Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.
In today’s COVID-19 update, a discussion about the AMA's financial impact survey and what it reveals about the effect of COVID-19 on physician practices, including what can we expect this winter.
Learn more at the AMA COVID-19 resource center.
- Carol Kane, PhD, director, Economic & Health Policy Research, AMA
- Chris Garofalo, MD, family medicine practice owner
Unger: Hello, this is the American Medical Association's COVID-19 Update. Today we're discussing the results of an AMA survey on the financial impact of COVID-19 on physician practices, and what this may mean to practices as we head into the winter. I'm joined today by Carol Kane, the AMA's director of economic and health policy research in Chicago. and Dr. Christopher Garofalo, family medicine practice owner in North Attleboro, Massachusetts. I'm Todd Unger, AMA's chief experience officer in Chicago. Carol, can you begin by telling us why the AMA conducted the survey?
Kane: Absolutely Todd, I'd be happy to. I guess we just wanted to better understand how physicians had been affected by the COVID-19 pandemic, and how they were dealing with the many challenges they have faced since its start. We recognized that there had already been a number of physician surveys that were conducted, but we still felt that there was a significant gap in information between what we knew and what we needed to know. And, we really wanted to go out there and get more precise information on how patient access had been affected in terms of patient visits, practice revenue, on issues with PPE. And, we really needed that information to really tailor our advocacy for the right kind of policy in order to help physicians, and the practice of medicine and allow patients to retain access to care. Very important.
Unger: Go ahead.
Dr. Garofalo: I was actually one of those physicians who actually answered that survey. And, I remember seeing it and thinking how appreciative I was, especially as a private practice owner in Massachusetts here, that AMA was taking an interest in this very appropriately. And, it was very enlightening to see that this was such a great topic for you to be covering. So, thank you.
Unger: Can you speak to that a little more personally, Dr. Garofalo, in terms of the impact that COVID has been having on your practice.
Dr. Garofalo: Yeah, I think the first thing that we noticed was a decrease in visits and it really dropped off a cliff, so to speak. I mean, it went from a 100% capacity, to 25% capacity. And, some of that was simply patients who just didn't want to come in, and some of that was the state had said, "You need to curtail this."
So, we saw decreases in visits, which made it difficult for us obviously to treat our patients in the way that we needed to. We also saw decrease visits because we were sending people more over to urgent care to get tested for things like COVID, which we initially had chosen not to do.
Unger: Carol, can you talk a little bit about the survey, we're hearing from one person on the other end of that survey. How many other physicians were surveyed? And, do you think that you were able to kind of capture the experience of the physicians at large with this?
Kane: Yeah. Well, first it's so gratifying to hear from one of our survey members, and how important you thought it was. In addition to you, we also surveyed 3,499 other physicians, for a total 3,500. And when we started the survey, we really wanted to make sure we had really accurate defensible data, with which to support our advocacy with. So, we worked with a trusted partner, a panel company that we had worked with many times before, to really make sure that those 3,500 physicians mirrored the physician population very closely in terms of age, and gender, and specialty, and the parts of the country in which they worked. And, we got very close on all of those basis points. So, we do feel very confident about our survey results, and that they reflect what physicians were going through, and what their practices were going through over the summer from the period of mid-July to the end of August.
Physicians took about 40 questions were in the survey. And, there were a couple of qualifications that physicians had to meet to get into the survey. Most importantly, they had to be providing at least 20 hours of patient care back in February prior to the pandemic to make sure that we were targeting actively practicing physicians. And, they had to be in one of the 50 states or D.C. and have completed their residency program.
Unger: All right. Well, let's talk about the findings. What are the key learnings coming out of the survey?
Kane: Well, there are a lot of findings that are both interesting and alarming. I guess the one that jumps out as one of the top-level findings is that, even more than four months after the survey, more than 80% of physicians said that their practice revenue was still down from February. And, I'm sure that resonates with Dr. Garofalo. And, the average decrease in practice revenue, again from February to the summertime was over 30%. I mean, that is huge. And, when you combine that with the PPE challenges that physicians have been facing both in terms of cost and access to them, it just really illustrates the financial strain that practices have been under, and is continuing.
