When Gary LeRoy, president of the American Academy of Family Physicians, thinks about what the next six months could hold for primary care practices, he sees chaos.

"I don't see any light at the end of this tunnel except an oncoming locomotive," LeRoy told Healthcare Dive.

Primary care has been uniquely vulnerable to the deleterious economic effects of the COVID-19 pandemic, since most of its revenue comes from in-person visits that plummeted in March amid widespread stay-at-home orders and fears about in-office virus transmission.

The pain has been particularly acute for doctors not backed financially by health systems, private equity or other entities. Roughly half of U.S. doctors own their own practices, and already operate on razor-thin margins after years of reimbursement cuts, unfavorable payment structures, expensive EHR and tech implementations and provider consolidation.

Add a pandemic to the mix, and it's a recipe for disaster. 

Though volumes have bounced back from the nadir earlier this year as states reopen and patients' deferred needs come to a head, visits and revenue have yet to fully return to pre-COVID levels. And the pandemic is intensifying, with infections surging past the previous peak in April, passing the 4 million mark late July.

Without a sustained public health and economic recovery, providers worry volume will drop again, leaving them right back where they started.

Donald Collins, a solo practitioner in internal medicine in Orlando, saw 20% of his regular visit volumes in March. By mid-June, most patients had returned. Collins was operating at about 80% of normal volume for that time of year.

But visits have started to slide again. Now, Collins is seeing about 70% of pre-COVID volume, and is concerned this initial dip could signal the beginning of another long drought in visits as COVID-19 cases skyrocket in Florida.

"I've had more calls and more patients diagnosed in the past week than in the previous three months," Collins, who's served a majority retiree and Medicare population in Orlando for two decades, told Healthcare Dive. "I don't see any end in sight."

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I don't see any end in sight.

Dr. Donald Collins

Internal medicine soloist in Orlando, Fla.

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In Alabama, Gov. Kay Ivey, a Republican, lifted most lockdown procedures in May. About two weeks later, patients started trickling back into small rural practice Professional Medical Associates in the southeastern town of Enterprise.

In-person visits are now down about 25% from regular volumes — a significant improvement from the 75% loss late March.

But, like Florida, Alabama has seen a steady rise in cases without new restrictions on businesses or public activities. Professional Medical Associates has settled into an uncomfortable holding pattern: There isn't an immediate risk of layoffs or practice closure, but it's lurking just around the corner.

"We're taking it day by day. We're really watching the bottom line more closely than we've ever watched it before," Beverly Jordan, a physician at the 55-employee practice, told Healthcare Dive.

After months of prolonged stress, about a third of primary care practices say they're spent from the pandemic and don't feel ready to face the next six months, according to a survey by the Larry A. Green Center and the Primary Care Collaborative conducted in late June.

More than 40% of practices feel unready for another wave, with less than half reporting they have enough cash on hand to stay open. 

"Just because some people think the pandemic is over, that doesn't mean the financial woes its created just magically disappear," LeRoy, who is also an acting family physician in Dayton, Ohio, said. "You have to dig yourself out of a financial hole — it's not a hole, it's a crater — created by the pandemic."

By one estimate, America's primary care practices could lose over $15 billion this year.

Getting patients back

As the ​pandemic spread, primary care practices adjusted business operations to stay open, but many fearful patients stayed away. Now, physicians fear the public health repercussions of long-delayed care, especially for the 45% of Americans with at least one chronic condition.

"The most common comment I get from diabetics is, 'I can’t come and go like I want to, I can't exercise like I want to, I can't eat like I want to, so I’ve put on 15 pounds and my blood sugar's out of control'," Jordan said.

About half of the public report delaying medical care amid the pandemic, according to a Kaiser Family Foundation poll conducted in May. Eleven percent report the condition deteriorated as a result. Experts caution outcomes will only worsen the longer treatments are delayed.

"Just wait until you see the undetected colon cancers, breast cancers," Jeff Gold, a primary care physician at Gold Direct Care PC in Marblehead, Massachusetts, told Healthcare Dive. "It's going to be a disaster," he said, not to mention the damaging effects on the nation's mental health from sustained loneliness and isolation.

