Dr. Eric Freeman, president and physician in chief of Old Dominion Pediatrics (Photo by Monica Escamilla)
As the COVID-19 pandemic continued to build last summer, Dr. Eric Freeman, president and physician in chief of Old Dominion Pediatrics, kept his practice open, even while contending with a dramatic drop in patient visits to their offices on Midlothian Turnpike. Many stayed away out of fear of contracting the virus. His choice to stay open was an economic one — and a reflection of dedication to his profession.
“The passion that I have for my craft and general pediatrics, and the ability to see the impact that I can have in the lives of my patients, is very rewarding,” Freeman says. “I am [treating] some of our families’ second and third generations. So to have that kind of rapport and bond, that [kind] of tight social relationship with my families, it’s very, very rewarding.”
But Freeman’s field is under fire from situations that are wreaking havoc nationally on primary care medicine professionals, ranging from economic strains to COVID-19 overload. Some practitioners shut their offices down during the pandemic as patient caseloads declined and they had to deal with a dearth of protective gear and sufficient testing.
An update in mid-November to a weekly survey of primary care providers noted that “primary care is at the front lines of the pandemic yet faces critical staffing shortages and limited resources.” More than half of respondents in the survey from the Primary Care Collaborative and The Larry A. Green Center report extreme levels of stress, almost two-thirds were dealing with staff shortages from illness or quarantine, and a third say they have insufficient supplies of protective gear.
Freeman, who is also a clinical assistant professor in family medicine and population health at the Virginia Commonwealth University School of Medicine, says that many of his colleagues who decided to shut their practices for economic or health reasons while the pandemic dragged on for months could not weather the economic impact wrought by the loss of income. Primary care medicine is known to compensate at lower rates than many specialties, and the fee for service structure in health care poses unique challenges for private practice physicians. These stresses have been compounded during the pandemic, when additional investments in infrastructure and supplies are needed even as income is cut due to a diminished caseload.
“I think it takes a very dedicated individual who would want to balance the life of not only being a physician, but a small-business entrepreneur,” Freeman says. “That is a very big hat to wear. I think that many physicians really don't get a lot of understanding in medical school about the economics of health care. We are all very well versed in medical education and medical-wise, but it takes more than that [to succeed].”
You can be a great doctor, but you also have to make money and invest in your practice. For example, Freeman this fall invested in telehealth technology to serve his 4,500 patients.
Dr. Mike Petrizzi has been with Hanover Family Physicians for 33 years and was a founding owner. He’s really involved in high school athletics. “The challenge in primary care is how to divide yourself up into the many ways [you need to as a primary care physician],” says Petrizzi.
He says there are many issues facing his field, like the right way to provide quality care and how to keep up to date. “The challenge is to do good care and let patients know who you are and [that you care],” Petrizzi says. “However, there are 20 people coming through your office every day, and there are [only] so many hours in a day and so many minutes allotted per visit. The biggest challenge, as in every specialty, is the amount of documentation and paperwork. There is a frustration with prior authorization and approvals, and which prescription patients should get. It’s a balance, and [decision-makers] have got to make [health care more] affordable.”
Petrizzi says the question of how private offices find funding for extra services is important. For example, small offices don’t have social workers, and the fee-for-service structure often limits investing in needed infrastructure.
“There will always be opportunities to improve what we do and always a cost to do that,” Petrizzi says. “If you are going to provide stellar service, it feels that subpar service is wrong.”
Doctors with larger health care provider practices can better weather the fiscal storm. Dr. Alex Krist, who works as a VCU primary care physician, had the benefit of telehealth technology quickly, soon after his practice closed in March, because he is a part of a big hospital system. Krist sees the pandemic as a crucial time for primary care practitioners.
Telehealth is one major change that’s likely to carry over post-pandemic. The use of these virtual visits successfully increased because the federal government eased restrictions on platforms from which the sessions could be conducted, and opened its use to Medicare and Medicaid patients. Private insurers followed suit.
