Before the coronavirus epidemic, Dr. Juliette Erickson and the four other physicians at Family Medicine of Grays Harbor would see as many as 130 patients a day.

Things changed dramatically at the Aberdeen practice with the March stay-at-home order, though medical appointments were not barred if urgent.

“We would sometimes only have four (patients) on our schedule,” Erickson said. “It’s devastating financially because we can’t even pay rent or our staff at that income.”

At the same time, the practice received a $37,000 bill for the annual license fee of its electronic medical records software and a $10,000 bill for flu shots. Monthly expenses for the practice typically run around $100,000, not including the physicians’ salaries or malpractice insurance.

The numbers kept her awake at night. “How do we provide patient care and still afford to pay the staff I need to do the patient care? How do we not abandon our patients during a pandemic?”

Practices like Erickson’s are vital to the communities they serve, not just for basic care but also to prevent strain on hospital emergency departments.

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“We’re taking care of 7,000 patients, and if we were to no longer exist, it would compound the disaster,” Erickson said.

Her practice is far from the only one in the state questioning whether it can survive the coronavirus outbreak, according to the Washington State Medical Association, which polled 5,000 physicians working in independent clinics in late March to try to assess the damage.

The results were alarming.

Twenty-six percent of the 311 responding practices had closed temporarily — and two practices had closed permanently, said Jennifer Hanscom, CEO of the medical association. Nearly two-thirds of practices reported they had laid off or furloughed staff because of lower patient volumes. In an April 8 follow-up survey, nearly a third of 134 practices said they had just 3–4 weeks of “days cash on hand,” defined as the number of days a practice could pay its operating expenses with cash available. (Ideally, a practice would have at least 16 weeks’ worth, according to the association.)

Among the practices forced to make cuts is Olympic Anesthesia in Bremerton, a group made up of 15 anesthesiologists with seven nurse anesthetists and an office staff of 10.

“As soon as we stopped doing elective surgeries, our surgery load dropped down to about 20% of what it was before,” said Dr. Brian Nyquist, an anesthesiologist and partner in the practice. “We pretty quickly realized within that first week how much trouble we were going to be in financially and as a group if we didn’t do something.”

Two doctors, already close to retirement, threw in the towel and retired early. Nyquist and another physician went part time; all providers have cut their pay in half. Four of the 10 staff members were laid off.

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“Even with that, we’re still going to be in the hole pretty soon,” Nyquist said.

Erickson’s practice in Aberdeen has also made cuts to stay afloat, including laying off two staff members and reducing everyone else’s hours to 32 a week. The doctors aren’t taking a salary.

“I have not personally paid myself since the end of February,” said Erickson. “It sounds a little self-sacrificing, but that was the least of my problems at the time.”

Both Nyquist’s and Erickson’s practices applied for federal small-business loans offered through the $349 billion Payroll Protection Program of the CARES Act. In both cases, it took tries with multiple banks to manage to get an application submitted before the initial round of funds ran out April 16.

Nyquist had yet to hear whether Olympic Anesthesia’s application has been approved, but Family Medicine of Grays Harbor received enough last week to cover payroll for its staff members — not providers — and rent and utilities for eight weeks.

The CARES Act separately infused $30 billion into the health-care system in the form of direct payments to providers that received Medicare reimbursements in 2019.

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Erickson’s practice received these funds, too — enough to cover slightly less than two weeks’ worth of expenses. “We were literally on a week-to-week budget, and now I think we’ll be OK for several months,” said Erickson.

The WSMA was glad Gov. Jay Inslee’s “Stay Home, Stay Healthy” order helped doctors move quickly into telehealth consultations, and the state’s requirement that physicians be paid for telemedicine services at the same rate as if those services had been provided in person.

Telemedicine’s availability is especially important while communities are practicing social distancing, and personal protective equipment is scarce.

With rules — and medical billing codes — changing quickly, Erickson’s office has scrambled to rebill and recode telehealth visits. Although the dust is still settling, at least one insurance company has paid the practice at the same rate for a telehealth visit as an in-person visit.

Those telehealth visits are helping patient volumes slowly rebound. In a recent week, Erickson saw 74 telehealth patients and eight in-person patients, about two-thirds the total number of patients she normally saw before the coronavirus hit.

If data on cases of COVID-19, the illness caused by the virus, continues to look favorable, Inslee said on Tuesday that elective surgeries may begin again soon — a development that’s been highly anticipated by practices like Olympic Anesthesia.

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Even so, the operating room looks entirely different now, Nyquist said, and all surgeries are taking longer.

“There are new procedures in place, such as waiting longer in between patients so more air exchange can happen in the operating rooms — and there have been real challenges with not enough PPE and testing,” Nyquist said.

This is sure to affect patient volumes in the future — as will the damaged economy.

“People have lost their jobs, and they don’t want to spend their money — which I completely understand — on health care,” Erickson said. “The priority is not going to be my copay, it’s going to be food and rent, as it should be.”

Since health insurance is most often tied to employment, Erickson said many people may end up going on Medicaid, the federal and state program that helps with medical costs for some people with limited income and resources.

“It’s going to be a big struggle to sustain a business on Medicaid unless Medicaid reimbursement comes up to the same payments that Medicare does,” Erickson said.

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Both Erickson’s and Nyquist’s practices have deep roots in their communities. Erickson serves as the medical director of an Aberdeen nonprofit hospice, and one of the other doctors in her practice is also head of Grays Harbor County’s health department, spearheading the county’s COVID-19 response. Olympia Anesthesia has served the Kitsap Peninsula for 50 years, Nyquist said.

Hanscom says that WSMA plans a follow-up survey to find out which practices are getting federal funds to keep going.

“We want to know, is it enough to bridge them to the other side of this outbreak so that all that pent-up demand that is occurring can be addressed,” Hanscom said.

Even with all the difficulties facing his practice, Nyquist tries to be optimistic. “If the practice goes away, we’ll all still be here trying to make a living. Despite all the negatives, we feel very fortunate to have our jobs because there are lots of people that don’t.”

The work makes him feel useful and needed, he adds. “I’m sorry I’m essentially not getting paid for it at this point, but I’m happy that I have work and that it’s helping people.”

Erickson, too, remains completely committed to her patients and the community in which they all live.

“We have to be open. People still need their meds refilled; they still need their Coumadin checked; some people are halfway through a cancer workup,” she said. “There’s absolutely no way we can just close our doors and wait for business to get better.”

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