One morning in March shortly after the coronavirus shutdown, Dr. John Waits was at his clinic at Cahaba Medical Care in rural Bibb County. The clinic has seen a 30-40% reduction in revenue.

“We normally have 16 patients in a morning; (that morning) we had four,” he said. “And two of them were no-shows.”

One of the remaining patients, a woman in her 80s, called the office because she couldn’t figure out how to use Google Hangouts, the platform used by the clinic’s telemedicine system. The patient had an iPhone with video capability but couldn’t figure out how to open the link. Waits eventually called the woman on FaceTime and did the appointment that way.

But it’s far from ideal. “The easiest thing to do would be to FaceTime everybody, but it’s not as secure,” said Waits’ partner, Dr. Laci Smith. And letting patients have a doctor’s cell number creates its own set of challenges. “If I’m off call for a week, I don’t want them leaving voicemails on my cell phone if they have chest pain.”

As the economic shutdown wallops small businesses in nearly every sector, healthcare providers haven’t been immune. They face a double whammy: A drastic decrease in patient volume and a decrease in the amount of money insurance is willing to reimburse for the one thing that’s been heralded as the future of healthcare: telemedicine.

“It’s natural to think that this is a medical crisis, so the hospitals and doctors’ offices must be getting slammed, but neither of those are true,” said Dr. Justin Cooke, a primary care physician and co-owner of Community Urgent Care in Fultondale.

“That’s not to take away from what our (hospital) colleagues are doing, because they’re under a tremendous amount of stress. But overall, the system has taken a financial hit.”

And in a state like Alabama, where 62 out of the state’s 67 counties already have a shortage of primary care providers, any doctors closing their doors could have a serious impact on healthcare.

“I don’t think there’s any dedicated physician that wants to look at their practice as a business, as a way to make money,” said Cooke. “But you have to pay staff, pay bills, pay rent. You have to have revenue in order to take care of your patients.”

Two weeks left

At the beginning of flu season last year, Cooke and his co-owners at Community Urgent Care in Fultondale decided to restructure their budget to create a nest egg in the bank.

Doctors aren’t known for their business acumen, he joked. But now, he says, that one decision seems almost clairvoyant.

Coronavirus hit the United States in late January, and most businesses shut down in Alabama by mid-March. Soon the clinic’s average of about 65-70 patients per day slowed to a trickle of around 15 telehealth calls per day, he said. Revenue plummeted 80 percent.

“If we had not put some money in the bank to fall back on, we’d have been out of business three weeks ago, easily,” said Cooke. “At the current rate of loss of revenue, we have about two to three weeks in reserve.”

Cooke and his partners applied for a loan a few weeks ago through the Small Business Administration’s Paycheck Protection Program that would help them continue paying their 20 employees as well as rent and utilities.

But they learned late Thursday the program has run out of money and they won’t get a loan.

“Unless Congress acts quickly to add additional funds, we might be looking at the possibility of having to close our doors until funding becomes available,” he said, “or even permanently.”

Digital divide

Telemedicine hasn’t been the financial savior that some expected.

The infrastructure needed for a workable, widely adopted telemedicine system “simply did not exist” in Alabama prior to coronavirus, said Dr. Christopher Adams, a rheumatologist at East Alabama Medical Center in Lee County.

“From my personal experience, we tried two different ways of doing it before our medical center IT department said to heck with it, we’re going to contract this out to a third party,” he said.

And yet, most of his telemedicine visits still take place via phone call instead of video call. Internet access remains spotty or nonexistent in parts of the state, and many people don’t have access to a laptop or phone with a camera.

“I practice in a somewhat rural area, as do many other doctors,” Adams said. “So half of my patients are university types and have the technology. The other half are out driving tractors, or welding, or in construction. These patients often don’t have a video capability.”

Low insurance reimbursements

Cooke said most of his office’s telemedicine visits are also over the phone. “A lot of our Medicare patients don’t have the hardware or the knowhow to participate in a video chat format for a visit,” Cooke said.

Most insurance plans, including Medicare, now reimburse a doctor at the usual office visit rate if the telehealth visit is through video. But because of the lack of infrastructure or internet service, many doctors are forced to rely on telephone visits.

About 80 to 85% of Adams’ patients can’t do video appointments, he said. For a recent 40-minute phone appointment, he said, he received $12 from Medicare, the rate for a 10-minute office visit.

“The telehealth reimbursement is tragic,” he said.

Transformed overnight

Part of the reason there’s no telemedicine infrastructure, said Smith, is that prior to the coronavirus pandemic, insurance in Alabama didn’t pay for telemedicine visits for primary care.

Specialists like cardiologists or psychologists could get reimbursed, but primary care doctors could not.

After coronavirus hit, the Centers for Medicaid and Medicare widened coverage so that a video telemedicine visit could be reimbursed at the same rate as an in-office visit. Other carriers followed suit, including Alabama Medicaid.

But that capability is so new that primary care doctors didn’t get much time to launch their telemedicine systems.

“Our whole healthcare system for 70, 80 years is designed around coming into the doctor’s office, and now in a weekend we were trying to implement in a week this thing we’d normally spend 18 months rolling out,” said Waits.

Pay cuts

In other areas of the state, pay cuts for doctors and staff are already a reality.

Last week, leadership at EAMC took temporary pay cuts to cover expenses from COVID testing and screening, increased staffing, and a lack of elective surgeries and non-emergency patient visits. EAMC has been at the epicenter of Alabama’s coronavirus outbreak, treating an average of 40-50 patients hospitalized with COVID-19.

“I asked our senior leadership team to take the first (pay) cut and then we asked our employed physicians as well,” said Laura Grill, EAMC president and CEO, in a statement. “Then (April 8) we communicated a reduction in pay to the rest of our leadership team – our directors and managers. I am very hopeful that these cuts will be temporary and that business will return to normal in the near future.”

‘We’re not quitters’

Cooke said one of the biggest lessons he’s learned from the coronavirus epidemic was that there’s no grand plan, nobody waiting in the wings to tell doctors how to transition to telehealth, how to reorganize their businesses. After the initial panic, he said, he and other providers have had to just move forward however they think is best.

“Even though patient volume is low,” he said, “the workload is still high and it’s still pretty stressful for everybody involved.”

Cooke said he and his partners are working on a plan to start allowing well patients to come in again for clinics. But not getting the Small Business Administration loan they’d hoped for means that more drastic measures aren’t off the able anymore.

If the worst happened and the clinic had to close, Cooke said he hopes it would only be temporary.

“We’re going to rebound from this,” said Cooke. “It’s just a matter of what that looks like, and the timing. Is there going to be a period where we have to close our doors? So many moving parts, it’s hard to tell. But we’re not quitters.”