How providers are adapting to post-PHE clinical care

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The first day Sterling Ransone, Jr, MD saw patients without a mask was, simply put, “creepy.”

“I can’t tell you how weird it was the first day I walked down the hall from my office to where my exam rooms are, not having a mask after a three-year habit,” said Ransone, a physician at family in Deltaville, Virginia, and chairman of the board of directors of the American Academy of Family Physicians (AAFP).

The White House last week lifted the public health emergency (PHE) order that overhauled how health care providers have been operating and advising patients for the past 3 years. The new post-pandemic era will require doctors and staff to adapt once again.

For Ransone, that transition involves getting used to his bare face, reminding patients of the latest and various symptoms of the virus, and separating himself from sick patients if they refuse to wear a mask.

As states, hospitals and health care systems across the country relax their mask mandates for health care workers, doctors will have to fall back on their own policies that mask patients with potential symptoms.

“Now that it’s time for our offices, we need to have a little more backbone,” Ransone said. “If they’re not willing to follow a health policy that protects the vulnerable, we won’t see them. And so it was pretty straightforward for us.”

Despite the policy, Ransone has taken care of patients who don’t reveal they are feeling sick until he enters the room.

“And I wasn’t masked,” Ransone said. Then, “I’m going to be wearing masks for the rest of the day just to try and protect the rest of my patients in case I get exposed.”

Masks are optional for both patients and staff in the University of Maryland Medical System, but Niharika Khanna, MD, MBBS, said she still wears one with her patients and her office advises staff to do the same . If patients experience respiratory symptoms, such as coughing, they are asked to wear one.

“When the patient first comes up to you, you have no idea what he’s got,” Khanna said.

Khanna is especially attentive to immunocompromised patients who have cancer, and Ransone takes care of several patients who have received kidney transplants and are on powerful immunosuppressant drugs.

“I know they’re appreciating our efforts to protect them, and I think other patients are realizing it’s a wise thing to do,” Ransone said.

Some patients are eager for an end to masking in doctors’ offices, but others have been excited to interact more with their care teams, according to William Dahut, MD, scientific director of the American Cancer Society. Many doctors will counsel their most immunocompromised patients as they did before the COVID-19 pandemic, he said.

“There have always been guidelines that oncologists have given to immunocompromised patients, we’ve always told them to avoid crowded places, crowded scenes, to be outside more than inside,” Dahut said. “Those general recommendations will continue.”

The AAFP supports masking to limit the spread of COVID, but “the most important thing people can do is get vaccinated,” said Tochi Iroku-Malize, MD, MPH, MBA, president of the AAFP.

But the accessibility of vaccinations is also changing.

Trial rounds

The government will continue to provide free COVID-19 vaccines because it still has supplies on hand. When this stock runs out, commercial insurance providers will be required to cover vaccinations, as they are considered preventative, but uninsured people will have to pay out of pocket.

The AAFP is pushing the Biden administration and Congress to keep the purchase price of those vaccines low enough for doctors to keep them in stock, according to Iroku-Malize. Once the federal government brings COVID-19 vaccines to the commercial market as early as year’s end, it could pose a challenge for suppliers, he said she.

“If the price of vaccines is too high, medical practices may find it difficult to make the initial investment in COVID-19 vaccines,” Iroku-Malize said. “Patients often prefer to receive advice and vaccine administration from their usual source of primary care, such as their GP.”

The federal government also said it still had a supply of treatments that the public can access for free, but did not disclose how much it has available or provide a timeline for moving to the private market.

COVID-19 tests, meanwhile, are no longer covered due to the end of the public health emergency and cost an average of about $45 per kit, according to an analysis by KFF (Kaiser Family Foundation).

Pediatrician Lisa Costello, MD, MPH, knows the price will be a challenge for some families she cares for at West Virginia University Medicine Children’s Hospital in Morgantown. Many still ask her where they can access the free tests.

“Testing whether you’re a high-risk person is something we need to ensure people continue to be educated,” Costello said.

