Clinical and Operational Practices in the Era of COVID-19: A Panel Discussion

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curncman
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Clinical and Operational Practices in the Era of COVID-19: A Panel Discussion

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Clinical and Operational Practices in the Era of COVID-19: A Panel Discussion

trader32176
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Re: Clinical and Operational Practices in the Era of COVID-19: A Panel Discussion

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Telecritical Care Clinical and Operational Strategies in Response to COVID-19

Published Online:17 Aug 2020

https://www.liebertpub.com/doi/10.1089/TMJ.2020.0186

Abstract

Background:The cororavirus disease 19 (COVID-19) pandemic has strained intensive care unit (ICU) material and human resources to global crisis levels. The risks of staffing challenges and clinician exposure are of significant concern. One resource, telecritical care (TCC), has the potential to optimize efficiency, maximize safety, and improve quality of care provided amid large-scale disruptions, but its role in pandemic situations is only loosely defined.

Planning and Preparation Phase:We propose strategic initiatives by which TCC may act as a force multiplier for pandemic preparedness in response to COVID-19, utilizing a tiered approach for increasing surge capacity needs. The goals involved usage of TCC to augment ICU capacity, optimize safety, minimize personal protective equipment (PPE) use, improve efficiencies, and enhance knowledge of managing pandemic response.

Implementation Phase:A phased approach utilizing TCC would involve implementing remote capabilities across the enterprise to accomplish the goals outlined. The hardware and software needed for initial expansion to cover 275 beds included $956,670 for mobile carts and $173,106 for home workstations. Team role deployment and bedside clinical care centering around TCC as critical care capacity expand beyond 275 beds. Surge capacity was not reached during early phases of the pandemic in the region, allowing refinement of TCC during subsequent pandemic phases.

Conclusions:Leveraging TCC facilitated pandemic surge planning but required redefinition of typical ICU staffing models. The design was meant to workforce efficiencies, reduce PPE use, and minimize health care worker exposure risk, all while maintaining quality care standards through an intensivist-led model. As health care operations resumed and states reopened, TCC is being used to support shifts in volume and critical care personnel during the pandemic evolution. The lessons applied may help health care systems through variable phases of the pandemic.

Introduction

The 2019 novel coronavirus disease 19 (COVID-19) pandemic has disrupted critical care resources to crisis levels. With surges of critically ill patients due to COVID-19, there have been well-documented shortages of key material and human resources,1 including personal protective equipment (PPE),2 mechanical ventilators,3 and intensive care unit (ICU) nurses and providers4 similar to those seen in other pandemics.5 Many health care institutions were concerned about the anticipated challenges of communication, care coordination, and crisis management, especially with increasing critical care resource scarcity. The constantly evolving recommendations for COVID-19 disease management only amplified these concerns due to the difficulty of managing the stress of rapidly changing clinical information.6

One resource, telecritical care (TCC), which involves providing care to critically ill patients through synchronous, two-way audiovisual communication, has had wide global adoption.7,8 The TCC industry has expanded since recent global pandemics, such as H1N1 influenza, severe acute respiratory syndrome, and Middle Eastern respiratory syndrome.8 The Society of Critical Care Medicine's Tele-ICU committee recently published a timely refresher that describes the various models of TCC and its contemporary applications.9 However, the management of COVID-19 creates its unique social and economic challenges,1–4 so existing TCC guidelines during pandemics10 may be insufficient to provide specific guidance. It is also unclear which TCC care delivery models are most apt for this evolving pandemic, as its role in pandemic and mass casualty planning is only loosely defined.7–12 Moreover, concerns of expensive startup and operating costs have limited the adoption of TCC in several centers.9,13

In this article, we describe strategic deployment of TCC to facilitate response in pandemic surge situations. Based on our own health system's experience with COVID-19, we describe organizational and structural adjustments that can be implemented utilizing TCC to maintain critical care quality standards while addressing concerns of health care safety, and operational efficiencies in this process. As resources become increasingly strained during pandemic evolution, we provide guidance to buffer the impact of potential challenges health systems may encounter. We argue that the costs of leveraging TCC may be favorable in comparison with other structural and operational surge planning preparations. The project received an institutional review board exemption.

Planning and Implementation
Atrium Health's Pre-COVID-19 Operations


Atrium Health is an integrated not-for-profit health care system in the southeastern United States with >40 hospitals and 900 care locations throughout the Carolinas and Georgia. Atrium Health's TCC service, Virtual Critical Care (VCC), was established in 2013 and now serves >300 adult critical care beds, across 12 hospitals and 3 states. VCC uses a largely decentralized hybrid hub-node-spoke care delivery model14 and is staffed full time by board-certified intensivists and certified critical care nurses 24 h daily, 365 days yearly, as well as part time by critical care pharmacists15 and respiratory therapists. VCC utilizes the eCareManager platform (Philips, Amsterdam, Netherlands).8,9 Depending on patient location, two integrated electronic medical records (Cerner, North Kansas City, MO and Epic, Verona, WI) provide access to documentation and clinical parameters, including laboratories and radiology. Before the COVID-19 pandemic, two hospitals already had mobile cart monitoring available in emergency departments.16 A real-time dashboard through a customized SharePoint tool (Microsoft, Redmond, WA) along with Microsoft Teams (Microsoft) and DocHalo (Halo Health, Cincinnati, OH) provides additional synchronous and asynchronous communication across the enterprise.

Atrium Health's TCC Pandemic Response

To complement facility-based, system-wide, and regional pandemic preparation, Atrium Health Incident Command and critical care leadership identified its needs in alignment with strategic capacity development consistent with the Society of Critical Care Medicine's (SCCM's) Preparation Checklist.17 VCC leadership then assessed which strategies would best be managed with a virtual strategy rather than the intrafacility approach (Table 1). As such, a phased multipronged strategy for TCC was developed specifically to optimize technological capacity, digital resource availability, and clinician training. Through this planning, an additional 275 beds could be added readily through remote cart acquisition and support. Should capacity for an additional 275–900 critical care beds be needed, then off-site facilities with TCC support could be added as schemes are adjusted. Figure 1 summarizes these goals in a surge capacity context. Figure 2 summarizes the physician and team-based staffing that would need to be adjusted, emphasizing patient care leadership through VCC intensivists.

Table 1. Telecritical Care Value in Relation to Intensive Care Unit Preparation Checklist by Society of Critical Care Medicine
ICU PREPARATION CHECKLIST FOR INCIDENT COMMAND STRUCTURE VCC ROLES


Preparedness Review and test your ICU emergency response plan and infection control policies.
Review external disaster management and evacuation plans.
Provide just-in-time training to staff. Provide real-time and rapid assessment of interfacility capabilities.
Can coordinate interfacility transfers.
Develop and coordinate asynchronous and synchronous institution-specific educational training to staff.
Logistics/surge capacity Assess ICU capability and identify contingency units.
Mitigate therapies that cause aerosolization.
Consult facilities management to safely cohort COVID-19 patients.
Understand how to sustain mechanical ventilation outside of an ICU. Provide clinical supervision of contingency units identified.
Virtual clinicians can assess appropriateness of aerosolized therapies.
Virtual clinicians can facilitate and manage mechanical ventilation and oxygen therapies outside of ICU.
Communication Understand your ICU's organization and chain of command.
Discuss communication methods with all departments, patients, and families.
Utilize online tools to maintain situational awareness and educate large groups. Facilitate real-time communication with patients and families through virtual platforms.
Facilitate team-based communication especially in rooms under isolation precautions.
Coordinate multispecialty interactions.
Critical care triage Ensure that all ICU staff members are familiar with your triage protocol.
Work with the emergency department to identify, isolate, and test for COVID-19.
Determine inclusion/exclusion criteria for ICU admission. Clinician oversight of ICU triage including ICU admission appropriateness.
Facilitate disposition from ICU especially if interfacility transfer needed.
Protection of ICU workforce Review policies for when ICU staff should be tested and take precautions.
Prepare contingency plans for staff or their families who are quarantined or infected.
Confirm that ICU staff will receive pay and benefits during quarantine situations. Home workstations allow ICU clinicians to function if deemed too high risk for bedside care, and if quarantined.
Minimize exposure risk as staffing is flexed for intensivists who can provide expertise from home.
External consultants can view patient from outside the ICU.
Staffing capacity Prepare alternative staffing strategies in the event of a surge in patients or illness among ICU staff.
Consider quarantine effects and work–rest cycles during increased patient load. Leverage the expertise of board-certified intensivists and nurses across the health care system.
Additional providers able to provide expertise across the region.
Essential equipment Ensure ICU staff members know how PPE will be distributed. Practice donning and doffing procedures.
Inventory equipment/supplies and anticipate shortages. Verify proper PPE precautions at bedside.
Facilitate ICU clinical standards being applied despite potential shortages of ICU-related equipment and medications.

