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MAY 10, 2020 -- After COVID-19 hit the Denver area, internist Jean Kutner, MD, and her clinical colleagues drastically reduced the number of patients they saw and kept a minimum number of people in the office. A small team sees patients who still require in-person visits on one side of the clinic; on the other side, another team conducts clinic-based telehealth visits. A rotating schedule allows for social distancing.
The rest of the practice's physicians are home, conducting more virtual visits.
Kutner is looking forward to reopening her practice completely at some point. She realizes that the practice probably won't be exactly the same as before.
"We have to embrace the fact that the way we practice medicine has fundamentally changed," said Kutner, professor of medicine at the University of Colorado School of Medicine, in Aurora, and incoming president of the Society of General Internal Medicine. She anticipates keeping many of these changes in place for the foreseeable future.
Nearly half of 2600 primary care physicians who responded to a recent national survey said they were struggling to remain open during the crisis. Most have had to limit wellness/chronic-disease management visits, and nearly half reported that physicians or staff were out sick. Layoffs, furloughs, and reduced hours are commonplace; some practices were forced to shut down entirely.
Social distancing helps reduce the rates of hospitalizations and deaths. Now, many physicians are considering when and how to reopen their offices and ramp up to full capacity.
But they're also aware that it won't be "business as usual" for quite some time. For example, remote monitoring capabilities have reduced the need for in-person checks of vital signs, such as respiratory rate oxygenation, blood glucose levels, heart rate. "We can't go back," she says.
Kutner sees the pandemic as an opportunity to innovate, to think about how primary practices can best utilize their resources, face-to-face time with patients, and when and how to best leverage virtual visits in a way that improves patient health. The goal, of course, is to meet the needs of the patients while keeping everyone safe.
Like many physicians in private practice, Kutner is concerned about revenue. She hopes the Centers for Medicare & Medicaid Services (CMS) makes its temporary waivers permanent.
What You Need to Consider When Planning to Reopen Your Office
Physicians say their post-COVID-19 practices will look very different from their pre-pandemic practices. Many plan to maintain guidelines, such as those from the AAFP, long after the pandemic has peaked.
If you are starting to think about reopening, here are some major considerations.
1. Develop procedures and practices that will keep your patients and staff safe.
"When we return, the first thing we need to do is limit the number of patients in the waiting room," said Clinton Coleman, MD, who practices internal medicine and nephrology in Teaneck, New Jersey. "No one is comfortable in a waiting room any longer," said Coleman, who is chief of internal medicine at Holy Name Medical Center in Teaneck.
Careful planning is required to resume in-person care of patients requiring non-COVID-19 care, as well as all aspects of care, according to CMS. Adequate staff, testing, supplies, and support services, such as pathology services, are just a few considerations. CMS recommends that physicians "evaluate the necessity of the care based on clinical needs. Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary."
The American Medical Association recently unveiled a checklist for reopening. One key recommendation was for practices to select a date for reopening the office, ideally preceded by a "soft" or incremental reopening to ensure that new procedures are working. The AMA also recommends opening incrementally, continuing telehealth while also inviting patients back into the office.
2. Figure out how to safely see patients, particularly in your waiting areas and common spaces.
Logistic factors, such as managing patient flow, will change. Waiting rooms will be emptier; in some locations, patients may be asked to wait in their cars until an exam room is available.
The AMA also suggests limiting nonpatient visitors by posting the practice's policy at the entrance and on the practice's website. If service calls for repairs are needed, have those visitors come outside of normal operating hours.
Commonly shared objects such magazines or toys in pediatric offices will likely disappear. Wipes, hand sanitizers, and the wearing of masks will become even more commonplace. Those who suspect they're ill or who have respiratory symptoms may be relegated to specific "sick visit" appointment times or taken to designated exam rooms, which will be thoroughly sanitized between patients.
3. Prepare for routine screening of staff and other facility workers.
According to recent CMS guidelines, you and your staff will need to undergo routine screening, as will others who work in the facility (housekeeping, delivery personnel, and anyone else who enters the area). This may mean regularly stocking screening tests and setting guidelines for what to do if one of your staff tests positive.
You may need to hire temporary workers if your staff tests positive. The CDC recommends at the very least understanding the minimum staffing requirements to ensure good patient care and a safe work environment. Consider adjusting staff schedules and rotating clinical personnel to positions that support patient care activities. You may also want to look into cross-training your office staff so that they can fill in or help out with each other's responsibilities if one or more persons are ill.
Kutner is on board with these changes. "We don't want to get rid of social distancing right away, because it will give us a new spike in cases — how do we figure out patient flow while honoring that?"
4. Develop a strategy for triaging and caring for a potential backlog of patients.
"Many of my partners are scared right now because they have no income except for emergencies," said Andrew Gonzalez, MD, JD, MPH, a vascular surgeon and assistant professor of surgery at Indiana University School of Medicine in Indianapolis. Almost all nonemergency surgery has been put on hold.
"If we don't operate, the practice makes no money," he said. He thinks revenue will continue to be a problem as long as patients fear in-person consultations or undergoing surgery for nonacute problems such as hernias.
