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Last week, Todd J. Maltese, DO, had to choose whether to keep his Long Island, New York, practice open and risk spreading COVID-19 coronavirus to his patients and employees, or shut its doors, losing the majority of outpatient visits that sustain them.

"I didn't get much sleep that night trying to find out what to do," Maltese told 乌鸦传媒. "But I woke up knowing we couldn't allow patients to come in anymore. If they're sick and get us sick, we can't help anyone."

On Friday, March 20, Maltese and his partner closed their neurology and sleep medicine clinic in Ronkonkoma, about 60 miles east of New York City. They scrambled to set up a "crash course" telemedicine service within 24 hours, and crossed their fingers that their billing department would find enough revenue in accounts receivable to sustain them through the pandemic.

Although he originally estimated the clinic would be able to go on like this for 3 months, if insurance companies do not expand coverage to reimburse telephone and telehealth visits, and if the number of cases in New York ends up , it will be longer before he can consider re-opening the doors.

"I want this curve to be flattened and I will deal with the repercussions financially," Maltese said. "My profitability is the last thing I care about right now."

Physicians across the country are having to close their clinics and transition to remote patient visits when possible to stop the spread of COVID-19. But for many physicians, sacrificing in-office visits has dire fiscal consequences.

"You have this situation where without the customer, the patients, we don't really have a job," Gary Leroy, MD, president of the American Academy of Family Physicians (AAFP), told 乌鸦传媒. "The system is not set up for us to quickly pivot to telehealth coverage for every single one of our patients."

The Centers for Medicare & Medicaid Services recently retroactively starting March 6, but whether private insurers will follow suit varies by state.

"If all companies pay, it will be more sustainable," Maltese said. "If only one or two are paying, it's not going to be sustainable."

Katie Kwon, MD, a nephrologist in St. Joseph, Michigan, who also closed her clinic on March 20, said she is working 16-hour days: on the phone with patients, answering questions, maintaining medications, and preventing them from going to the emergency room.

Up to 70% of her patients do not have smartphones and many over 65 do not feel comfortable navigating telemedicine services, so Kwon performs most remote visits through telephone calls. But without a video component, the vast majority of her time spent doing this is not reimbursable, she said.

"There are doctors like me all over the country who are doing a lot of work every day to keep their patients safe, and right now it is not compensated," Kwon told 乌鸦传媒. "Unless we expand coverage to voice-only telemedicine and compensate that at a largely equivalent level, we are going to see a lot of small practices go out of business."

Providers in small practices everywhere are being faced with difficult decisions as the coronavirus sweeps across the nation, said Ike Z. Devji, JD, an asset protection attorney who represents physicians.

"They want to know how to downsize or lay off employees they love and respect and want to keep," Devji told 乌鸦传媒. "But if there is no business, how long can they sustain that overhead, and what sacrifices do they need to make to ensure the practice stays solvent and everyone, including the owner, has something to come back to?"

Defining 'Essential'

Among the questions small practice physicians face: Are their services "essential?"

"We've set up this perverse incentive where we want people to stay at home and doctors to not be spreading the virus to patients, but if it's that or lose the practice you've spent your lifetime building, that's a tough choice," Kwon said. "I don't think I'm willing to say everything I have spent the last 13 years doing is nonessential."

One of the hardest-hit specialties is primary care. Providers are not only on the front lines of the pandemic, but are ceasing non-urgent, preventive visits, which comprise most of their appointments, Leroy said.

On top of that, many providers have to find their own personal protective equipment (PPE) amidst the national shortage for themselves and their staff, he added.

"The healthcare system that supports the vast majority of healthcare visits for this country, primary care physicians, are receiving a critical stress test right now, and they can ill afford to fail," Leroy told 乌鸦传媒. "We have nearly 200 million office visits each year that we provide for this country. You take that away, and you've kicked the legs out from a teetering system."

While the majority of physicians can sustain themselves off savings, their employees often live paycheck-to-paycheck and will be the first to feel the economic repercussions from COVID-19.

Kwon and Maltese are suspending their personal salaries for the time being and dedicating all income to keep their staff employed. Maltese still had to lay off one employee.

Amber Lovitt, NP, was furloughed earlier this week from the pain management clinic where she worked in Houston. Now, "stuck in limbo," she is considering asking to work at a local emergency room or urgent care center to replace at least some of her lost income, she said.

"I think it's really ironic being a nurse practitioner and being out of work during a pandemic," Lovitt said. "I'm the main breadwinner at my house and it's terrifying."

How long practices can sustain themselves will vary depending on the type of practice.

A Federally Qualified Health Center in Dayton, Ohio, may survive for 2 weeks, whereas a rural family physician in the same situation may not last 2 days, Leroy said. The best-case scenario could be 30 days, he added.

"We are 2 weeks in and now it's getting to crunch time, where some of us are going to have to make some very critical decisions," Leroy said.

The AAFP is advocating for relief to be provided in the form of non-interest loans and expanded

The $2-trillion economic stimulus package recently passed in the Senate will include $100 billion for hospitals and other facilities to "receive the support they need for COVID-19 related expenses and lost revenue." It also budgets $200 million for the Federal Communications Commission to help healthcare providers offering telehealth.

"This is no time for physician's offices and health centers to go out of business," Leroy said. "If we go out of business, America is out of business."

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