At the height of the coronavirus pandemic in New York City, when hospitals and their ICUs were overwhelmed, patient visits at South Slope Pediatrics in Brooklyn had plummeted to 25% of what they once were. Most of those visits were taking place remotely via telemedicine, which didn’t always pay as much as in-person care.
Unlike some medical practices, which closed to in-person visits entirely during the pandemic, South Slope Pediatrics kept its office open six days a week. The small, independent practice continued to provide newborn checkups to moms who were released from the hospital while dispatching nurses in protective gear to vaccinate kids through car windows and outside apartment doors when people were afraid to come into the office.
Still, the practice was losing so much money it turned to GoFundMe to stave off layoffs after getting denied for a federal loan in the first round of the Payroll Protection Program in April.
“What makes the business in pediatrics is not the sick visits, it’s the wellness visits. So if they go down that’s a big problem,” said operations director Matteo Trisolini, whose husband owns the practice. “They’re really difficult to do remotely.”
Coronavirus has posed a threat to the city’s primary care infrastructure, including the nonprofit health centers that serve low-income New Yorkers and the small, independent practices that were already a dying breed amid the trend of health care consolidation. Like other businesses, many medical practices are trying to rebuild after laying off or furloughing staff and reducing services during the pandemic.
Now, as the rest of the city prepares to enter Phase 3 of reopening on July 6th, patients are slowly starting to return to South Slope Pediatrics and other doctor’s offices. More than 80% of primary care practices surveyed between May 22nd and June 4th were open to in-person visits, although the overwhelming majority at reduced capacity, up from about 60% in mid-April, according to a joint biweekly survey of primary care practices conducted by NYU researchers and the city Health Department.
Between telemedicine and in-person visits, patient volume at South Slope is now about 65% of what it was before the pandemic.
But despite the number of cases dropping across the city, many New Yorkers remain wary of in-person medical care, and South Slope and other small practices remain on uncertain footing. Like many small businesses, doctor’s offices are attempting to balance health and safety with the need to boost revenue, which took a nosedive when New Yorkers started to skip non-emergency medical care and stay home.
“There’s a light at the end of the tunnel, but they seem very concerned about practice revenue still not being what it was,” said Donna Shelley, a professor at the NYU School of Global Public Health, who has been working on the biweekly surveys of primary care practices. “That’s still the number one cause of stress.”
Many doctors are putting in place extensive safety protocols in an effort to make patients and staff feel safe and spacing out appointments more than usual.
After shutting down its offices and shifting exclusively to telemedicine during the height of the pandemic, Rest Medical cautiously began scheduling in-person visits again in late May at its locations in Jackson Heights, Queens, and the Wakefield section of the Bronx. At both offices, patients now wait to be seen in tents that are set up outside, rather than in the waiting room.
Patients who have symptoms of coronavirus or might have been exposed aren’t allowed in at all.
“You have patients who want to come to the office but maybe you’re not encouraging them to based on the facts and circumstances they present on the phone,” said Eric Huebscher, a consultant who provides business management services to Rest Medical and has been assisting other medical practices during the pandemic. Patients also have to get their temperature checked before going inside.
Dr. Michele Reed, who has a practice with offices in Rosedale, Queens and Garden City, Long Island, hasn’t gone as far as setting up tents. But she does screen patients over the phone before booking an appointment, have their temperature taken outside the office, and usher each patient into an exam room as soon as they come in rather than having them fill out paperwork in the waiting room.
The biggest challenge, she says, is getting a hold of protective equipment and cleaning supplies she needs.
“That’s been ridiculous, getting supplies,” Reed said. “You talk to another doctor and they say, ‘I just ordered from such and such’ and you call the place and they’re gone.”
The Medical Society of the State of New York says obtaining personal protective equipment has been a major challenge for doctor’s offices during the pandemic.
