Cormay Caine misses a full day of work and drives more than 130 miles round trip to take five of her children to their pediatrician. The Sartell, Minnesota, clinic where their doctor used to work closed in August.
Caine is one of several parents who followed Dr. Heather Decker to her new location on the outskirts of Minneapolis, an hour and a half away. Many couldn't get appointments with swamped nearby doctors for months.
"I was kind of devastated that she was leaving, because I don't like switching providers, and my kids were used to her. She's just an awesome doctor," said Caine, a postal worker who recently piled the kids into her car for back-to-back appointments. "I just wish she didn't have to go that far away."
So does Decker, who had hoped to settle in the Sartell area. She recently bought her four-bedroom "dream home" there.
The HealthPartners Central Minnesota Clinic where Decker worked was a victim of the wave of Covid-19-related closings that is starting to wash across America, reducing access to care in areas already short on primary care doctors.
Although no one tracks medical closings, recent research suggests that they number in the thousands. A survey by the Physicians Foundation estimated that 8 percent of all physician practices nationally — around 16,000 — have closed under the stress of the pandemic. That survey didn't break them down by type, but another from the Virginia-based Larry A. Green Center and the Primary Care Collaborative found in late September that 7 percent of primary care practices were unsure whether they could stay open past December without financial assistance.
What this pandemic has done is put a big spotlight on what was already a big crack in our health care system.
And many more teeter on the economic brink, experts say.
"The last few years have been difficult for primary care practices, especially independent ones," said Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis. "Putting on top of that Covid, that's in many cases the proverbial straw. These practices are not operating with huge margins. They're just getting by."
When offices close, experts said, the biggest losers are patients, who may skip preventive care or regular appointments that help keep chronic diseases such as diabetes under control.
"This is especially poignant in the rural areas. There aren't any good choices. What happens is people end up getting care in the emergency room," said Dr. Michael LeFevre, a practicing physician in Columbia, Missouri, who is head of the family and community medicine department at the University of Missouri. "If anything, what this pandemic has done is put a big spotlight on what was already a big crack in our health care system."
Federal data show that 82 million Americans live in primary care "health professional shortage areas," and the country needed more than 15,000 more primary care practitioners even before the pandemic began.
Once the coronavirus struck, some practices buckled when patients stayed away in droves for fear of catching it, said Dr. Gary Price, president of the Physicians Foundation, a nonprofit grant-making and research organization. Its survey, based on 3,513 responses from emails to half a million doctors, found that patient volumes had dropped by more than a quarter at 4 in 10 practices.
A survey released last month by the California Medical Association found that revenues dropped by at least half in a quarter of practices in the state. One respondent wrote: "We are closing next month."
Decker's experience at HealthPartners is typical. Before the pandemic, she saw about 18 patients a day. That quickly dropped to six or eight, "if that," she said. "There were no well checks, which is the bread and butter of pediatrics," she said.
In an emailed statement, officials at HealthPartners, which has more than 50 primary care clinics around the Twin Cities and western Wisconsin, said that closing the clinic in Sartell "was not an easy decision" but that the pandemic caused an immediate, significant drop in revenue. While it continued to provide dental care in Sartell, northwest of Minneapolis, the company encouraged employees to apply for open positions elsewhere in the organization. Decker got one of them. Officials also posted online information for patients about where more than 20 clinicians were moving.
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The pandemic's financial ripples rocked practices of all sizes, said LeFevre, the Missouri doctor. Before the pandemic, he said, the 10 clinics in his group saw a total of 3,500 patients a week. Covid-19 temporarily cut the number in half.
"We had fiscal reserves to weather the storm. Small practices don't often have that. But it's not like we went unscathed," he said. "All staff had a one-week furlough without pay. All providers took a 10 percent pay cut for three months."
As revenues dropped in medical practices, overhead costs stayed the same. And practices faced new costs, such as personal protective equipment, which grew more expensive as demand exceeded supply, especially for small practices without the bulk buying power of large ones.
Doctors also lost money in other ways, said Rebecca Etz, co-director of the Green Center research group. For example, she said, pediatricians paid for vaccines upfront, "then when no one came in, they expired."
Some doctors took out loans or applied for Provider Relief Fund money under the federal CARES Act. Dr. Joseph Provenzano, who practices in Modesto, California, said his group of more than 300 physicians received $8.7 million in relief in the early days of the pandemic.
"We were about ready to go under," he said. "That came in the nick of time."
While the group's patient loads have largely bounced back, it still had to permanently close three of 11 clinics.
Said Dr. Ada Stewart, president of the American Academy of Family Physicians: "We've got to keep practice doors open so that we don't lose access, especially now that people need it most."
Caine, the Minnesota mom, said her own health care has suffered because she also saw providers at the closed Sartell clinic. While searching for new ones, she's had to seek treatment in urgent care offices and the emergency room.
"I'm fortunate because I'm able to make it. I'm able to improvise. But what about the families that don't have transportation?" she said. "Older people and the more sickly people really need these services, and they've been stripped away."