Commentary: Primary care physicians roll with the coronavirus changes

By Kristine B. Diehl, MD

No one would have believed nine weeks ago, as we looked toward St. Patrick’s Day, that our world would have been changed so dramatically by the coronavirus between then and Memorial Day weekend.

At that time, our office scrambled to make changes in our small family practice and taking care of patients who might have been exposed to the virus. Decisions to make changes to our processes felt urgent, causing us to make quick specific plans to keep ill or exposed patients out of our mainstream patient areas. We had plans with details for running the office, including supplying gowns and masks for the nurses and doctors who were directly in contact with patients. Little did we know while making those plans that vital personal protective equipment (PPE) would become unavailable to small physicians’ offices for nearly eight weeks!

Dr. Kristine B. Diehl

As outside facilities became established for testing, our office staff changed gears, screening patients to keep potential illness completely out of the office to protect the health of other patients and employees. As Delaware progressively shut down with a full lockdown in place by March 22, we officially closed our physical office after a patient who was scheduled for a routine physical exam came to the office with symptoms of a cold, despite being screened for illness symptoms. We knew then that we needed to pivot once again, and we implemented the use of telemedicine the next day. By the end of that week we had our full schedules switched over to telemedicine.

Most physicians during this crisis started out sprinting to take care of COVID-19 concerns, prepared to screen exposed or ill patients for the coronavirus while taking care of the routine medical needs in their practice. The race became a marathon with many doctors’ offices struggling to meet the demands of patients who were stranded at home, afraid to come into the office.  

Prior to March most primary care doctors did not attempt telemedicine, finding the cost of the system greater than the reimbursement.  As a consequence, most telemedicine had been provided by outside programs connected to the insurance companies.

Thankfully, the demands during the pandemic changed telemedicine requirements and many cost-effective systems have met the expectations of the insurance companies  Unfortunately, the challenge to initiate the process overwhelmed some doctors, causing some to lay off staff, others were forced to close their practice, and many were hoping they would get approved for the promised loans for small businesses.  Going forward there is a threat that telemedicine requirements may be changing again, possibly before the pandemic ends, leaving us holding our breath and watching the insurance industry. 

Our practice was fortunate to survive the first few weeks with our scramble to change gears and initiate telemedicine. Thankfully, Medicare quickly approved telemedicine for full reimbursement, but unfortunately that didn’t account for the fact that many seniors do not have computers or smartphones. Recognizing the limitations, Medicare has now added payments for telephone calls, promising “retrograde” reimbursement for earlier calls to patients without video technology, but we have yet to see the delayed payments for those calls.

For our younger patients with regular insurance, many are frustrated they have had to proceed through telemedicine not office visits,  but we have been able to review health issues, renew medications, and handle many emergent problems that way, so we are thankful for the technology option. The goal from the beginning was to keep emergency rooms and hospitals free to care for COVID-19 patients, and we have been successful.

We have also been fortunate to care mostly for healthy patient’s concerns through telemedicine. A “new normal” day for our practice has us treating elevated blood pressure, asthma, and allergies issues, along with increased anxiety issues many patients are experiencing due to the pandemic. Our care has also included diagnosing several patients with COVID-19, ordering the testing after a telemedicine call. But, medical care for those patients doesn’t stop there; we continue to manage their care through daily calls and check-ins. It should be said that while hospital workers are on the front lines, outside primary care providers have been in the trenches, counseling many patients on safety measures for working in an essential job or reminding families to stay in quarantine for potential exposures.

The disappointing reality for private practices continues to be the ongoing challenge from private insurance companies, especially with companies promising telemedicine coverage during the coronavirus pandemic but paying an inconsistent reimbursement amount compared to what was promised.

An even greater concern for us now is the listed dates for the termination of telemedicine coverage by these Insurance providers in the next four weeks. How will we be able to safely offer care to our healthy patients in the office while treating our potential COVID-19 patients if we can’t utilize telemedicine?

At this time, we have realized we are perhaps halfway through the marathon of changes needed to manage the COVID-19 health crisis. We are again reevaluating how to take care of patients’ needs, hoping we get paid and reimbursed for the care of patients already seen and still to be seen. 

Many small business owners will be left stranded economically after this shutdown ends. But the fundamental health care system is what breaks during a health crisis when the insurance-based system fails to accommodate the reimbursements necessary for the survival of its fundamental physician base.

Kristine B. Diehl, MD, is a family physician with Delaware Family Care Associates in Wilmington,  and is board certified in Family Practice and Integrative Medicine. She is also a member of the Medical Society of Delaware’s Public Health Subcommittee.