A Bridge in Time

Federal relief efforts were lifesavers for many providers during COVID-19. What lessons have they learned from the experience?

October 2021 – The Journal of Healthcare Contracting

By Mark Thill

Statistics provide the bones of the story. But words provide the flesh.

Medicare spending for physician services dropped as much as 57% below expected
pre-pandemic levels in April 2020, according to the American Medical Association. Medicare Physician Fee Schedule spending at the end of June 2020 was still 12% less than expected. During the first half of 2020, the cumulative estimated reduction in Medicare physician spending associated with the pandemic was $9.4 billion (19%).
Expenses spiked while revenues dropped. Impacts on total spending for the first six months of 2020 ranged from a 6% reduction for nephrology to a 29% reduction for ophthalmology and a 34% reduction for physical therapists. At the state level, impacts ranged
in aggregate from a 13% reduction in Oklahoma to a 27% reduction in New York.

Now, the words of clinicians, describing the “new normal,” from a survey sponsored by the Primary Care Collaborative in July 2020:

“More telehealth, lots of stress about patient numbers, angry/exhausted coworkers.” – New York
“Lower salary for more work, risk of serious illness every day, doing my staff’s jobs because they are afraid to touch and be in the room with patients, spending my own money ($30k) on PPE for the entire clinic despite working for a huge hospital system, and having the federal govt specifically exclude me in COVID-19 workplace benefits (FFCRA). Pretty much a nightmare.” – Texas
“Insecurity, exhaustion, moral outrage, despair, grief, rage, despondency. Seriously questioning whether to continue to stay and serve a society that doesn’t seem to value me, my loved ones, or what we do. Currently working ~120 hrs/wk providing unfunded care at my own personal expense to gravely ill persons. I have maxed out my own resources and reserves.” – Colorado

On March 27, 2020, President Trump signed into law the $2.2 trillion Coronavirus Aid, Relief and Economic Security Act, also known as the CARES Act. For healthcare providers, the Act expanded the Medicare accelerated payment program, in essence, giving physicians an advance on future Medicare payments. Through the CARES Act, the Paycheck Protection Program (PPP) and Health Care Enhancement Act, the federal government allocated $178 billion in payments to be distributed through the Provider Relief Fund (PRF) to healthcare providers. The Consolidated Appropriations Act, 2021, passed into law on Dec. 27, 2020, allowed eligible businesses – including eligible providers – to receive a second PPP loan, referred to as a “second draw.”

“Nerve-racking“

The federal help served as a bridge of support for many practices, but it was not without hiccups.

“It all happened very quickly,” says Julianne Andrews, senior director and senior wealth advisor, Mercer Advisors. “Banks were overwhelmed with applications. Online processes crashed. People were trying to submit applications at 3 in the morning. It was nerve-racking for all.”

Hardly surprising. After all, over just a one- or two-week period, medical practices faced something they had seldom if ever faced before, she says. “Healthcare is not a seasonal thing, so practices seldom deal with cash flow issues. Some of my clients have been practicing for 20, 30, even 40 years, yet they were concerned they might go out of business – which was unthinkable just a few weeks earlier.”

Compounding the problem was (and remains) the fact that aside from those that are owned by health systems or corporations, most physician practices are run by physicians themselves, not financial people, she says. They lacked a handle on how many months of cash reserve they held and how long they could stay open before making dramatic changes. Many applied for PPP loans, but as they waited to hear whether their applications had been approved, some made significant cuts to salaries and overhead.

“As with any program that is newly established in a time of crisis, there were initial challenges around accessing the portal, gathering the information necessary to input, and tracking the electronic deposit of the funds,” says an AMA spokesperson. “Asking questions of the Medicare Administrative Contractors and the distributing agency proved difficult in the beginning, as both were also navigating other aspects of the pandemic.”

Early on, CMS approved almost 24,000 applications totaling $40.4 billion in advanced Medicare payments to physicians, health professionals and other Medicare Part B suppliers. But the payments, while successful and supportive, came with their own set of challenges, the spokesperson adds. “Originally, repayment of the loans was due 210 days after the advance payment was issued in the form of an automatic 100% reduction in new Medicare payments. Additionally, outstanding balances were going to be subject to a 10.25% interest rate. These terms proved to be a challenge for physician practices, as the slow reopening of practices allowed for only a partial recoup of the losses.” The terms of the program were modified by the Continuing Appropriations Act, 2021.

