Nearly 60% of 3,513 respondents in The Physician Foundation biennial survey believe COVID-19 will reduce the number of independent physician practices in their communities.
More than 8-in-10 physicians (86%) believe the COVID-19 pandemic won't be under control until at least next year, and 72% believe the accompanying delays in routine care will adversely affect patient health.
That's according to The Physicians Foundation biennial Survey of America's Physicians, which also found that 49% of physicians don’t believe the coronavirus will be controlled until after June 2021.
"The data reveals a near-consensus among America's physicians about COVID-19's immediate and lasting impact on our health care system," said The Physicians Foundation President Gary Price, MD.
"We are living through a historical shift in the way we practice and how we deliver care to patients. Our healthcare landscape is constantly changing right now, and we expect it will be radically different for both physicians and our patients long after the pandemic passes," Price said.
The online survey was conducted for The Physicians Foundation by physician recruiters Merritt Hawkins. The poll, taken from July 15 to July 26, was received by more than 500,000 physicians nationwide, and 3,513 physicians responded, giving the survey a margin of error of +/- 1.86%.
In addition to routine care delays, 75% of physicians say patients will feel "indirect effects" of the pandemic through job losses that may disrupt health insurance coverage.
In addition, 67% of physicians said patients' reluctance to seek care during the pandemic poses a threat to their health, and 65% said the closure of physician offices also will adversely affect patients.
Nearly 60% of physicians said the national reopening, even as the pandemic rages in many parts of the nation, poses a bigger risk to patients than continuing social distancing policies.
The survey also found that:
59% believe COVID-19 will reduce the number of independent physician practices in their communities.
8% have already closed their practices as a result of COVID-19, a number totaling approximately 16,000 practices nationally.
43% have reduced staff due to COVID-19.
96% will not leave medicine because of pandemic-related health risks.
75% said they received sufficient federal funding to remain open from the Paycheck Protection Program.
50% believe hospitals will have a stronger influence over care organization and delivery because of the pandemic.
37% saw volume decreases of 25% or less, and 41% saw volume decreases of 26% or more.
:
12% – representing about 100,000 physicians nationally – have switched to a primarily telemedicine practice as a result of COVID-19, up 1,577% from only 6,000 in 2018.
52% plan to increase the use of telemedicine in their practice in the next 12 months.
4% said they plan to switch to a primarily telemedicine practice.
"This survey emphasizes how the pre-existing issues within our healthcare system, such as physician shortages and lack of patient access to health care, will continue to worsen unless we empower and support physicians as they continue to work tirelessly through a global pandemic ," said Robert Seligson, CEO of The Physicians Foundation.
Many of the more than 4,000 people surveyed by the Commonwealth Fund said their care costs are a significant and in some cases insurmountable burden.
Nearly half (43%) of working-age adults had spotty health insurance coverage in the first half of 2020, and many more faced dauntingly high deductibles and out-of-pocket costs, and hard choices on paying the rent, buying food, or seeking healthcare, according to a new survey released today by the Commonwealth Fund.
"The survey shows a persistent vulnerability among U.S. working-age adults in their ability to afford coverage and healthcare," said study lead author Sara R. Collins, Commonwealth Fund Vice President for Healthcare Coverage, Access, and Tracking.
"That vulnerability could worsen if the COVID-19 pandemic and related economic downturn continue," Collins said. "Coverage inadequacy is compromising people's ability to get the care they need and leaving many with medical debt at a moment of widespread health and financial insecurity, and an uncertain future."
The Biennial Health Insurance Survey, which the Commonwealth Fund has conducted since 2001, randomly interviewed 4,272 adults via cellular and landline telephone in Spanish and English from January through June.
Among the findings:
People of color, small business workers, people with low incomes, and young adults had the highest uninsured rates. More than one-third of Latino adults, small business workers, and adults with low incomes were either uninsured or spent some time uninsured in the past year.
The growth in the underinsured since 2010 has been driven by employer health plans with inadequate coverage. One-quarter of adults with employer plans were underinsured.
One-quarter of working-age adults with adequate coverage for the full year reported medical bill problems or debt in the past year.
Half of adults who spent any time uninsured or underinsured reported problems paying medical bills or that they were paying off medical debt over time.
African Americans were significantly more likely than whites to report problems with medical bills (45% vs. 35%).
Among adults who reported any medical bill or debt problem 37% said they had used up all their savings to pay their bills, 40% had received a lower credit rating as a result of their medical debt, and 26% were unable to pay for basic necessities such as food, heat, or their rent.
The survey also noted that Americans are shouldering a heavying increase in premiums, out-of-pocket costs and copays over the past decade that is leaving them financially stressed and vulnerable to lapses in coverage.
