The COVID-19 virus has tested the world’s population and economy, leading to changes in the way we deal with all aspects of life. The idea of months ahead of social distancing, mask wearing, high unemployment, business closures, new rules for eating in restaurants and limited attendance at concerts and sporting events does not bode well.
Likewise, the virus has placed an undue burden on many health care workers on the front lines. Assuming we bring the management of this virus under control, it remains unclear what impact it will have on the health care profession.
Prior to the pandemic, nephrology had already lost much of its glitter as a specialty when compared to other internal medicine subspecialties. The nephrology match program in 2020 was 62%, meaning 38% of the positions remained unfilled or were filled by candidates coming from the supplemental offer and acceptance program.1 The number of candidates filling slots has remained stable but the number of nephrologists going into private practice is continually diminishing (70.3% of fellows in 2011 vs. 51.5% in 2018).2 A significant number of international medical graduates represent 69% of fellows, but they have visa issues that require them to work in underserved areas (J-1 visa) or with an academically affiliated hospital (H1b). There also appears to be more fellows albeit a small number, who have no internal medicine training in the United States. Thus, they are ineligible to take nephrology boards.
Additionally, many nephrology fellows have an eye toward working as hospitalists or as critical care physicians due to better initial compensation, scheduling and lifestyle reasons. According to the Medscape 2020 Physician Salaries Report, nephrology has the lowest percentage of practicing physicians among all specialties (at 44%) who feel they are fairly compensated.3
With the new normal created by the novel coronavirus, what does that hold for the future of the nephrology physician work force in both the near and long term? There are several things to consider.
As mentioned, fewer physicians are going into private practice. However, it is possible this will be offset short term with the potential of fewer nephrologists retiring as planned due to recent economic volatility and its impact on 401k accounts, retirement plans and joint ventures. One need only look back at the impact on the nephrology workforce in 2008 when the recession decimated retirement nest eggs. Many of the true first wave of nephrologists had planned for retirement at that time and yet continued practicing for several additional years before they were more secure in their financial future to finally leave practice.
Currently, many nephrology practices are feeling the financial effect of diminished patient volumes and hospital consults being minimized due to stay-at-home orders and patient fears of leaving home during this time. A recent survey by the Medical Group Management Association indicated 97% of physician practices have experienced a negative financial effect directly or indirectly as a result of COVID-19. On average, practices report a 55% decrease in revenue and 60% decrease in patient volume since the beginning of the COVID-19 crisis.4 Although monthly capitated payment income and medical directorship money is still there for nephrologists, office clinic and consult income has been affected in some areas. How quickly practices recover economically (assuming there is not a recurrence) now that states are lifting this restriction and allowing elective procedures – and what impact that will have on future practice growth and need for additional physicians – has yet to be determined.
The biggest game changer potentially for nephrology, however, is the increased utilization and quick acceptance of telehealth by physicians and patients and how that will alter the nephrologist-patient relationship in the future. With CMS waiving originating site and geographic restrictions on the use of telehealth, drive time for most nephrologists has been impacted greatly as has seeing patients in the office. If the temporary reimbursement rates to nephrologists for telehealth visits remain in effect after the COVID-19 crisis dissipates, and there is good reason to believe they will based on comments made by CMS Administrator Seema Verma this trend should continue and grow.5 Getting paid at equal rates via telehealth for office and dialysis visits will alter every physician’s day and schedule. Drive time for nephrologists will be down substantially. Office visits and dialysis rounding can be done from a physician’s office or even home, further reducing drive time. With the ability to handle a greater patient load, we might see workforce in practices shrink unless there is a significant increase in the incident patient population.
The COVID-19 crisis and our response to it is rapidly changing. There is no clear-cut end in sight nor is there a way to determine the long-term effects it has had on our country and way of life. One thing is for sure. It has the potential to change the physician/patient relationship forever and the way nephrologists will practice in the future. Only time will tell us how.