Category Archives: Telemedicine

Election 2020: What Exactly Is Joe Biden’s Healthcare Plan? And Really, Telehealth to Care for Our Patients?

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So, first I wanted to relate an experience, which exemplifies the failure of telehealth, or maybe the failure of healthcare workers who are taking advantage of the “new” health care system of patient care.

Consider the case a two weeks ago. As I was about to operate on a cancer surgery patient, I was asked to evaluate a patient healthcare conundrum. One of our nurse teammate’s husband was sick and no one knew what was the problem. He had lost 23 pounds over 3 ½ weeks, was dehydrated, appetite, sore throat, weak and needed to go to the emergency room multiple times for intravenous fluids. Each time he was told that they were very sorry but they had no idea what the problem was.

His Primary care physician would not see him in person, and he had another telehealth visit, which he was charged for and was prescribed an antibiotic with no improvement.

I asked if he had a COVID test which he did and it was negative.

I then asked if I could examine him or if she had any pictures. She had pictures, with no skin rashes except I noticed something interesting on the intraoral pictures, which showed left sided ulcers on his cheeks, left lateral posterior tongue and palate, again-only on the left side.

I asked if this was true in that the ulcers were only on one side of his mouth? When his wife responded with a yes to the question I then responded that he had intraoral shingles involving the nerve to the tongue, cheek, palate ( glossophyngeal nerve ) and sometimes also affected additional nearby cranial nerve, which is probably why he was having some of his stomach problem. She thought that was interesting and wanted to know what to do since he was about to have some gallbladder studies.

I outlined a treatment plan and low and behold he is getting better. My question is why didn’t anyone in the doc’s office or ER never complete a thorough physical exam? Oh, wait- how does one do a complete physical exam through the telehealth system? What about heart or lung disease patients, how does a nurse or physician listen to their heart or lungs, etc?? Are we physicians forgetting our teachings and training regarding the proper approach to physical diagnosis?

And now what about Biden’s proposal for health care?

Leigh Page pointed out that physicians — like all Americans — are trying to size up Joe Biden’s healthcare agenda, which the Democratic presidential nominee has outlined in speeches and on his official website.

Many healthcare professionals, patients, and voters of all political stripes think our current healthcare system is broken and in need of change, but they don’t agree on how it should change. In Part I of this article, we take a look at Biden’s proposals for changing the US healthcare system. Then, we include comments and analysis from physicians on both sides of the fence regarding the pros and cons of these proposed healthcare measures.

Part 1: An Overview of Biden’s Proposed Healthcare Plan

Biden’s proposed healthcare plan has many features. The main thrust is to expand access to healthcare and increase federal subsidies for health coverage.

If elected, “I’ll put your family first,” he said in a speech in June. “That will begin the dramatic expansion of health coverage and bold steps to lower healthcare costs.” He said he favored a plan that “lowers healthcare costs, gets us universal coverage quickly, when Americans desperately need it now.”

Below are Biden’s major proposals. They are followed by Part 2, which assesses the proposals on the basis of comments by doctors from across the political spectrum.

Biden Says We Should Restore the ACA

At a debate of the Democrat presidential candidates in June 2019, Biden argued that the best way to expand coverage is “to build on what we did during the Obama administration,” rather than create a whole new healthcare system, as many other Democratic candidates for president were proposing.

“I’m proud of the Affordable Care Act,” he said a year later in his June 2020 speech. “In addition to helping people with preexisting conditions, this is the law that delivered vital coverage for 20 million Americans who did not have health insurance.”

At the heart of the ACA are the health insurance marketplaces, where people can buy individual insurance that is often federally subsidized. Buyers select coverage at different levels ― Gold, Silver, and Bronze. Those willing to pay higher premiums for a Gold plan don’t have high deductibles, as they would with the Silver and Bronze plans.

Currently, federal subsidies are based on premiums on the Silver level, where premiums are lower but deductibles are higher than with the Gold plan. Biden would shift the subsidies to the Gold plan, where they would be more generous, because subsidies are pegged to the premiums.

In addition, Biden would remove the current limit on subsidies, under which only people with incomes less than 400% of the federal poverty level qualify for them. “Many families making more than 400% of the federal poverty level (about $50,000 for a single person and $100,000 for a family of four), and thus not qualifying for financial assistance, still struggle to afford health insurance,” the Biden for President website states.

Under the Biden plan, there would still be a limit on insurance payments as a percentage of income, but that percentage would drop, meaning that more people would qualify. Currently, the level is 9.86% or more of a person’s income; Biden would lower that level to 8.5%.

“We’re going to lower premiums for people buying coverage on their own by guaranteeing that no American ever has to spend more than 8.5% of their income on health insurance, and that number would be lower for lower-income people,” Biden said in the June speech.

Add a Public Option, but Not Medicare for All

In the primary, Biden parted company from rivals who backed Medicare for All, a single-payer health system that would make the government pay for everyone’s healthcare. “I understand the appeal of Medicare for All,” he said in a video released by his campaign. “But folks supporting it should be clear that it means getting rid of Obamacare, and I’m not for that.” But he nor anyone else who supported Obamacare has come up with a way to finance this type of healthcare system.

However, Biden embraced a “public option” that would allow people to buy into or be subsidized into “a Medicare-like” plan. It is unclear how similar the public option would be to regular Medicare coverage, but the Biden campaign has made it clear that it would not take funds from the Medicare trust fund, which is expected to start losing funds by 2026.

The more than 150 million Americans who have employer-sponsored insurance could keep it, but they could still buy into the public option if they wanted to. In addition, the public option would automatically enroll ― at no cost to them ― some 4.8 million low-income Americans who were excluded from the ACA’s Medicaid expansion when many states chose to opt out of the Medicaid expansion.

In addition, the 37 states that participate in expanded Medicaid could switch coverage to the new public option, provided that they continue to pay their current share of the costs. (In June, Oklahoma became the 37th state to allow the expansion, following the results of a ballot measure.)

“We need a public option now more than ever, especially when more than 20 million people are unemployed,” Biden said in the June speech. “That public option will allow every American, regardless of their employment status, the choice to get a Medicare-like plan.”

Lower the Medicare Age

In spring 2020, Biden proposed lowering the age to qualify for Medicare from 65 to 60. This provision is not included among the official policies listed on the Biden for President website, but it has been cited by many, including the Biden-Sanders Unity Task Force.

This provision would bring almost 23 million people into Medicare, including 13.4 million from employer-sponsored coverage, according to one analysis. It’s not clear whether these people would buy into Medicare or simply be covered. Their care would not be paid for by the Medicare Trust Fund but would use tax dollars instead. Oh, finally, we find out that our taxes would go up. How much is the problem as we consider all the other programs that Biden and Harris have promoted.

Provide Relief in the Covid-19 Pandemic

Biden would cover the cost of COVID-19 testing and the cost of health coverage for people laid off during the pandemic.

“Testing unequivocally saves lives, and widespread testing is the key to opening our economy again,” Biden said in his June speech. “To fix the economy, we have to get control over the virus.”

Prescription Drug Reform

Biden would repeal a Bush-era exception that bars the Medicare program from negotiating prescription drug prices for the Part D prescription drug benefit. “There’s no justification for this except the power of prescription drug lobbying,” the Biden for President website states.

In addition, Biden’s prescription drug reform plan would do the following:

• Limit launch prices for drugs. The administration would establish an independent review board that would assess the value of new drugs and would have the power to set limits on their prices. Such drugs are “being abusively priced by manufacturers,” the Biden for President site says.

• Limit price increases to inflation. As a condition of participation in government programs, drug prices could not rise more than the general inflation rate. Biden would impose a tax penalty on drug makers whose prices surpassed inflation.

• Allow consumers to buy prescription drugs from other countries. Biden would allow consumers to import prescription drugs from other countries, provided the US Department of Health and Human Services certifies that those drugs are safe.

• Stop tax breaks for pharma ads: Biden would drop drug makers’ tax breaks for advertising, which amounted to $6 billion in 2016.

Stop Surprise Billing

Biden proposes to stop surprise billing, which occurs when patients receive care from a doctor or hospital that is not in their insurer’s network. In these situations, patients can be surprised with very high bills because no payment limit has been negotiated by the insurer.

Twenty-eight states have enacted consumer protections to address surprise medical billing, but Congress has not passed such a measure. One proposed solution is to require payers to pay for out-of-network services on the basis of a benchmark, such as the average Medicare rate for that service in a specific geographic area.

