Updated at 7:50 p.m.: Revised to include new information throughout.

AUSTIN -- A doctor’s order for coronavirus testing does not ensure a patient in Texas will receive one.

A lack of widespread testing means Texas may not have a true grasp of how many people have COVID-19 or how quickly the virus is spreading, physicians said.

“Until we can test more, we really don’t know what we are dealing with,” said Dr. Christopher Crow, President of Catalyst Health Network, whose organization has roughly 200 primary care locations across North Texas. “As the supply becomes available we need to have a better system.”

While the state’s public health labs are ramping up their limited testing capacity, only patients who meet strict criteria are accepted. In Washington, a top federal public health official acknowledged the lack of testing capacity as a “failing.”

Doctors are increasingly turning to commercial labs that can test people for the virus in higher volumes. But some clinics are reluctant to take patient samples because they have no access to masks and other protective equipment that are in short supply but critical in keeping medical staff from being infected.

“It’s a problem with doctors and staff seeing patients every day desperately wanting those things and they can’t get them,” said Dr. Michael Garrett, a family medicine physician in Austin.

Meanwhile, some patients are receiving conflicting information from doctors and insurance companies about where to get tested. Public health officials advise people with symptoms to call their primary care physician. But some clinics have directed ill patients to emergency rooms for coronavirus testing, where they risk exposing dozens of others, according to interviews and email exchanges shared with The Dallas Morning News.

“I will tell you the emergency room is the worst place for anybody to go, unless you have got a fever and are having a hard time breathing,” said Tom Banning, CEO of the Texas Academy of Family Physicians. “We are in a very new and unique time. I don’t think anybody was particularly prepared for what the virus has thrown upon the system.”

The emphasis on testing comes amid an investigation into what could be Texas’ first case of community spread in Montgomery County, outside Houston. Public health officials are not sure how the man, who in his 40’s, contracted the virus since he hasn’t traveled out of state or come into contact with another person known to be infected. Tests by the U.S. government and other scientists have found the coronavirus can live in the air for several hours and on some surfaces for as long as two to three days.

“The limited testing is not ideal,” said David Lakey, Vice Chancellor for Health Affairs and Chief Medical Officer at The University of Texas System, who used to lead the state’s public health agency. “We need much more capacity to do the testing in order to figure out the current situation much better than we are doing right now.”

Dr. Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Diseases, addressed the frustration over the lack of testing at a congressional hearing on Thursday.

“That is a failing. It is a failing, let’s admit it,” Fauci said, adding that that the U.S. is not set up for the immediate and readily available testing in other countries. “Do I think we should be? Yes. But we are not.”

Private labs

Two commercial labs — Quest Diagnostics and LabCorp — recently rolled out tests for coronavirus that should expand patient access. Neither company has detailed the cost for the test, but several insurance companies pledged this week to waive co-pays for the procedure when ordered by a doctor.

Within the past few days, two medical practices said they have received test kits from LabCorp that will allow them to test up to 400 people a day — rivaling the public health labs’ current capacity of roughly 240. It costs the providers about $51 per person to run the test, said Jose E. Camacho, Executive Director of the Texas Association of Community Health Centers.

Within the coming days, hospitals in the Dallas-Fort Worth area are going to set up testing places outside the emergency room, said Stephen Love, President and CEO of the Dallas-Fort Worth Hospital Council. It is not yet clear which hospitals are taking that step.

The issue of payment for private testing, however, could become a barrier for the roughly five million Texans who lack health insurance. One San Antonio public health official suggested this week private testing in the city could cost up to $2,400 without insurance, according to local news reports.

The state’s network of public health labs, that includes locations in Dallas County and Austin, does not charge for the tests. The network doubled its testing capacity this week and by automating equipment for a portion of the testing, should be able to test up to 500 people a day, said Chris Van Deusen, a spokesman for the Texas Department of State Health Services.

Still, the government labs prioritize patients for testing who show symptoms and have come into contact with an infected person, traveled recently to an area with an outbreak or are at risk of a severe case of the disease.

“Each circumstance is different,” Jennifer Shuford, Infectious Disease Medical Officer at Texas Department of State Health Services, told physicians during a conference call this week. “We do occasionally test outside of our testing criteria for those reasons.”

Officials could not say how many doctors’ requests for patient testing have been declined or directed to private labs.

Garrett tried to refer a patient to testing Wednesday afternoon. The patient had recently returned from New York with a fever and cough, but tested negative for flu and strep. After contacting government and commercial labs without success, he heard back from local public health officials Thursday who plan to run the test, he said. Two other physicians, however, said they each made a request for testing that was rejected.

Texas testing numbers

It remains unclear how many people in Texas have been tested for the virus, which causes cough, fever and shortness of breath.

The Texas Department of State Health Services reported at least 150 people had been checked through last week, but the number has likely jumped since then. A spokesman said the agency does not know exactly how many people have received tests through private labs, which is how a case in Collin County was discovered. Neither Quest nor LabCorp responded to questions about the number of people they have tested in Texas to date. Quest Diagnostics expects to have the ability to run “tens of thousands of tests a week within the next six weeks,” a spokeswoman said.

Still, some hurdles for private testing remain. Physicians must collect the patient specimens, which generally includes taking a nose and throat swab.

“The dilemma is this: the safety precautions needed to do the testing, the average physician practice doesn’t have those sitting around,” said Crow, whose organization is working to set up a centralized location for taking patient test samples.

“Primary care is your front-line supply of health care in a community; you don’t want to be pulling supply out of the system,” he said. “And so testing at the physician office is not what we are wanting to do.”

The risk is real, said Dr. Clive Fields, the Chief Medical Officer at Village MD that caught two of the Houston-area coronavirus cases. Three physicians and two nurses from the practice had to go into 14-day quarantines after they saw patients who tested positive for coronavirus, who had recently returned from a Nile river cruise in Egypt.

While Texas doesn’t have a cache of protective face masks or gowns available, the state is working to get some, DSHS Commissioner John Hellerstedt told physicians on the Wednesday conference call.

“This is going to be one of the greatest public health challenges in living memory,” he said. “There are limitations to what we have and we’re going to have to do the best under bad circumstances.”