ICU, intensive care unit; PPE, personal protective equipment; VCC, Virtual Critical Care.

Goal 1: augment capacity for VCC

Increase the system-wide total number of beds available for critically ill patients by equipping non-ICU rooms with VCC interface technology. Notably, an additional 130 mobile telehealth carts were purchased for critical care overflow and emergency department use (Table 2). Internal carts from other existing telehealth platforms (telestroke and behavioral health) were also repurposed to be compatible with existing critical care platforms with minimal investment to achieve the initial 275-bed surge goal.

Coordinate hardware and software acquisition and installation with the Atrium Health Information and Analytics Services (IAS) team to supply the necessary number of remote workstations across the enterprise.

○ Allows clinicians who cannot perform bedside duties (e.g., high-risk pre-existing conditions, self-quarantined, and retired) to work from home.

Train and credential advance practice providers (APPs) to perform VCC duties in alignment with scope of practice defined by state regulations, while exploring virtual supervision rules of site-based APPs through VCC intensivists.

Develop a team-based approach toward patient care (Fig. 2), whereby critical care procedures would preferentially be performed by surgeons, anesthesiologists, and/or certified registered nurse anesthetists, allowing bedside intensive care providers to facilitate medical care.

Develop and coordinate use of institution-specific educational and resource materials for non-intensivists to provide critical care, including just-in-time resources.

Goal 2: (a) minimize health care worker exposure while (b) controlling PPE use

Add virtual access in multiple clinical areas, including proximate nursing workstations and non-ICU areas, such that ICU staff can communicate with patients in isolation without direct exposure.

Verification of proper PPE worn by bedside teams by VCC nurses.

Assistance with monitoring, communication, and documentation during high-risk procedures (e.g., intubation and advanced cardiac life support) by VCC nurses and physicians, thereby minimizing the need for additional personnel entering and exiting rooms for these purposes.

Goal 3: improve efficiencies in bedside ICU team management


As bedside providers are increasingly taxed, expand roles and degree of involvement of VCC providers in all aspects of clinical decision making, order entry, care coordination, and documentation.

Minimize potential delayed recommendations from specialists by providing remote virtual capabilities in non-ICU clinical areas, such as echocardiography reading rooms, infectious disease, and endocrinology specialists' offices.

Facilitate coordination through surgery and anesthesiology teams for procedural support for on-site teams.

Promote virtual team-based rounding as traditional ICU interprofessional rounding teams might have members deemed “nonessential” and hence only available remotely.

Serve as a central point of coordination and communication for evolving critical care clinical algorithms, based on advancing knowledge of management of COVID-19.

Goal 4: optimize ICU bed utilization

Create a real-time ICU surveillance dashboard listing active ICU patients, including COVID-19 confirmed or suspected cases, which provides insight into each facility's ICU capacity and better equips Atrium Health's Incident Command structure.

Centralize ICU triage decision making by the creation of a dedicated intensivist “VCC quarterback” position with explicit responsibilities to facilitate admission, transport, and communication to ICUs across the system.

Lessons Learned During Implementation


We describe the components and strategies of a multifaceted TCC program's response to the COVID-19 pandemic as it supports the organization's Incident Command structure, which, in turn, aligns with the SCCM's pandemic preparation checklist.17 Several key lessons are being learned during this early phase of the pandemic (Table 3). The approach described did facilitate rapid capacity expansion with the aim to provide intensivist-led critical care coverage 24 h a day, 7 days a week to the system's hospitals and ICUs. Alternative strategies mainly involved repurposing noncritical care trained frontline ICU staff to function without intensivist oversight, perhaps leading to provider dissatisfaction or burnout,18,19 or even potential adverse patient outcomes.20,21 In addition, a nonvirtual-care-based strategy may also pose a higher risk of exposure by bringing more health care workers to the bedside, whereas virtual patient care solutions may increase staff safety.22 Notably, important aspects of larger integrated health care systems also applied that favored a virtual intensivist option: (1) the geographical distances and number of facilities limit the ability for rapid workforce deployment directly to a site as staff may not physically be able nor willing to travel physically across long distances; (2) staffing by the health care system's own virtual intensive care team (virtual care physician, nurse, pharmacist, and respiratory therapist) is perhaps more likely to adhere to existing clinical and operational standards as this team is already familiar with current practices, protocols, electronic health record, and site-specific capabilities; (3) the ability to regionalize advanced critical care support such as nonconventional mechanical ventilation modes, extracorporeal membrane oxygenation, and other complex needs may be partially eased by incorporating telemedicine.23

Table 3. Assessment of Telecritical Care-Specific Goals, Learned to Date During Pandemic

Goal 1: Augment capacity for VCC
 VCC augmentation likely more cost-effective and rapid than structural facility changes
 Initial home workstation technology acquisition investment required; further acquisition may be limited by supply-chain shortages of specific equipment (e.g., webcams)
 Extensive support from technology department required for setup and maintenance
 Team-based care and role changing can cause initial confusion, so practice and intense initial communication of newer team models with VCC are recommended
 Just-in-time training is challenging for many providers to complete, variable in composition, and may not be relevant especially if TCC support is present
Goal 2: Minimize health care worker exposure while controlling PPE use
 Providing virtual access nearby was helpful for consultants, but bedside teams often would simply opt to resort to bedside use in PPE if PPE available.
 Assessment of donning/doffing compliance was technically challenging for VCC nurses as not always in camera view
Goal 3: Improve efficiencies in bedside management
 Augmentation of critical care nursing, pharmacist, and respiratory therapy roles is well received across facilities
 VCC help with clinical decision making, especially for respiratory failure management, is well received for sites particularly for those without 24-h-intensivist models
 For patients in 24–7 intensivist-covered facilities, an extra onsite intensivist is favored over a VCC intensivist if manpower can be flexed
 Moving ventilators and IV pumps outside the room limited the virtual intensivist's ability to assess patients
 Bedside communication is hampered by PPE and visitor restrictions, and virtual intensivists were challenged in involving families particularly if language barrier exists.
Goal 4: Optimize ICU bed utilization
 VCC can support Incident Command with real-time metrics of bed utilization
 Teleintensivist quarterback triage position is most useful for interfacility transfer, triage assessment, and resource utilization; recommendations were best received by physicians with intimate knowledge of system resources and capabilities.
 Support limited to only those hospitals in the system network, limiting geographical impact

An important initial step involved rapid expansion of an available pool of teleintensivists. These providers come from within the system's existing clinician workforce that engenders trust24 and assures familiarity with existing critical care resources, while also facilitating nimble redeployment of providers to areas of need within the system. Moreover, the expansion of home workstations limits the need to hire new VCC clinicians and ensures staff availability even when under quarantine or other stay-at-home restrictions. By having intensivists work remotely, this may also mitigate the risk of hospital-acquired COVID-19 transmission. If nonintensivists are pulled to manage critically ill patients during major surge periods, VCC teleintensivists can support in bedside critical care decision making. Layering teleintensivist support over nonintensivists may be better received than asking or even mandating nonintensivists to complete just-in-time critical care training. As such, the VCC intensivists can support clinical decision making across all ICUs, including advanced modes of mechanical ventilatory support when needed. The VCC “Quarterback” position also is proving useful for coordinating interfacility transfer requests and active triage to capable facilities during bed and staffing crises; notably initial feedback was that this was best received by those intensivists with more intimate knowledge of different ICU staffing and capabilities. In summary, by expanding the teleintensivist pool, several potential physician staffing issues may be minimized.