He hopes vaccines and COVID-19 treatments like Paxlovid will remain free in the coming months so patients can continue to access them easily.

The future of telemedicine

Relaxed regulations on prescribing controlled substances via telehealth and across state lines have allowed doctors to treat patients near and far during the pandemic. But many providers were concerned about a proposal by the U.S. Drug Enforcement Administration (DEA) to crack down on the prescribing of controlled substances via telehealth, according to A. Mark Fendrick, MD, an internal medicine physician at the University of Michigan in Ann Arbor.

“We were all panicking about what was going to happen to what many doctors think is a very valuable policy,” Fendrick said of the telehealth flexibilities introduced during COVID-19.

The DEA, after receiving 38,000 comments on the proposed regulations, pulled that plan last week, delaying the cliffhanger until November.

Fendrick said telehealth has enabled doctors to reach patients who have historically faced barriers to care, such as lack of transportation.

“The benefits of this outweigh the potential harms,” ​​he said. “Any policy you make that restricts access because you want to reduce unpleasant and unfortunate outcomes will also reduce access to clinical indications.”

The AAFP said it hopes for clear guidance from the DEA in the coming months on what the new prescribing telehealth landscape will look like.

Changes to Medicaid

About half of the patients who see Khanna have Medicaid insurance.

During the public health emergency, states were not allowed to remove anyone from Medicaid, whether they no longer qualified for the program or not. But a law passed in Congress last year requires states to once again verify Medicaid eligibility. As many as 15 million people could lose their Medicaid coverage.

This could affect the treatments Khanna recommends to his patients who are being kicked off because those who go uninsured or switch to private insurance will have to pay more out of pocket. Maryland will begin removals in June.

“When you have an uninsured patient versus Medicaid, it’s a huge difference in what you can ask the patient to do, the drugs you can provide, the tests you can provide,” Khanna said.

States were allowed to remove people from Medicaid starting April 1, with Arkansas, New Hampshire and South Dakota starting now. But many states are only now starting the review process. About a dozen states, including Indiana, Ohio, Utah and West Virginia, began removing people this month.

Uninsured rates have hit historic lows in the US during the pandemic. Keeping Americans on health insurance is a top priority for the AAFP, Iroku-Malize said.

“We know that disruptions in health coverage keep people from seeking and accessing the care they need,” he said.

Many people who are removed from Medicaid will be eligible for health insurance through their employers or through the Affordable Care Act’s private market. But premiums and deductibles are often higher in these plans, and studies have shown that patients delay doctor visits and do not fill prescriptions or receive treatment.

Stay aware

Hospitals receiving federal funds will still be required to report COVID-19 test results to the Centers for Medicare and Medicaid Services through 2024, although private labs will no longer be required to do so. The Centers for Disease Control and Prevention will also continue to monitor virus levels in communities through wastewater. But some states will no longer collect data.

Gone are the days when doctors and others watched daily case count totals with the kind of fervor typically reserved for real-time score updates during sports matches, according to Costello.

“We just need to be aware of the numbers that might come in,” Costello said.

Ransone, however, cautioned that doctors don’t become complacent. In early May, Ransone saw two patients with conjunctivitis, what the patients thought was simply pink eye, a symptom of the latest variant of COVID-19. Both patients told him it wasn’t possible they had COVID-19 because they didn’t have a cough.

“I don’t want to see doctors’ offices fall into the trap that it’s over and be a potential hotbed of infection for other patients,” Ransone said. “It’s up to us to remind people of their current symptoms so people know when to wear a mask when they’re around Grandma.”

Moving away from universal masking in the office has benefits. Many of his older patients have hearing difficulties and have used lip-reading to help him figure it out, he said. During the pandemic, masks have hindered that form of communication. Now they can see his mouth again and better understand what he’s saying.

“Being able to have that face-to-face contact, without the intervention of a mask, has been really helpful for a lot of my older patients,” she said.

Amanda Schmidt is a journalist who lives in Virginia.

Additional reporting, by Lisa Gillespie.

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