Pediatric practices face financial strain [PODCAST]

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“Physicians are trained to do what is best for their patients and to do no harm. Independent practices have sat quietly watching, feeling hopeless as our communities cannot access the care they need, shamefully shutting our doors to spend hours on the phone with insurers.  But no more.  We can no longer remain quiet: Our pediatric patients may not be suffering from COVID-19 at the alarming rate of adults, but this pandemic will send long-standing shockwaves to future generations if our voices are not heard.”

Nidhi Kukreja is a pediatrician.

She shares her story and discusses her KevinMD article, “How COVID-19 will close pediatric practices.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Nidhi Kukreja. She is a pediatrician, and she wrote the KevinMD article “How COVID-19 will close pediatric practices.” Nidhi, welcome to the show.

Nidhi Kukreja: Thank you so much, Kevin.

Kevin Pho: So before we get into your article, can you share your story and your journey to where you are today?

Nidhi Kukreja: Sure. I was born in India. We moved here when I was three years old, to the Chicago area, and grew up in the suburbs, not really suburbs, far suburbs, you could say. From a young age, I think I knew I wanted to go into medicine or be a doctor, like a lot of young people do, right? I think it was in fifth grade where we first had our human body class, and I was fascinated. From there, in ninth grade, my dad had open-heart surgery, a triple bypass, and I felt like I just needed to know what was going on. So I decided to go to undergrad and med school in St. Louis, at SLU, and then came back to Chicago, got married, and we both did residency in the city. I did peds at Rush, and since I graduated, I have been working on the southwest side of the city.

I think being an immigrant largely influenced my decision of where to practice, and how and why. I felt like I really wanted to give back to immigrant communities. We had a really strong work ethic instilled in us growing up, where education was super important, and I wanted to use what I had learned and who I had become to help people who were similarly struggling. We did decently growing up, but I remember when we moved to our first apartment, and I guess it’s a very clear memory in my mind, eating on a table made out of a cardboard moving box. So those kinds of things really made me decide that I wanted to work with young immigrant families, and that’s where I’ve been since, for about 10 years.

Kevin Pho: And how has the pandemic affected both you and your practice?

Nidhi Kukreja: It’s a daily struggle. There was a quiet period, right, in the last month or two, but now we’re trying to plan for the fall, like I think everybody is, for the second surge. And yeah, there have been a lot of sleepless nights. We’ve made it so far. Telemedicine has been a wonderful boon for our practice. I found it to be a really nice way to connect with patients, but the question is how long we can survive. The majority of our visits are not telemedicine anymore, but probably about 25 to 40 percent are.

It’s a struggle. It’s real. The things we see are very real, and I think that’s more important than our own struggles and trying to sort it out, but we can talk about it some more. The socioeconomic struggles that we’ve seen with our patients are tough. It’s not something that’s just a word, honestly. And I’m sure you know: We worry about the kids we see, and things are getting worse for them.

Kevin Pho: That segues nicely into your KevinMD article, “How COVID-19 will close pediatric practices.” Now, for those who haven’t read your article, can you walk my audience through your article and share the story of why you decided to write it?

Nidhi Kukreja: Since I started practicing in a private practice, I’ve learned a lot about the reimbursement issues that specifically apply to our largely Medicaid population. Our clinic is 85 percent Medicaid, and several years ago, before I started at this practice, Illinois had gone to an MCO setup, basically, for Medicaid. These are privately owned insurance companies that manage the Medicaid funds that the state has, in order to distribute them to practices that are seeing these patients. Since that’s happened, things have been pretty chaotic for practices. There’s been real irregularity of payments, and asking for payments to come back, to be returned: “Oh, that patient wasn’t assigned to you,” even though at the time we review everything and they were, and things like that. There are newborns not being assigned at the right time, when we need to see them. So we see them, the payment’s delayed, and the payment may not ever come, but we see them because it’s a newborn and they need to be seen.

So there are things like that. When COVID happened, this was all in the background, but it really stirred me up and made me feel like we may actually close. This might be the end of our practice, and it really made me sad about where our patients would go and what would happen. So yeah, there were some sleepless nights, and that’s where the article came from.

Do I really, at this point, think our practice is going to close, or that many, many pediatric practices are going to close? Probably not. I think we’re doing OK. We have had some support from the Paycheck Protection Program, and now the CARES Act has been extended to Medicaid practices at a certain percentage. I think it’s two or three percent, not the six percent that Medicare practices got. But I felt like, at the time, writing it was important, because yeah, maybe I’m preaching to the choir, and maybe all physicians know this, but I wanted that article to be seen by a broader audience than I could reach by just talking to the people I know.