The participation of VCC nurses can offset clinical load from nurses working at the bedside under normal circumstances25; their expanded role in pandemic situations can provide additional critical relief. The COVID-19 pandemic has exacerbated the pre-existing shortage of ICU nurses in the United States,26,27 leading to higher patient-to-nurse ratios, or to less experienced nurses (such as non-ICU nurses flexed to ICUs), providing front-line care. Atrium Health's VCC nurses have, on average, 14 years of bedside ICU experience and are certified as critical care registered nurses. Their assistance during pandemic situations may enhance patient safety, the accuracy of documentation, and reduce the risk of bedside nurse burnout.19,27 In addition, remote provision of PPE education may help preserve crucial PPE supplies, optimize PPE use, and increase overall safety for on-the-ground clinical staff. Lastly, the involvement of virtual care pharmacists and respiratory therapists was continued to augment support the virtual and on-site care teams.

This enormous augmentation of the health system's VCC resources requires substantial monetary investment; this is especially relevant considering that the program, like many others, is not directly revenue generating. The initial surge budget assumed one bed per patient and was estimated to be ∼140% of current ICU bed capacity, and 300% capacity for critical surge. At critical surge capacity, 130 mobile carts and 102 home workstations would be needed. The estimated costs of $173,106 for home workstations and $956,670 for the initial 130 mobile carts (Table 2) do not account for labor and other indirect expenses. Although these costs seem high, they are far less than building or restructuring hospital facilities; moreover, the process is clearly faster than building new hospitals or units. The system's clinical and administrative leadership has prioritized these investments as part of its pandemic preparation, but also for future planning for critical care and other services. Still, such scale and complexity may prove cost prohibitive for smaller health systems, and the response outlined may be feasible only for larger systems with more mature TCC programs. Importantly, global supply-chain shortages affected by the pandemic did affect our ability to also purchase additional equipment when needed, such as webcams, mobile carts, and other specialized equipment.

Despite the benefits of a robust TCC program in pandemic situations, there remain many uncertainties and potential limitations of this strategy. Many facilities used extension tubing to move ventilators and intravenous pumps to outside the patient's room; this helped to minimize bedside staffs' PPE usage but impaired the ability for VCC intensivists to assess the patient and intervene. Teleintensivists also cannot provide procedural assistance other than remote review of bedside ultrasonographic images.28,29 Audiovisual experience with bedside staff using PPE is occasionally quite challenging, so communication with the bedside clinicians often would occur outside the patient rooms. Restrictions and limitations on patient and family visitation may further risk poor bedside communication. These factors limited the role of virtual intensivists to involve families, with several noting that when language barriers exist, the communication is limited even further. Given that COVID-19 may affect those with racial and ethnic disparities,28 this may limit utility of VCC families with non-English speakers. Communication risks with other team members, role confusion, and potentially conflicting medical decision making between bedside and virtual providers can still occur. The leadership changes depicted in Figure 2, with the virtual intensivist depicted as team leader could be a significant adjustment for bedside teams, so practice or simulation is recommended if feasible. TCC is only as effective as its technology, so hardware and software issues resulting from internet service disruption or cybersecurity issues, for example, require rapid resolution. Furthermore, difficult end-of-life decision making, especially considering evolving discussions amid resource scarcity,30 can be challenging for virtual intensivists and potentially reduce patient/family satisfaction. Administrative and financial barriers, including fiscal viability, information technology optimization, and credentialing of new providers, can create additional strain on health systems already taxed with high patient volumes, PPE shortages, and staff safety concerns.31 The full value of TCC in pandemic situations also may not be fully realized without regional coordination between geographically proximate health systems and institutions. Such intersystem connectivity is not feasible at present, although being investigated by the SCCM.

Despite these numerous challenges, the efforts undertaken position a large health care system's TCC program to fulfill a critical role not only in the acute phase of pandemic planning, but also in postpandemic clinical and research operations. As the COVID-19 pandemic enters a reopening phase with cautious resumption of previous health care operations, the level of virtual support can flex upward or downward as needed. Creative modeling is now being considered to improve efficiency and streamline the number of teammates needed at any given location to provide bedside care during periods of lower acuity and census. The infrastructure is also now in place for virtual clinical research capabilities across the health care system's critical care population, with several COVID-19 therapeutic trials relying on the virtual intensivist for screening and enrollment. The experiences from this COVID-19 response will surely spur new innovations as the “lessons learned” become clearer.

Still, many questions remain as to the impact of the VCC's role in the pandemic response. We aim to improve understanding of whether the outlined steps provide meaningful impact and identify those resources that are required to accomplish each goal outlined. We specifically aim to understand which of these virtual solutions may aid the various phases of the pandemic and which persist after the pandemic has resolved.

Conclusions

We describe strategic initiatives within an integrated health care system that permits TCC to become the nexus of critical care delivery and coordination during the COVID-19 pandemic, aiding the Incident Command in its execution of pandemic preparedness and ability to deliver care as the situation evolves. By emphasizing efficiency, safety, and quality, the health care system's TCC program evolved from a luxury to a necessity by complementing bedside clinical care while respecting the physical and psychological safety of front-line workers. The VCC model may serve as a resource to other systems looking to expand their telehealth programs. Further research is needed to address important questions related to this model's cost-effectiveness and impact on patient outcomes and operational goals. By addressing these questions, TCC programs can continue to advance the field through innovations in clinical care and clinical research. Such advancements are not restricted to pandemic situations, when traditional methods of care delivery are challenged, but may also affect the transition to the near future state. Our hope is the lessons learned may catalyze the quality, versatility, and value of our organization in the care of a complex critically ill population.
trader32176
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Re: Clinical and Operational Practices in the Era of COVID-19: A Panel Discussion

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Economic and Clinical Impact of Covid-19 on Provider Practices in Massachusetts

September 11, 2020

https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0441

Summary

A survey developed through a partnership of clinicians, researchers, and public and private entities in Massachusetts was hosted by Harvard Medical School. Between May 20 and July 9, 2020, respondents from 398 practices shared details on the revenue and expense implications of the novel coronavirus, as well as insights into the personal impact Covid-19 is having. More than 60% of practices reported they would cut salaries of providers or employees, cut services or other operating expenses, and furlough or lay off more employees without additional financial assistance, with a roughly 40% likelihood of following through. Consolidation, selling, or closing the practice were reported by 20%–40% of practices, driven by independent practices such as primary care (60% noted closure at 21% likelihood). The authors include policy actions that may mitigate the harm to access to care.

The Covid-19 pandemic has substantially disrupted the U.S. health care system and economy. Beyond the more than 6 million infections and 183,000 deaths reported in the U.S. as of September 1, 2020,1 the unemployment rate stood at 9.9%, with nearly 15 million unemployed individuals at the end of August. About 1.5 million health care jobs were lost in March and April 2020 alone,2,3 and while there has been some recovery, as of August 7, health care is down by 797,000 jobs since February 2020.4 Despite this disruption in the health care industry, data on its impact on provider practices have been scant.