Closely Monitor Healthcare Mergers

Biden would take a more active stance in enforcing antitrust laws against mergers in the healthcare industry.

“The concentration of market power in the hands of a few corporations is occurring throughout our health care system, and this lack of competition is driving up prices for consumers,” the Biden for President website states.

Overhaul Long-term Care

Biden’s latest plan calls for a $775 billion overhaul of the nation’s caregiving infrastructure. Biden says he would help create new jobs, improve working conditions, and invest in new models of long-term care outside of traditional nursing homes.

Restore Funding for Planned Parenthood

Biden would reissue guidance barring states from refusing Medicaid funding for Planned Parenthood and other providers that refer for abortions or that provide related information, according to the Biden for President website. This action would reverse a Trump administration rule.

Boost Community Health Centers

Biden promises to double federal funding for community health centers, such as federally qualified health centers, that provide care to underserved populations.

Support Mental Health Parity

Biden says he supports mental health parity and would enforce the federal mental health parity law and expand funding for mental health services.

Part 2: Physicians’ Opinions on Biden’s Healthcare Plans: Pro and Con

Biden’s plans to expand coverage are at the heart of his healthcare platform, and many see these as the most controversial part of his legislative agenda.

Biden’s Medicare expansion is not Medicare for All, but it can be seen as “Medicare for all who want it.” Potentially, millions of people could enter Medicare or something like Medicare. If the Medicare eligibility age is dropped to 60, people could switch from their employer-sponsored plans, many of which have high deductibles. In addition, poor people who have no coverage because their states opted out of the Medicaid expansion would be included.

The possibility of such a mass movement to government-run healthcare alarms many people. “Biden’s proposals look moderate, but it is basically Medicare for All in sheep’s clothing,” said Cesar De Leon, DO, a family physician in Naples, Florida, and past president of the county’s medical society.

Reimbursements for Doctors Could Fall- No, Will Fall!

A shift of millions of people into Medicare would likely mean lower reimbursements for doctors. For example, the 13.4 million people aged 60 to 65 who would switch from employer-sponsored coverage to Medicare would be leaving some of the best-paying insurance plans, and their physicians would then be reimbursed at Medicare rates.

“Biden’s plan would lower payments to already cash-strapped doctors and hospitals, who have already seen a significant decrease in reimbursement over the past decade,” De Leon said. “He is trying to win the support of low-income voters by giving them lower healthcare prices, which doctors and hospitals would have to absorb.

“Yes, the US healthcare system is dysfunctional,” De Leon added, “but the basic system needs to be fixed before it is expanded to new groups of people.”

The American Association of Neurological Surgeons/Congress of Neurological Surgeons warns against Biden’s proposed government-run system. “We support expanding health insurance coverage, but the expansion should build on the existing employer-based system,” said Katie O. Orrico, director of the group’s Washington office. “We have consistently opposed a public option or Medicare for All.

“Shifting more Americans into government-sponsored healthcare will inevitably result in lower payments for physicians’ services,” Orrico added. “Reimbursement rates from Medicare, Medicaid, and many ACA exchange plans already do not adequately cover the costs of running a medical practice.”

Prospect of Higher Taxes- Absolutely, grab your wallets and your retirement funds!!

Paying for ambitious reforms means raising taxes. Biden’s plan would not make the Medicare trust fund pay for the expansions and would to some extent rely on payments from new beneficiaries. However, many new beneficiaries, such as people older than 60 and the poor, would be covered by tax dollars.

Altogether, Biden’s plan is expected to cost the federal government $800 billion over the next 10 years. To pay for it, Biden proposes reversing President Trump’s tax cuts, which disproportionately helped high earners, and eliminating capital gains tax loopholes for the wealthy.

“Rather than tax the average American, the Democrats will try to redistribute wealth,” De Leon said.

“The elephant in the room is that taxes would have to be raised to pay for all these programs,” said Gary Price, MD, president of the Physicians Foundation. Because no one likes higher taxes, he says, architects of the Biden plan would try to find ways to save money, such as tamping down reimbursements for physicians, to try to avoid a public backlash against the reforms.

“Physicians’ great fear is that efforts to keep taxes from getting too high will result in cutting physician reimbursement,” he said.

Impact of COVID-19

Perhaps an even larger barrier to Biden’s health reforms comes from the COVID-19 crisis, which didn’t exist last year, when health reform was the central issue in the presidential primary that pitted Biden against Vermont Senator Bernie Sanders, the chief proponent of Medicare for All.

“The top two issues on voters’ minds right now are the pandemic and the economy,” said Daniel Derksen, MD, a family physician who is professor of public health policy at the University of Arizona in Tucson. “Any other concerns are pushed down the list.”

The COVID-19 crisis is forcing the federal government to spend trillions of dollars to help businesses and individuals who have lost income because of the crisis. Will there be enough money left over to fund an ambitious set of health reforms?

“It’s not a good time to start reforms,” warned Kevin Campbell, MD, a cardiologist in Raleigh, North Carolina. “Given the current pressures that COVID-19 has placed on physicians, healthcare systems, and hospitals, I don’t believe that we can achieve meaningful change in the near term.”

However, supporters of Biden’s reforms think that now, during the COVID-19 crisis, is precisely the right time to enact healthcare reform. When millions of Americans lost their jobs because of the pandemic, they also lost their insurance coverage.

“COVID-19 has made Biden’s healthcare agenda all the more relevant and necessary,” said Don Berwick, MD, who led the Center for Medicare & Medicaid Services (CMS) under President Obama. “The COVID-19 recession has made people more aware of how vulnerable their coverage is.”

Orrico at the neurosurgeons group acknowledges this point. “The COVID-19 pandemic has exposed some cracks in the US healthcare system,” she said. “Whether this will lead to new reforms is hard to say, but policymakers will likely take a closer look at issues related to unemployment, health insurance coverage, and healthcare costs due to the COVID-19 emergency.”

Many Physicians Want Major Reform

Although many doctors are skeptical of reform, others are impatient for reform to come and support Biden’s agenda ― especially its goal to expand coverage.

“Joe Biden’s goal is to get everyone covered,” said Alice Chen, MD, an internist who is a leader of Doctors for Biden, an independent group that is not part of the Biden campaign. “What brings Democrats together is that they are united in the belief that healthcare is a right.”

In January, the American College of Physicians (ACP) endorsed both Medicare for All and the public option. The US healthcare system “is ill and needs a bold new prescription,” the ACP stated.

The medical profession, once mostly Republican, now has more Democrats. In 2016, 35% of physicians identified themselves as Democrats, 27% as Republicans, and 36% as independents.

Many of the doctors behind reform appear to be younger physicians who are employed by large organizations. They are passionate about reforming the healthcare system, and as employees of large organizations, they would not be directly affected if reimbursements fell to Medicare levels ― although their institutions might subsequently have to adjust their salaries downward.

Chen, for example, is a young physician who says she has taken leave from her work as adjunct assistant clinical professor of medicine at the University of California, Los Angeles, to raise her young children.

She is the former executive director of Doctors for America, a movement of thousands of physicians and medical students “to bring their patients’ experiences to policymakers.”

“Doctors feel that they are unseen and unheard, that they often feel frankly used by large health systems and by insurance companies,” Chen said. “Biden wants to hear from them.”

Many idealistic young physicians look to health system leaders like Berwick. “I believe this nation needs to get universal coverage as fast as we can, and Biden’s policies present a path to get there,” the former CMS director said. “This would be done chiefly through Biden’s public option and his plans to expand coverage in states that have not adopted the ACA Medicaid expansion.”

But what about the potential effect of lowering reimbursement rates for doctors? “The exact rates will have to be worked out,” Berwick said, “but it’s not just about who pays physicians, it’s about how physicians get paid.” He thinks the current fee-for-service system needs to be replaced by a value-based payment system such as capitation, shared savings, and bundled payments.

The Biden-Sanders Task Force

Berwick was a member of the Biden-Sanders Unity Task Force, which brings together supporters of Biden and Sanders to create a shared platform for the Biden campaign.

The task force issued a report in early July that recommended a variety of healthcare reforms in addition to expanding access to care. One of them was to find ways to address the social determinants of health, such as housing, hunger, transportation, and pollution, which can harm health outcomes.

Chen specifically cites this provision. “We need to focus on the social determinants of heath and try to encourage better health,” she said. “I remember as a doctor advising a patient who was a young mother with several small children that she needed to exercise more. She asked me, ‘When am I supposed to exercise, and who will watch my kids?’ I realized the predicament that she was in.”

