Primary care doctors are delivering toilet paper, testing patients in their cars, and going online to combat the coronavirus epidemic

Lydia Ramsey

Mar 21, 2020, 00:13 IST

Primary care doctors are delivering toilet paper, testing patients in their cars, and going online to combat the coronavirus epidemic

Primary care doctors are finding themselves on the front lines of the coronavirus response and are navigating how to do their part, often without the right protective gear or access to testing.
Many are moving their practices online, some have started administering COVID-19 tests. Tia, a women's health practice, has fully moved its practice online, closing its in-person clinic indefinitely.
All have the hopes of keeping as many patients as possible out of the emergency room.
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A week ago, Dr. Matthew Abinante decided that his primary care practice should test for the novel coronavirus.

Abinante runs Elevated Health, a direct primary care practice based in Huntington Beach, California. That means he charges patients a monthly fee for care and doesn't take insurance. On a typical day, his office isn't stocked with protective gear like N95 masks that are needed to take care of patients who have COVID-19, the disease caused by the coronavirus.

But in the wake of the coronavirus pandemic, he's set up a system where he is testing patients behind the loading dock of the office building where his practice is located. He runs out in gloves, mask, and white coat, patients open their car window, he collects the sample and runs back inside.

As of Friday he'd done about 60 tests and had one confirmed positive. He's offering testing beyond his usual slate of patients to the entire community for a fee of $125. That includes a telephone visit to be sure the patient has reason to be tested.

'I took an oath to do no harm'

Not everyone is happy Abinante is doing the testing. His landlord told him to stop testing. And he was reported to the fire department, who came by to make sure everything was OK.

"I took an oath to do no harm, help patients at all cost," Abinante said. "I felt like we were perfectly positioned to help."

For roughly 50% of the US population, primary care doctors are the first place they go to get their healthcare. Amid the coronavirus epidemic, doctors are faced with tough choices about how to care for patients - both those who are falling ill with COVID-19 and those they might otherwise see in a given week. Some are making the switch to seeing most patients online and test in-person, while some are opting to shut down entirely.

Ultimately, the main goal is to keep people out of hospitals and emergency rooms, unless they really need to be there.

"We created a mantra called, 'We want our patients healthy, happy, and at home'," said Dr. Chris Chen, CEO of ChenMed, a family-owned group of primary care clinics.

Moving seniors' primary care from a clinic to home

To do that, Miami-based ChenMed has decided to move more than 90% of the care it provides out of its 59 clinics. Instead, its caring for patients virtually or in their home, a decision the company made over the weekend.

ChenMed manages the health of seniors 65 and older enrolled in Medicare Advantage plans. Under the arrangements, plans pay ChenMed a set amount to keep their members healthy.

ChenMed offers services like on-site pharmacies, transportation to and from appointments, exercise options, and social networking with other seniors.

A doctor and patient at a ChenMed clinic

But with COVID-19, there's recommendations from the Centers for Disease Control and Prevention for people 60 and older to stay at home as much as possible as the virus spreads. The population ChenMed serves is one that's particularly getting hit hard by the coronavirus, with the highest death rates reported.

That makes congregating inside a clinic and in-person preventive visits too big of a risk. Chen said the organization began discussing what to do instead about a month ago.

That includes providing for some of the necessities of staying inside.

"I don't want seniors hunting for toilet paper," Chen said. Instead, the care teams ChenMed has on staff will take care of that for them.

The drivers who used to bring patients in for visits will now deliver sterilized laptops and tablets to patients' homes so they can have remote visits.

For now, ChenMed's population has only had a few confirmed cases of COVID-19. The patients have been tested through state health centers, as ChenMed currently doesn't have the ability to collect samples from patients.

If they do, Chen said, the plan will be to bring the tests to patients' homes.

"We want them to remain socially distant," he said.

Testing patients out of parking lots in Houston

Dr. Clive Fields, the chief medical officer for primary care company VillageMD, who is based in Houston, started noticing patients were canceling appointments.

Each of VillageMD's doctors manages the health of about 2,000 patients a year, including those with commercial insurance, Medicaid, and Medicare plans.

drive through coronavirus Denver Colorado

To keep patients from canceling visits as well as triage patients concerned they might have coronavirus, VillageMD is moving most of their visits online, a service they had anticipated opening in July 2020.

"We'll go from zero to a thousand visits a day over the first ten days," Fields said.

Ideally, the move will keep patients at home and out of the emergency room.

To help, VillageMD is keeping its clinics open and testing patients. In Houston, the clinics had two of the first six positive coronavirus patients in the area.

"We're providing testing now at a less than optimum situation," Fields said.

Fields has been testing patients from within their cars, coming out to the parking lot, handing them a test through the window and then having them self-administer the test, which is inserted through the nose to reach the back of the nose and throat.

It doesn't meet every requirement of how to safely and effectively administer tests, he said, but "It's the best we got."

For patients who test positive for coronavirus, Field said, the hope is for VillageMD to manage it at home, monitoring symptoms and making sure patients are staying quarantined, until or if the patient's symptoms get worse and they need medical care at the hospital.

Opting for a fully online clinic

Tia, a women's health clinic that opened in 2019 in New York City, made the decision on Sunday to shut its clinic down indefinitely in the wake of the coronavirus pandemic. It'll still see patients via video and chat.

"Like many other providers, we started saying, 'What is our role in all this,'" Tia CEO Carolyn Witte told Business Insider.

More than two weeks ago, patients started coming into the office worried about symptoms of COVID-19 and wanting testing. The clinic used swabs it had on hand and tried to send them to the state labs. The state wouldn't pick them up.

By March 13, the clinic made the decision to stop doing in-person coronavirus assessments. By the following Sunday - the day hospitals in New York made the decision to cancel elective procedures - the organization decided to go all-virtual. That put patients and healthcare providers who would otherwise have to travel to the office at less risk as well as free up staff that did in-person clinical work to help out online with coronavirus assessments.

Tia's virtual services before the pandemic were solely chat-based. In five days, Witte said, the startup built in video visits, which allows the office to prescribe new medications and more comprehensive visits. Changes the Centers for Medicare and Medicaid Services announced about payments for online visits are helping the organization make the transition.

It's required additional training for the staff, who come from a gynecology background rather than internal medicine.

As of Wednesday, there had been 50 Tia patients reporting symptoms, five of whom Tia routed to the emergency room to get tested. Some have been hospitalized, Witte said.