Through a partnership of clinicians, researchers, and public and private entities in the Commonwealth of Massachusetts, we queried provider practices about the impact of Covid-19 on their clinical and economic activities using a survey hosted by Harvard Medical School. Respondents included 398 practices across specialties, from small independent private practices to large provider organizations, over 50 days from May 20 through July 9, 2020.

Our results show that Covid-19 has affected practices in profound ways, from reductions in the health care workforce, to a decline in visits and clinical activities, to the consequent reductions in revenues and resulting economic distress. These effects were felt throughout the delivery system, though with heterogeneity across specialties and types of practices. Telehealth has provided a partial clinical substitute and financial boost, as has direct financial assistance from federal and state sources, but a clear sense of economic peril remained across respondents.

Practices are considering strategies to cut costs (e.g., cutting services or personnel) or generate revenues (e.g., increase volume or improve coding) to maintain viability, and a nontrivial share are considering consolidation, sale, or closure. These projected actions, to the extent they are realized, could curtail access to care, especially among communities that rely on independent private practices. To the extent that consolidation or sales of practices to private entities occurs, insurers may face higher prices of health care services in future contract negotiations from previously independent practices.

Demand Shock and Financial Peril

As millions of patients stayed home nationally, large amounts of outpatient care were canceled or deferred. In March and April, outpatient visits nationwide had declined 60%.5 While there has been some recovery since then,6 the uncertainty associated with the novel coronavirus and the economy continues to stress the health care industry. Reports from hospitals offered anecdotes of about 30% declines in inpatient admissions, 50% reductions in emergency department visits, and 70% reductions in outpatient procedures compared to the same time last year.7 The expansion of telehealth and payment for telehealth by Medicare and other payers have helped practices maintain some elements of care delivery and provided a revenue stream,8 but telehealth visits have not completely substituted for the forgone in-person visits.

Our results show that Covid-19 has affected practices in profound ways, from reductions in the health care workforce, to a decline in visits and clinical activities, to the consequent reductions in revenues and resulting economic distress. These effects were felt throughout the delivery system … a clear sense of economic peril remained across respondents.

With a largely fee-for-service payment system nationwide, many practices — small businesses that depend on in-person visits for revenue — found themselves in financial peril.9,10 Stories of practices furloughing additional workers, cutting salaries, and nearing closure or sell-off grew.11 Early survey data of physician practices from several states showed large declines in visits and revenue in April.12,13 Despite these signals of economic distress, comparative evidence on how primary care, behavioral health, medical and procedural specialties, and other provider practices have fared under Covid-19 has been lacking. Moreover, the extent to which practices consider cost-cutting and revenue-generating strategies to survive the pandemic has not been studied.

Practice Survey Design and Analysis

The survey was fielded to health care provider practices including physician and non-physician practices in Massachusetts from May 20 through July 9, 2020. The survey instrument is shown in the Appendix. Participation was voluntary, and no deadline was imposed. Each question on the survey was optional. All responses were kept confidential on the Harvard Medical School survey platform. All results are reported in aggregate, without revealing any practice identities.

For questions that asked about information before and after March 2020, ascertaining how an outcome changed from before to after the Covid-19 pandemic, we included responses only when data were provided for both before and after March 2020. Responses for some questions, such as clinical visits or revenues and expenses, were scaled by the total number of clinical workers within the respondent’s practice, defined as full-time equivalent (FTE) physicians, nurse practitioners, physician assistants, nurses, and other clinical personnel. Aggregate statistics that reflect the average clinician were weighted by clinical FTEs when analyzed across practices. This gave larger weight to larger practices. On the other hand, aggregate responses reflecting the average practice were unweighted, which gave small and large practices equal weight.

Responses were aggregated overall and by categories of provider specialty, which includes primary care, behavioral health, and medical and procedural specialties; health systems; and all other providers. This latter category included physical therapy, chiropractor practices, dentistry, community health centers, and other providers. In addition, we analyzed responses from primary care and non-primary care practices by type of affiliation, defined in a binary fashion as independent (privately owned) and non-independent (which includes hospital or health-system owned). Further details regarding data cleaning and processing are provided in the Appendix. The Harvard Institutional Review Board approved this research study.

Study Population

A total of 398 provider practices and organizations completed the survey, with eligible responses included in the analysis. Table 1 shows distribution of responses by specialty and practice affiliation. On average, practices had 27.6 clinical FTEs and 25.6 nonclinical FTEs.

Primary care practices comprised 29% of the sample, averaging 13.2 clinical FTEs and 16.5 nonclinical FTEs per practice. Slightly more than half (54%) were independent practices, which were considerably smaller (9.5 clinical FTEs and 8.0 nonclinical FTEs per practice) than non-independent primary care practices, which averaged 17.4 clinical and 26.1 nonclinical FTEs. Behavioral health practices accounted for 24% of the sample and medical and procedural specialties 18% of the sample. Two health systems were included, which averaged 2,717 clinical FTEs and 1,600 nonclinical FTEs.

There were 9,509 FTE nonclinical staff across all practices in the sample, among whom 1,955 (20.6%) FTEs were reported furloughed or laid off at the time of data collection. Analogously, 22.6% of nurses, case managers, and other clinicians were furloughed or laid off.

Among all respondents, commercial payers accounted for 45% of practices’ patients on average, followed by Medicare (20%), Medicaid (19%), self-pay (10%), other insurance (5%), and lastly uninsured and unable to pay (1%). This general pattern was consistent across provider categories

Behavioral health had larger proportions of self-pay patients than other categories, while health systems had larger proportions of commercially insured patients (Appendix).

About 54% of primary care practices reported independent, private practice status, 36% reported a hospital or health system affiliation for contracting purposes, and 12% reported a hospital or health system affiliation for clinical or educational purposes. Behavioral health respondents were overwhelmingly independent private practices

There were 9,509 FTE nonclinical staff across all practices in the sample, among whom 1,955 (20.6%) FTEs were reported furloughed or laid off at the time of data collection. Analogously, 22.6% of nurses, case managers, and other clinicians were furloughed or laid off. The proportion of advanced practice providers (NPs/PAs) furloughed or laid off was lower at 10.9%, and that for physicians was the lowest at 3.3% (123 of 3,756 physician FTEs). By specialty category, sizeable reductions in nurses and other clinical staff as well as nonclinical staff were seen in primary care, health systems, and medical and procedural specialties. Behavioral health reported the lowest share of workers affected. Findings for primary care and all other practices by affiliation are also shown in the Appendix.

Changes in Clinical Activity

Across all practices, in-person visits per clinical FTE per month averaged 205 pre–Covid-19 and declined to 115 post–Covid-19, a reduction of 90 in-person visits (44%). Meanwhile, telehealth visits per clinical FTE per month increased from essentially none pre–Covid-19 to 33 post–Covid-19, thus making up less than half of the decline in in-person visits (Figure 4). Both independent and non-independent practices reported large reductions in in-person visits, with a smaller share replaced by telehealth among independent practices

Decomposed by specialty category, the declines in in-person visits were similar for primary care (81%), behavioral health (74%), medical and procedural specialties (78%), and all other practices (76%). Health systems experienced a 31% decline in in-person visits. All specialty categories reported incomplete substitution of in-person visits by telehealth with the exception of behavioral health, which was able to almost fully substitute for the decline in in-person visits with telehealth (Figure 5).

Within primary care, specialty, health systems, and other practices, reductions on the order of 60% to 80% of procedures, imaging, tests, and referrals were reported to be canceled or deferred. Again, behavioral health was an exception, with smaller shares of some of these activities deferred. The proportion of visits affected differed in some cases relative to analogous calculations from the previous question, accounting for the incomplete substitution by telehealth. The proportion of prescriptions affected was smaller for all practices. Similar patterns were found among independent and non-independent practices (Appendix).