Price is also glad to see the provision in Biden’s plan. “Social determinants of health has been a key focus of the Physicians Foundation,” he said. “To my knowledge, this is the first time that a political candidate’s healthcare policy has included this point.

“Physicians are not in control of the social determinants of health, even though they affect their reimbursements,” he said. Under Medicare’s Merit-based Incentive Payment System, for example, doctors are penalized when their patients don’t meet certain health standards, such as when diabetes patients can’t get their A1C levels under control, he says.

However, Price fears that Biden, in his efforts to make peace with Sanders supporters, may have to some degree abandoned his moderate stance on health reform.

Is the Nation Ready for Another Health Reform Battle?

Clearly, many Democrats are ready to reform the system, but is the nation ready? “Are American voters ready for another major, Democratic-led health reform initiative?” asked Patricia Salber, MD, an internist and healthcare consultant who runs a blog called The Doctor Weighs In.

“I’ve been around long enough to remember the fight over President Clinton’s health plan and then President Obama’s plan,” she said. Each time, she says, there seemed to be a great deal of momentum, and then there was a backlash. “If Biden is elected, I hope we don’t have to go through the same thing all over again,” Salber said.

Derksen believes Biden’s proposed healthcare reforms could come close to rivaling President Obama’s Affordable Care Act in ambition, cost, and controversy.

He shares Biden’s goal of extending coverage to all ― including paying the cost of covering low-income people. But the result is that “Biden’s agenda is going to be a ‘heavy lift,’ as they say in Washington,” he said. “He has some very ambitious plans to expand access to care.”

Derksen speaks from experience. He helped draft part of the ACA as a health policy fellow in Capitol Hill in 2009. Then in 2011, he was in charge of setting up the ACA’s insurance marketplace for the state of New Mexico.

Now Biden wants to begin a second wave of health reform. But Derksen thinks this second wave of reform could encounter opposition as formidable as those Obama faced.

“Assuming that Biden is elected, it would be tough to get this agenda passed ― even if he had solid Democratic majorities in both the House and Senate,” said Derksen,

According to polls by the Kaiser Family Foundation (KFF), 53% of Americans like the ACA, while 37% dislike it ― a split that has been relatively stable for the past 2 years, since the failed GOP effort to repeal the law.

In that KFF poll, the public option fared better ― 68% of Americans support the public option, including 42% of Republicans. These numbers help explain why the Biden campaign moved beyond its support of the ACA to embrace the public option as well.

Even when Democrats gain control of all the levers of power, as they did in 2009, they still have a very difficult time passing an ambitious healthcare reform bill. Derksen remembers how tough it was to get that massive bill through Congress.

The House bill’s public option might have prevailed in a reconciliation process between the two bills, but that process was cut short when Sen. Ted Kennedy died and Senate Democrats lost their filibuster-proof majority. The bill squeaked through as the Senate version, without the public option.

The ACA Has Survived-But at What Cost?

The ACA is much more complex piece of legislation than the public option.

“The ACA has survived for a decade, despite all efforts to dismantle it,” Salber said. “Biden wants to restore a law that the Republicans have been chipping away at. The Republicans eliminated the penalty for not having coverage. Think about it, a penalty of zero is not much of a deterrent.”

It was the loss of the ACA penalty in tax year 2019 that, paradoxically, formed the legal basis for the latest challenge of the ACA before the Supreme Court, in a suit brought by the Trump administration and 18 Republican state attorneys general.

The Supreme Court will make its ruling after the election, but Salber thinks the suit itself will boost both Biden and the ACA in the campaign. “I think most people are tired of all the attempts to repeal the ACA,” she said.

“The public now thinks of the US healthcare system as pathetically broken,” she added. “It used to be that Americans would say we have the best healthcare system in the world. I don’t hear that much anymore.”

Physicians who oppose the ACA hold exactly the opposite view. “Our healthcare system is in shambles after the Obamacare fiasco,” Campbell said. “Even if Biden has a Democrat-controlled House and Senate, I still don’t think that there would be enough votes to pass sweeping changes to healthcare.”

Biden Could Choose Issues Other Than Expanding Access

There are plenty of proposals in the Biden healthcare plan that don’t involve remaking the healthcare system.

These include making COVID-19 testing free, providing extra funding for community health centers, and stopping surprise billing. Proposals such as stepping up antitrust enforcement against mergers would involve administrative rather than Congressional action.

Some of these other proposals could be quite expensive, such as overhauling long-term care and paying for health insurance for laid-off workers. And another proposal ― limiting the prices of pharmaceuticals ― could be almost as contentious as expanding coverage.

“This proposal has been talked about for many years, but it has always met with strong resistance from drug makers,” said Robert Pearl, MD, former CEO of the Permanente Medical Group and now a faculty member at Stanford School of Medicine and Graduate School of Business.

Pearl thinks the first item in Biden’s drug plan ― to repeal a ban against Medicare negotiating drug prices with drug makers ― would meet with Congressional resistance, owing to heavy lobbying and campaign contributions by the drug companies.

In addition, Pearl thinks Biden’s plans to limit drug prices ― barring drug makers from raising their prices above the general inflation rate and limiting the launch prices for many drugs ― enter uncharted legal waters and could end up in the courts.

Even Without Reform, Expect Lower Reimbursements

Although many doctors are concerned that Biden’s healthcare reforms would reduce reimbursements, Pearl thinks reimbursements will decline even without reforms, owing in part to the COVID-19 pandemic.

Employer-based health insurance has been the bedrock of the US healthcare system, but Pearl says many employers have long wanted to get rid of this obligation. Increasingly, they are pushing costs onto the employee by raising deductibles and through premium sharing.

Now, with the pandemic, employers are struggling just to stay in business, and health insurance has truly become a financial burden, he says. In addition, states will be unable to balance their budgets and will try to reduce their Medicaid obligations.

“Before COVID-19 hit, healthcare spending was supposed to grow by 5% a year, but that won’t happen for some time into the future,” Pearl said. “The COVID economic crisis is likely to continue for quite some time, forcing physicians to either accept much lower payments or find better ways to provide care.”

Like Berwick, Pearl believes healthcare will have to move to value-based payments. “Instead of producing more services, doctors will have to preserve resources, which is value-based healthcare,” he said. The primary form of value-based reimbursement, Pearl thinks, will be capitation, in which physicians agree to quality and service guarantees.

Even steadfast opponents of many of Biden’s reforms foresee value-based payments taking off. “Certainly, there are ways to improve the current healthcare system, such as moving to value-based care,” said Orrico at the neurosurgeons’ group.

In short, a wide swath of observers agree that doctors are facing major changes in the payment and delivery of healthcare, regardless of whether Biden is elected and succeeds with his health agenda.

Notice that no one has mentioned tort reform in healthcare. Why Not???????

Pandemic fears are boosting demand for trustworthy news; And What Have We Learned from Sweden’s Experience?

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During these last few months of the pandemic one of my concerns is the lack consistent reliable data with which the media pundits of all sorts deliver their predictions and many times with false knowledge and predictions. Question, what is the correct social distancing length? Studies keep on changing! One of the key features of the web is its ability to turn regular people into citizen journalists. The cost of publishing text on the web is almost nil. The barriers to entry in the media industry are low, too. And many readers are not picky about where their news comes from: the stories that go viral can come from amateur scribes or veteran ones, media startups or established outfits. But this is not always the case. New research suggests that when a crisis hits, readers turn to reliable sources.

In 2018 Paul Resnick and James Park, two researchers at the University of Michigan, devised a pair of tools for measuring the popularity of English-language news stories on Facebook and Twitter. The first, dubbed the “Mainstream Quotient”, measured the proportion of highly-shared links that came from mainstream news sources, such as the New York Times, the BBC and, yes, The Economist. The second, the “Iffy Quotient”, measured the share originating from less trustworthy sources, based on ratings provided by NewsGuard, a company that tracks misinformation published online.

Both indices have shifted significantly during the pandemic. Beginning in February, when the coronavirus started to spread outside China, traffic to traditional media outlets and news sites surged, whereas dodgier sites attracted fewer readers. The Mainstream Quotient rose steadily during this period, a phenomenon Messrs Resnick and Park call a “flight to quality”. The Iffy Quotient, meanwhile, tumbled. The drop was particularly steep during March, when many countries instituted lockdown measures (see chart).

