Small doc groups struggle with telehealth, state panel finds

Many Massachusetts physician groups are struggling to leverage telehealth as they continue to deal with lagging patient volumes, according to new data.

Small physician groups across the country had not seen volumes return to pre-pandemic levels as of early October, in part because they have not been able to incorporate telehealth into their practice, which was mirrored in Massachusetts.

Overall, there were more struggling physician practices in Massachusetts than successful ones as of September and October, according to data released Wednesday by the Massachusetts Health Policy Commission. Although some typically larger providers could use telehealth to increase access, many found it difficult to use or clinically inadequate, and patient volumes declined, in part due to technological barriers. Many clinicians were burned out as they weighed the future of their business.

"I have been considering early retirement and dramatic consolidation," one independent specialist practice wrote in HPC's fall survey. About a third of independent practices have shifted to a concierge model and 11% have consolidated with other practices. Many of the clinical and non-clinical staff who were furloughed at behavioral health practices have not been rehired.

"We put a tremendous amount of chronic disease management and patient contact on hold," a primary care provider wrote.

Some of the most significant discharge declines—ranging from 100% to 41% in April—across Massachusetts hospitals involved osteoarthritis, cardiac dysrhythmias, heart failure and acute myocardial infarctions, according to Massachusetts Center for Health Information and Analysis data. While some discharge volumes like diabetes mellitus and alcohol-related disorders rebounded to pre-pandemic levels in June, many were still off by at least a 20%.

Overall emergency department visits were down about 20% in September compared to the same prior-year period, which is often a primary referral source for hospitals. But many Massachusetts systems were taking in more behavioral health cases through the ED, which isn't an ideal setting.

"We have heard anecdotally from hospitals that they are struggling with ED volumes specific to behavioral health patients, and are seeing a spike in ED boarding," said David Seltz, executive director of the HPC, said during the commission's board meeting Wednesday. "That is a trend that the secretary (of health and human services) is very concerned about."

COVID-19 relief funds helped soften the blow for Massachusetts hospitals, according to data from 37 of 61 of the commonwealth's acute-care facilities. Federal and state relief funds could not offset the sharp decline in revenues in March and April, but they helped neutralize losses in May and led to double-digit positive margins in June and July. Though, one commissioner cautioned, those large gains may not account for clawbacks of overpayments or when funds weren't used appropriately.

Hospitals are adapting to payer mix changes, which have been trending toward coverage that nets lower reimbursement levels. Since March, MassHealth enrollment has increased 7.8% as commercial enrollment declined 1.6%, often stemming from residents who lose their employer-based coverage. Medicare enrollment in Massachusetts increased 3.2% over that span.

As reported across the country, COVID-19 is disproportionately impacting people of color. Black and Hispanic commonwealth residents accounted for 38.3% of COVID-related inpatient discharges from April to June compared to 20.5% of non-COVID discharges.

Providers were most concerned about the socioeconomic impacts of COVID-19 on patients related to job loss, evictions, food insecurity and other consequences. The next-highest concerns involved staff burnout, mental and physical effects on COVID-19 patients, and access to in-person care.