On average, practices reported achieving approximately 67% of their full capacity for telehealth at the time of survey completion (Table 2). “Full capacity” was defined as telehealth use by all clinicians in a practice with adequate technology for doing so.

Behavioral health practices reported an average of 88% of full capacity reached, whereas medical and procedural specialties and other practices were roughly halfway to full capacity. Primary care and health systems reported an average capacity of 71% and 74%, respectively. Similar responses were found among independent and non-independent practices

Changes in Revenues and Expenses

Reported total practice revenues declined to a greater extent than total practice expenses (Figure 7a). Primary care practices reported average total revenues of $24,000 per clinical FTE per month before March 2020 and $11,000 after March 2020 (54% decline), compared to reported average expenses of $27,000 before and $19,000 after (30% decline). A similar pattern was found across the other specialties (with the exception of health systems, which experienced fewer reactive revenues and expenses).

This change in revenues and expenses was generally consistent with anecdotal evidence from practices, that they tried maintain their expenses — the largest component of which was employee salaries — in the early months of the pandemic as revenues fell; the aim was to defer more difficult decisions of cuts in personnel or practice closure.

Primary care practices reported average total revenues of $24,000 per clinical FTE per month before March 2020 and $11,000 after March 2020 (54% decline)…. A similar pattern was found across the other specialties.

Independent practices faced larger percent reductions in revenues than non-independent practices (Appendix). Within primary care, revenues among independent practices declined from $19,000 per clinical FTE per month to $11,000 (42% decline) amidst a 18% decline in expenses, while revenues among non-independent practices decreased by 61% while expenses decreased by 35%. A similar pattern was observed among non–primary care practices).

This pattern is consistent with reports of smaller, privately owned community practices facing relatively more financial peril relative to practices that may have some hospital or health system support. In general, non-independent practices reported larger revenues and expenses at baseline, which may reflect larger clinical operations in these settings. These hospital- or health system–affiliated practices also did report larger drops in revenue than in expenses, which — combined with reductions in admissions, elective procedures, and other sources of revenue — may generate different or additional economic pressure that smaller independent practices do not face. Further context for interpreting these findings may be gleaned from qualitative responses.

Practices reported receiving various amounts of financial assistance from federal, state, and other sources.

Primary care practices reported receiving $10,026 per clinical FTE in federal loans, which need to be repaid, and $9,502 per clinical FTE in federal relief or grants, which do not need to be repaid. Health systems and medical and procedural specialists reported similar amounts of assistance. Behavioral health and all other practices reported less assistance. Personal or family assistance of about $500 per clinical FTE in primary care and $1,200 in medical and procedural specialties was reported. State assistance included that for community health centers. Generally, average assistance for independent practices was greater than that reported by non-independent practices.



Commentary
Economic and Clinical Impact of Covid-19 on Provider Practices in Massachusetts

A survey of health care providers reveals significant adverse effects on the ability to serve patients and sustain the practice. Without policy solutions and financial support, practice sales and closures may be imminent.
By

Zirui Song, MD, PhD, Mia Giuriato, MA, Timothy Lillehaugen, MPH, Wayne Altman, MD, FAAFP, Daniel M. Horn, MD, Russell S. Phillips, MD, Katherine Gergen Barnett, MD, Asaf Bitton, MD, MPH, Susan Edgman-Levitan, PA, Elisa Choi, MD, FACP, FIDSA, et al.

September 11, 2020
Summary

A survey developed through a partnership of clinicians, researchers, and public and private entities in Massachusetts was hosted by Harvard Medical School. Between May 20 and July 9, 2020, respondents from 398 practices shared details on the revenue and expense implications of the novel coronavirus, as well as insights into the personal impact Covid-19 is having. More than 60% of practices reported they would cut salaries of providers or employees, cut services or other operating expenses, and furlough or lay off more employees without additional financial assistance, with a roughly 40% likelihood of following through. Consolidation, selling, or closing the practice were reported by 20%–40% of practices, driven by independent practices such as primary care (60% noted closure at 21% likelihood). The authors include policy actions that may mitigate the harm to access to care.

The Covid-19 pandemic has substantially disrupted the U.S. health care system and economy. Beyond the more than 6 million infections and 183,000 deaths reported in the U.S. as of September 1, 2020,1 the unemployment rate stood at 9.9%, with nearly 15 million unemployed individuals at the end of August. About 1.5 million health care jobs were lost in March and April 2020 alone,2,3 and while there has been some recovery, as of August 7, health care is down by 797,000 jobs since February 2020.4 Despite this disruption in the health care industry, data on its impact on provider practices have been scant.

Through a partnership of clinicians, researchers, and public and private entities in the Commonwealth of Massachusetts, we queried provider practices about the impact of Covid-19 on their clinical and economic activities using a survey hosted by Harvard Medical School. Respondents included 398 practices across specialties, from small independent private practices to large provider organizations, over 50 days from May 20 through July 9, 2020.

Our results show that Covid-19 has affected practices in profound ways, from reductions in the health care workforce, to a decline in visits and clinical activities, to the consequent reductions in revenues and resulting economic distress. These effects were felt throughout the delivery system, though with heterogeneity across specialties and types of practices. Telehealth has provided a partial clinical substitute and financial boost, as has direct financial assistance from federal and state sources, but a clear sense of economic peril remained across respondents.

Practices are considering strategies to cut costs (e.g., cutting services or personnel) or generate revenues (e.g., increase volume or improve coding) to maintain viability, and a nontrivial share are considering consolidation, sale, or closure. These projected actions, to the extent they are realized, could curtail access to care, especially among communities that rely on independent private practices. To the extent that consolidation or sales of practices to private entities occurs, insurers may face higher prices of health care services in future contract negotiations from previously independent practices.
Demand Shock and Financial Peril

As millions of patients stayed home nationally, large amounts of outpatient care were canceled or deferred. In March and April, outpatient visits nationwide had declined 60%.5 While there has been some recovery since then,6 the uncertainty associated with the novel coronavirus and the economy continues to stress the health care industry. Reports from hospitals offered anecdotes of about 30% declines in inpatient admissions, 50% reductions in emergency department visits, and 70% reductions in outpatient procedures compared to the same time last year.7 The expansion of telehealth and payment for telehealth by Medicare and other payers have helped practices maintain some elements of care delivery and provided a revenue stream,8 but telehealth visits have not completely substituted for the forgone in-person visits.

Our results show that Covid-19 has affected practices in profound ways, from reductions in the health care workforce, to a decline in visits and clinical activities, to the consequent reductions in revenues and resulting economic distress. These effects were felt throughout the delivery system … a clear sense of economic peril remained across respondents.

With a largely fee-for-service payment system nationwide, many practices — small businesses that depend on in-person visits for revenue — found themselves in financial peril.9,10 Stories of practices furloughing additional workers, cutting salaries, and nearing closure or sell-off grew.11 Early survey data of physician practices from several states showed large declines in visits and revenue in April.12,13 Despite these signals of economic distress, comparative evidence on how primary care, behavioral health, medical and procedural specialties, and other provider practices have fared under Covid-19 has been lacking. Moreover, the extent to which practices consider cost-cutting and revenue-generating strategies to survive the pandemic has not been studied.
Practice Survey Design and Analysis

The survey was fielded to health care provider practices including physician and non-physician practices in Massachusetts from May 20 through July 9, 2020. The survey instrument is shown in the Appendix. Participation was voluntary, and no deadline was imposed. Each question on the survey was optional. All responses were kept confidential on the Harvard Medical School survey platform. All results are reported in aggregate, without revealing any practice identities.