The researchers argue that consumers seek out reliable news sources during times of uncertainty, in the same way that fearful investors turn to gold. Whether these patterns will last remain unclear. The Iffy Quotient has already started to creep back up, for both Facebook and Twitter. And recent efforts by social-media platforms to crack down on fake news may prove only temporary. Once the pandemic subsides, demand for unreliable news may return to pre-covid levels. For now, at least, the flight to quality has taken off.

Pandemic Spike in Telehealth Levels Off

Crystal Phend of MedPage pointed out that Telehealth’s early bonanza during the pandemic has given way to persistently elevated use in primary care, a Department of Health and Human Services (HHS) report showed.

Analysis of Medicare fee-for-service (FFS) data showed an increase in Medicare primary care visits from 0.1% of all primary care in February to 43.5% in April, representing an increase from about 2,000 to 1.28 million telehealth visits per week.

Meanwhile, there was a “precipitous” drop in in-person visits for primary care in mid-March as COVID-19 took hold in the U.S., then a rise from mid-April through May, according to the report from the Office of the Assistant Secretary for Planning and Evaluation.

Use of telehealth in primary care “declined somewhat but appears to have leveled off at a persistent and significant level by the beginning of June,” the report noted. It still accounted for 22.7% of Medicare beneficiaries’ primary care visits as of June 3rd.

Overall, weekly primary care visit rates have not yet returned to pre-pandemic levels.

“Based on early experience with Medicare primary care telehealth at the start of the COVID-19 public health emergency, there is evidence that Medicare’s new telehealth flexibilities played a critical role in helping to maintain access to primary health care services — when many beneficiaries and providers were concerned with transmission of COVID-19,” the authors noted. “The stable and sustained use of telehealth after in-person primary care visits started to resume in mid-April suggests there may be continued demand for telehealth in Medicare, even after the pandemic ends.”

The findings overall match those from healthcare provider databases suggesting a 60% to 70% drop in health care office visits, partially offset by telehealth visits, with the start of the pandemic. Drug market research firm IQVIA has reported from physician surveys that about 9% of patient interactions were via telehealth prior to the pandemic but 51% during the shutdown, with expectation of a 21% rate after the pandemic, the HHS report noted.

There have been calls for Medicare to make the loosened rules around telemedicine permanent, and some legislative movement in that direction, but private insurers have signaled the opposite.

Fred Pelzman, MD, an internal medicine physician at Weill Cornell Medicine in New York City (and MedPage Today columnist), said an informal survey of his patients indicated they would be willing to do up to 50% of their care via video tools.

“We went from a handful of video visits in our practice to several thousand over the course of the months,” he said. “It’s a great way to take care of people, kept a lot of people safe, we think. What has happened is that as we started to open our practice back up again and offer appointments, the floodgates have opened and patients are declining video visits.”

Those patients opting for in-person visits tend to be older, braving what feels like a quiet time in the pandemic for the state to take care of necessary visits, he noted. “I think ultimately that we’ll plateau. It will probably come down a little more.”

The study included Medicare FFS Part B claims from January through May 2020 for primary care services along with preliminary Medicare Part B primary care claims data up to June 3. Primary care services included evaluation and management, preventive services, and advance care planning.

Telehealth usage increased most in urban counties early in the pandemic and saw smaller declines in May compared with rural counties across the country. Among cities, Boston had the greatest proportion of primary care visits by telehealth (73.1%) and Phoenix the lowest (37%).

Notably, the rate “was not strongly associated with differences in COVID-19 severity across cities as measured by rate of hospitalizations per thousand Medicare FFS beneficiaries,” the report pointed out.

I read an article predicting that telehealth visits are the future of medicine. This is truly worrisome due to the many incorrect diagnoses as well as poor control of chronic diseases that I have seen coming through my office alone. Physical diagnosis is made by looking at the patient, listening to the patient, hearing what the patient is really saying, touching the patient and using the different diagnostic tools such stethoscopes, ophthalmoscopes, otoscopes, percussion hammers, etc. to make the correct diagnoses and to follow our patients. How is that done virtually? The only ones benefitting the most from these virtually visits are the practices and the electronic medical record companies selling the practices additional software to utilize telehealth. And patients are finding that not all telehealth “visits” are paid for by their insurance companies.

How Did Sweden Flatten Its Curve Without a Lockdown?

One expert credits a “good-enough strategy”; others worry that it won’t last. Who is correct?

Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage reported that

Despite never implementing a full-scale lockdown, Sweden has managed to flatten its curve, prompting its health leadership to claim victory — but others question the cost of the strategy, as the country has a far higher death toll than its Scandinavian neighbors.

In late July, Sweden’s 7-day moving average of new cases was about 200, down from a peak of around 1,140 in mid-June. Its daily death totals have been in the single digits for two weeks, well below its mid-April peak of 115 deaths in a single day.

However, on a per-capita basis, Sweden far outpaces its Scandinavian neighbors in COVID deaths, with 567 deaths per million people compared with Denmark’s 106 deaths per million, Finland’s 59 deaths per million, and Norway’s 47 deaths per million. The Swedish figure is closer to Italy’s 581 deaths per million.

While the positive trends have led Anders Tegnell, PhD, chief epidemiologist at the Swedish Public Health Agency and architect of Sweden’s coronavirus strategy, to state that the “Swedish strategy is working,” others have criticized the approach, including two dozen Swedish academics who published a recent USA Today editorial.

“In Sweden, the strategy has led to death, grief, and suffering,” they wrote. “On top of that, there are no indications that the Swedish economy has fared better than in many other countries. At the moment, we have set an example for the rest of the world on how not to deal with a deadly infectious disease.”

The Swedish Public Health Agency has not openly stated that herd immunity was its goal, though many suspect that this was the intention. Tegnell told reporters last week he thought the recent trends indicated that immunity was now widespread in the country. But with rates of antibody positivity around 10%, that seems impossible. (Officials at the agency did not respond to MedPage Today‘s request for comment.)

So how has Sweden managed to get its outbreak under control?

Behavior Change

While Sweden didn’t officially lock down, many in the country have described a locked-down “feeling” that has eased in the summer months.

At the start of the outbreak, only high schools and universities closed; daycare and elementary schools have been open. Businesses have also remained open, but typically at reduced hours, and restaurants have functioned at reduced capacity.

Swedes have been asked to keep their distance in public, refrain from non-essential travel, and work from home when possible. Gatherings of more than 50 people are also banned. People age 70 and over are advised to stay away from others as much as possible.

Masks were never required and aren’t commonly worn.

This response hasn’t changed over time, through the June surge and into today’s decline, so there’s no definitive explanation for the flattening, though, and experts have several theories.

“Swedes in general have changed their behavior to a great extent during the pandemic and the practice of social distancing as well as physical distancing in public places and at work has been widespread,” said Maria Furberg, MD, PhD, an infectious diseases expert at Umea University Hospital in northeastern Sweden.

“During the months of March to early June, all shops were practically empty, people stopped dining with friends, and families stopped seeing even their closest relatives,” Furberg told MedPage Today. “A lock-down could not have been more effective. Handwashing, excessive use of hand sanitizers, and staying home at the first sign of a cold became the new normal very quickly.”

Mozhu Ding, PhD, an epidemiologist at the famed Karolinska Institute, said the decline is “likely to be a combination of measures taken by individuals, businesses and a widespread information campaign launched by the government.”

“Even without a strict lockdown order, many businesses allowed employees to work from home, and universities are offering distance courses to the students,” Ding told MedPage Today. “Individuals are also taking personal hygiene more seriously, as items like hand sanitizers and single-use gloves are often sold out in pharmacies and grocery stores.”

Immunity

Experts told MedPage Today there weren’t clear data to prove Tegnell’s assertion of widespread immunity in Sweden.

Furberg said there is likely “some sort of unspecific immunity that protects parts of the population from contracting COVID-19” but it’s not necessarily secondary to SARS-CoV-2 exposure.

For instance, a study by the Karolinska Institute and Karolinska University Hospital recently found that about 30% of people with mild or asymptomatic COVID showed T-cell-mediated immunity to the virus, even though they tested negative for antibodies.

“This figure is [more than] twice as high as the previous antibody tests, meaning that the public immunity to COVID-19 is probably much higher than what antibody studies have suggested,” Ding told MedPage Today. “This is of course very good news from a public health perspective, as it shows that people with negative antibody test results could still be immune to the virus at a cellular level.”

