How COVID-19 will close pediatric practices

The COVID-19 pandemic has turned our lives upside down.  It has wreaked havoc on the economy, leaving many jobless, and many industries questioning where their future lies.  In my view, it has brought the weak infrastructure of the U.S. health care system to a breaking point.  These deficiencies were already present: limited public health prowess, hospitals’ inefficiencies, poor coordination of care, and disjointed health care messages between federal and state levels.

Most devastating, a broken system of caring for our poor, and a lackadaisical attitude towards preventative care for our youngest has left practices without a financial buffer and at risk for shutting their doors.  I practice on the Southwest side of Chicago, in a primarily Latino neighborhood, and I love what I do.  At Vida Pediatrics, we work very hard to serve our 85 percent Medicaid population.  While several independent practices around us have closed in the last several years due to reimbursement issues, we keep our doors open and have new patients on a daily basis.  It helps that we are a part of a network of providers integrated with Ann & Robert H. Lurie Children’s Hospital.  With their support, we pride ourselves on keeping patients out of the emergency room, having very high vaccination rates as well as chronic disease management rates.   

But our founder, pediatrician Dr. Alejandro Clavier, hasn’t slept in weeks, and his patience is wearing thin.  As his sidekick, I marvel at his ability to remain positive as always, and maintain his focus on patient care as his guiding light.  Our practice did not receive the SBA loan in the first round of federal funding.  As the days went by awaiting word about whether it would happen in the second round, Vida Pediatrics and our livelihoods felt in peril. Earlier this week, we learned that the loan was approved.  But, as Dr. Clavier describes it as “a medium-sized band-aid” won’t fix a festering wound. 

The initial injury was not the COVID-19 pandemic.  There are forces that have slowly been eroding away at the fiber of small independent practices.  Several years ago, Illinois transitioned to managed care organizations running the show, handing over public Medicaid funds to privately owned insurance companies.  Ever since this transition, primary care offices that serve children with these plans have seen irregularity of payments, erratic denials of claims, problems with “redetermination,” wherein patients lose coverage and months pass before they are reinstated, and delays in getting newborns eligible for coverage.

Medicaid reimbursement rates remain at levels they were over 15 years ago, and Medicare reimbursement levels are more than twice that of Medicaid.  This may sound like a “whine-fest” of doctors who are used to being overly paid now being paid a bit less.  But when pediatricians suffer, patients suffer, and nobody wins.  It translates to hours lost from patient care to hours on the phone with billers and insurance.  It translates to missed visits, missed vaccines, missed opportunities for recognition of developmental disorders, and mental health concerns, as well as abuse and neglect.   Compounded by COVID-19, it translates to a paucity of preventative care amidst a pandemic. 

Many offices have made the difficult decision of limiting the number of Medicaid patients they see.  Instead of expanding to serve the needs of growing populations, many have had to contract, lose staff by attrition or the stress of being overworked, and certainly not being able to recruit new providers, even though they are desperately needed.  Or simply close.  

Dr. John Kowalski established his practice in 1988 on Archer Avenue in Chicago’s Brighton Park neighborhood, later moving to Oak Lawn just outside the city, but never faltering on a promise he had made to his young self to keep his doors open to Medicaid patients.  You see, as a junior in college, Dr. Kowalski developed cancer, and his treatment was completely covered by his Medicaid plan. After almost 30 years in private practice, Dr. Kowalski estimates that he saw over 10,000 patients.  The last five years of practice, however, brought him to his knees, requiring him to take loans on his line of credit in order to keep up payroll.  This last year was the worst as recoupment after recoupment forced him into early retirement.  Mixed with pride for his years of service, there’s a sense of bitterness towards the MCOs that pulled him away from the joy of practice, and relief looking ahead to a future without administrative burdens. 

Imagine this occurring multiple times over, to multiple practices that serve thousands of patients, in multiple states throughout this country.  And this at a time when 40 percent of the country’s children are enrolled in Medicaid.  Where will our patients go?  To urgent care centers, to emergency rooms?  Who will help coordinate their care with specialists?  What specialists will see them, and how long will the wait times be?  At a time when we are already seeing an uptick in anxiety, depression, and child abuse, I do not want to even imagine what this will look like. 

And do you know what the ultimate kicker is? The federal government, despite being urged to do so by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists, has not, as of yet, provided Medicaid practices with COVID-19 relief funding like they have for Medicare practices and hospitals.  Primary care providers who do not serve an aging population are once again being left in the dust, and what’s worse, their patients will suffer the consequences.

Physicians are trained to do what is best for their patients and to do no harm. Independent practices have sat quietly watching, feeling hopeless as our communities cannot access the care they need, shamefully shutting our doors to spend hours on the phone with insurers.  But no more.  We can no longer remain quiet: Our pediatric patients may not be suffering from COVID-19 at the alarming rate of adults, but this pandemic will send long-standing shockwaves to future generations if our voices are not heard.

Nidhi Kukreja is a pediatrician.

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