In 2010, for example, 7% of people in either employer or individual private plans had deductibles that amounted to 5% or more of income, an indicator of underinsurance. By 2016, the share had more than doubled to 15%.
In addition, between 2010 and 2020, the share of privately insured adults with deductibles of $1,000 or more doubled — from 22% to 46%, the survey found.
"Even before the pandemic, people were struggling with inadequate health coverage and mounting medical debt," said Commonwealth Fund President David Blumenthal, MD. "It has never been more important to ensure that all U.S. residents have affordable, comprehensive coverage to survive this pandemic and beyond."
To alleviate the problem, the Commonwealth Fund is calling for expanding Medicaid in the 12 states that have yet to do so, enhancing Affordable Care Act marketplace subsidies, increasing outreach and enrollment efforts, and banning non-ACA compliant short-term policies that expose people to catastrophic healthcare costs.
Also Monday, CMS announced that it would resume inspections of provider facilities.
Hospitals treating Medicare beneficiaries admitted with COVID-19 will see a 20% payment increase on September 1 that acknowledges the additional cost of treating the virus, the Centers for Medicare & Medicaid Services announced Monday.
"To safeguard taxpayer dollars spent on this increased payment, CMS will now require that a positive COVID-19 laboratory test result is documented in the patient's medical record," CMS said.
Only the results of viral testing (i.e., molecular or antigen) that are consistent with Centers for Disease Control and Prevention guidelines can be used.
The test must be taken within two weeks of admission, either at the hospital or before admission. It can be manually entered into the patient's medical record.
"For example, a copy of a positive COVID-19 test result that was obtained a week before the admission from a local government-run testing center can be added to the patient’s medical record," CMS said.
"In the rare circumstance where a viral test was performed more than 14 days prior to the hospital admission, CMS will consider whether there are complex medical factors in addition to that test result for purposes of this documentation requirement."
CMS said it will conduct post-payment medical audits to confirm the presence of a positive COVID-19 (viral) laboratory test result.
"If the positive test result is not found in the medical record, the increased payment will be recouped by CMS as an overpayment," CMS said.
CMS Resumes Provider Inspections
Also Monday, CMS announced that it will resume routine inspections of all Medicare and Medicaid certified providers and suppliers.
The inspections had been suspended this spring in response to the coronavirus pandemic, CMS said, so that it could "prioritize infection control and immediate jeopardy situations and to give healthcare providers and suppliers time needed to respond to the spread of COVID-19."
"CMS has worked closely with states to complete focused infection control surveys of virtually all nursing homes in the country in just a few months," CMS Administrator Seema Verma said.
"These surveys fortified healthcare facilities around the country to prepare for and implement actions to prevent transmission of the virus and provided indispensable insight into the situation on the ground.”
In the guidance released Monday, CMS directed the resumption of onsite revisit surveys, non-immediate jeopardy complaint surveys and annual recertification surveys as soon as resources are available.
In addition, CMS is providing guidance on resolving enforcement cases that were previously on hold because of survey prioritization changes.
The ACP warns that delivery delays at the USPS could harm millions of people who rely on the mail for prescription medications.
The ongoing disarray at the U.S. Postal Service have raised concerns among the nation's primary care doctors.
The American College of Physicians on Monday warned that "recent reports of changes" at USPS could worsen delivery delays with the potential to harm millions of people who rely on the mail for prescription medications.
"Any prescription medication can only be as effective as a patient’s ability to access it," ACP President Jacqueline W. Fincher, MD, said in a media release.
"A delay in receiving a necessary prescription could be life-threatening," Fincher said. "My patients who rely on their insulin, or their inhalers, or any other type of medication can’t wait weeks to see whether or not their prescription will be delivered."
"The new organization will align functions based on core business operations and will provide more clarity and focus on what the Postal Service does best; collect, process, move and deliver mail and packages," USPS said.
However, the initiative has raised concerns among Democrats that the Trump administration is attempting to "kneecap" the post office ahead of the November elections, which will rely heavily upon mail-in ballots.
House Democrats have earmarked $25 billion for the USPS in their latest coronavirus relief package, but Senate Republicans and President Donald Trump oppose the funding.
In an interview with Fox Business News last week, President Trump admitted that he was opposed to additional funding for the USPS as a means of limiting mail-in voting.
The president's comments prompted House Speaker Nancy Pelosi (D-CA) to call the House back into session from summer recess to address the issue.
ACP President Fincher said she's hearing reports that the Department of Veterans Affairs, which fills 80% of its prescriptions by mail, has already experienced "significant delays" in mail-order prescription drugs to veterans.