“It took a while [for insurance companies] to pay for virtual visits,” says Krist, who views the pandemic’s effect on primary care as an opportunity to improve on the way compensation and the profession are structured.
Dr. Rebecca Etz, associate professor in the department of family medicine and population health at VCU School of Medicine and co-director of the Green Center. (Photo by Jay Paul)
Understanding the Big Picture
As an associate professor in the department of family medicine and population health at VCU School of Medicine and co-director of the Green Center, Dr. Rebecca Etz has her finger on the pulse of primary care practitioners’ feelings about the rewards and challenges facing their profession through the Green Center survey.
With anywhere from 500 to 1,000 responses a week, the survey provides a snapshot of financial strain from the pandemic: 54% of respondents have experienced COVID-19-related furloughs and layoffs; 26% say that at least a third of practice work continues to be unpaid; 28% have permanently reduced the size of their staff because of COVID-19; and 19% report that clinicians in their practice have retired early because of COVID-19 or are planning on it.
Etz points to underlying systemic problems. “Prices for services are not set by the doctors, they are set by a third party,” she says. “If you listen to the national conversation, they talk about reimbursements. Our system is set up to prioritize things that require equipment. Then when you introduce the pandemic, doctors needed to invest in new equipment and materials, without a capital infusion. We have seen a tremendous strain on the practices.”
Freeman says adjustments needed in 2021 and tight budgetary margins within independent private practices will put additional pressure on primary care doctors. Etz adds that some practices are worried about skyrocketing prices for protective gear even as they space out patient visits, leading to fewer physical interactions with patients and fewer reimbursements.
Prepared to Serve
Another problem cited by Etz and Krist is the “upside-down” statistical makeup of doctors in the U.S., with only 20% working as primary care physicians — numbers that are declining.
About 100 primary care physicians across five specialties work at VCU Health System’s hospitals and clinics. These primary care doctors practice family medicine, general internal medicine, general pediatrics, general OBGYN and geriatrics. It also has more than 75 advanced practice providers, such as physician assistants and nurse practitioners, as well as medical residents from these specialties who see patients in primary care settings.
Experts project a shortage of 54,000 or more primary care physicians in the U.S. over the next decade.
Virtual visits have expanded access, especially during the pandemic.
“Even though this technology was already an established practice at Bon Secours when COVID-19 began, we did make an additional investment in telehealth,” says Jenna Green, a spokeswoman for Bon Secours in Richmond. “We ensured all our hospital sites had a telehealth technology presence by increasing the number of devices systemwide, which helps to protect our clinicians and does not interrupt current telehealth programs that were already in place prior to COVID-19.”
From March to October in Richmond, Bon Secours practitioners have conducted more than 169,000 virtual visits. It also offers a direct-to-consumer app that has been used for more than 5,200 virtual visits since October. In 2019, these services were used by just 700 patients, Green says.
The Next Generation
On top of economic and stress-related challenges facing primary care doctors, experts project a shortage of 54,000 or more primary care physicians in the U.S. over the next decade.
To cultivate the next generation, Freeman mentors the undergraduate VCU student group Black Men in Medicine to encourage diversity in the medical field.
Second-year VCU medical students Caitlyn Syptak and Sarah Beaverson lead the VCU School of Medicine Student Family Medicine Association, which has been taking aim at this shortage for years, helping students see the primary care specialty with a fresh perspective through presentations, workshops and funds to attend conferences.
“The largest draw to family medicine specifically is just the longitudinal care,” Syptak says. “It's the idea of creating almost lifelong relationships with my patients that allows me to get to know their families, to get to know the community around me, and be able to use that to really influence and advocate for my patients and be able to kind of comprehensively care for them, as well as understanding where they come from so I can provide proper care for them.”
Beaverson says that family medicine is crucial to providing holistic care for patients. She says that she’s looking forward to being that first touch point in the health system, helping patients who are confused and don't know where to go. “What draws me to primary care medicine is helping people navigate the complexities of care and being there for patients,” she says.