The situation is unlikely to improve until the economy does, with the U.S. unemployment rate now 11.1%, down from April's high of 14.7%. Job losses have pushed significant numbers of Americans — 27 million, per one estimate — to lose health insurance.

People without health insurance generally delay non-essential doctors visits, even though primary care practices, which account for 1 billion visits annually, got creative to stay open.

In one example, Family Medicine of Malta in Saratoga County, New York, pitched a tent behind its building to see patients with COVID-19 symptoms, physician Marc Price told Healthcare Dive.

In March, the tent had heaters to make patients more comfortable. Now, it has air conditioners.

Practices fending for themselves to get PPE

More than 9,200 healthcare professionals were infected with COVID-19 between Feb. 12 and April 9, according to the Centers for Disease Control and Prevention, partially due to high risk of exposure and a lack of personal protective equipment (PPE). Meanwhile, the Trump administration has largely left it to states and individual providers to fend for themselves in securing protective gear amid pervasive national shortages.

Shortages of test supplies and PPE eased somewhat in March and April, but still persist. While it's easier now to procure gowns, N95 masks and face shields, they can be unbearably expensive, practices say.

"PPE is sometimes twice or four times the normal costs," Jordan said. "We need more than we've ever had to have before. And it's a more expensive part of the budget than it's ever been before, while financially we're still down. We're still recovering from the big, huge hit."

Another factor dragging on independent practices is a supply chain that favors large hospitals and health systems with buying power. Doctors are having to hunt down a potpourri of supplies from multiple vendors, or explore more nontraditional avenues as a result.

Two practices Healthcare Dive spoke to for this story said they were donated N95 masks from harbor freight or construction companies in their communities. Another bought plastic ponchos off Amazon and let them sit in a bag for three days in between uses so they could decontaminate. One eventually bought gowns from China.

"At one point, we were making our own PPE out of trash bags and plastic transparent shields," Michael Ciampi, a physician at Ciampi Family Practice in South Portland, Maine, told Healthcare Dive.

Fewer than 4 in ten clinicians feel safe and confident with their access to PPE, according to the Larry A. Green survey of primary care practices published Friday.

Telehealth is a lifeline — if it's paid for

The Trump administration temporarily relaxed rules around telehealth — most notably allowing traditional Medicare to reimburse for it — spurring unprecedented adoption and incentivizing doctors to offer the service. Primary care practices say telehealth was a godsend in bringing in a portion of lost revenue, and losing the flexibilities would be devastating.

A study published in Health Affairs in late June said practice revenue loss in 2020 could more than double if telemedicine payment policies are not sustained.

Before the pandemic, many commercial payers reimbursed for virtual care significantly less than in-person visits, and some didn't cover it at all. Most major insurers, including UnitedHealthcare, Anthem and CVS-owned Aetna, waived co-pays and other cost sharing for virtual care to drive usage early on in the pandemic, and are extending the changes on a month-to-month basis.

That leaves physicians uncertain whether a claim for virtual care will be paid.

Family Medicine of Malta didn't implement telehealth before the pandemic because reimbursement levels weren't high enough, Price said. Now it pays its EHR, MEDENT, a flat $30 per month per provider fee. Its payers reimburse between 60% and 100% of an in-person visit for telehealth on average, and since the practice conducted six to eight telehealth visits a day in March and April, the service quickly became profitable.

Now, Price conducts between zero and three virtual visits a day.

But "I'm not going to do it if it's not reimbursed," Price said. "From a financial point of view, that's where I become a business owner — if I'm not paid for it, I'm not going to do it."

Providers have also taken advantage of the federal government not enforcing HIPAA regulations, allowing them to use common consumer platforms like Skype and Facetime to connect with patients. The Trump administration has also allowed Medicare to reimburse for visits conducted over the phone retroactive to March 20, when previously visits needed a video element to receive reimbursement.

That's been a particular help in rural and minority communities, where people often don't have access to a computer or adequate broadband for a high-quality video visit.