For questions that asked about information before and after March 2020, ascertaining how an outcome changed from before to after the Covid-19 pandemic, we included responses only when data were provided for both before and after March 2020. Responses for some questions, such as clinical visits or revenues and expenses, were scaled by the total number of clinical workers within the respondent’s practice, defined as full-time equivalent (FTE) physicians, nurse practitioners, physician assistants, nurses, and other clinical personnel. Aggregate statistics that reflect the average clinician were weighted by clinical FTEs when analyzed across practices. This gave larger weight to larger practices. On the other hand, aggregate responses reflecting the average practice were unweighted, which gave small and large practices equal weight.

Responses were aggregated overall and by categories of provider specialty, which includes primary care, behavioral health, and medical and procedural specialties; health systems; and all other providers. This latter category included physical therapy, chiropractor practices, dentistry, community health centers, and other providers. In addition, we analyzed responses from primary care and non-primary care practices by type of affiliation, defined in a binary fashion as independent (privately owned) and non-independent (which includes hospital or health-system owned). Further details regarding data cleaning and processing are provided in the Appendix. The Harvard Institutional Review Board approved this research study.
Study Population

A total of 398 provider practices and organizations completed the survey, with eligible responses included in the analysis. Table 1 shows distribution of responses by specialty and practice affiliation. On average, practices had 27.6 clinical FTEs and 25.6 nonclinical FTEs (Table 1).


FTEs is full-time equivalents. Clinical FTEs include physicians, nurse practitioners, physician assistants, nurses, and other clinical personnel. Nonclinical FTEs include all other staff. Source: The authors.

Primary care practices comprised 29% of the sample, averaging 13.2 clinical FTEs and 16.5 nonclinical FTEs per practice. Slightly more than half (54%) were independent practices, which were considerably smaller (9.5 clinical FTEs and 8.0 nonclinical FTEs per practice) than non-independent primary care practices, which averaged 17.4 clinical and 26.1 nonclinical FTEs. Behavioral health practices accounted for 24% of the sample and medical and procedural specialties 18% of the sample. Two health systems were included, which averaged 2,717 clinical FTEs and 1,600 nonclinical FTEs.

There were 9,509 FTE nonclinical staff across all practices in the sample, among whom 1,955 (20.6%) FTEs were reported furloughed or laid off at the time of data collection. Analogously, 22.6% of nurses, case managers, and other clinicians were furloughed or laid off.

Among all respondents, commercial payers accounted for 45% of practices’ patients on average, followed by Medicare (20%), Medicaid (19%), self-pay (10%), other insurance (5%), and lastly uninsured and unable to pay (1%). This general pattern was consistent across provider categories (Figure

Behavioral health had larger proportions of self-pay patients than other categories, while health systems had larger proportions of commercially insured patients (Appendix).

About 54% of primary care practices reported independent, private practice status, 36% reported a hospital or health system affiliation for contracting purposes, and 12% reported a hospital or health system affiliation for clinical or educational purposes. Behavioral health respondents were overwhelmingly independent private practices (Figure 2).

Changes in Workforce

Summed across all practices, the number of workers before Covid-19 (defined as March 2020) and furloughed or laid off due to Covid-19 are notable.
There were 9,509 FTE nonclinical staff across all practices in the sample, among whom 1,955 (20.6%) FTEs were reported furloughed or laid off at the time of data collection. Analogously, 22.6% of nurses, case managers, and other clinicians were furloughed or laid off. The proportion of advanced practice providers (NPs/PAs) furloughed or laid off was lower at 10.9%, and that for physicians was the lowest at 3.3% (123 of 3,756 physician FTEs). By specialty category, sizeable reductions in nurses and other clinical staff as well as nonclinical staff were seen in primary care, health systems, and medical and procedural specialties. Behavioral health reported the lowest share of workers affected. Findings for primary care and all other practices by affiliation are also shown in the Appendix.
Changes in Clinical Activity

Across all practices, in-person visits per clinical FTE per month averaged 205 pre–Covid-19 and declined to 115 post–Covid-19, a reduction of 90 in-person visits (44%). Meanwhile, telehealth visits per clinical FTE per month increased from essentially none pre–Covid-19 to 33 post–Covid-19, thus making up less than half of the decline in in-person visits (Figure 4). Both independent and non-independent practices reported large reductions in in-person visits, with a smaller share replaced by telehealth among independent practices (Appendix).
Figure 4.
Figure 4

Decomposed by specialty category, the declines in in-person visits were similar for primary care (81%), behavioral health (74%), medical and procedural specialties (78%), and all other practices (76%). Health systems experienced a 31% decline in in-person visits. All specialty categories reported incomplete substitution of in-person visits by telehealth with the exception of behavioral health, which was able to almost fully substitute for the decline in in-person visits with telehealth (Figure 5).
Figure 5.
Figure 5

Clinical activities deferred or canceled due to Covid-19 varied by specialty (Figure 6).
Figure 6.
Figure 6

Within primary care, specialty, health systems, and other practices, reductions on the order of 60% to 80% of procedures, imaging, tests, and referrals were reported to be canceled or deferred. Again, behavioral health was an exception, with smaller shares of some of these activities deferred. The proportion of visits affected differed in some cases relative to analogous calculations from the previous question, accounting for the incomplete substitution by telehealth. The proportion of prescriptions affected was smaller for all practices. Similar patterns were found among independent and non-independent practices (Appendix).

On average, practices reported achieving approximately 67% of their full capacity for telehealth at the time of survey completion (Table 2). “Full capacity” was defined as telehealth use by all clinicians in a practice with adequate technology for doing so.
Table 2.
Percent of Full Capacity for Telehealth Reached, by Specialty

Scroll table to see more
Practices Mean Std. Dev.
By Specialty Category
Primary Care 112 71 28
Behavioral Health 93 88 21
Medical/Procedural Specialties 68 50 40
Health Systems 2 74 19
All Other Practices 88 53 42

The survey asked: Approximately what percent of your practice’s full capacity for Telehealth is your practice doing now? (“Full capacity” means telehealth usage by all clinicians in your practice with adequate technology for doing so.) Source: The authors.

Behavioral health practices reported an average of 88% of full capacity reached, whereas medical and procedural specialties and other practices were roughly halfway to full capacity. Primary care and health systems reported an average capacity of 71% and 74%, respectively. Similar responses were found among independent and non-independent practices (Appendix).
Changes in Revenues and Expenses

Reported total practice revenues declined to a greater extent than total practice expenses (Figure 7a). Primary care practices reported average total revenues of $24,000 per clinical FTE per month before March 2020 and $11,000 after March 2020 (54% decline), compared to reported average expenses of $27,000 before and $19,000 after (30% decline). A similar pattern was found across the other specialties (with the exception of health systems, which experienced fewer reactive revenues and expenses) (Figure 7b).
Figure 7a.
Figure 7a
Figure 7b.
Figure 7b

This change in revenues and expenses was generally consistent with anecdotal evidence from practices, that they tried maintain their expenses — the largest component of which was employee salaries — in the early months of the pandemic as revenues fell; the aim was to defer more difficult decisions of cuts in personnel or practice closure.

Primary care practices reported average total revenues of $24,000 per clinical FTE per month before March 2020 and $11,000 after March 2020 (54% decline)…. A similar pattern was found across the other specialties.

Independent practices faced larger percent reductions in revenues than non-independent practices (Appendix). Within primary care, revenues among independent practices declined from $19,000 per clinical FTE per month to $11,000 (42% decline) amidst a 18% decline in expenses, while revenues among non-independent practices decreased by 61% while expenses decreased by 35%. A similar pattern was observed among non–primary care practices).

