Primary care visits are down significantly, creating financial problems for clinics but also potentially setting the stage for a wave of patients needing hospital emergency care at a time when COVID-19 is straining the system.

If left unmanaged, chronic conditions can turn into severe asthma attacks, diabetic shock, drug overdoses or mental health crises that can require hospital-level care.

“If we collapse and the other centers do as well, it will be a domino effect that will overwhelm the hospital system,” said Karina Forrest-Perkins, chief executive at People’s Center Clinic & Services in Minneapolis.

The state’s safety-net clinics, which have a larger proportion of medically high-risk patients, are caught in a financial squeeze. With patient revenue dropping 50% at some locations, most have laid off workers and don’t know how much longer they can keep operating.

“There is still that block of patients out there that we need to care for, and whether we survive to do that is really at a tipping point,” said Jonathan Watson, chief executive at Minnesota Association of Community Health Centers, which represents 17 safety-net clinics.

Two-thirds of the clinics’ patients have incomes below the poverty level; one-third are uninsured; and about half are enrolled in the state Medicaid or MinnesotaCare programs.

“We are doing some of the visits for free right now,” said Forrest-Perkins. “We don’t have the ability to bill for them, and we are getting hundreds of them a week.”

Two of the People Center’s three locations have shut down, 27 workers were laid off and senior leadership furloughed their salaries.

Almost overnight, clinics have set up video and telephone links to replace the face-to-face visits that are discouraged during the coronavirus pandemic.

“It is either innovate or perish,” said Gregg Harrison at the Native American Community Clinic in Minneapolis.

The Minnesota Department of Human Services, which operates the state insurance programs, recently made it possible for clinics to bill for more telemedicine visits, including phone calls, which had been ineligible for payment.

COVID-19 emergency funding is available, but the dollars are earmarked for coronavirus testing, health care and medical supplies.

“There’s very little of that funding that can simply be used to replace the lost fee revenue,” said Steve Knutson, chief executive at Neighborhood HealthSource in Minneapolis.

The nonprofit safety-net clinics are not alone. Across the state, medical offices of all types are laying off staff, cutting pay or reducing services.

A special $50 million health care emergency fund authorized by the Legislature has gotten requests for relief that are five times more than what it can provide.

“More funding needs to happen to provide us with stability,” Watson said.

St. Paul-based Minnesota Community Care, the state’s largest safety-net clinic with 37,000 patients, has closed 13 of its 17 locations. At one, space set aside for optometry was converted into a prenatal care clinic, with its own separate entrance.

“The magnitude of resources needed is unfathomable,” said Paige Anderson Bowen, the clinic’s chief advancement officer. “The needs for those resources to be available were yesterday, not four weeks from now, and that cannot be understated.”

“Our clinic is forced to create and evolve in ways much faster than we are ready for, but this is what we as a community clinic [are] supposed to do,” said Dr. Lauren Graber, medical director for population health at the St. Paul clinic.

Graber, who did nine video chats and one in-clinic session Friday morning, said telemedicine gives her new insight into her patients.

“People are excited to show me their home,” she said. “In some ways it is a different, more intimate look.”

The rapid adoption of telemedicine could make it easier for patients and clinicians to interact even after the COVID-19 pandemic subsides.

“Before this, we wanted more innovative ways to go to our patients,” said Shawna Hedlund, director of health access and advocacy at Minnesota Community Care.

“This put our foot on the gas,” she said. “I hope this fundamentally changes health care and how we deliver it.”

One area that has been hit particularly hard is dental care, which many safety-net clinics see as core to their mission because private dental clinics often won’t take Medicaid enrollees because of low reimbursement rates.

With the recommendation that most nonemergency dental work be postponed, the clinics have shut down most services.

“We went from 100 dental patients a day to seeing none,” said Ann Cazaban, chief executive at Southside Community Health Services in Minneapolis. “We’ve had to furlough 62 employees.”

Under an agreement with Abbott Northwestern Hospital, Southside’s dental clinic took care of some dental patients who had gone to the emergency room at the Minneapolis hospital, a channel that is now closed.

The clinics are still seeing patients who need immediate medical attention, with most being screened before they walk in the door.

“We still want to see the folks with strep throat and see the folks who have other acute conditions,” said Harrison of the Native American Community Clinic.

Nate Beske, who has been a patient at the Community-University Health Care Center in Minneapolis since 2008, will soon start his therapy visits with a clinic psychologist by phone.

He first came to the clinic over a decade ago when he was struggling with drug and alcohol addiction and was living in a car “because everyone was kind of through with me.”

Sober now for many years, he said he’s not hesitant to switch to a new way of getting therapy.

Beske is a patient representative on the clinic’s board and he worries about its future.

“My concern is the folks who are the Nate of 2007 or 2008,” he said. “Those are the folks that are at extreme risk of losing basic services.”