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Figure.  Monthly Physician Practice Interruption Rate, Overall and by Return Status
Monthly Physician Practice Interruption Rate, Overall and by Return Status

Month of interruption was defined as the first month during which a physician billed zero claims. Source: Authors’ analysis of Medicare claims data (2019-2020) and Doximity data.

Table.  Change in Physician Practice Interruption Rate Between April 2019 vs April 2020, by Physician Characteristics
Change in Physician Practice Interruption Rate Between April 2019 vs April 2020, by Physician Characteristics
1.
Mehrotra A, Chernew ME, Linetsky D, Hatch H, Cutler D, Schneider EC. The impact of COVID-19 on outpatient visits in 2020: visits remained stable, despite a late surge in cases. Commonwealth Fund. Published February 22, 2021. Accessed July 29, 2021. https://www.commonwealthfund.org/publications/2021/feb/impact-covid-19-outpatient-visits-2020-visits-stable-despite-late-surge
2.
2020 Survey of America’s physicians: COVID-19 impact edition. The Physicians Foundation. Accessed July 19, 2021. https://physiciansfoundation.org/wp-content/uploads/2020/12/2020-Survey-of-Americas-Physicians_Exec-Summary.pdf
3.
Primary Care Collaborative. Quick COVID-19 primary care survey. Larry A. Green Center. Accessed July 29, 2021. https://www.green-center.org/covid-survey
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    Research Letter
    September 20, 2021

    Physician Practice Interruptions in the Treatment of Medicare Patients During the COVID-19 Pandemic

    Author Affiliations
    • 1Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
    • 2Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
    JAMA. 2021;326(13):1325-1328. doi:10.1001/jama.2021.16324

    The COVID-19 pandemic disrupted the practice of medicine across the US. The majority of physicians—especially those practicing in outpatient settings—saw visit volume fall in March of 2020, only returning to prepandemic levels in September.1

    In response, many physicians reported practice interruptions, with some expressing intent to retire or close their practice.1,2 We analyzed Medicare data to assess physician practice interruptions and provide preliminary evidence on whether those interruptions suggest early retirements or exit from medical practice.

    Methods

    We analyzed Medicare physician claims for 100% of fee-for-service beneficiaries from January 1, 2019, to December 30, 2020, and Doximity data on physician age. We counted the monthly number of claims billed by each physician in 2019 and 2020. We defined a practice interruption as a month in which a physician who had previously billed Medicare billed zero Medicare claims. For example, if a physician who had previously billed Medicare did not bill Medicare in April of 2020, we considered April 2020 a practice interruption. We defined interruptions with return as those for which the physician resumed billing Medicare within 6 months of the last billing month and interruptions without return as those for which the physician did not resume billing Medicare within 6 months. We excluded physicians in training, pediatricians, and physicians who billed fewer than 50 Medicare claims during 2018, as these groups may bill Medicare intermittently for reasons other than practice interruptions.

    To compute monthly practice interruption rates in 2019 vs 2020, we regressed our 3 practice interruption outcomes on calendar month interacted with an indicator for 2020. We then tested for differential changes by physician characteristics (age, sex, specialty, practice size, practice location) in the month of peak practice interruptions (April) from 2019 to 2020. Analyses were conducted using Stata version 17 (StataCorp), with statistical significance defined as 2-sided P < .05. The study was deemed not to involve human participants by the University of Minnesota institutional review board.

    Results

    Our sample included 547 849 physicians billing Medicare. Practice interruption rates were similar before and during the COVID-19 pandemic, except for a spike in April 2020, when 34 653 (6.93% [95% CI, 6.89%-6.97%]) physicians billing Medicare experienced a practice interruption (Figure), relative to 1.43% (95% CI, 1.39%-1.46%) in 2019 (P < .001). Overall, 1.14% (95% CI, 1.12%-1.16%) of physicians stopped practice in April 2020 and did not return, compared with 0.33% (95% CI, 0.32%-0.35%) in 2019 (P < .001).