Unger: So, it's really happening on both ends. So, you're talking about revenue decrease and higher expenses at the same time for PPE and the like.
Unger: Go ahead.
Dr. Garofalo: I would echo that. I think we have seen that on our side as well. We saw significant decreases in revenue, again, especially at the start. Once we were able to get telemedicine, which I know we'll touch on in a bit, up and running that really improved. And we actually, at this point for the past month, we're probably about 80 to 90% of what we were. So, we're right around where everybody else is. We did see an increase in our PPE and it was difficult to get, and the stuff that we could get was more expensive. That was one reason that we decided not to do testing in our office, which was really difficult for us to make that decision. But it was just really hard to have that a level of PPE in our office, and to be able to afford that at the time.
Unger: Carol, I'd like to talk a little bit more in depth about PPE. It continues to be a problem. Can you give us an idea of just how much more spending physicians were seeing, and what their situation is right now?
Kane: Absolutely Todd. We found that over the summer, at least a quarter of physicians said that their PPE spending was at least 75% higher, than it had been in February. And, the average increase in PPE spending was 57%, so very, very large increases. And in addition to the cost, even four months after the start of the pandemic, physicians were still telling us that they were having difficulty getting PPE. Over a third of physicians said that getting adequate PPE for their practices was "very, or extremely difficult." And, this seemed to be particularly acute for practices that were smaller, or that were physician-owned, just because they don't have the purchasing power that these larger practices, or practices that are part of health systems can rely on.
Unger: Does that continue to resonate with you, Dr. Garofalo?
Dr. Garofalo: It does. We have eight physicians, an NP and a PA in our practice. so, we're a moderate size practice. But yes, it is very difficult to get that. We actually dipped into our state, fortunately Massachusetts had a program to get some PPE when we could not get it from our usual suppliers. So, that was actually very helpful. And I think, the state, I know the AMA, AAFP, a variety of groups have all stepped in to help. One of the issues with PPE I think, is sort of how you define what is appropriate to PPE. Prior to this pandemic, nobody would have thought of using an N95 mask more than once. It's not meant for that.
Dr. Garofalo: I think that a lot of us have just gotten used to a, sort of a new normal where nurses and physicians will use a PPE, an N95 mask for a day, a week. So even if places are getting enough PPE, I'm not necessarily convinced that's necessarily as safe as what it would have been pre-pandemic.
Unger: Dr. Garofalo, you mentioned before about telehealth and I'm curious to find out about the use of telehealth and expansion in own practice. How has that been affecting you?
Dr. Garofalo: It has been a lifesaver, a practice saver. We had actually started looking into telehealth prior to the pandemic. My practice was actually one of the practices in Massachusetts that was part of the telehealth initiative with the AMA Texas, and Florida Medical Association. So, we had actually started looking into that, and just as we were starting to look at vendors, bam, along comes COVID. And so, we really had to step it up. And, it was nice in my practice because I had been looking at vendors already. So, we are able to choose a vendor fairly quickly, get up and running. I trialed it for about a week in my practice. I went back to the rest of the group, and I said, "We have got to do this." And I said, "Here's how you do it." And, we quickly got everybody on board. So, patients were pretty enamored with it. They liked it.
They also realized that even if this wasn't the best way to do a visit, that we needed to do it at that time.
Unger: Did you find it in terms of offsetting losses from your in-office visits, how did that net out in the end?
Dr. Garofalo: That netted out very well. One of the things in Massachusetts, and I think in some other parts of the country, our governor actually said that, "Insurance companies were mandated to pay at parity." So in-office visit that would have happened in the office would now pay the same as doing it on telehealth. And, that was actually really important. And, I know that we are extremely fortunate in Massachusetts. I know there's a lot of practices, I've talked to colleagues around the country for whom that was not done in their state, and I know they are probably having a lot more trouble than we are.
So, I think that's one thing that's really important that the AMA can advocate for, as well as at your state-society. We brought our revenue, it took a couple of months, but we got ourselves up 50%, 75%, and now we're like at that 80, 85% mark.
Unger: Well, Carol is the survey... Did the result's kind of bare out with Dr. Garofalo is saying? What are you seeing from that on telehealth?
