Increased Organizational Stress in Primary Care: Understanding the Impact of the COVID-19 Pandemic, Medicaid Expansion, and Practice Ownership

• Practices report high levels of stress, burnout, and moral injury

• EHR use felt to compromise person-centered care

• Administrative work with insurance contributing to sense of disenchantment with the profession

• We're burnt out, we all admit to each other. Not only the clinicians, but the nurses too. Pretty much everybody is just exhausted.

• So when you talk about physician burnout, they’re there. Which is sad because I have amazing physicians that I work for who are phenomenal, who care deeply for their patients. And the thing that's getting in their way right now is the bureaucracy of the EMR. Are you putting the things in the right places, are you checking the boxes.

• The complicated administrative work with insurance is a nightmare…Instead of improving the knowledge base, instead of facilitating processes to improve the care of patients, we have this monstrous machine that has been created.

• We don't get paid for taking care of patients. We get paid for doing [things] to them. And the electronic medical record (EMR) is kind of like a cash register. It's not really about taking care of a patient. It's about did you click this right button?

• Practices still recovering from financial strain accrued during COVID-19

• Financial stresses due to low volume of patients and payment for COVID-19 tests and vaccines

• We had a lot of struggles getting payers to pay for COVID tests.

• COVID was really tough for us. We are an independent practice and so it was difficult and we still have not fully recovered from the hit.

• [The Director of Medicaid] sent a memo saying COVID vaccines will be paid $40 for Medicaid patients. But a lot of Managed Care Organizations (MCO)s did not pay that until later on, or it was rejected, like by Anthem HealthKeepers. Or was rejected first and then later on they only paid us like $15 or $20.

• As a consequence of COVID we no longer have that office.

• Practices stressed with high rates of staff turnover and chronic shortage of clinicians

• Practices lack capacity to meet demand for primary care

• I'm always struggling because I don't ever have enough people. And it seems like as soon as I get just enough people to get by, someone's leaving or we have a new clinical need.

• That to me is the biggest thing that I'm burnt out on. It’s constant re-onboarding, retraining, redoing the whole thing. It's costing us thousands of dollars a person.

• We are struggling. We are very stressed. We've lost a lot of providers. Not just providers, actually, but everybody in the healthcare system. At every level people have left.

• This is an organization where people tend to stay for a long time and our staff turnover was below 10% before COVID. But in the past two years, it's been like 35%. We've got 225 employees; we had to rehire 75 employees in the first year, and something close to that in the second year.

• Medicaid payments insufficient to adequately care for population

• Medicaid is really a challenge because it's really underpaying me.

• I feel like payment for Medicaid has not kept up with the expenses of a practice.

• All those added administrative burdens are really bad…It's just one of those things that I think Medicaid should listen to, like, I'm saving your patients from going to the emergency room, after all my clinic is right across from the ER. So there’s different kinds of support that I really need to help these families.

• I could say I won't see you again because I don't accept Medicaid anymore. And if that happens, the majority of my patients will probably not be seen anywhere else except in the emergency room.

• Unsupported mandates from health systems

• Lack of health system support for primary care

• Independent practice recruitment struggles

• Benefits of a health system

• One of my partners resigned last summer…because of partnering with [the health system], because of their insistence on things that were not necessary and weren't part of our agreement. I too nearly resigned twice within 12 months and looked at a Plan B of what else would I do?

• They have this big emphasis on resilience. What I can't get them to understand is how to better take care of people in the office. And to do that you’ve got to fix the system too. And they are very much into telling you great things about how to be more resilient. Hell, I'm pretty resilient. I'm still here after four decades. But what we need help with is the system, improving systems of care, so that I can spend my time doing Doctor level stuff.

• The hospital systems that I'm employed by, they get the money, and it doesn’t go to primary care…Instead, it goes to the Accountable Care Organization (ACO), it goes to the hospital system, it goes to whatever group the primary care doctor is working for. It’s not designated as this money is for primary care.

• We have great difficulty recruiting new doctors to the organization. We are competing with hospital-based hiring that pays brand new primary care physicians high salaries and gives them a high benefit package, which they deserve. We of course try to sell [new recruits] on the other features; more personal care, more personal involvement, maybe even the possibility of buying into the practices and owner as a partner. There's a lot more that can be offered in some regards, but not financially.