Heather Bartos, MD, OB/GYN, received no salary for most of last year. She was still working all week: delivering babies in nearby hospitals, performing routine exams, logging into telehealth appointments. But because she has her own private practice, soon after COVID-19 was declared a pandemic by the World Health Organization, she had to make a choice between reducing her employees’ work hours or going without pay herself; she chose the latter.
“When people think ‘doctor,’ they think ‘someone who makes a ton of money,’ ” says Dr. Bartos, who’s based in Frisco, TX. “But no. I’ve taken a huge financial hit this year. A lot of doctor's offices have shut down. A lot of friends of mine have either had a reduction in work hours, or they were furloughed, or laid off. It seems so stupid — we need healthcare workers right now. But it's a tough time to be a medical professional.”
In April 2020, the amount Americans spent on health services (excluding medications) dropped nearly 32%, reports the Health Systems Tracker. That number bounced back up; by October 2020, health spending was down less than 2% when compared to the previous year. Still, medical professionals felt the strain. In a July 2020 survey of 3,513 physicians, 8% indicated they’d closed their practice in the last four months, 72% said they’d experienced a reduction in income, and 43% said they’d reduced their staff, reports The Physicians Foundation.
Doctors, dentists, and other health care workers faced several financial roadblocks. First, fewer patients booked appointments. Although early in the pandemic, most headlines were focused on overflowing hospitals, many medical professionals were having the opposite problem. “There’s the front line, but then there's also what I call the middle line, which is the doctor's offices, and we certainly saw patient volume go down,” Dr. Bartos explains. If people could delay a procedure, they did. In some cases, states ordered delays of certain non-urgent office visits. As a result, dermatology, OB/GYN, physical therapy, dental, and other practices took a huge financial hit, Dr. Bartos says.
Max Meinerz, DDS, a dentist who owns three practices in Wisconsin, says his offices saw a 10% to 40% reduction in patient volume. He says many people felt unsafe coming into the office during the pandemic, but the loss of health insurance following layoffs or furloughs may have played a role, too. “For our practices with less-affluent patients who may have lost their jobs during the COVID pandemic, we’ve seen a 30% to 40% decrease in patient flow with a 20% to 30% decrease in revenue,” Dr. Meinerz says. Visits among patients who remained employed or were higher income dropped just 10% to 20%, he says, adding that many higher-income people are actually spending more money on elective dental procedures, such as Invisalign and teeth whitening. But, in general, fewer patients has meant a reduction in income for the practice.
Additionally, medical costs have increased during the pandemic. In order to see patients safely, health care providers needed to use extra personal protective equipment (PPE), which can be expensive. “We have to buy all of our own equipment. That's not a cost that can be pushed onto anybody else, so we absorbed it,” Dr. Bartos explains. She adds that when PPE became scarce, her practice didn’t receive the same help sourcing the life-saving equipment as hospitals. “I would send a nurse to Costco at 7:00 a.m. to try to get Clorox wipes or anything else that we could get,” she says. They were also “baking” their N95 masks in order to get more than one use out of them. Items like hand sanitizer were in such short supply that patients would steal bottles from her office. At one point, Dr. Bartos found herself mixing her own disinfectant. “I used Everclear, distilled water, and essential oil so it didn't smell like a booze lounge in [the office],” she says.
Increased PPE costs — as well as strict regulations around in-person visits and the risk medical professionals took on in order to see patients during a pandemic — made care more expensive to provide. “We had higher overhead, lower patient volume, then had all these extra screening measures we had to put in... Just from a payroll standpoint and an organizational standpoint, it's a whole area I never thought I was going to have to do in medicine,” Dr. Bartos says. And Dr. Meinerz points out that insurance third-party payers have been “unable or unwilling to meaningfully reimagine the reimbursement paid to their providers.”
A particular area of concern has been telehealth reimbursements. Many medical professionals began seeing patients virtually during the pandemic. There's been a push for Medicaid and other insurance companies to reimburse these visits at comparable rates to in-office appointments. Sometimes they are: Dr. Bartos says that so far, she’s been able to bill insurance the same rate for in-office and virtual appointments. But she doesn't know if that will remain true going forward, and other physicians have struggled to get paid in full. Leada Malek, DPT, a board-certified sports physical therapist based in San Francisco, CA, says she’s heard of insurance companies only paying for 25 minutes of an hour-long telehealth session.
Government assistance programs like the Families First Coronavirus Response Act, which reimburses employers who pay for employees’ COVID-19 sick leave via tax credits, and the Paycheck Protection Program, which has paid loans meant to help small businesses fulfill payroll costs, are helpful, but not perfect solutions. ”FFCRA is a tax credit, and corporate taxes aren't due until October of 2022. So there's no money coming back from these kinds of things for 18 months,” Dr. Bartos explains. Adds Dr. Meinerz: “The revenue metrics used to determine PPP eligibility say nothing of the increased cost of care and associated drop in profitability that comes with higher overhead.”
Many offices had to close or drastically cut back on staff. Malek worked in an out-patient private practice for four years before the pandemic hit. One reason she loved her job was because it was secure; physical therapy is known for being a stable field. That changed during the pandemic. “While we are essential health care workers and we were still able to work during the peak of the pandemic, in March we went on full lockdown and the practice had to close its doors,” Malek explains. She was furloughed — temporarily, but with no clear end date in sight — and began receiving unemployment benefits.
“I applied to nine different jobs because my work wasn’t going to take me back anytime soon. A year ago, if I’d applied to nine jobs, I would have had nine interviews. This year, I got one — for a lateral move that wouldn’t benefit my career at all,” Malek says. Meanwhile, she had friends working on the front lines of the pandemic. She was so desperate to feel helpful that she purchased liability insurance and opened her own online practice. “I started offering virtual sessions free to front line and essential workers,” she says. Those sessions were so popular that she opened her own virtual practice: “Within three months, I had a full schedule.”
Recently, Malek also took on a part-time job in a physical clinic. With the combined salary from that work and her virtual practice, she’s making about 75% to 80% of what she was before the pandemic.
Like many other health care professionals, Malek plans to continue offering telehealth appointments even after the pandemic. Initially, she was licensed as a physical therapist in California, which meant that she could only legally work with patients who were also in California. In order to expand her patient pool, she ended up getting licensed in Colorado as well. Physical therapy licensing fees vary by state, but can cost $300 or more.
But, some medical professionals have resorted to ethically dubious practices in order to make money where they can. Malek says she’s seen physical therapists frame their services as “wellness” offerings rather than physical therapy, which allows them to practice across state lines without getting additional licenses — even though what they’re practicing is PT.
Dr. Bartos says she heard of a dentist who charged patients $25 per visit to cover PPE costs. “I don't know that that's legal when you have insurance, because you're not really allowed to charge over things. But I think people were just desperate,” she says.
Dr. Bartos says many smaller OB/GYN, dental, and medical offices — including her own — also provide cosmetic procedures such as Botox or fillers to boost their income. Though many states prohibited nonessential procedures like these at certain points during the pandemic, she knows physicians who surreptitiously continued to provide them. “We turned patients [asking for cosmetic procedures] away sometimes. I'm a business woman, but I'm also morally a physician. I have to kind of take into account the right thing to do. But I think a lot of doctors struggled with that,” she says.
Malek, Dr. Bartos, and Dr. Meinerz believe their industries will bounce back as more people get vaccinated and feel more comfortable returning for in-person health care visits. In the meantime, they’re doing their best to remain patient and stay afloat. As Dr. Meinerz says, “We are in healthcare because we love helping people and will continue to do so — even though things are hard right now.”