Indeed, T-cell immunity is coming into focus as a potentially important factor in COVID infection. A paper published in Nature in mid-July found that among 37 healthy people who had no history of either the first or current SARS virus, more than half had T cells that recognized one or more of the SARS-CoV-2 proteins.

Another 36 people who had mild-to-severe COVID-19 were all found to have T-cell responses to several SARS-CoV-2 proteins, and another 23 people who had SARS-CoV-1 (the virus responsible for the SARS outbreak in 2003) all had lasting memory T cells — even 17 years later — that also recognized parts of SARS-CoV-2.

It could be that T cell immunity is the result of a previous infection with common cold coronaviruses, but this hasn’t yet been established; nor is it certain that T cell immunity is driving Sweden’s decline in COVID cases.

Path Forward

Summertime is another factor that may account for the decline, which began around late June — not directly because of the weather, but social factors related to it.

Swedes are “outdoors more, and students are not at school,” said Anne Spurkland, MD, a professor of immunology at the University of Oslo in Norway.

Also, “perhaps Sweden has finally gotten better control over the disastrous spread of the virus in nursing homes which to some extent can explain their relatively high death rates,” Spurkland told MedPage Today. About half of Sweden’s 5,730 deaths occurred among those in elder care homes.

Norway is still requiring that Swedes quarantine for 10 days when coming into Norway, and Denmark has not fully reopened its borders to its neighbor yet either.

That doesn’t bode well for the Swedish economy. If the goal of avoiding a lockdown was to spare economic woe, its success has been limited.

According to Business Insider, “international tourism and trade are decimated. … Sweden’s National Institute of Economic Research predicts Sweden’s GDP will fall 5.4% in 2020, after predicting a 1% rise [in] December 2019. It also expects unemployment to rise around three percentage points, to 9.6%, between the end of 2019 and the end of 2021.”

Spurkland said it’s still “too early yet to conclude whether the Swedish approach was the wisest over all,” as it remains to be seen whether Norway and other countries that did lock down will avoid a second wave of infections in the fall.

Yet she cautions that choosing to take on a higher case load may have health consequences far beyond the immediate infection.

“What we have learned these months is that COVID-19 is not only about death, it is also about ill health,” Spurkland said. “Quite a number of people going through the infection have long-term symptoms, that may be stopping them from resuming their daily life. We do not know yet how large a proportion of those who get the virus will fall into this category, but it is certainly a concern.”

“So, when deciding on taking a herd immunity approach to handle a totally new virus we do not know anything about,” she said, “the Swedish government has also unknowingly put the general population at risk for much long-term ill-health caused by the virus.”

Furberg doesn’t see it that way: “I am very proud of the way Swedes have adapted to the restrictions and regulations and I believe the Public Health Agency of Sweden has picked a good-enough strategy for our country.”

What Americans Need to Understand About the Swedish Coronavirus Experiment

Sweden made headlines for never shutting down. Here’s what’s really happening there.

Matthew Zeitlin pointed out that Tooutsiders, life in Stockholm, Sweden, appears perfectly normal: Walk down a cobblestone street, and you may see two friends sitting at a cafe enjoying the spring air or a group of kids kicking a soccer ball in the park. Cars and bicyclists may zip by; a family may walk past you on their afternoon stroll.

Whereas most of the Western world has been in lockdown for weeks, Sweden has opted to forgo any sort of shelter-in-place policy in response to the coronavirus and instead allow businesses and parks to stay open and groups of under 50 to gather.

That’s not to say the country hasn’t been proactive at all. The policy in effect in Sweden is similar to what had been implemented in much of the United States before shelter-in-place orders were issued — and the one that will soon be in place in states that reopen. The Swedish government has recommended that people wash their hands frequently, maintain social distance, work from home if they can, and those who are elderly or more susceptible to Covid-19 stay home. The government recommended that universities switch to online teaching; they quickly followed course. Social distance is required by law in restaurants, and bar service is banned. The government changed its sick leave rules to encourage anyone who is feeling symptoms to stay home. “Instead of saying ‘close down all of society,’ we have looked at society and closed down… aspects of society,” where the disease is most likely to spread, Anders Tegnell, the epidemiologist at Sweden’s Public Health Agency in charge of recommending policy to the government, told The Daily Show. “I think that’s had a great effect.”

Sweden may not be so much an alternative, as a glimpse of the future.

Sweden’s approach has been hailed by critics of American and European pandemic policies as a less restrictive — and less economically devastating — alternative to state or national shutdowns, but it’s also been lambasted by others as an unnecessarily risky strategy that has led Sweden to have the highest Covid-19 death toll among the Nordic nations. As more and more areas of the United States reopen, Sweden may not be so much an alternative as a glimpse of the future.

As of Sunday afternoon, the country had 25,921 confirmed cases and3,220deaths, according to the Johns Hopkins Coronavirus Resource Center. These are much higher figures than those of the country’s neighbors, but lower than those in some other wealthy Western European countries on both an overall and population-adjusted basis. Sweden also has suffered problems familiar to residents of countries that have had more severe outbreaks and stricter policies. Nursing homes have been hard hit, and Tegnell described Sweden’s failure to protect nursing home residents as its greatest shortcoming so far. Immigrant and ethnic minority communities also have suffered, due in part to their larger households. Just over half of all households in Sweden in 2016 consisted of only one person, while immigrants were substantially more likely than native-born residents to live in overcrowded conditions or multigenerational household.

Even with the less aggressive containment measures, the economic effects of the virus have been severe for the country. Sweden’s National Institute for Economic Research projected that gross domestic product would contract by 7% in 2020 and the unemployment rate would rise to just over 10%. The large fall in consumer and business confidence, the institute said in a release, point “to a rapid and severe downturn, not least in large parts of the service sector.”

“The economy will shrink both due to a drop in exports and is already contracting due to lower consumption. But the underlying causes differ: The export sector is mostly affected by the international situation, whereas the drop in consumption is directly related to the government’s recommendation of social distancing,” said Lina Maria Ellegård, an economist at Lund University.

In the first three months of the year, the Swedish economy contracted by less than 1% — less than the United States’ fall — but the production of both goods and services declined in March. The car industry — one of Sweden’s major export sectors — along with real estate, hospitality, and restaurants led the way.

That’s because even without lockdowns or orders, the behavior of Swedes still changed — to an extent. According to data collected by Google and Apple, Swedes have cut back on their travel to places like stores and restaurants and decreased their use of transit-like buses substantially, though not as dramatically as their Nordic neighbors in Denmark. Still, travel over the Easter holiday fell by 90%, Tegnell said on The Daily Show.

Multiple experts in Sweden I spoke to agreed that because a recommendation made by Swedish leadership is culturally viewed as more of a demand, the freedoms allowed have not resulted in free-for-alls. “There’s a basic misconception that there’s one big huge after-ski party,” said Lars Trägårdh, a Swedish historian. “That’s not true.”

Sweden’s voluntary restrictions policy is made possible by the high levels of trust throughout Swedish society. “We have a lot of social trust and a lot of trust in the institutions, and the institutions have confidence in the citizens,” said Trägårdh. “That’s why we decided to have this voluntary approach as opposed to one that’s more hardcore.”

The photos circulating online don’t fully represent the broader reality on the ground either. “I’ve seen pictures in the newspapers and news media of what looks to be crowded restaurants in Stockholm. What I’ve seen is mostly pretty sparse restaurants. Every other table is empty, and there’s very little business,” said Bo Becker, an economist at the Stockholm School of Economics. “Life doesn’t go on as usual, but maybe the lockdown is less severe than in other countries.”

But even if Sweden’s policy of allowing businesses to open and people to move out and about is not that different from some policies American states have or will soon implement, there’s been one major difference: the schools. Schools for children up to age 15 have remained open, all the way down to daycares and preschool. “That makes a world of difference,” Trägårdh told me. “It’s a gender issue.”

Sweden has one of the highest rates of female participation in the labor force for rich countries. Forcing young children to stay home would put many mothers in a bind or even knock them out of the workforce entirely.

“Closing down schools works well if you are in a well-to-do, middle-class family that has a house and a garden and can afford to have one person staying at home,” Trägårdh said. “That may not look like a doable proposition if you are a single parent or do not make a lot of money.”

