By Rebecca Pifer

Telemedicine continues to be an integral method of care delivery for primary care physicians as COVID-19 drags on, according to a new survey, even as some states and payers begin to pare back virtual care access and coverage.

Data out Monday from the Larry A. Green Center and the Primary Care Collaborative found almost two-thirds of clinicians report telemedicine is a key way to maintain access, even as the needs of patients exceed pre-pandemic levels.

However, primary care doctors are also concerned about the sustainability of virtual care. If regulations and payment restrictions on digitally delivered care relaxed temporarily during COVID-19 are restored, 41% of clinicians say their practice may not be able to continue offering telehealth. Meanwhile, roughly a fifth of clinicians have already had to pull back their use of telemedicine since payments were reduced.

Losing virtual care would be a difficult pill to swallow for clinicians who turned to the service in the early days of COVID-19. Telemedicine helped many physicians adapt to the changing environment of the virus, allowing them to retain patient volume and becoming a valuable source of revenue as in-patient visits flagged.

However, as public health emergency orders continue to lift across the U.S., some states have halted virtual care coverage while others introduce legislation to keep access intact, resulting in a patchwork system of virtual care coverage and reimbursement.

And the verdict is still out on what telehealth flexibilities Washington will allow after the nationwide public health emergency ends. Despite broad bipartisan support for the service, the return of restrictions — even nominal ones — could sound the death knell for telehealth services offered by cash-strapped primary care offices, many of which have faced closure at one point over the past year and a half.

The Larry A. Green Center and the PCC have been surveying primary care doctors since March last year to track the stresses of the coronavirus pandemic. The groups' most recent survey of almost 1,300 primary care doctors nationwide conducted in mid-August found more than half of respondents said mental exhaustion is a constant worry as COVID-19 and patients' health needs surged during the summer.

In a bright spot, COVID-19 cases, hospitalizations and deaths are currently down from a peak in late August and early September, though tens of thousands of people are still getting sick every day.

But the sustained virus has resulted in growing pressure on primary care doctors, who are for many patients the front door to the healthcare system and serve as a quarterback for medical needs.

The U.S. primary care system is suffering from the prolonged loss of financial stability, staff and mental health, with more than half of respondents saying pandemic-related strain is severe or near so, similar to levels seen during last year's peak.

And 71% of respondents said patient visits were more complex and taking more time, while 54% said they were unable to hire staff for open positions in their practices and 45% noted they knew primary care clinicians who had retired early or left practice because of COVID-19.

"There is a quiet suffering as we deal with physical and mental issues of our patients, our country, and the world," one primary care physician in Texas wrote.

Patients with long-haul COVID-19 and people who are vaccine-hesitant are serving as major stressors on clinicians.

PCC found the majority of primary care doctors are managing the care of long-haul patients despite limited-to-nonexistent guidance on how to do so. More than a third of people who contract COVID-19 have symptoms that persist for months after diagnosis, according to a study published in late September.

And roughly 44% of Americans have yet to be fully vaccinated against the coronavirus, despite the widespread availability of free vaccines for adults since April.

"We need more support. It's a moral injury to have our pay cut and be severely understaffed," one physician in Utah wrote. "Most of the burden of educating patients and getting them vaccinated has fallen to primary care and we are already overwhelmed with taking care of patients with worsening mental and physical health."

More than half of clinicians said two to three conversations were needed to change vaccine-hesitant patients' minds about receiving the dose, while more than two-thirds of primary care doctors reported for most of their vaccine-hesitant patients, it's a gut or political opinion that just can't be changed.

"Left with the most difficult-to-vaccinate portion of the population, primary care clinicians must be adequately supported for the multiple conversations that are needed to counter vaccine hesitancy and help meet our country's vaccine goals," PCC CEO Ann Greiner said in a statement.

Less than a third of practices say vaccinating patients is common in their practice. But those offices administering vaccines are reporting moderate success, with solid demand among those who want to be vaccinated.

Nearly six in 10 respondents said they have patients asking for a booster shot, one in three said they've found patients requesting the vaccine due to fear of the delta variant, and slightly more than half say their practice has received an adequate vaccine supply for their patient population.

Currently, providers are administering on average 988,000 doses a day, according to the Centers for Disease Control and Prevention. That's significantly down from the peak of 3.38 million reported in mid-April as vaccinations lag, especially in the South and West.