Cullen spent the first month of the pandemic overhauling his practice so he could see most patients virtually. He also devoted hours to filling out paperwork, hoping for a loan from the Small Business Administration.
So far, he’s had no luck.
“By the time we figured it out, the money was all gone,” Cullen said of the federal funds made available to struggling businesses by Congress. He applied again when more money was made available but has not heard back; the last time he asked his office manager, all he got was a laugh in response.
Many small doctors’ practices, like Cullen’s, are struggling to survive as many patients shelter at home and put off consultations for all but the most urgent issues. Although they’re still ministering to patients amid a health crisis, they’ve been unable to get loans under the Paycheck Protection Act, passed as part of the coronavirus relief package in late March.
A survey done by a Richmond-based advocacy group for primary care doctors, called the Larry A. Green Center, found that half the doctors who sought such loans were unsuccessful. Of 2,774 doctors who responded to the survey, 19 percent said they had to temporarily close their practices because of financial problems; 42 percent had to lay off or furlough staff. About 10 percent say they will have to close in the next month because of financial shortfalls.
“Primary care has been underresourced and undersupported for decades in the United States,” said Rebecca Etz, the center’s co-director.
Independent doctors say they are uniquely squeezed — forced to compete for grants against bigger practices and hospitals, or against other small businesses for loans they admit they are unlikely to be able to repay.
Without the funds, Cullen may soon be unable to pay the two young doctors who work for his practice, both of whom are saddled with hundreds of thousands of dollars in students loans.
Some are angry their plight has been ignored by federal lawmakers while cash-starved hospitals are slated to receive $100 billion in government relief. About $3.9 billion of that pool has gone to practices with 10 or fewer clinicians, according to the American Academy of Family Physicians, but it has generally paid out far less than the Small Business Association loans.
“If someone is willing to die for you, at least pay them enough to stay open,” said Joseph Valenti, an obstetrician-gynecologist in Denton, Tex.
Physicians with small primary care practices say they’ve struggled for years with stagnant insurance reimbursement rates and high overhead. Some doctors hope the crisis will provoke a reckoning that assigns greater value to what they do. But many fear they won’t last long enough to see it.
While telemedicine has been touted as part of the answer to their survival, many doctors serve rural communities with scant or no access to the Internet. Others, like Cullen, have started doing virtual visits but are frustrated by insurance payments they say are stingy and slow to arrive. Cullen said he still has not been paid anything for telehealth consultations because he submitted the wrong codes to insurance companies.
Eighteen percent of the doctors responding to the survey also said they had been denied payment for virtual visits.
Meanwhile, doctors find themselves scrounging for protective gear while going deeper in debt.
Independent doctors say they would like the federal government to renew the advance Medicare payments that ended last month and offer them more direct grants. The loans, in contrast, must be repaid if certain conditions aren’t met, and doctors say the requirements for forgiveness are overly complex and constantly changing. They would also like to see an expansion of a Medicare pilot program that rewards doctors for keeping patients out of the hospital.
But small practices that do not see many Medicare patients must appeal to individual insurance companies to float them money and pay them equally for virtual or phone appointments, as for in-person visits.
Now doctors say their patients are raising money for them online, a humbling but necessary act of charity and an evolution of the online fundraisers that are already commonplace for people experiencing medical emergencies. The Green Center survey found 236 doctors had been supported by patient donation.
Many physicians say their latest financial problems linked to the pandemic are only the most recent stress on a fast-vanishing model of health care in the United States as hospitals and large practices buy out independent doctors — often bringing higher costs.
“Eight or 1o weeks from now, practices are going to be dying and people will say, ‘Who could have foreseen this?’ ” said Farzad Mostashari, a former Obama administration health official who now runs a private health-care company. “There’s a cliff that’s fast approaching.”
In Wilmington, Del., James Gill was ready to apply for a loan for his practice the day the program opened. But his bank wasn’t. He spent a day waiting for PNC’s website to be ready, then the next two weeks checking constantly for updates.
Nearly two weeks later he finally got a response: They needed more paperwork from him. He sent it over. The next day he saw his senator on the news, announcing the program was out of money.
When he tried again after a second pot of money was announced, other banks told him to stick with PNC, because if he switched he would be at the end of their lists. He heard he had gotten the loan about a day before he exhausted a $200,000 line of credit.
“It’s been horrible,” he said. “A health care business, in the middle of a pandemic, you’re going to let go bankrupt? We have thousands and thousands of patients who would be high and dry.”
Matteo Trisolini also acted quickly but to no avail: The co-owner of South Slope Pediatrics in Brooklyn sat refreshing the page to apply for a Small Business Association loan the first moment he could. He also learned from news reports that the program had run out of money. His application for the second round was met with confusing directives and, ultimately, rejection.
Only after telling patients the practice was in danger of closing in a few weeks did one of them connect Trisolini with a local financial institution that finally helped him secure a loan. Supporters also raised about $30,000 to help pay salaries for the pediatric staff and to cover bills for patients who couldn’t.
“The community came to the rescue,” he said.
“We’re not saying that doctor’s offices are more important than the deli next door. We are equally important, and we equally need the help from the government.”
But, he added, “we should have been first.”