Shutting down daycare and schools could increase risk as well, Erik Angner, a philosopher and economist at Stockholm University, explained, by leading working parents to turn to their own parents for help. “If you close daycares, then either one parent has to stop working or grandma or grandpa shows up,” he said. But since the elderly are most at risk, it was even more important to keep schools and daycares open

As other countries work through their peak infections, they will have to figure out how to reach a new status quo where the disease’s spread is still slow but restrictions can be lightened. “Now that everybody else is starting to shift toward opening up, people are talking about Sweden,” said Trägårdh. “Other Nordics are realizing you can’t keep schools closed forever. We’re in the long run here. It’s not a 60-meter race, it’s more like a marathon.”

While Sweden has a higher death rate than its Nordic neighbors and other wealthy European nations like Germany, it has been lower than rates in the Netherlands, France, and the United Kingdom. According to the Financial Times’ figures, Sweden has seen an 18% jump in excess deaths since the start of the outbreak, while Denmark has seen a 5% rise. Excess deaths in England and Wales are up 37%.

“The data out of Finland, Norway, and Denmark looks much better,” said Angner. “But everything will hinge on what will happen next.”

There’s some evidence that Sweden has managed to take the heaviest blow from the virus already — about a fourth or fifth of the population of Stockholm may have been infected, which would put the infection rate at a level similar to that found in New York City, which has had many more deaths and been under a near-total lockdown for almost two months. On Tuesday, health officials in Stockholm said the number of new deaths linked to Covid-19 was slowly decreasing from one week to the next.

The Swedish example carries both optimistic and pessimistic tidings for the United States as it embraces a partial, scattered reopening cheered on by the White House. It suggests that, even without punitive mandates, people can and will take measures to keep themselves safe from the disease. But even though people are protecting themselves without formal orders, the economy will be only slightly better off than it was under lockdown. Meanwhile, the American push to reopen is being driven by distrust of the government combined with the absence of robust safety-net programs to stem the economic bleeding. In the American context, Sweden’s example may be no example at all.

As a paper that was just accepted for publication, written by this author and two coauthors, we need reliable data to evaluate our progress as well as our failures to predict, based on appropriate statistical models and in order to lead us all in the correct path for future strategies for this pandemic and future crises.

Telehealth use, Coverage by Insurers Soaring in Response to COVID-19; COVID Testing, Contact Tracing and How to Reopen the US and Pandemic Resilience?

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Dr. Sarah-Anne Schumann, UnitedHealthcare’s chief medical officer for employer and individual health care plans in North Texas and Oklahoma, says telehealth visits are soaring.

The growth of telemedicine is apparent at UnitedHealthcare’s sister company, Optum, which went from 1,000 telemedicine-trained care providers to 5,000 in a matter of weeks. That number is expected to grow to 10,000 providers by the end of April.

In the interview that follows, Schumann, who is a family doctor in addition to her role with UnitedHealthcare, gives us a look at the growth of telemedicine during the coronavirus from the viewpoint of both the insurer and the physician.

How has the acceptance and reliance on telehealth grown given the COVID-19 pandemic?

Telehealth has been around for a long time, and basically what telehealth does is it allows people to see a doctor anywhere and anytime on a mobile device or computer. It’s available 24 hours a day, seven days a week. People can get their medical conditions diagnosed and treated that way. With the coronavirus, now that there’s a lot of risk with going into a doctor’s office — a risk of you exposing other people or you being exposed to coronavirus — more and more doctors’ practices have very quickly scaled up their technology to allow their doctors to provide telehealth.

Can you quantify the growth?

I have some statistics. Seventy-six percent of hospitals can connect patients and care providers using digital and other technology. On the employer side, nearly nine out of 10 employers offer telemedicine to their employees.

When did UnitedHealthcare start allowing for telehealth visits?

We did allow for telehealth before COVID, but our policies have changed. We have much broader coverage since COVID. Our policy now is we are covering telehealth with no cost-sharing at all. That started on March 31. As of now through June 18, we are waiving all cost-sharing for in-network health visits for our Medicaid, Medicare Advantage and our fully insured individual and group health plans. For self-funded employers, they can opt in to telehealth with no cost-sharing.

That’s not just for COVID-related visits, but for absolutely any telehealth visits. It’s not just primary care and urgent care, but also for outpatient behavioral health and physical therapy, occupational therapy and speech therapy.

Did UnitedHealthcare broaden the coverage because of the COVID-19 pandemic?

Yes. Some primary care offices are closed right now both for safety and because there’s decreased volume for a lot of the businesses. This is a very safe way to get people assessed when they’re feeling sick but not sick enough to go to an emergency room.

It’s my understanding that insurance won’t pay the same for a telehealth visit vs. an in-person doctor visit. Is that true with UnitedHealthcare?

They are covered at a different rate, but there are many ongoing conversations. Right now, with COVID, for the doctors’ practices that have moved over to provide telehealth, they are being reimbursed at the same rate as an in-person visit. Another change, because the doctor’s offices had to pivot so quickly to start offering this, right now, there can even be phone-only visits that are covered.

Typically, do you Facetime or how do the providers get the visuals from the patient?

If you have a smartphone, which most people have, or a tablet or computer, that’s usually how it works. But right now, you can do phone-only visits.

How does a patient find out if their existing doctor is signed up and licensed to practice telemedicine?

Call the practice or go on their website. It’s best to try your own doctor first, but if that doesn’t work, try your (insurance company’s) website and it will connect you with a national provider.

What should employers know about telehealth?

Telehealth, of course, is not for everything. But for simple, urgent medical issues like allergy symptoms or pink-eye or rashes or fever, telehealth is a great way for their employees to access care. It reduces the burden on the health care system and it reduces cost and improves accessibility to care. Another thing for employers to think about is, right now while people are at home, there’s a lot of increased stress and anxiety, and virtual visits can be a way to connect with a therapist or psychologist or psychiatrist.

Do you think the COVID-19 pandemic will cause permanent changes in how people access health care?

A lot of the changes that we are experiencing in society because of the pandemic are going to be permanent changes. Things like people working from home. Some people are more productive when they’re working from home. It’s the same thing with telemedicine. Now that people are introduced to this, I think in the cases where telemedicine is a good substitute, waiting to see the doctor for urgent-care type visits where you don’t need to have a blood test done or get IV medication or things like that, people are going to see that telemedicine is a great substitute.

How to reopen the US, according to Johns Hopkins and Harvard: Test 20 million people a day, hire an army of contact tracers, and expand healthcare coverage

Hilary Bruek reported that experts from Harvard and Johns Hopkins, as well as the former FDA commissioner, have each released their plans for how to reopen the country safely.

The plans suggest the US will need to massively ramp-up its disease testing and tracing capabilities to allow people to return to work and school. 

Collectively, the reports suggest the US will need: around 5 million tests a day by July, 100,000 public health workers to contact trace, and a “national infectious disease forecasting center.” 

Most Americans are still stuck at home, but a trio of reports, out from Harvard, Johns Hopkins, and former US Food and Drug Administration Commissioner Scott Gottlieb, are starting to lay a foundation for what reopening the country might look like, if done safely.

Though staying inside is certainly keeping more infections at bay right now, it’s not without its costs.

Aside from the strain stay-at-home orders are putting on families, friends and communities, the newfound national quiet means the US is “hemorrhaging $100 billion to $350 billion a month,” according to the new Harvard analysis, which was released on Monday.

A hasty, careless reopening would be a deadly disaster, though.

If everyone rushed back into the streets, hugging, kissing, shaking hands, and entirely abandoning social distancing measures, more than 300,000 people nationwide could die, according to federal documents from the Department of Health and Human Services, first released in a report from the Center for Public Integrity on Tuesday.

That’s why any thoughtful plan to reopen the country must involve massive additional investments in public health, especially the testing and tracing of US coronavirus cases.

Here are the key topline suggestions from the experts for not only emerging from the coronavirus crisis successfully and safely, but also, as the Harvard report put it, becoming a “pandemic resilient” nation.

Harvard’s Roadmap to Pandemic Resilience says more testing is fundamental to recovery 

Broadly, the Harvard report suggests the task ahead of us is “bigger than most people realize.”

“We need to massively scale-up testing, contact tracing, isolation, and quarantine—together with providing the resources to make these possible for all individuals,” the authors write. 

Here’s how:

In the coming months, the US should rapidly ramp up its capacity to test for the coronavirus, eventually testing upwards of 2 to 6% of the population on any given day. (Currently, the US tests around 150,000 people per day, or about 0.04% of the population.) The plan starts with: 5 million tests per day by early June, and continues trending upward towards 20 million tests a day nationwide, by late July. That kind of widespread testing would be on a scale larger than Germany (testing 0.06% of the country per day, with more than 50,000 coronavirus tests), and would even surpass South Korea, which so far has tested more than 1.1% of the country, overall, for COVID-19.