"Mail-order prescriptions can be particularly important in rural areas where the local pharmacy may be a long distance away," Fincher said. "We also know that increasingly insurance plans are moving patients to mail-order services."
The problem is exacerbated of late, Fincher said, by the COVID-19 pandemic, which has pushed more Americans to transition to mail delivery of their prescription drugs.
"This may be most important for those with chronic conditions, who are more likely to need a prescription and are also more at risk from a COVID-19 infection," she said.
"Children's hospitals have pitched in to our all-of-America COVID-19 response by providing backup capacity, extra supplies of PPE, and other support," HHS Secretary Alex Azar said.
"Throughout the distribution of the Provider Relief Fund, we have sent these funds as quickly as we can to those who have been hardest hit by the virus, and this distribution recognizes the contributions of children's hospitals helping to meet the challenges of this pandemic," he said.
The money comes from the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act, which allocated $175 billion in relief funds to hospitals and other providers.
Rick Pollack, president and CEO of the American Hospital Association, thanked HHS for the latest round of funding, but said more money will be needed.
"We continue to urge the Administration to distribute additional relief to all hospitals and health systems, as well as those in so-called 'hot spots,'" he said.
While most children's hospitals have been spared the pandemic-related surges, they've also seen their patient volumes and revenues flatten as they've suspended non-urgent surgeries offered back-up capacity for other hospitals and borne the additional costs of acquiring personal protective equipment.
HHS has already allocated about $13 billion in CARES Act and Paycheck Protection money so far this year for pediatric and adulty safety net hospitals.
Azar said the additional $1.4 billion will target free-standing children's hospitals that are not affiliated with hospital systems.
To qualify for the aid, the hospitals must either be an exempt hospital under the Centers for Medicare and Medicaid Services inpatient prospective payment system or be a Health Resources and Services Administration-defined Children's Hospital Graduate Medical Education facility.
The deal was finalized over the strong objections of healthcare unions.
Prime Healthcare this week finalized its $350 million acquisition of the bankrupt St. Francis Medical Center in Southeast Los Angeles County.
In a media release, for-profit, Ontario, California-based Prime said the acquisition signals "a new era of service excellence and award-winning healthcare for an essential medical facility in Los Angeles County."
"Prime is prepared to lead St. Francis into a bright future and we are grateful for the opportunity along with the support we have received from the community," said Sunny Bhatia, MD, CEO of Region I of Prime Healthcare.
Prime bought the 384-bed nonprofit hospital in Lynwood, California from Verity Health System of California, Inc. over the howls of protests from the Service Employees International Union-United Healthcare Workers West, which had accused Prime of a "history of bilking taxpayers and cutting services."
"Prime's shocking history of deceit, fraud and repeated elimination of health services that patients depend on is simply out of step with owning a hospital like St. Francis, which is a lifeline to the people of Lynwood and surrounding communities," said Mauricio Medina, a certified nursing assistant at St. Francis and a member of SEIU-UHW.
The union had petitioned California Attorney General Xavier Becerra to scotch the deal, which transitions the hospital to for-profit.
Instead, Becerra gave the deal his "conditional approval."
“The conditions we have attached to the proposed sale of St. Francis focus on maintaining or improving care and services at the hospital – from treatment for COVID-19 to cancer and emergency care," Becerra said. "No change in ownership, no bankruptcy filing can be allowed to diminish that priority."
Prime was the highest bidder for the hospital in the U.S. Bankruptcy Court for the Central District of California, and the acquisition was finalized after a contentious four-month review and public hearing process.
Under the terms of the acquisition, Prime committed more than $350 million to the hospital, which includes a $200 million base price and $15 million in payroll and benefits upgrades for staff.
Rich Adcock, CEO of Verity Health, said Prime was the "only bidder with the fortitude to support the hospital in its time of greatest need, despite the burden of the pandemic, the uncertain future and economic impact on hospitals."
Researchers say their findings "suggest that the mortality associated with COVID-19 during the early phase of the New York City outbreak was comparable to the peak mortality observed during the 1918 H1N1 influenza pandemic."
How does the lethality of COVID-19 compare with that of the Influenza pandemic of 1918?
In a study this week in JAMA Network, researchers at Harvard Medical School tried to find out by comparing estimated excess deaths in New York City during the first two months of the COVID-19 pandemic this spring and the peak of the Influenza 1918 pandemic.
The 1918 Influenza killed about 50 million people across the world, including 675,000 people in the United States.