Kevin Pho: I think it’s very important for you to write these stories, because a lot of people outside of the physician community actually don’t know some of the financial struggles that a lot of private practices are going through. So I was wondering if you could share: What are some of the real-life consequences that you face from being so uncertain regarding the financial status of your practice?

Nidhi Kukreja: I can tell you about something we were discussing yesterday at our team meeting. This fall, we’re expecting a surge of all the fall and winter viruses, right, just like we always do. However, to be careful and to follow CDC guidelines, we need to make sure that we’re not giving nebulizer treatments in our office, or if we are, that we have plenty of PPE, which we don’t. We have some. We can see some patients, as we’ve seen this summer in our office, several a day maybe, or maybe just a few a day, who are sick. Like I said, we do a lot of telemedicine, and we’re able to guide patients where to go to get COVID testing. We’re not doing COVID testing in our office right now, but in the fall, we want to be able to do flu testing, and we want to be able to do COVID testing, because those two mimic each other and we don’t really know. Strep testing, of course.

And we want to be able to provide the appropriate treatments for the patients, as we’ve always done, like nebulizers for a patient who’s wheezing. So if you can’t use a nebulizer, you have to use an inhaler, right? And that’s safer. Inhalers cost like $40 to $80 a pop. We can’t reuse them. We get paid about $40 to $80 for a visit. So we’re trying to figure out how we’re going to manage, because that means we’re doing this at a loss.

Kevin Pho: If you were a policy expert in charge of health care policy in the country, what are some of the solutions that you would propose to fix this?

Nidhi Kukreja: Oh my goodness, I’m not a policy expert, but yeah, no, I think things do need to come from the top down. I think there needs to be regular payments for each patient we see, not a third of Medicare payments. I don’t understand why Medicaid rates are much lower than Medicare rates, and why, in Illinois at least, they’re stagnant for about 20 years, whereas the cost of living and just the cost of owning a practice have gone up significantly. So that’s one thing. As far as our patients are concerned, that obviously would trickle down and help them. But not to sound like this is all about our practice and our survivability, there is so much more needed in leveling the playing field for our families.

Kevin Pho: We are talking to Nidhi Kukreja. She’s a pediatrician in Chicago, and she wrote the KevinMD article “How COVID-19 will close pediatric practices.” Now, Nidhi, there are a lot of other private practices that are also struggling during this pandemic. Is there anything that you’ve learned that you can share with these practices to help them?

Nidhi Kukreja: I think what I’ve learned is to focus. Like I said, things should come from the top down, and we need things to change, like, yesterday, because that just makes me upset. So I think I’m still learning that I need to focus on the small things that I can do as an individual. I’d love to think that things would happen that way, but they don’t, and they’re not right now. I still have hope that they will, but in the meantime, one thing that I’ve been thinking that I really need to understand and do is, for example: The kids who I think are going to be affected most by the COVID pandemic and by school closures are the children who have IEPs and 504 plans, developmental delays, or learning disabilities, and I think those kids and their families are going to need a lot of help advocating for their needs in the fall, come school, because it didn’t really happen in the springtime. So I think as pediatricians and as providers, I need to, one, just educate myself, and be prepared to answer questions and give my patients as much information about what they can do.

Kevin Pho: Sure. And my final question: Do you have a take-home message that you want to share with the KevinMD audience?

Nidhi Kukreja: I think it’s to not give up. Yes, things are really, really hard right now, and it’s easy to be discouraged. I have a quote that I found. It’s not my quote. Robin Ali Haye posted it, and she’s a physician coach, and it’s from “The Courage to Create” by Rollo May: “A choice confronts us. Shall we, as we feel our foundation shaking, withdraw in anxiety and panic? Frightened by the loss of our familiar mooring places, shall we become paralyzed and cover our inaction with apathy? If we do those things, we will have surrendered our chance to participate in the forming of the future. We will have forfeited the distinctive characteristic of human beings, namely, to influence our evolution through our own awareness. We will have capitulated to the blind juggernaut of history and lost the chance to mold the future into a society more equitable and humane.”

So I think we have the chance, as people who are privileged and sometimes in positions of power. We need to keep speaking up.

Kevin Pho: Well, thank you so much for sharing your story and your insight, and thank you so much for being on.

Nidhi Kukreja: Thank you, Kevin. Take care.

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