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How Providers Are Adjusting to Clinical Care Post-PHE

Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.

Sterling Ransone, Jr, MD’s first day of seeing patients without a mask was, simply put, “unsettling.” 

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

The White House last week lifted the public health emergency (PHE) order that overhauled the way healthcare providers operated and advised patients over the past 3 years. The new postpandemic era will require clinicians and staff to once again adjust. 

For Ransone, this transition entails getting used to his bare face, reminding patients of the latest and varying symptoms of the virus, and parting ways with sick patients if they refuse to wear a mask.

As states, hospitals, and healthcare systems around the country relax their mask mandates for care providers, clinicians will have to fall back on their own policies that patients with potential symptoms mask up. 

“Now that it’s up to our offices, we have to have a little bit more backbone,” Ransone said. “If they’re not willing to follow a health-related policy that will protect the vulnerable, we will not see them. And so for us, it’s been pretty straightforward.”

Despite the policy, Ransone has cared for patients who don’t disclose they are feeling sick until he enters the room. 

“And I wasn’t masked,” Ransone said. So, “I will wear masks for the rest of the day just to try to protect the rest of my patients in case I was exposed.”

Masks are optional for both patients and staff at 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 are experiencing respiratory symptoms, like a cough, they are asked to wear one. 

“When the patient first walks up to you, you have no idea what they have,” Khanna said. 

Khanna is especially mindful of immunocompromised patients who have cancer, and Ransone cares for several patients who have received kidney transplants and are on potent immunosuppressive drugs. 

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

Some patients have anxiety about the end of masking in doctor offices, but others have been excited about interacting more with their care teams, according to William Dahut, MD, chief scientific officer for the American Cancer Society. Many clinicians will advise their most immunocompromised patients the same as they did prior to the COVID-19 pandemic, he said. 

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

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

But the accessibility of vaccinations is also shifting.

Testing Shifts

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 the immunizations, as they are considered preventive, but people without insurance 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 that clinicians can keep them in stock, according to Iroku-Malize. Once the federal government transitions COVID-19 vaccines to the commercial market — as early as later this year — it may pose some challenges for providers, she said. 

“If the price of the vaccines is too high, physician practices may struggle to make the upfront investment in COVID-19 vaccines,” Iroku-Malize said. “Patients often prefer to receive vaccine counseling and administration from their usual source of primary care, like their family physician.” 

The federal government has also said it still has a supply of treatments for the public to access for free, but has not revealed how much it has on hand or given a timeline for the transition to the private market. 

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

Pediatrician Lisa Costello, MD, MPH, knows that price point 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 free tests. 

“Testing if you’re a higher risk person is something we need to ensure that people continue to be educated about,” Costello said. 

She’s hopeful that COVID-19 vaccines and treatments such as Paxlovid will stay free in the coming months so patients can continue to easily access them. 

Future of Telehealth

Relaxed regulations of prescribing controlled substances via telehealth and across state lines allowed clinicians to treat patients near and far during the pandemic. But many providers were worried about a proposal from the US Drug Enforcement Administration (DEA) to clamp 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 is for many clinicians a very valuable policy,” Fendrick said of the telehealth flexibilities introduced during COVID-19. 

The DEA, after getting 38,000 comments on their proposed regulations, pulled back on that plan last week, delaying the cliff until November. 

Fendrick said that telehealth has allowed clinicians to reach patients who have historically faced barriers to care, such as lacking transportation. 

“The benefits of that outweigh the potential harms,” he said. “Every policy you make that tightens access because you want to decrease the untoward and unfortunate outcomes will also decrease access to clinical indications.”

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

Medicaid Changes

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

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

That could affect the treatments Khanna recommends for her patients who get kicked off because those who become uninsured or transition to private insurance will have to pay more out of pocket. Maryland will start 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 medications you can provide, the testing you can provide,” Khanna said. 

States were authorized to remove people from Medicaid as of April 1, with Arkansas, New Hampshire, and South Dakota starting right away. But many states are just now getting the review process going. About a dozen states, including Indiana, Ohio, Utah, and West Virginia, started removing people this month. 

Uninsurance rates hit record lows across the United States during the pandemic. Keeping Americans on health insurance is a top priority for the AAFP, Iroku-Malize said. 

“We know health care coverage disruptions prevent people from seeking and accessing the care they need,” she said.

Many people who are removed from Medicaid will be eligible for health insurance through employers, or through the Affordable Care Act’s private marketplace. But premiums and deductibles are often higher in these plans, which studies have shown result in patients delaying medical visits and not filling prescriptions or receiving treatment. 

Staying Mindful

Hospitals that receive federal funds will still have to report COVID-19 test results to the Centers for Medicare and Medicaid Services through 2024, although private labs will no longer be obligated 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 clinicians and others would watch for daily totals of case counts with the type of fervor typically reserved for live scoring updates during sports games, according to Costello.

“We just have to be mindful of the numbers that might be coming in,” Costello said.

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

“I don’t want to see physician offices fall into that trap that it’s over and be a potential nidus for infection for other patients,” Ransone said. “It’s incumbent upon us to remind people of the current symptoms so that folks will know when they need to wear a mask when they’re around their grandmother.”

The move away from universal masking in the office has benefits. Many of his older patients have difficulty hearing and had used lip reading to help understand him, he said. During the pandemic, masks got in the way of that form of communication. Now they can see his mouth again and better decipher what he says.

“Being able to have that face-to-face contact, without a mask intervening, has been really beneficial for a lot of my older patients,” he said. 

Amanda Schmidt is a journalist living in Virginia.

Additional reporting, by Lisa Gillespie. 

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