“Physicians in New York State continue to face enormous challenges in obtaining PPE that is slowing the ability of community-based physicians to return to treating patients in-person on a regular basis again,” Dr. Bonnie Litvack, president of MSSNY, said in a statement Friday. “Too many vendors sell only to government or large health systems, ignoring community physicians, or make PPE available in minimal quantities at grossly inflated prices.”
Reed says she hasn’t received any assistance with PPE from New York City but has received some supplies from the Nassau County Office of Emergency Management. Meanwhile, shipments of masks she ordered from China have been delayed.
Even with safety measures in place, medical practices continue to rely heavily on telemedicine and some say they see it playing a major role in health care even after the pandemic has run its course–that is, if they can get paid for it. During the pandemic, many health insurers started paying the same amount for a telemedicine visit as an in-office visit in order to make it viable for doctors to provide those services. But those enhanced rates have fast-approaching expiration dates and each insurer is operating on a different timeline.
Telemedicine also poses a challenge for some patients and there are limitations on the types of services that can be provided remotely.
“Some are really appreciating the opportunity to do telehealth and get reimbursed for it,” said Shelley of the doctors she’s surveyed. “Others are having a lot of difficulty because patients don’t have or won’t use the technology. Some say they’re willing to continue to use telemedicine, but only if the reimbursement stays the same.”
At South Slope Pediatrics, all sick patients are still being seen virtually while wellness visits are performed in the office.
The practice was ultimately able to avoid laying off staff, thanks to the more than $26,000 it raised through its GoFundMe and its successful application in the second round of PPP loans. But that money is set to run out in August.
“We need at least 10% more daily visits by then, not to break even, but to be able to lose an amount of money on a monthly basis that is not going to sink my ship,” Trisolini said.
Some say the government should start encouraging people to get routine health care again.
“I think there should be a campaign with doctors and public health officials all working together to get the message out to patients that doctor’s offices are open and taking precautions and now is the time to resume medical care,” said MSSNY’s Litvack. “I think that is a team effort so patients know it is safe and it is time.”
There’s some debate about whether the American health system needs to go back to dispensing the same volume of checkups, tests and elective surgeries as it did before the pandemic, and whether many doctors’ visits can’t be permanently replaced by video chats and other forms of telemedicine. Nearly half of Americans have skipped some form of medical care because of coronavirus, and of those who did, only about 11% say their condition has worsened as a result.
However, doctors say additional ramifications for skipping care may become apparent in the near future. A patient might find out they have colon or breast cancer later than they normally would because they skipped a screening, for instance, or the lower child vaccination rate during the pandemic might lead to a resurgence of a disease such as the measles. Primary care practitioners are also the ones responsible for helping patients manage chronic conditions such as diabetes and high blood pressure–the same diseases that put people at higher risk for severe cases of COVID-19–so they don’t get so bad they need to go to the hospital.
While it will take some time to fully grasp the collateral health consequences of the coronavirus, there are already anecdotal reports of people suffering dire consequences for putting off care during the pandemic. One emergency room doctor at Mount Sinai, who asked to remain anonymous because he is not authorized to speak to the press, told Gothamist in late May that he and other staff were sometimes sitting around bored because there were so few people coming into the ER. Those who were coming in seemed to have waited longer than they normally would to seek care.
“We are mostly worried about all the patients who are too scared to come in,” the ER doctor said. “I’m definitely seeing people way sicker from commonplace stuff than normal. Like appendicitis that went on for way too long at home [or] strokes that are completed and now we can’t catch up with treatment.”
South Slope Pediatrics is not yet urging patients to come back in the same numbers they did before. Rather, they are attempting to adjust to the “new normal.”
“I’m not ready to change my guidelines right now and I’m not ready to see sick patients in person,” said Trisolini. “Anyone who thinks we’re going back to normal is just kidding themselves.”
Echoing the sentiment of other doctors who spoke to Gothamist, Trisolini added, “The only thing that looks like normality will be when we have a vaccine that works.”
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