Kane: Well, I think that Dr. Garofalo's practice, because of its location in Massachusetts is really on the favorable end. I mean, what you were saying that not all practices have been as lucky to have that parity and payment. But even on top of that, we found that even when you account for the increase in telehealth visits, and I can get into some of the details, that for the average physician, the increase in telehealth visits did not make up for the loss in, in-person visits. And, just to give you some examples of the change over this period, which was market; we went from only 20% of physicians using telehealth on a weekly basis in February to 77% using it on a weekly basis, at what we call the height of telehealth, which for most physicians was in April, to 68% over the summer.
So, it's still much higher than it had been in February, very much so. And, the average number of telehealth visits went from six per week in February to 29 per week, over the summer to 16, I'm sorry, to 29 per week in April, the height of use, to around 16 over the summer. So, we're still up three times what we were in February, but that just wasn't enough to make up for the in-person loss. And in fact over the summer, around 70% of physicians were telling us that their total patient visits, including in-person and telehealth were still below what they have been, and a little bit different than your experience, I would say. And, that for the average physician who is providing about a hundred visits per week in February, it was down to just above 70 per week over the summer, including those types of visits.
Unger: So, we did see telehealth health practices seeing patients, but we haven't seen it increase patient volume to pre-pandemic levels.
Unger: All right. Well, what needs to be done to help practices through what continues to be a difficult time, and one that might just get worse as we head into the winter? Dr. Garofalo, do you want to start?
Dr. Garofalo: I think that getting telehealth visits to be paid at parity is one of the most important things. And, I realize that not everybody may end up utilizing telehealth in that way, or up to 100% of that level. But I think making sure that we have the ability to do that. I think telling our patients that this is a safe way to do visits if we need too, is an incentive for the patient to do it, and also for the physician to do it. It keeps our waiting rooms less full. It means patients don't have to go out quite as much.
So, I think payment parity is one of the bigger ones. I also think that making sure that physicians have access to PPE. Again, one of the things that we found is if we can't see patients who have fevers, who have chills, who have symptoms of COVID in our office, we end up sending them to urgent care. There's great urgent cares around us, we're not worried about that, but that definitely takes patient visits and revenue away from our practice, and again has an effect on that. So, making sure that we have enough PPE, so that we can offer that service if we choose to do so.
Unger: Carol, can you tell us what do you think needs to be done to help physician practices right now?
Kane: Sure. Well, I think they definitely need help getting adequate PPE for their practices for starters. And, the AMA has been involved in that through partnering with an organization called Project N95, through which our physician members can gain access to the PPE that they need. And, making sure that PPE is of quality and certified, and that partnership will continue through the fall, as we have seen COVID-19 cases start to spike again. Our advocacy group has also worked to secure a number of types of federal financial assistance for physician practices. And, examples of that include the CARES Act, the Small Business Association, Paycheck Protection Program, the Medicare Accelerated and Advanced Payment Program. And, when we actually talked to physicians during the survey about those programs, for physicians who had applied and then received that federal aid, they did say that it was "very, or extremely useful for their practice."
But of course, as that survey illustrates, we're not done, it's simply not enough. And, the AMA is continuing in this vein to try to get additional funding for the Paycheck Protection Program, for the HHS Public Health Emergency Fund as well. And, to try to extend relief in the Medicare sequester, and Medicare payment cuts that have been planned, which would be kind of the worst combination of things.
We also working with our specialty societies, and the RVS Update Committee, we were able to develop a code which was then approved by the CPT Editorial Panel. And, physicians will be able to use that code to try to get a payment for the additional supply costs through the acquisition and PPE, and other things that they're all going through, in order to keep their staff and their patients safe in the practice.
Unger: Just a follow up on one thing you said—the collaboration with Project N95 that the AMA did earlier this year will be repeated. Look for information for that coming soon, so that you can reserve more high-quality PPE. I want to thank Dr. Garofalo, and Carol Kane for being here today, sharing their perspectives, and for all of the hard work to make sure that physicians have what they need as we enter this summer or this winter period. That's it for today's COVID-19 update. We'll be back with another segment soon. For resources on COVID 19 visit ama-assn.org/COVID-19. Thanks for joining us, and please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.