Primary Care’s Complaints

“Neither the CARES Act nor any other COVID relief bill provided dedicated funding for primary care, with moderate estimates that primary care practices lost $15 billion in 2020,” says Ann Greiner, president and CEO, Primary Care Collaborative. “While Congress did provide dedicated, well-justified support to [Federally Qualified Health Centers], rural hospitals and clinics as well as public health, primary care should have been treated similarly given its key roles in educating, triaging, and managing COVID patients.

“Primary care made the most of temporary telehealth flexibilities to connect with patients, reach hard-to-reach communities, ensure behavioral health needs were met, and protect their staff against the virus. But it’s not enough to make up for a $15 billion disinvestment.”

Meanwhile, in a March 25, 2021, letter to U.S. Senate Majority Leader Charles Schumer, Donald Crane, president and CEO of America’s Physician Groups, which represents over 340 physician groups, wrote, “Physicians that practice outside of hospital systems have spent thousands of dollars making investments in infrastructure such as licensing costs for telehealth services and telework setup, waiving co-pays as well as providing COVID-19 testing and vaccination leading to increases in clinical overhead. Despite these investments, funding allotments from the [Provider Relief Fund] have excluded these providers in favor of other care settings.

“Congress should prioritize future expansions and additional funding for the PRF toward extending relief for these overlooked physician practices and their associated entities, the monies they have already invested in combating the pandemic and serving patients nationwide, and the widespread negative effect that the pandemic has had on their practices.”

Today, many practices look at the Provider Relief Fund as a bridge across a period of time when they had no revenue, says Andrews. Some have used the entire COVID-19 experience as a learning opportunity.

“Those that are looking more closely at cash flow, P&L, overhead and overall cash management are coming out of this experience healthier than before,” she says. “Maybe they cut head count a bit, or they’re thinking more carefully before borrowing from the bank, which has always been open to lending to physicians. Some practices with multiple offices are taking a hard look and closing one or two of them, because they have learned that multiple locations create a ton of overhead.

“When demand for your services is predictable, revenue is only going up. So it’s easy to take your eye off the ball. The lesson is, even if we don’t have another pandemic in the near future, keep several months of cash on hand.”

For Ann Greiner, the pandemic demonstrated the shortcomings of the current fee-for-service payment system. “It was an epic failure in the pandemic,” she says.

“The pandemic underscores the need for a broad shift to prospective payment models that engender more investment in primary care and better support a comprehensive team providing a comprehensive set of primary care services, which will improve population health and enhance equity.”

“We continue to learn more as the nation continues to vaccinate individuals and opens back up to pre-pandemic activities,” says the AMA spokesperson. “One of the biggest lessons involves telemedicine, which has proved to be a critical part of the future of the effective, efficient and equitable delivery of healthcare.

“Many more lessons from the COVID-19 have been raised for the future, including the need for a national health strategy to acquire and manage critical personal protective equipment resources during public health emergencies; interagency coordination between federal departments and agencies for public health emergency responses; and how to ensure continuity of care for patients and continued viability of non-hospital practices.”

Where the Money Went

The federal government’s COVID-19 relief efforts and programs were welcomed by physician practices, according to the American Medical Association. Physicians have tapped into a number of available sources of support, including:

CARES Act Provider Relief Fund.
Medicare Accelerated and Advance Payment (AAP) Program.
SBA Paycheck Protection Program.
Emergency Economic Injury Disaster Loan (EIDL) Emergency Advance.
Main Street Lending Program.

For physicians who paid expenses with payments received through the general and targeted distribution payments, expenses were limited to those that another source had not reimbursed and were not obligated to reimburse. Categories of expenses that can be reported include general and administrative expenses and other health care-related expenses such as:

Mortgage /rent.
Insurance.
Personnel.
Fringe benefits.
Lease payments.
Utilities/operations.
Other general and administrative expenses not captured above.
Supplies and equipment.
Information technology.
Facilities.
Net unreimbursed expenses attributable to coronavirus.
Lost revenues attributable to coronavirus.