The Harvard study found that, during the peak of the 1918 H1N1 influenza outbreak in New York City, between October and November 1918, a total of 31, 589 all-cause deaths occurred among 5.5 million residents, yielding an incident rate of 287.17 deaths per 100,000 population.
The incident rate ratio for all-cause mortality during the H1N1 pandemic when compared with similar two-month spans from 1914 to 1917 was 2.80.
From March through May 2020 the COVID-19 outbreak in New York City saw 33,465 all-cause deaths occurred among 8.3 million residents, yielding an incident rate of 202.08 deaths per 100 000 population.
The incident rate ratio for all-cause mortality during the study period of 2020 compared with corresponding periods from 2017 through 2019 was 4.15.
In other words, the absolute increase in deaths over baseline during the peak of 1918 H1N1 influenza pandemic was higher than that observed during the first two months of the COVID-19 outbreak in New York City.
Nonetheless, the researchers said their findings "suggest that the mortality associated with COVID-19 during the early phase of the New York City outbreak was comparable to the peak mortality observed during the 1918 H1N1 influenza pandemic."
Notably, the baseline mortality rates from 2017 to 2019 were less than half that observed from 1914 to 1917, thanks to improvements in hygiene and advancements in medicine, public health, and safety.
As a result, the relative increase during early COVID-19 period was substantially greater than during the peak of the 1918 H1N1 influenza pandemic.
The study also could not directly compare the "native virulence" of the 1918 H1N1 influenza strain and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
And, it's not clear how many deaths from SARS-CoV-2 infection have been prevented because of modern interventions not widely available a century ago, including standard resuscitation, supplemental oxygen, mechanical ventilation, kidney replacement therapy, and extracorporeal membrane oxygenation.
"If insufficiently treated, SARS-CoV-2 infection may have comparable or greater mortality than 1918 H1N1 influenza virus infection," the researchers said.
The proposed reforms are now under review by the Office of Management and Budget.
Sweeping revisions of the Stark and Anti-Kickback statutes are expected to be unveiled soon as the federal government grapples with the shifting landscape of value-based care and industry consolidation.
Kathleen McDermott, a former U.S. assistant attorney, and now a partner at Washington, D.C.-based Morgan Lewis, offered some guidance on what to expect in this email exchange with HealthLeaders.
HL: When will this final rule be made public?
McDermott: Health and Human Services has suggested late August or early September 2020, though that projection may change. The regulations currently are under review by the Office of Management and Budget.
HL: Why are these revisions to Stark and Anti-Kickback needed?
McDermott: These statutes were enacted decades ago and were drafted with the older healthcare reimbursement systems in mind. The goal of these recent changes is to modernize the regulations implementing these laws to account for present risks and allow for innovation in value-based arrangements that involve clinical care coordination. Removing unnecessary regulatory barriers to clinical care coordination (in particular, by the strict liability Stark Law) should make our health system more efficient and our citizens healthier.
HL: What should we be looking for in this final rule?
McDermott: The core proposals regarding value-based arrangements should be confirmed with more regulatory details and reconciliation or harmonization of definitions that were left open in the proposed rule related to patient engagement tools and participation.
Notably, the rules introduced the concept of considering social determinants of health (nutrition, housing and transportation) for patient incentives and in the safe harbor for local transportation. This important concept could in the future open the door to a wide variety of non-medical services and arrangements to assure access to quality and coordinated care. We should also expect the implementation of several significant revisions to existing Stark Law regulations.
HL: Do you anticipate any significant changes in the final rule, compared with the proposal that was issued last fall?
McDermott: Yes, there were several areas that were left open for comment and may not result in a specific final rule.
HL: Will any of this require an act of Congress?
McDermott: Technically no, but some may argue that the regulatory changes go beyond the agency’s rule-making authority to interpret and implement a statute, such as changes to the definition of remuneration.
For example, some may argue that the anti-kickback safe harbors and Stark Law exceptions currently exceed statutory authority in some respects, but no one seems to be complaining in this regard. Nonetheless, we don’t anticipate this will impact the agency’s path to modernization.
HL: Is any significant opposition to these revisions? From whom? And what is the basis of their opposition?
McDermott: The whistleblower bar has raised concerns that modernizing the fraud and abuse laws may encourage more fraud and abuse. Whistleblowers bring cases for private gain and some of these changes may impact existing cases or cases that could have been brought under prior or superseded rules. Stark Law definitional changes to fair market value and commercial reasonableness could have a big impact on whistleblower cases based on regulatory violations.
HL: Are there any unintended consequences that could arise from this?
McDermott: This modernization effort is a leap of faith that healthcare providers can be incentivized to effectively coordinate good clinical care and patients will participate meaningfully in coordinated care activities to manage their health. There will be many unintended consequences, hopefully all good ones.
