For 42 years, James Hay, MD, had been seeing patients at the family practice he started in the Southern California beach town of Encinitas. Hay, the former president of the California Medical Association, loved his work and thought he'd keep at it at least through the end of the year.
On March 6, however, one of his partners saw a patient who -- according to a call from a county health official -- was the first confirmed case of COVID-19 in a resident who hadn't recently traveled out of town. That meant the virus was now being transmitted locally.
That turned out to be incorrect; the patient had been skiing in another state. But the positive test sent shockwaves through his practice.
It was all the more disconcerting for Hay, 73, who knew his age and a minor medical issue put him at greater risk for severe illness if he were to get infected because so little was known about how the virus behaved. When his practice partner Amy Kakimoto, MD, called him that night with the patient's test result, "she said, 'Stay home.' So I haven't been inside the office since March 11."
County public health officials issued a shut-down order a few days later and soon, office visits and revenue for Hay's six-physician practice -- and tens of thousands of others throughout the country -- plummeted as few patients ventured in for care. His group had to cut way back as many on his team took weeks off.
"I've stayed home, because of my age, doing video visits with patients instead," he said.
All that prompted Hay to come to a difficult decision. He told MedPage Today that he was retiring early, and May 28 was his last day seeing patients. He would save the practice his salary and he wouldn't have to worry as much about risks to his own health.
Hay is not alone. Dozens of physicians, practice managers, and medical society executives around the country said that among older doctors still practicing -- 120,000 of whom were 65 or older in 2017, according to one survey -- talk of an earlier-than-planned retirement is getting louder in the eye of the pandemic. While far from a groundswell, Don Palmisano Jr., executive director and CEO of the Medical Association of Georgia, heard from doctors in one health system that "older physicians have voiced their intent to possibly retire."
Three Factors
The reasons for early retirement are threefold, according to physicians interviewed for this story, some of whom asked they not be named because they haven't made a decision, haven't told their spouses, or don't want to go public with their fear that they could unknowingly bring the virus home to their families.
First among the influential factors is analysts' projections of a looming major decrease in commercial coverage, in a mid-May update from the national consulting firm Health Management Associates, for example, and a similar report from the Kaiser Family Foundation. The HMA report estimated the number of people with employer sponsored-plans could drop from 165 million as of February (pre-COVID) to as low as 138 million by year's end, depending on whether job losses are moderate, heavy, or severe.
Meanwhile, the number of uninsured are estimated to increase from 29 million to as high as 34 million, the HMA report projects.
While some laid-off workers will be able to afford an individual marketplace plan (though not in the Obamacare exchanges, which the Trump administration decided not to reopen), millions more are expected to enroll in Medicaid, which reimburses at 50% to 60% of commercial payers' rates, and 70% to 75% of what Medicare pays for the same services.
HMA estimates Medicaid enrollment could go from 71 million people to 76-89 million by the end of this year, said Eric Hammelman, an author of the HMA analysis.
"There will be drastically reduced 'churning,' of patients going on and off Medicaid for the duration of the emergency," especially since the Families First Coronavirus Response Act (FFCRA), which took effect in mid-March, limited the ability of states to involuntarily disenroll or terminate people from the Medicaid project if they didn't reaffirm their eligibility. That alone is adding between three to four million people to the Medicaid rolls, Hammelman said.
Many doctors now limit the number of Medicaid and underinsured patients they see, balancing their practices' bottom lines with profits from commercial payers; if the number of commercially insured goes down, so will a practice's ability to accept Medicaid, several acknowledged.
Nathan Kaufman, a health system consultant, said the impact will be particularly severe for California. "There are large health systems in that state that are going to get creamed because so much of their commercial business will shift to Medicaid." The recent HMA analysis projected an increase in Medicaid enrollment in California between 1.5 million and 3 million by late summer.
Glenn Melnick, PhD, health economist at the University of Southern California, said that while not all people who lose their jobs will be without coverage, the bad news is millions will not have access to their regular providers, realizing that many will not accept Medicaid payment. "And the question is, how quickly the Medi-Cal system will expand," he said, referring to California's Medicaid program.
Several analysts said it's unclear whether employers will hire workers back, but on a part-time basis without health coverage, until the pandemic subsides. It wasn't part of the HMA analysis, but Hammelman said they've been hearing stories suggesting "a lot of folks are shifting over to the gig economy. And what does that mean longer term for jobs and what does that mean longer term for insurance?"
More Hassle
The second reason is the dramatically increased amount of time and level of difficulty and hassle now required to treat a patient under COVID-19 rules, especially in practices where restrictions allow one patient or family member into an office at a time, or when doctors feel compelled to see a coughing patient in the parking lot instead of an exam room. That greatly reduces the number of patients a doctor can see in a day.
Telemedicine can suffice, but the satisfaction -- compared with seeing a patient in person -- is less than optimal, several physicians said, especially for some older doctors who have been less eager to embrace technology.
Doctors and their teams must gown and mask with appropriate personal protective equipment (PPE), which some doctors said is still difficult to find. They may insist that their patients do so as well, which can meet with resistance. Many physicians have learned to get by with video consults instead of face-to-face encounters.
"I had one patient tell me he didn't want to wear a mask," said Barbara Hummel, MD, 76, a family doctor in solo practice in Greenfield, Wisconsin. "He said it was his right not to. I said, 'well, unfortunately it's my right not to see you, if you're not willing to wear a mask.'"