But “even this number may not be high enough to protect public health,” the report authors warn.

“Given that 40% of the economy is already open,” the report says, “our first priority for a massively scaled up pandemic testing program should be to stabilize the essential workforce.” Policy makers should listen to worker voices, the report also said, “because workers have expert knowledge about how to make their jobs safe and when safety-related rules are not being followed.” 

Tests will eventually also be needed for others, including:

  1. Everyone with coronavirus symptoms, and their close contacts.
  2. People with presumed exposure (healthcare workers, essential workers, etc.)
  3. Nursing home residents and staff.
  4. Incarcerated people.
  5. Companies and schools.
  6. “Those who have tested negative within a very recent window and those who show immunity in reliable antibody tests (assuming these prove feasible) should be free to return to work,” the report said.
  7. The authors were cautious about the idea of immunity cards or passports, though. “Certificates of immunity should be used only in contexts where people have equal access to testing and where a recent negative test result provides the same access to mobility as immunity,” the report says. “Any other use of immunity certificates would be likely to violate constitutional equal protection requirements.” 
  8. In order to be able to follow 14-day quarantine orders successfully, people will need to be supported with more job protection and healthcare, the report added.
  9. The cost of testing and tracing at this scale is an estimated $50 – 300 billion over two years, which, the authors write is still far cheaper than “the economic cost of continued collective quarantine,” at $100 to 350 billion a month. 
  10. A Pandemic Testing Board should also be established by the federal government, the report suggests, with a National Director of Testing Supply appointed to help ramp up testing efforts. “In virtually every successful historical example of such rapid coordination, a central authority has set goals and ensured that each part of the chain meets the interlocking goals required for the chain to succeed,” the report authors add.  

There’s just one problem, though: the Harvard approach relies on all coronavirus tests being accurate, but some are not

Claudio Furlan/LaPresse noted that the swab-the-nose-and-throat coronavirus testing delivers about 30% false negatives, which means that roughly 3 in 10 people who have the virus could wrongly assume they don’t after they’re tested, and then could go on to infect others at work or at school.

Coronavirus blood tests, which are meant to determine whether a person has been infected in the past with the coronavirus and developed disease-fighting antibodies, have so far performed much worse than the swab tests, with some operating at just 30% accuracy, the New York Times recently reported.

Johns Hopkins’ ‘National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in the US’ adds an army of contact tracers to the Harvard testing plan

The goal of deploying thousands of contact tracers across the US, the report authors write, is to “find every COVID-19 case in the midst of a national epidemic … and then work quickly to contain spread through intensive case and contact tracing interventions,” by warning others who might’ve been exposed to those sick people to stay home.

“This entire operation has never been done before,” New York Governor Andrew Cuomo said Wednesday, as he announced during a news conference that his state would be partnering with Johns Hopkins to roll out a new army of contact tracers in the tri-state area, to the tune of $10 million.

“You’ve never heard the words testing, tracing, isolate before,” Cuomo said. “No one has. We’ve just never done this.”

Here’s how the plan could work, nationwide:

  • Hire “an extra 100,000 contact tracers across the United States,” the report says. “While this figure may be stunning, it is still the equivalent of less than half the number [of contact tracers] employed in Wuhan,” the authors point out. 
  • Contact tracers will need to be trained by existing state and territorial public health departments on: disease transmission, principles of case isolation and quarantine, ethics of public health data collection and use, risk communication, cultural sensitivity, and more. 
  • The plan could provide jobs for: former government employees, retired public health and public safety workers & medical personnel, medical and public health students, Medical Reserve Corps or Peace Corps members, community health workers, and others “seeking employment—especially those who have lost their jobs due to COVID-19.” People with good communication and interviewing skills would be especially well-qualified for the task.
  • The new workforce will cost the US an estimated $3.6 billion, and the report authors urge Congress to fund this idea in its fourth stimulus package.
  • The cost of not tracing is also high: “It is estimated that each infected person can, on average, infect two to three others,” the authors write. “This means that if one person spreads the virus to three others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections.” 

Apple and Google have also released their own plans to make contact tracing and surveillance happen more automatically on our phones

Apple and Google are both working on new apps and other press-of-a-button opt-in functionalities for phones that would harness Bluetooth technology to track where we’ve been, and then warn others who’ve been near us, in the event we get sick with the coronavirus, in a new brand of push notification-friendly contact tracing.

The companies promise that “user privacy and security” will be paramount in any forthcoming app design.

Other countries have already tried out similar Bluetooth-reliant tracing techniques, but they’re not always very successful, as you need a large percentage of the population to use them in order to have any major impact on transmission. 

Scott Gottlieb’s ‘Road Map to Reopening’ from the American Enterprise Institute adds in the element of a weather forecasting service for pandemics 

James Gathany reviewed that Scott Gottlieb reviewed the “Road Map to Reopening” from the American Institute and reported that Gottlieb calls it a “National Infectious Disease Forecasting Center,” and says “this permanent federal institution would function similarly to the National Weather Service, providing a centralized capability for both producing models and undertaking investigations to improve methods used to advance basic science, data science, and visualization capabilities.” 

Gottlieb also cautioned that we should not rush to return the US to business-as-usual, even as some restrictions are lifted. As schools and businesses reopen, “teleworking should continue where convenient” he said, and “social gatherings should continue to be limited to fewer than 50 people wherever possible.”

‘It’s going to be brutal,’ billionaire Mark Cuban says of economy’s recovery from coronavirus, and ‘there’s no way to sugarcoat it’

‘It’s going to be brutal. There’s no way to sugarcoat it at all.’

That is outspoken billionaire and Dallas Mavericks owner Mark Cuban, who has been increasingly visible as the National Basketball Association has been temporarily suspended due to the deadly COVID-19 pandemic.

Reporter DeCambre reviewed an interview with Mark Cuban with Maria Bartiromo. Cuban, speaking with Fox Business anchor Maria Bartiromo, explained why he thought the recovery from the economic fallout wrought by the illness caused by a novel coronavirus strain could be a long and ugly one for the average American and small businesses in particular.

“It’s going to be brutal. There’s no way to sugarcoat it at all. And when we get to the other side, companies are going to be operating differently,” Cuban said on the business network.

The entrepreneur, who boasts a net worth of $4.3 billion, according to Forbes, says that challenges for businesses are manifold and include additional costs that will be incurred to sanitize and retrofit spaces as nearly shutdown economies attempt to reboot after a virus-imposed hibernation.

“Companies are going to have to be agile … Companies are going to have to build from the bottom up,” Cuban said.

The “Shark Tank” star said he remains confident that some normalcy will return in two to three years but predicts that investors and business owners will need to endure some pain to get to the other side.

His comments came as Robert Redfield, director of the Centers for Disease Control and Prevention, was quoted in the Washington Post as saying in an interview published on Tuesday that “there’s a possibility that the assault of the virus on our nation next winter will actually be even more difficult than the one we just went through.”

The deadly contagion that was first identified late last year in Wuhan, China, has, infected more than 2.6 million people globally and killed about 179,000, according to data aggregated by Johns Hopkins University, as of Wednesday morning.

On Thursday, investors and others will be watching for a House vote on a nearly $500 billion aid package for small businesses amid the coronavirus pandemic, after the Senate passed the measure on Tuesday.

The passage of the bill and the possibility of restarting stalled economies may be conferring some optimism on markets, with the Dow Jones Industrial Average DJIA, +1.10%, the S&P 500 SPX, +1.39% and the Nasdaq Composite Index COMP, +1.64% all closing sharply higher Wednesday.

That said, Cuban believes that small businesses may require at least a third installment of funds to operate through the crisis, and he is looking to invest in companies that sit outside the criteria for obtaining government-backed loans.

“We haven’t talked about those companies that are 501 and up. They are suffering the most,” he said, referring to language that stipulates that businesses need to have 500 or fewer employees to qualify for the small-business recovery funding. 

So, when do we really reopen the economy and back to the “new” normal and do we use scientific data? I think as we can see we need data based on more testing, but the testing has to be accurate and more sensitive and then we need comprehensive contact tracing and case follow-up tracing. Also, what technology will we use for contact tracing and could it be the use of APPS on our phones or other home health and fitness wearables or other real time monitors?

