind on vaccinations. His staff has been calling their parents to reassure them it was safe to come in. Adams feels confident that most will. Blue Ridge’s volume has already returned to 85 percent of prepandemic levels — higher than many other pediatric practices, according to our latest data.

But some services remain hard to deliver. Because of staff furloughs, the Gentle Hands OB/GYN practice cannot always perform ultrasounds or lab testing immediately and is struggling to find imaging centers to serve patients. If Ashby, the owner of the practice, notices a suspicious lump on a patient’s breast, she used to be able to refer patients to a radiology center across the street, which saw her patients immediately. “Now, I give women a prescription. They have to find an imaging center that is open and I have to hope the result comes back to me,” she says. “I think this is going on across the country.”

Complicating matters, some patients may not be reaching out when they should. The Community Health Center of Yavapai, a federally qualified health center (FQHC) in Northern Arizona that has three staff behavioral health counselors, has seen a drop-off in use of their services, despite promotion on Facebook. “Our behavioral health providers were busy before COVID-19,” says Colin Kerr, M.D., the health center’s medical director. “It may be denial. Patients don’t realize there is a secondary, significant depression setting in just from the isolation.” Counselors have been reaching out to patients they are particularly concerned about, “in some cases successfully, and in other cases not,” he says.

Loss of Office Visits and Procedures Has Exacted Heavy Toll

Proliance Surgeons’ decision to curtail elective surgeries, days before a state moratorium, cost the organization about $1 million per day over the eight-week shutdown. And while Proliance qualified for CARES Act funding, this made up for only a small fraction of the losses. “We’re going to be digging our way out of a financial hole for quite some time,” Peterson says.

Gentle Hands’s Ashby also expects to see lasting damage. Because the practice shares a tax ID with other clinics and therefore doesn’t qualify as a small business, it wasn’t eligible for a loan through the Payroll Protection Program. While her partner took a 50 percent pay cut, Ashby expects to go without a salary for at least six months — at least until she can afford to bring back furloughed staff. “You have to lead by example,” she says.

Blue Ridge saw its visit volume drop by 80 percent for different reasons. Because daycares and schools closed, kids weren’t catching as many of the usual strep or ear infections and parents were delaying well-child visits. The clinic has been buoyed, however, by $500,000 in CARES Act funding and a 5 percent increase in Medicaid rates. And as part of the Community Care of North Carolina network of primary care providers, it has received a bump in its care management fees as well as assistance for telehealth and personal protective equipment (PPE). “They have stepped up way beyond anything I ever dreamed,” says Adams.

The Yavapai health center, where a third of patients are uninsured, has been buffered from financial losses by funds from the federal agency overseeing FQHCs. It has received about $70,000 a month to cover the additional time staff have been devoting to pandemic response, as well as some modest CARES Act funding. The health center also has been able to purchase PPE through the Arizona Alliance of Community Health Centers.

The extra funding enabled Yavapai’s leaders to update infection control procedures and educate staff on new policies. “We were lucky we were not busy with COVID-19 patients at that point, because it took a tremendous amount of work,” says Kerr. Yavapai recently saw in-person visits rebound to 75 percent of typical volume in May, but now expects to scale back to 50 percent as Arizona’s COVID-19 cases climb. The FQHC has also restricted dental care to emergencies.

Practices Are Finding New Ways to Care for Patients

Like clinicians around the country, the physicians we spoke with have expanded their outreach and virtual visits, enabling some to forge deeper connections with patients. CareMount went from 25 telemedicine visits a month across its 45 clinics to 1,500 per day. Ascension, a large, multistate health system, saw a hundredfold increase in the number of telemedicine visits in recent months.

Clinicians say the approach has not only created some efficiencies but has also opened windows into their patients’ lives. “One of the beauties of telehealth is you get a sense of what kind of home kids live in,” says Blue Ridge pediatrician Adams. “Do they have toys to play with? Do they have space? And I think some of the kids are more talkative when they’re in their own home as opposed to sitting in a scary doctor’s office.”

CareMount’s DeFilippo has found video visits have enabled her to include more family members in end-of-life discussions: “These are never easy conversations, but they’ve been easier to navigate because the patient was around someone who loved them.”  

But physical exams and surgical procedures are clearly not possible via telehealth, and clinicians recognize that some patients may have challenges accessing virtual care. “Many of the populations that have difficulty accessing in-person care also face barriers in using virtual care,” says Baligh Yehia, M.D., M.P.P., chief medical officer of clinical and network services at Ascension. “These include patients living in rural communities, those with lower socioeconomic status, individuals with low digital literacy, and persons with limited English proficiency. If telehealth continues to accelerate without engaging and embracing these vulnerable communities, it may sustain or exacerbate existing health disparities.”  

Still, some clinicians say the pandemic has given them an opportunity to connect with patients who otherwise don’t come in. When people call about getting a COVID-19 test, CareMount’s DeFilippo uses it as an opportunity to talk about immunizations and chronic disease management. She says the pandemic has also led to greater and welcomed collaboration among colleagues: “It has restored a lot of my hope and faith in the goodness of medicine and the positive reasons we became doctors.”

Publication Details

Publication Date: June 25, 2020
Contact: Martha Hostetter, Consulting Writer and Editor, Pear Tree Communications
Citation:

Martha Hostetter and Sarah Klein, As the Pandemic Evolves, So Do Ambulatory Care Practices (Commonwealth Fund, June 2020). https://doi.org/10.26099/bryd-1508

Experts

Martha Hostetter
Consulting Writer and Editor
Consulting Writer and Editor