    Practice interruption rates varied by physician characteristic (Table). The increase between April 2019 and April 2020 in interruption rates and interruption-without-return rates was larger for older physicians (≥55 years) than for younger physicians (change in interruption rates: 7.23% [95% CI, 7.10%-7.35%] vs 3.90% [95% CI, 3.81%-3.99%], P < .001; change in interruption-without-return rates: 1.30% [95% CI, 1.24%-1.36%] vs 0.34% [95% CI, 0.31%-0.37%], P < .001). Female physicians, specialists, physicians in smaller practices, those not in a health professional shortage area, and those practicing in a metropolitan area experienced greater increases in practice interruption rates in April 2020 vs April 2019, but those groups typically had higher rates of return, so the overall change in practice interruptions without return were similar across characteristics other than age.

    Discussion

    Practice interruptions in the treatment of Medicare patients during 2020 exceeded those in 2019 and were concentrated in April—coinciding with the nadir of outpatient clinical volume due to the COVID-19 pandemic. Most practice interruptions were temporary, though not all. The pandemic appears to have impeded return to practice more for older physicians than for younger physicians, consistent with anecdotal reports and survey findings regarding intent to close practices, retire, or otherwise transition away from clinical medicine.2,3

    This work has several limitations. First, the analysis was limited to Medicare claims, which likely reflect only part of physicians’ clinical activities. Second, it is impossible to definitively attribute practice interruptions without return to retirement, or practice interruptions with return to furloughs. Third, this measure of practice interruption likely misses meaningful interruptions that lasted for less than a month or did not involve complete cessation in treating Medicare patients. Further study is needed to understand the long-term effects of practice interruptions on the physician workforce and access to care.

    Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Associate Editor.
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    Article Information

    Corresponding Author: Hannah T. Neprash, PhD, Division of Health Policy and Management, School of Public Health, University of Minnesota, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455 (hneprash@umn.edu).

    Accepted for Publication: September 9, 2021.

    Published Online: September 20, 2021. doi:10.1001/jama.2021.16324

    Author Contributions: Dr Neprash had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Both authors.

    Acquisition, analysis, or interpretation of data: Both authors.

    Drafting of the manuscript: Neprash.

    Critical revision of the manuscript for important intellectual content: Both authors.

    Statistical analysis: Neprash.

    Obtained funding: Chernew.

    Conflict of Interest Disclosures: Dr Neprash reported receiving grants from Arnold Ventures. Dr Chernew reported receiving grants from Arnold Ventures; receiving personal fees from American College of Cardiology, American Medical Association, and GI Roundtable; holding equity in Virta Health; serving as chair of the Medicare Payment Advisory Commission; and that he is a partner in, and holds equity in, V-BID Health Equity.

    Funding/Support: This research was supported by Arnold Ventures.

    Role of the Funder/Sponsor: Arnold Ventures had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The views presented here are those of the authors and not necessarily those of Arnold Ventures, its directors, its officers, or its staff.

    References
    1.
    Mehrotra A, Chernew ME, Linetsky D, Hatch H, Cutler D, Schneider EC. The impact of COVID-19 on outpatient visits in 2020: visits remained stable, despite a late surge in cases. Commonwealth Fund. Published February 22, 2021. Accessed July 29, 2021. https://www.commonwealthfund.org/publications/2021/feb/impact-covid-19-outpatient-visits-2020-visits-stable-despite-late-surge
    2.
    2020 Survey of America’s physicians: COVID-19 impact edition. The Physicians Foundation. Accessed July 19, 2021. https://physiciansfoundation.org/wp-content/uploads/2020/12/2020-Survey-of-Americas-Physicians_Exec-Summary.pdf
    3.
    Primary Care Collaborative. Quick COVID-19 primary care survey. Larry A. Green Center. Accessed July 29, 2021. https://www.green-center.org/covid-survey
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