A woman is tested for COVID-19 in a parking lot in Richmond where the health department set up a temporary walk-up testing center. Fewer Virginians are being tested for COVID-19 through local health departments, making it difficult to track statewide case rates. (2020 photo by Ned Oliver/Virginia Mercury)
Dr. Sterling Ransone is a family physician in Deltaville and current member of Virginia’s testing task force, a workgroup assembled in late April to boost the state’s once-sluggish COVID-19 test rates.
Twice now, in teleconferences, he’s heard what he described as “proclamations” from state officials on the number of days Virginia has gone without reported shortages of personal protective equipment.
“Quite honestly, that really concerns me,” Ransone said. “And each time, I’ve had to speak up, because the reason they’re not getting reported shortages of PPE is because we have been asked to reuse disposable equipment.”
Ransone has two N95 respirator masks, disinfected through one of the state’s Battelle decontamination systems, that he rotates throughout the week. At his office, surgical masks are reused unless they’re dirty or wet. Disposable gowns are gingerly removed and saved for future use.
That careful conservation is concerning to him when it comes to testing for COVID-19, a process that generally involves face-to-face contact with saliva, snot and other virus-bearing particulates. Ransone’s practice, owned by Riverside Health System, offers testing on a limited basis — Ransone said he’s issued 10 tests a day, which has been enough for him to keep up with current demand. But he worried about what will happen if the demand for tests surges in the coming weeks, both from a supply and safety perspective.
“If I can’t keep my staff safe, I can’t do testing,” he said. But in Deltaville, a town of just over 1,000 jutting into the Chesapeake Bay, he’s also a primary source for it. The closest hospital is 30 minutes away, Ransone said. The town doesn’t have a single testing location listed within a 50-mile radius, according to the state’s map of COVID-19 testing sites.
Virginia, like the rest of the country, has spent months fighting supply shortages in an effort to build a comprehensive network of COVID-19 testing sites. But despite gradually increasing its numbers (the state averaged more than 11,000 tests per day over the last week), many primary care physicians are still reporting difficulties in sourcing the basic supplies that make in-office testing possible.
Dr. Sandy Chung, a Northern Virginia-based pediatrician and president of the Virginia chapter of the American Academy of Pediatrics, said protective equipment still remains an essential barrier, especially for independent practices that aren’t linked to a larger health system. “Practices are still reusing the same N95 mask that they’ve had for the last month, two months,” she added. “The places that do sell us PPE, it’s at three to five times the normal cost. So at the same time that practices have reduced revenue because of all the reduced visits, we’re being asked to pay extra.”
Her office is also offering some testing, but on what Chung described as a “very limited capacity.” Some of it is rapid antigen testing, a more recent diagnostic tool, which carries the risk of false negatives and sometimes has to be confirmed with much more reliable nasal swabs.
Chung said there is disconnect between the ongoing limitations for primary care providers and Virginia’s recent move into Phase Three reopening. Like many doctors, she’s seeing a growing demand for tests as offices reopen and more Virginians ease back into normal routines. “We get reasons like, ‘I just came back from Myrtle Beach and I’d like to know if I’ve been exposed,’” Chung said.
But right now, the availability of testing through primary care doctors is still limited, especially depending on the region. Dr. Clifford Deal, president of the Medical Society of the Virginia, said some practices just aren’t interested in providing it given the risks involved. Both Chung and Ransone said they’re concerned about the months ahead, especially if transmissions rise, need for testing continues to grow, and physicians still aren’t able to source supplies.
“The state has done a lot of large-scale testing events,” Chung said. “We want to be able to serve our patients, but I would say your private practices are still being left out.”
State health officials say shifting more testing to primary care settings is also a major priority moving forward. Part of that is an effort to boost testing across-the-board in Virginia, which still ranks among the lowest 15 states in tests per 100,000 residents — well below neighbors such as Maryland, Tennessee, and Washington, D.C., according to data from Johns Hopkins University.
But from a health standpoint, linking testing to medical care is also an important aspect of combating COVID-19. While tests themselves have become more available through community events and retail pharmacy chains, those settings don’t necessarily allow patients to ask follow-up questions or learn what symptoms might require further care.
“I would say it’s absolutely critical that primary care clinicians become involved,” said Dr. Parham Jaberi, the deputy commissioner of public health and preparedness for the Virginia Department of Health. “We want people to stay connected to their medical home. A doctor can interpret the results, realizing a person’s condition. We know there are all these false positives and false negatives. If someone is older, they have diabetes and heart disease, and they’ve got a fever and a cough — well, even if their test comes back negative, as a physician, I’ll look at them differently than I would a healthy 22-year-old.”
Expanding resources to primary care settings, though, is a different question, especially considering ongoing challenges in procuring personal protective equipment both statewide and nationally. Jaberi said a few practices have gotten protective equipment through local health departments, but resources are still almost exclusively directed toward hospitals, nursing homes, and other large facilities, which are also reusing normally disposable supplies. “The answer is always ‘No,’” said Chung, who added that one of her colleagues had been told that his local department was no longer providing equipment to doctors.
There have been some efforts to direct resources toward providers in underserved communities. Soon after the state’s testing task force was organized, leaders reached out to the Virginia Community Healthcare Association, which represents more than 100 affordable health centers across the state. CEO Neal Graham said many were interested in testing but faced some of the same barriers as private physicians.
Ultimately, members were able to increase tests by roughly 2,000 a week through a partnership with VDH and the state lab in Richmond, which provide health centers with free testing supplies and protective equipment, Graham said. About 50 to 55 sites — roughly a third of the state’s total — now offer some form of regular COVID-19 testing.
The state also reached out to free clinics, which, like community health centers, offer free or deeply subsidized care. Rufus Phillips, CEO of the Virginia Association of Free and Charitable Clinics, said there are now 27 sites offering testing through free kits provided by the state lab.
Like most practices, though, that testing is limited. Dr. Wendy Klein, the recently retired medical director of the free clinic Health Brigade in Richmond, said her office receives a total of 75 kits every week. CrossOver Healthcare Ministry, another free clinic in Richmond, received the same number of kits and tests about as many patients every week, said CEO Julie Bilodeau.
“I think in an ideal world, we’d do more testing,” she added. But she also pointed out that manpower is one of the primary restrictions for her practice, which operates largely through volunteers.
There are other challenges that make testing in primary care offices difficult, Klein said. One significant concern is infection control, especially if offices aren’t conducting testing outdoors. From a logistics standpoint, community testing events — orchestrated largely through local health departments — can also accommodate much larger numbers of people than individual practices, said Dr. Danny Avula, director of the Richmond and Henrico Health Departments.
They can also take up significant time for health department staff, depending on how much testing is being done. Avula said the events run by his department — currently scheduled in four-hour shifts about three times a week — generally take eight staff members and seven to eight volunteers from the state’s Medical Reserve Corps. “I would love to shift more testing to the primary care setting, but I think it’s tough, given we can do up to 300 tests,” he added.
So far, that’s been the state’s focus. As of July 5, VDH has organized testing at 341 long-term care facilities and 199 community events. Jaberi said expanding testing to primary care factors into the state’s long-term testing goals, but there are still immediate issues with providing access to some of the most vulnerable populations, including nursing home residents and the un- and underinsured.
“I do agree there has to be that balance,” Chung said. But many primary care providers say they’re taking an increasingly frontline role when it comes to testing, especially as restrictions loosen and demand — as well as cases — remain likely to grow.
“If the state has PPE, I think the focus should now be on primary care providers and frontline providers who need to do the testing and take care of these patients,” she added.
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