As restrictions ease, most physicians will face an enormous backlog of patients and will need to find new ways of triaging the most serious cases, he says. Telehealth will help, but Gonzalez predicts many of his colleagues will be working longer hours and on weekends to catch up. "Physicians are going to have to really think about ways of optimizing their time and workflow to be very efficient, because the backlog is going to prodigious."
5. Anticipate changes in patient expectations.
This may entail your reconsidering tests and procedures you previously performed and considering developing new sources for some services, phasing some others out, and revising your current approach. It will most likely also mean that you make telemedicine and televisits a greater part of your practice.
Carolyn Kaloostian, MD, a family medicine and geriatric practitioner in Los Angeles, points to increased reliance on community agencies for conducting common office-based procedures, such as performing blood tests and taking ECGs and x-rays. "A lot of patients are using telemedicine or telephone visits and get the lab work or x-rays somewhere that's less congested," she said. To become sustainable, many of these changes will hinge on economics ? whether and how they are reimbursed.
The pandemic will leave lasting effects in our healthcare delivery, according to Kaloostian. She is sure many of her colleagues' and patients' current experiences will be infused into future care. "I can't say we'll ever be back to normal, necessarily."
Even if CMS rolls back its telehealth waivers, some physicians, like Coleman, plan to continue using the technology extensively. He's confident about the level of care he's currently providing patients in his practice. It allows him to better manage many low-income patients who can't access his office regularly. Not only does splitting his time between the clinic and telehealth allow him to be more available for more patients, he says it also empowers patients to take better care of themselves.
6. Consider a new way to conduct "check-in visits."
One thing that will likely go by the wayside are "check-in" visits, or so-called "social visits," those interval appointments that can just as easily be completed virtually. "Patients are going to ask why they need to drive 3 hours so you can tell them their incision looks fine from an operation you did 5 years ago," Gonzalez said.
He's concerned that some people will remain so fearful of the healthcare system that a formerly busy practice may see the pendulum swing in the opposite direction. If an aneurysm patient skips a visit, they may also decide not to undergo their CT scan — and something preventable will be missed. "Not everybody has the option to stay away until they feel comfortable. They're basically playing hot potato. And at some point, the music's going to stop," Gonzalez said.
The pandemic has prompted some very honest conversations with his patients about what truly needs to get done and what may be optional. "Everyone has now become a hyper-rational user of healthcare," he said.
7. If you haven't yet, consider becoming more involved with technology.
In addition to greater use of telehealth, Kaloostian, assistant professor of clinical family medicine at the Keck School of Medicine, University of Southern California, Los Angeles, foresees continued reliance upon technology such as smartphone apps that connect with a user's smartwatch. This allows for more proactive, remote monitoring.
"For example, any time a patient is having recurrent nighttime trips to the bathroom, I'll get pinged and know that," she explained. It means she can reach out and ask about any changes before a fall occurs or a condition worsens. "It provides reassurance to the provider and to the patient that you're doing all you can to keep an eye on them from afar."
8. Update or reformulate your business plans.
Some physicians in smaller practices may have to temporarily or permanently rethink their situation. Those who have struggled or who have closed down and are considering reopening need to update their business plans. It may be safer economically to become part of a bigger group that is affiliated with an academic center or join a larger healthcare system that has more funds or resources.
Additionally, Kaloostian suggests that primary care physicians become more flexible in the short term, perhaps working part time in an urgent care clinic or larger organization to gain additional sources of revenue until their own practice finances pick back up.
For offices that reopen, the AMA recommends contacting medical malpractice insurance carriers to check on possible liability concerns. Congress has provided certain protections for clinicians during this time, but malpractice carriers may have more information and may offer more coverage.
Coleman says a hybrid model of fewer in-person and more telehealth visits "will allow me to practice in a different way." If CMS reimposes prior restrictions, reimbursement may be affected initially, but that will likely change once insurers see the increased cost-effectiveness of this approach. Patients with minor complaints, those who need to have medications refilled, and patients with chronic diseases that need managing won't have to deal with crowded waiting rooms, and it will help mitigate problems with infection control.
If there's any upside to the pandemic, it's an increase in attention given to advanced care planning, says Kutner. It's something she hopes continues after everyone stops being in crisis mode. "We're realizing how important it is to have these conversations and document people's goals and values and code status," she said.
Are Offices Likely to Open Soon?
An assumption that may or may not be valid is that a practice will remain viable and can return to former capacity. Prior to passage of the CARES Act on March 27, a survey from Kareo, a company in Irvine, California, that makes a technology platform for independent physician practices, found that 9% of respondents reported practice closures. Many more reported concern about potential closures as patient office visits plummet because of stay-at-home orders and other concerns.
By mid-April, a survey from the Primary Care Collaborative and the Larry Green Center found that 42% of practices had experienced layoffs and had furloughed staff. Most (85%) have seen dramatic decreases in patient volume.
"Reopening the economy or loosening physical distancing restrictions will be difficult when 20% of primary care practices predict closure within four weeks," the survey concluded.
For the practices and the doctors who make it through this, we're going to probably be better, stronger, and more efficient, Gonzalez predicts. This shock has uncovered a lot of weaknesses in the American healthcare system that doctors have known about and have been complaining about for a long time. It will take an open mind and lots of continued flexibility on the part of physicians, hospitals, healthcare systems, and the government for these changes to stick.
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