This pattern is consistent with reports of smaller, privately owned community practices facing relatively more financial peril relative to practices that may have some hospital or health system support. In general, non-independent practices reported larger revenues and expenses at baseline, which may reflect larger clinical operations in these settings. These hospital- or health system–affiliated practices also did report larger drops in revenue than in expenses, which — combined with reductions in admissions, elective procedures, and other sources of revenue — may generate different or additional economic pressure that smaller independent practices do not face. Further context for interpreting these findings may be gleaned from qualitative responses.

Practices reported receiving various amounts of financial assistance from federal, state, and other sources (Figure 8).

Primary care practices reported receiving $10,026 per clinical FTE in federal loans, which need to be repaid, and $9,502 per clinical FTE in federal relief or grants, which do not need to be repaid. Health systems and medical and procedural specialists reported similar amounts of assistance. Behavioral health and all other practices reported less assistance. Personal or family assistance of about $500 per clinical FTE in primary care and $1,200 in medical and procedural specialties was reported. State assistance included that for community health centers. Generally, average assistance for independent practices was greater than that reported by non-independent practices .

Forecasted Responses to Covid-19

Respondents were asked to forecast what strategies — and with what likelihood — their practices would adopt in response to Covid-19 without additional financial assistance.

Among all practices, the most common responses were “cut salaries of providers or employees,” “cut services or other operating expenses,” and “Furlough or lay off employees,” which ranged from 61% to 68% of respondents; the average reported likelihood of taking these actions was 41% to 43%. These three responses were most cited among primary care practices, with 79% to 82% of respondents selecting them, reporting an average likelihood of taking these actions of slightly more than 50%. Behavioral health practices were less likely to select these responses. These three responses may represent efforts to keep the practice open without consolidation or closure.

Among all practices, generating revenue through providing more services or improved diagnostic coding was selected by 44% and 25% of respondents, respectively, with average likelihood among those selecting these options of 21% and 12%, respectively. These may also represent strategies to maintain a practice during Covid-19.

About 42% of all practices selected “close the practice” with an average likelihood among those selecting this option of 17%. By specialty, 47% of primary care practices selected closure with a reported likelihood averaging 15%. This was similar among medical and procedural specialists, and lower among behavioral health practices.

Among all practices, 23% selected consolidation with other practices and 18% consolidation with hospitals or health systems, with average likelihoods of around 7% for each option. In addition, 26% selected “sell the practice” with an average likelihood of 10%. Sales of practices may include those to private equity, provider groups, or larger health systems, which may result in consolidation similar to the prior two options. About 17% of practices selected “evolve toward membership-based practice,” sometimes referred to as a concierge or direct care model, in which patients pay a prospective fee for access to a provider or practice. This option was most cited among primary care practices (28% selected, average likelihood 8%).

About 42% of all practices selected “close the practice” with an average likelihood among those selecting this option of 17%.

Independent practices were more likely to choose practice closure, consolidation, or sale relative to non-independent practices (Appendix). Within primary care, 60% of independent practices selected “close the practice,” with an average likelihood of 21%, while 28% of non-independent practices selected this option, reporting a 6% likelihood. Similarly, 33% of independent primary care practices selected “sell the practice,” with a mean likelihood of 11%, compared to 21% of non-independent practices selecting this option, with a likelihood of 6%. An analogous pattern was found among all other types of practices.

For those considering closing their practice, we see double-digit monthly numbers (10–34) projecting closures in June, July, August, September, October, and December. Another 57 respondents considering a closure would hold off until 2021 or later (Figure 9). Based on affiliation, more independent than non-independent practices anticipate closures (Appendix). There is some variation based on specialty and the sample sizes are smaller in the subgroups, but the distribution of purported closures by specialty appears largely in line with the overall all practices data

Preferred Payment Model

Respondents were asked to report their preference, using a 10-point scale covering intensity of support or opposition, regarding four payment models, ranging from pure fee-for-service (FFS) to a prospective per-member-per-month global payment (capitation) for their practice’s services. To separate the mechanism of payment from the amount of payment, the survey asked respondents to assume current fees (prices). In recognition of key components of global payment models, but to not overly complicate the question, the question also asked the respondent to assume accurate risk-adjustment and adequate quality measurement.

Results weighted by FTE reflect the average preferences of a clinician, assuming practice-level preferences represent individual clinician preferences. In the weighted results, large practices or provider groups have proportionally larger weight and influence on the averages. Unweighted results, which render small and large practices equally weighted, reflect average preferences of a practice. Within each specialty category, we reported P values from a t test of the difference in means between each alternative payment mechanism and pure FFS (the reference group).

In general, smaller practices had a stronger preference for pure FFS, while larger practices had a stronger preference for alternative payment mechanisms, notably global payment. For example, the average primary care practice (unweighted result) reported a preference of 5.2 for global payment (P value of 0.08 in its difference relative to pure FFS), while primary care clinicians on average (weighted result) reported a preference of 5.3 for global payment (P value of 0.11 in its difference relative to pure FFS).

Behavioral health providers and practices preferred pure FFS to alternative payment mechanisms (p≤0.001). In unweighted results, medical and procedural specialty practices on average preferred pure FFS (8.8) relative to other payment mechanisms such as global payment (1.9) (P value of the difference <0.001). Upon weighting by clinical FTE, the average specialist preference for global payment was notably greater (5.3 and no longer significantly different from pure FFS). This again highlights the influence of larger practices that preferred global payment.

Overall, practices not infrequently reported a strong preference for pure fee-for-service over alternative models despite reporting economic peril caused by the decline in visits and utilization.

The average preference among independent primary care clinicians (weighted results) for pure FFS, partial FFS with a prospective payment, and global payment were similar, while non-independent primary care clinicians preferred partial FFS with a prospective payment to pure FFS (6.9 vs. 5.4, p=0.04), but did not prefer global payment to pure FFS, although this was not statistically significant (4.9 vs. 5.4, p=0.11). A similar pattern between independent and non-independent clinicians was observed for all other specialties as a whole (Appendix).

Unweighted results showed that primary care practices had generally mixed preferences among the payment option. Meanwhile, independent specialty practices more clearly preferred pure FFS to other options. Within each category of affiliation, a comparison of weighted and unweighted results again implied that larger practices preferred global payment more than smaller practices, as weighting by clinical FTE increased the preference for global payment. Overall, practices not infrequently reported a strong preference for pure fee-for-service over alternative models despite reporting economic peril caused by the decline in visits and utilization.

Provider Perspectives

Lastly, the survey offered respondents the opportunity to describe in their own words how Covid-19 had impacted their practice

The open-text comments are presented to show the common themes in these responses, grouped by patient impact, personal impact, practice impact, and perspectives that discussed telehealth. A total of 100 respondents discussed fewer patients and the consequent lower revenues, which was by far the most common theme. Fear among patients and staff, low morale and stress of adaptation, the expense of revamping practices space for the Covid-19 era, and furloughs and reduced wages were also frequently mentioned. While some respondents reported that telehealth was feasible, often among behavioral health practices, other respondents noted that telehealth is not a sufficient substitute for in-person visits, such as proceduralists.