HL: Will this accelerate the healthcare sector's general trend toward consolidation?
McDermott: At some level, yes, but the healthcare sector’s trend toward consolidation seems more often driven by factors other than regulatory requirements. Whatever is consolidated today will be unwound tomorrow, if history is any guide.
Of the 48,835 active emergency physicians in the United States, 92% practice in urban areas with just 8% practicing in rural communities.
Large swaths of rural America are enduring shortages of emergency physicians, and the problem is expected to worsen as a generation of rural doctors retires with no one to replace them, a new emergency medicine workforce analysis has found.
"The number of emergency physicians is increasing but there is a clear unmet need for emergency physicians in rural areas," said Christopher Bennett, MD, MA, assistant professor of emergency medicine at Stanford University School of Medicine and lead study author, which was published this week in Annals of Emergency Medicine.
"Policymakers and health leaders should prioritize opportunities to make sure that emergency departments across the country are led by appropriately trained and certified emergency physicians," he said.
Of the 48,835 clinically active emergency physicians in the United States, 92% (44,908) practice in urban areas with just 8% (3,927) practicing in rural communities, down from 10% in 2008, the study found.
"Demand for emergency care in rural areas will remain high while emergency physician shortages in these communities continues to pose significant challenges for health systems and patients," Bennett said.
The analysis also shows that the rural emergency physician workforce is closing in on mid-career or retirement, with more than 70% having completed their medical training more than 20 years ago.
The median age for urban emergency physicians is 50 years old, while the median age in large rural communities is 58 years old, and 62 years old in smaller rural communities, the study found.
Relief does not appear to be coming any time soon, as the study found that 96% of the emergency medicine residency or fellowship graduates within the past four years practiced in more urban areas.
On a brighter note, residency programs continue to expand, and that could help alleviate the shortage.
There were 4,565 residents in 145 programs in 2008, and in 2020 there are 7,940 residents in 247 programs.
"There are reasons to be optimistic about the pipeline of residents and trainees, however; we need to encourage a larger percentage of these individuals to work in rural America," Bennett said.
The study also found that women comprise 28% of emergency physicians, up from 22% in 2008.
The Community Health Access and Rural Transformation Model will pick 15 rural communities for its Community Transformation Track, which starts next summer.
The Trump Administration has unveiled a two-track pilot program that will provide $75 million in "up-front funding" for 15 rural communities to transform their care delivery models.
The volunteer Community Health Access and Rural Transformation (CHART) Model will pick 15 rural communities for its Community Transformation Track, which begins next summer.
The Centers for Medicare & Medicaid Services will also accept applications for 20 slots in a related Accountable Care Organization Transformation Track to begin in January 2022.
CMS Administrator Seema Verma said the agency was acting on an Aug. 3 executive order by President Donald J. Trump calling for a new model "to ensure that rural healthcare providers are able to provide the necessary level and quality of care."
"This new model is appropriately called CHART, or the Community Health Access and Rural Transformation Model, because it charts a course to a sustainable healthcare delivery system in rural communities," Verma said at a media teleconference Tuesday.
Verma said the model "provides three things for rural communities."
"First, it provides new upfront seed funding for rural communities to organize their efforts to transform healthcare delivery in their communities."
"Second, it allows for operational and regulatory flexibilities that enabled enhance care for fee for service beneficiaries."
"Third, it offers technical and learning support to participants to ensure the model success," she said.
CMS will detail the CHART models during a webinar on Aug. 18 at 1 p.m. ET.
Under the model, Verma said, 15 select rural community stakeholders and state Medicaid organizations could receive up to $5 million over 18 months to help transform care delivery.
The model would also provide capitated payments that de-emphasize volumes for participating hospitals, and also could waive Conditions of Participation in specific circumstances when requested to do so by applicants.
CMS believes this would allow rural hospitals to move to outpatient- and emergency department-focused models instead of relying entirely on inpatient models. It would also allow rural providers to ramp up telehealth services or develop hub-and-spoke arrangements with larger, regional providers.
In turn, the model participants would be held accountable for quality outcomes measured by total cost, admissions and ER visits, and other metrics that the community would pick.
CMS said the related ACO Transformation Track builds on the success of the ACO Investment Model, which the agency claims has saved $382 million over three years.
The ACO Transformation Track participants will enter a two-sided risk arrangements as part of the Medicare Shared Savings Program and may use all waivers available in the MSSP program.
Verma said CMS will issue a Request for Applications in the Spring of 2021 and pick 20 rural ACOs to participate starting in January 2022.