Providers who decide to stick it out are having to come up with novel ways to organize and sanitize their practices, said pediatrician David Arkin, MD, owner of a three-physician practice in suburban Richmond, Virginia.
"It's cumbersome to be seeing patients one at a time, to clean the rooms in between each patient, seeing the sick ones out in their cars in the parking lot, and taking co-pay money over the phone," said Arkin, but it's all necessary to keep themselves and patients safe.
Age Group at Risk
The third major impact on the older physician is the health risk they and their families face should they become infected. Even a pediatrician like Arkin, 70, can become ill. In fact he did, with three weeks in March spent at home with his worried wife, being "the sickest I've ever been."
Arkin believes he was infected by an undiagnosed asymptomatic child. "I only saw a few sick patients and none of them had anything that looked or sounded like COVID. Kids don't have to be sick in order to spread an illness."
He hopes he has protective antibodies and isn't too worried about getting sick again, so for now, he'll keep going. "So far I'm doing okay with that, but it might come back to haunt me. I don't know."
Hummel also said she's "not ready to quit," but she noted her office is in Milwaukee County, which as of Monday had by far the greatest number of COVID-19 cases and deaths in Wisconsin, at 7,799 and 299, respectively. Two of her patients have tested positive.
A past president of the Wisconsin Medical Society and former chair of the American Medical Association's Senior Physicians Governing Council, she said a lot of her colleagues are "really nervous. We're in an age group that puts us at high risk."
Personal Decisions
Hummel limits her practice to one patient at a time, which means she's seeing one patient every 45 minutes to an hour, and gloving, masking, and "gowning up like crazy so I look like something from another planet."
Telemedicine helps, but not so much for Hummel. "I'm old fashioned enough to believe in hands-on medical care. How do you deal with a sore throat by telemedicine? I can't look at their chest pain or their shortness of breath."
But Hummel loves seeing patients so much, she's willing to risk it, even "supporting my practice with my own personal funds, my personal savings account." She got some federal Paycheck Protection Program (PPP) funds, and that helped, but it only went so far. By September, she said, she'll make a decision. "I can't leave myself with nothing to get through the rest of my life."
Another solo practice physician in his early 60s, in the COVID-19 high-risk specialty of otolaryngology, said he too will retire early because of the pandemic.
"The COVID risks -- and more so the COVID financial impacts on practicing, with low patient volumes, no elective surgery, increased costs for PPE when available, and liability issues -- make early exits for those already considering retirement more attractive," he said, requesting anonymity.
The physician fears another COVID wave this fall or next year, when further federal support may be limited, a kind of coup-contrecoup to practices as they struggle to recover.
Bottom Line
While all three factors have prompted doctors to reconsider their roles in the healthcare workforce, the financial bottom line may be the most important, said R. Shawn Martin, CEO-designate for the American Academy of Family Physicians (AAFP).
"Cash flow problems are putting a lot of pressure on doctors now," Martin said. And for physicians who are older, or under pressure financially, there's this risk, and "there's an incentive for them to leave the workforce."
Martin said AAFP members are reporting that hospitals and corporations are seeking to buy their practices.
Some will retire and sell out, Martin said. "What we're really worried about is the people ... in their mid-50s who sell their practice in a fire sale back to some venture or private equity company, because it's not worth it to kind of ride out this wave and they just want to unload the asset."
He added that what AAFP and other physician groups really want right now are federal dollars to maintain practice operations. "Do we need to pay telemedicine better? Of course. Do we need to figure out ways to provide more robust services in an asynchronous way? Of course. But right now, they just need to keep their doors open."
Matt Salo, executive director of the National Association of Medicaid Directors, said a lot of providers across the treatment spectrum have seen utilization and revenue drop by as much as 90% or more. "What is going to happen to them? Can they sustain two, four, six, nine months more where their revenue takes a hit like that?"
Compounding the issue is how states will reduce the amount they spend on Medicaid, even if the federal government approves plans to raise the federal match. They can reduce the number of people covered, reduce the benefits offered, or reduce provider payment, he said.
In California, for example, where 13 million people were enrolled in Medi-Cal before the pandemic -- one-third of the state's population -- the May revised budget calls for reductions or cancellations of coverage in many prevention and treatment programs.
On the chopping block: adult dental, audiology, incontinence creams, speech therapy, optician and podiatric care, acupuncture, optometry, nurse anesthetists, occupational and physical therapy, pharmacist services and referrals for treatment for opioids and other illicit drugs, pharmacist services and diabetes prevention programs, a projected saving to the general fund of $54.7 million.
"States have to balance their budgets," Salo continued. It's "a really unfortunate perfect storm where states are scrambling over the next couple of months figuring out what to do. And the unfortunate answer is, barring significant congressional intervention [to] massively reduce reimbursement rates."
Bob Doherty, senior vice president at the American College of Physicians, echoed that concern. "As people lose employer-sponsored care, more will end up in Medicaid, especially in expansion states," he said. And without increases in the federal Medicaid match rates, "states will likely respond by cutting payments to physicians and hospitals, and optional benefits and eligibility. Physicians will not be able to accept more Medicaid patients if the already-low Medicaid rates are cut further."
For Hay, retirement plans are evolving. He's long been active in AMA leadership and hopes to spend time promoting a return to civil discourse, and running and birding and maybe, when it's safer to travel, going on a few trips with his wife. At least he won't have to worry so much about COVID-19.