No analysis could do justice to personal anecdotes shared by the respondents. While some were lengthy, a selection of representative responses in their own words is provided here:

“I could never have prepared for something of this magnitude. It’s affected my psyche. I feel like any day I may get infected and not survive. I will continue to see my patient. They need me.” — Pediatric practice

“I have never until now feared for my practice’s viability. I don’t think any amount of financial assistance will get us to pre-Covid-19 operation levels. The amount of renovation needed to make the space safe for that volume is not possible.” — Family Medicine practice

“The pandemic was worse than tsunami. I lack words to describe how precariously my business has suffered since the Covid-19. I have lost my whole life savings and would need at least $350,000 to stand again.” — Home Care practice

“We are working twice as hard, for half the result. It is exhausting and disheartening. Everyone, providers and staff, is burning out.” — Endocrine practice

“I continue to pay for office space that I can’t use. Now I have to pay for a telemedicine service also, in order to provide video sessions for my patients. Because I’m simultaneously homeschooling my daughter, I can’t work as many hours. My husband was furloughed so we’re desperate financially. Without assistance from the PPP loan my practice would have to close.” — Clinical Psychology practice

“The advent of Covid-19 has decimated our practice as the majority of our behavioral health consultants to the nursing homes have been restricted from entry. Telehealth services are made difficult as the average age of our population is 85 and they reside in LTC facilities. Sadly, many of our patients have died from Covid, which will likely result in the loss of customers as nursing facilities close and consolidate.” — Geriatric Psychiatry practice

“The pandemic has caused tremendous uncertainty and threatened to end primary care as we know it. We are doing our part to take the best care of our patients that we can and keep sick patients out of ERs, hospitals, and other health care settings, but we are not being compensated enough to keep our practice open. Our patients would suffer tremendously if we cannot stay open.” — Family Medicine practice

“As ophthalmologists, this has been a disaster. Telehealth is not an option. Elective surgery is not permitted. We have very high fixed costs. Our income will be in negative numbers unless we close practice or file for bankruptcy. Even if we open fully, hard to know when patients will return. I am truly torn as to what to do. I love my patients, staff, and fellow doctors but can’t afford to take on more debt to continue. We are no different than the thousands of other businesses that have and will continue to fail as this pandemic plays out.” — Ophthalmology practice

“Covid has destroyed my practice. I used to think that healthcare was the safest field to be in as it would always be needed no matter how the rest of the economy was. This belief has been shattered. My practice has evaporated. Patients have been terrified and will not seek medical care unless they are dying.… Haircutters are reopened yet neurosurgery cannot do surgeries that are not life-threatening. Many other states are already allowing elective procedures but not Massachusetts. Medicare is also not supportive as I submitted an application for the accelerated payment program but it is in limbo as they stopped paying those for no obvious reason. My emergency disaster loan still never completed processing either. I used to feel important to the community and now I am superfluous.” — Neurosurgery practice

Limitations

We note several limitations of these data. First, the survey was fielded to a convenience sample of provider practices across Massachusetts, which may not be representative of all practices in the state despite our efforts to circulate the survey broadly. Second, participation in a voluntary survey may not be random, rendering the responses susceptible to biases due to selection effects, whereby participation may be correlated with unobservable practice characteristics that may be correlated with certain responses. Third, survey responses may be influenced by other biases in reporting, such as recall bias, which could produce inaccurate or exaggerated responses.

Additionally, our data capture a cross-section of respondents over a 7-week period in late May through early July 2020. Economic conditions at the practices may change with time for many reasons. For example, the number of furloughed or laid-off workers may change as more workers exit practices or some return due to reopening or conclusion of federal programs that provided income assistance. To the extent that demand for services is higher upon reopening than during normal times due to deferred or postponed care, practices may make up some lost finances in the early days of reopening. On the other hand, a rebound in utilization may be slow, given the new precautions needed to be established in clinic and lag in resumption of full clinical activities.

Policy Implications

These data add to survey evidence from other states12,13 and to surveys of primary care practices nationwide that paint a picture of physician practices in distress.14 It offers granular details and a sense of the heterogeneity between physician specialties and among health care providers more broadly. Much uncertainty over the fate of practices remains, as many states undertake a phased reopening during which health care utilization will rebound.

At a policy level, public payers, private payers, and employers may consider collective action to support vulnerable practices on the verge of closure, sale, or consolidation.

At a policy level, public payers, private payers, and employers may consider collective action to support vulnerable practices on the verge of closure, sale, or consolidation. Preventing these outcomes would help maintain access to care, especially in disadvantaged communities or rural areas where few alternative providers exist. For policy makers and insurers who are concerned about provider consolidation and its implications for prices, helping to maintain the viability of independent practices may make further sense. Given lower tax revenues and other resource constraints exacerbated by the economic downturn, public and private payers may find it difficult to support providers in need despite current savings from deferred or canceled care.7 Recent trends in outpatient utilization point to a fairly robust rebound in visits several months into the pandemic.6 Our data suggest that independent practices, including primary care, have been more affected by the pandemic demand shock, while mental health providers were on average better able to substitute in-person visits with telehealth and maintain their revenue. To the extent that financial resources could be mobilized to support providers most in need, public and private entities could target practices of certain specialties or in certain settings, such as independent practices in the community that lack financial support from a hospital or health system.

The policy mechanism for delivering financial support to practices could vary. It includes cash advances, additional lump sum payments, increasing fees within established fee schedules, and prospective payment models. Recently, the Commonwealth of Massachusetts has established a formal mechanism for practices to request a one-time Alternative Interim Payment equaling up to 2 months’ worth of average 2019 MassHealth (Medicaid) payments for physician services, up to $500,000, as a cash advance.15,16 Commercial payers in the state have also taken steps to support provider practices during the pandemic, including a program from Blue Cross Blue Shield of Massachusetts to transition primary care payments toward a value-based or prospective model.17 Outside of Massachusetts, Blue Cross Blue Shield of North Carolina has introduced a payment model that similarly seeks to stabilize practices during the pandemic and transitions primary care payment toward a prospective arrangement.18 These and related efforts to help practices remain solvent during the pandemic may serve as an example for other states and insurers.

Summary of Key Findings

Study population: Respondents included 398 practices across specialties in Massachusetts, from small independent private practices to large provider organizations, over 50 days from May 20 through July 9, 2020.

Workforce: Cumulatively, 21% of nonclinical staff, 23% of nurses/other clinical staff, and 11% of nurse practitioners or physician assistants were reportedly furloughed or laid off due to Covid-19. Fewer physicians were out of practice.

Patient visits: In-person visits declined by 44% after March 2020, driven by fewer visits to primary care and specialty practices, with less than half of this decline substituted by telehealth visits. Telehealth substitution for in-person visits was more complete in behavioral health. Health systems experienced less of a decline in in-person visits.

Clinical activity: About 60%–80% of procedures, imaging, tests, and referrals were canceled or deferred in primary care, specialty practices, and those other than behavioral health.

Telehealth capacity: Practices on average reported reaching about two-thirds of their full capacity for telehealth, led by behavioral health, health systems, and primary care.

Revenues and expenses: Practice revenues declined more than did practice expenses after Covid-19. Independent practices reported larger percent reductions in revenues relative to expenses (42% reduction in revenues vs. 18% reduction in expenses among independent primary care practices) than did non-independent practices.

Practice responses: More than 60% of practices reported they would cut salaries of providers or employees, cut services or other operating expenses, and furlough or lay off more employees without additional financial assistance, with a roughly 40% likelihood of following through. Consolidation, selling, or closing the practice were reported by 20%–40% of practices, driven by independent practices such as primary care (60% noted closure at 21% likelihood).

Payment preferences: Going forward, smaller practices preferred pure fee-for-service to alternative payment models including global payment, while larger practices had a stronger preference for global payment. Independent behavioral health and specialist providers were more likely to clearly prefer pure fee-for-service, while primary care providers viewed global payment more favorably relative to pure fee-for-service than did other providers. Practices not infrequently reported a strong preference for pure fee-for-service over alternative models despite reporting economic peril caused by the decline in visits and utilization.

Stories: Respondents offered anecdotes of patient impact, personal impact, practice impact, and more, such as the following: “We are working twice as hard, for half the result. It is exhausting and disheartening. Everyone, providers and staff, is burning out” and “I have never until now feared for my practice’s viability. I don’t think any amount of financial assistance will get us to pre-Covid-19 operation levels. The amount of renovation needed to make the space safe for that volume is not possible.”
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