"The fact that now we can get paid for what's essentially an in-office visit minus the exam — that's a big deal for us," Richard Kirkpatrick of Kirkpatrick Family Care in Longview, Washington, told Healthcare Dive.

Some 70% of the patient population in the midsize manufacturing and lumber mill town is on Medicare. It was common for Kirkpatrick to process 80 to 90 phone calls a day before the pandemic from patients checking in on their conditions.

"We just dealt with them and never got paid, which was sort of unfair because they took the place of office visits," Kirkpatrick said. "Now, if Medicare stops paying for audio-only visits — how do you spell nightmare?"

Despite signals from Congress and HHS that they're open to permanently codifying some of the regulatory changes, doctor's aren't optimistic Medicare, or private insurers, will continue paying at parity, allow audio-only reimbursement or use non-HIPAA-compliant platforms. If the relaxations are yanked, providers will be forced to choose whether they want to invest in a telehealth vendor's system, which can cost tens of thousands of dollars.

Many say they won't. Despite the uptick in use and strong consumer satisfaction, most physicians predict fewer than 10% of visits next year will be virtual, according to a July report from Sage Growth Partners.

And some primary care doctors are still leery of telehealth, viewing it as a poor replacement for physical interaction.

"As somebody who's used to examining patients, to looking at patients, picking up on nonverbal cues — you're very limited. It's almost comical sometimes," Collins said. "But I will continue to use it when patients request."​

A primary care Marshall Plan? 

Federal aid has helped to keep providers operational. But if the rising tide of COVID-19 cases in the U.S. devastates practice volumes once again, more funds will be needed, practices say.

Congress allocated $175 billion for providers earlier this year, along with setting up the Paycheck Protection Program, which provides loans to small businesses to help them stay afloat that can be forgiven if companies meet certain stipulations like continuing to pay staff. More than 22,300 doctor's offices, including mental health specialists, received PPP loans of $150,000 or above.

But there's rancor among small, independent offices about where the money went. Family practices got only $15 million of the $100 billion in Medicare loans, while acute care and critical access hospitals received more than 80%. And practices that took out loans early on in the program are facing a looming repayment date: as soon as Monday, which could exacerbate their financial burden as the pandemic worsens.

Behemoth for-profit operators and nonprofit systems with huge cash reserves have gotten the lion's share of the $175 billion in bailout funds, too. According to a Healthcare Dive analysis from late June, the country's biggest nonprofits had received $7.1 billion in grants from the Trump administration.

​"PPP was the big help. I don't think the stimulus package was well managed," Marni Carey, executive director of trade group Association of Independent Doctors, told Healthcare Dive. "The hospitals — don't get me started on the hospitals getting the money. That's ridiculous."

The American Academy of Family Physicians and its allies have proposed a "primary care Marshall Plan" to rebuild the sector, building on a value-based CMS model that pays primary care practices based on value over five years starting in 2021. The groups recommend insurers pay practices a prospective fee to care for patients for the duration of the pandemic.

Some are calling for more targeted aid. Farzad Mostashari, CEO of Aledade, a company that helps practices join accountable care organizations, has proposed giving primary care practices $15 billion in grants, noting that's roughly what CMS spends on primary care in four months. 

Congress is considering a fifth round of rescue funding, though details are sparse as legislators began discussions July 20.

It's unlikely, based on what's been done so far, primary care practices would receive direct aid.

Despite all the challenges, some suggest the pandemic might have a positive impact in bringing attention to years of consolidation, closures and neglect in the sector. Visits to U.S. primary care physicians had dropped by a fourth between 2008 and 2016, according to a study of commercially insured patients.

For better or for worse, the pandemic has highlighted problems with the nation's primary care ecosystem the public and private sector should now work to solve, doctors say.

"It's shining this burning spotlight on how unviable our U.S. healthcare system is. It was one crisis from falling all apart. And now it's been torn apart," LeRoy said. "So: How do we put this thing back together again?"

Correction: A previous version of this article misstated how much Dr. Price is reimbursed for telehealth.