Between stay-at-home orders, hospital restrictions and resource limitations, the COVID-19 pandemic resulted in a significant decline in physician gross revenue affecting all specialties, with infectious disease experiencing a 1.8% gross revenue decline in 2020 relative to pre-pandemic baseline values, despite being in high demand (Health Affairs 2024;43[7]:994-1002).
“I think the decline overall for ID physicians during this time was, one, due to increased time spent working with hospitals and hospital systems to develop COVID-19 treatment protocols and isolation standards and, two, due to a decrease in elective procedures or surgeries that would have normally resulted in ID consultations from post-op infections, etc.,” said Ronald Devine, MD, FACP, FIDSA, an ID specialist with the Atlanta ID Group, who was unaffiliated with the study.
Dr. Devine said spending more time seeing COVID-19 patients and lack of documentation for billing during the crisis also might have contributed to this decrease in ID revenue in 2020.
The researchers analyzed revenue from 427,140 physicians across different specialty- and provider-type categories from one of the largest repositories of commercial plan data, the Blue Cross Blue Shield Axis database (2018-2022). They used these data to compare pre-pandemic (2018-2019), pandemic (2020) and post-pandemic (2022) revenue across specialties.
“While all specialties experienced a sharp decline in revenue in 2020, and this was across hospital-owned health systems and independent clinicians, there was significant variability in recovery of revenue in 2022,” said Ravi Parikh, MD, MPP, a medical oncologist at the University of Pennsylvania, in Philadelphia, and lead study author.
Most specialties recovered to near baseline (2018-2019) revenue between January and June 2022, and certain specialties even experienced a recovery far above baseline: Pathology saw a 26.6%, rheumatology a 12.4% and gastroenterology a 12.1% increase in adjusted recovery in revenue in 2022 compared with pre-pandemic levels, according to the study.
However, some specialties have not recovered including ID, which experienced a 5.66% revenue drop between 2018 and 2022. Dr. Devine reported hearing from other ID physicians that they saw a dip in their revenue over this five-year period.
“I would think that ID physicians are still doing additional work for hospitals or hospital systems that evolved from COVID-19 work and remain uncompensated, which decreases in their time to see patients and therefore decreased revenue,” Dr. Devine wrote in an email to Infectious Disease Special Edition.
Many specialties with higher volumes of elective procedures observed a similar revenue decrease. Surgery revenue, for example, decreased by 4.45% over this same period.
“I have observed this nationwide revenue drop in my own private practice,” said George Tsioulias, MD, PhD, a general surgeon in Astoria, N.Y. “Certainly, my practice has not recovered from COVID. I think it’s going to take many years to get there. Although my patient volume has increased substantially, almost double or triple since the COVID years, my revenue has not commeasured with this increase in volume.”
Other specialties such as cardiology, pulmonology and critical care, obstetrics-gynecology and anesthesiology are even further below pre-pandemic revenue baselines than ID, with cardiology suffering the highest adjusted revenue decrease of 10.91%.
Compared with Drs. Tsioulias and Devine’s ID colleagues, Dr. Devine himself and Mazen Al-Mansour, MBBS, a hernia specialist at the University of Florida in Gainesville, did not suffer this decrease in revenue. While Dr. Devine, who works in private practice at a tertiary care hospital, attributes this to the fact that he “continued to maintain relative volumes,” of patients before and after the pandemic, Dr. Al-Mansour believes his immunity to revenue decline is because his compensation depends on relative value units (RVUs), which have not changed at his hospital.
“My suspicion is that there may have been a drop in collections per RVU in many places. So, if you made 6,000 RVUs in one year and pre-COVID that translated as a certain dollar amount, now the same 6,000 RVUs might translate to a lesser amount,” he told IDSE. “But I don’t think that’s necessarily related to COVID itself. I think it’s maybe just the overall decline in reimbursement from insurance carriers.”
Drs. Tsioulias and Al-Mansour both said the revenue decline observed could be caused by dropping reimbursement rates and encouraged physicians to voice their concerns. “As a medical community as physicians, we need to be more active in advocacy,” Dr. Al-Mansour said. “This continued trend of decreased reimbursement, I think it’s really endangering medical care.”
However, Dr. Parikh maintains that because this study controlled for changing reimbursement rates, geography and other patient-level characteristics, “I don’t think that’s what we’re observing necessarily in this data set. This data set looked at commercial insurance file claims so the denominator of patients was those that had commercial insurance, and these make up a majority of the patients we’re seeing in a lot of specialties and a lot of clinics.”
Because the data suggest large practice size and participation in accountable care organizations (ACOs) protected physicians against revenue decline, Dr. Parikh suggested physicians consider alternative care methods and partnering with ancillary third-party services. “For services that are highly dependent on referrals, we found a strong benefit, strong robustness to pandemic-related decline by being affiliated with a health system or ACO,” he explained.
Because virtual care and telemedicine, popularized during the pandemic, are here to stay, Dr. Parikh recommended physicians engage in virtual methods to make their practices more resilient. Necessary also is the involvement of the government in monitoring reimbursement rates, as well as the specialties and types of physicians experiencing lagging revenue recovery who are more prone to consolidation and private equity acquisition, according to Dr. Parikh.
“I think the government should be monitoring trends in reimbursement across payors, Medicare and commercial payors, and looking at the associations between revenue declines and consolidation of care and private equity acquisition and the like, because we do know that those things could result in lower quality and potentially higher cost care and are generally seen as potentially worrisome,” Dr. Parikh said.
The sources reported no relevant financial disclosures outside their practices.
This article is from the October 2024 print issue.