This technology needs to integrate multiple longitudinal electronic medical records across all sources including healthcare providers and healthcare facilities, labs, clinics, pharmacies, long-term care facilities, etc. with nationwide coverage and interoperability and more important it needs to be HIPPA compliant to respect personal information.

Big wishes and needs, which will lead the way to solutions and attaining our goals of defeating COVID-19 and also prepare the US for whatever the next possible pandemic may raise its ugly head!

The Increasing Infection Rate and Tips for Running Your Practice or Your Business in a Coronavirus/Pandemic Crisis

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Dr. Deborah Birx, the White House’s coronavirus response coordinator, expressed recently that 200,000 Americans could die even “if we do things perfectly.” However, the Society of Critical Care Medicine has projected that more than 960,000 people in the United States may require ventilators during the course of this pandemic. A study from the Intensive Care National Audit and Research Center in the UK gathered data from a sample of those on advanced respiratory support as treatment for COVID-19. Sixty-six percent of those patients died. If these numbers are correct, then we may see over 600,000 deaths in the United States by the time this pandemic is over, and those numbers may increase if we are unable to produce enough ventilators for our response. Each day the numbers get worse.

We need a national strategy

Local government officials across the nation are implementing curfews and extreme social distancing measures. However, in these same states, we continue to see people congregating on beaches, at parks and in other public areas. The federal government’s inability to take decisive action will lead to a wave of death that in many ways will be much worse than the disaster seen on 9/11. Federal officials have plucked the low-hanging fruit of mitigation — and now it’s time to reach deeper and enact a national quarantine.

Part of that strategy is a plan for our practices as healthcare givers and other small and medium business owners and managers. 

I found an interesting article written by Debra A. Shute included in a Medscape email. As I was reviewing the article and editing it for my use I found that during these difficult times, when businesses are being cut back or shut down that many of these suggestions can be applied to all of us in our times of financial and healthcare needs. 

We all have the same requirements as small or medium sized businesses. We want to survive, protect our businesses and our employees, assist our clients, so that when the pandemic is over, we can get back to what we do best, running our business, whatever that might be.

I was also amazed this morning when I went in to the office to take a look at what additional PPEs that I had to give to the local hospitals and clinics. I already loaded up a full SUV of gloves, surgical gowns and masks. Anyway, I noticed an office, a vein clinic, still open with at least 14 cars in their office parking lot. Is this office a necessity? I think not and what are they thinking driving from an area of increasing COVID-19 infection to our “neck of the woods” where so far, we have a low incidence of COVID-19 infection. More importantly our area has a larger population of older patients. Think of Italy and their mortality due mostly to the fact that they have the second oldest population in the world.

What is this physician thinking? Evidently the greed factor plays a role here and not the safety of her patients, her staff and yes, even herself as a physician. I am amazed and disheartened to see this idiocy in such a serious crisis.

Considerations to consider in this time of a pandemic:

  1. Do you or your practice need to continue to keep your practice doors open to see patients? Many states are mandating shutting all nonessential businesses including physician and nurse practitioner offices unless essential emergent care is needed. The same questions can be applied to most businesses if you think your business is essential and the state government hasn’t shut down with threats of jail time and fines.
  2. What patients are you going to see in this time of crisis and what are the challenges. i.e. eighty or older patients with no suspicious symptoms for the COVID-19 virus.
  3. The safety of three parts of your practice- a. your patients, b. your staff and c. you the treating practitioner.

If you need to continue to run your practice what tips can we provide? Debra Shulte, a freelance writer, summarized it in her article: 7 Tips for Running Your Practice in the Coronavirus Crisis, which appeared on the Medscape Web post. The rapidly increasing numbers of COVID-19 cases in the US raises the possibility that some physician and nurse practitioner offices will need to decide or be forced to close temporarily, as occurred in London last month as well as many areas in the U.S. Just recently, Maryland’s Governor Hogan sent out through the Health Department new regulations closing offices. So, now many practices across the country have to adjust to the way they operate, amid daily changes in this pandemic. The question is-what should you do to adapt to this new way of operating your practice?

  1. Create a Task, Practitioner and Staff Force or Core Team to Manage Change

“The readiness of medical practices to address the myriad challenges posed by this crisis has so far been a mixed bag”, said Owen Dahl, MBA, a Texas-based medical management consultant. Leadership is going to have to access what’s happening in the community, what’s happening with staff members who may or may not have the disease and may or may not have to self-quarantine.” Dahl said.

The physicians, the administrator, CEO, or managing partner should be involved in decision making as the global crisis unfolds, added Laurie Morgan, MBA, a California-based practice management consultant. And depending on the size of the practice, it may be useful to delegate specific components of this work to various department managers or other individuals in the group.

The Team should assess:

  1. Recommendations and/ or mandates from local, state, and federal governments
  2. Guidance from specialty and state medical societies
  3. How to triage patients over the phone, i.e. what questions to ask? Can they participate in Virtual visits and do they and your office have the hardware and software technology? Or can or should they be referred to an alternate site of care (culture sites).
  4. Where to send patients, if necessary, for testing?
  5. The practice’s inventory of personal protective equipment (PPE)
  6. Review of and possible revision of current infection control policies
  7. Possible collaborations within the community including hospitals, clinics and Health Departments, etc.
  8. Reimbursement policies for suspected COVID-19 triage, testing, and follow-up treatment- in office or virtually. Interestingly enough there is a new ICD-10 code for COVID-19 for coding visits and treatment.
  9. Whether some employees’ work (e.g. billing, coding) can be done remotely
  10. Options for paying personnel in the case of a temporary shutdown
  11. What’s covered and excluded by the group’s business interruption insurance
  12. Consider Postponing Nonessential Appointments

What’s more, it is critical for practices to form a strategy that does not involve bringing patients into the office, said Javeed Siddiqui, MD, MPH, an infectious disease physician, epidemiologist, and chief medical officer of TeleMed2U. “One thing we really have to recognize in this pandemic is that we don’t want people going and sitting in our waiting room. We don’t want people coming, and not only exposing other patients, but also further exposing staff. Forward triaging is going to be essential in this type of pandemic.”

One medical group, with multiple locations in Massachusetts, for example, announced to patients recently that it will postpone appointments for some routine and elective procedures, as we have done in my practice, as determined by the group’s physicians and clinical staff.

“Taking this step will help limit the number of people passing through our facilities, which will help slow the spread of illness (as recommended by the CDC),” noted in an email blast to patients.

  1. Overcommunication to Patients

With a situation as dynamic and unprecedented as this, constant and clear communication with patients is crucial. “said Morgan. “In order to be effective and get the word out, you have to be overcommunicating.”

Today’s practices have ways to communicate to keep people informed, including email, text messaging, social media patient portals, and even local television and radio.

One email or text message to the patient population can help direct them to the appropriate streams of information. Helping direct patients to updated information is critical.

In contrast, having the front desk field multitudes of calls from concerned patients ties up precious resources, according to Siddiqui. “Right now, practices are absolutely inundated, patients are waiting on hold, and that creates a great deal of frustration,” he said. Work out how to manage the crisis calls!

“We really need to take a page from every other industry in the United States, and that is secure SMS, email communication, and telehealth,” Siddiqui said. “Healthcare generally tends to be a laggard in this because so many people think, ‘Well, you can’t do that in healthcare,’ as opposed to thinking, ‘How can we do that in healthcare?”

  1. Take Advantage of Telemedicine

Fortunately, technology to interact with patients remotely is almost ubiquitous. Even for practices with little experience in this arena, various vendors exist that can get secure, HIPAA-compliant technologies up and running quickly. Many of the practice management electronic medical records systems already have the capacity for telemedicine including patient portals.

Various payers have issued guidance regarding reimbursement for telemedicine specific to COVID-19, and on March 6, Congress passed a law regarding Medicare coverage and payment for virtual services during a government-declared state of emergency. Some of the rules about HIPAA compliance in telemedicine have been eased for this emergency.

But even with well-established telemedicine modalities in place, it’s crunch time for applying it to COVID-19. “You need to find a way to have telemedicine available and use it, because depending on how this goes, that’s going to be clearly the safest, best way to care for a huge number of people,” said Darryl Elmouchi, MD, MBA, chief medical officer of Spectrum Health System and president of Spectrum Health Medical Group n Michigan.

 “What we recognize now, both with our past experience with telehealth for many years and specifically with this coronavirus testing we’ve done, is that it’s incredibly useful both for the clinicians and the patients,” Elmouchi said.

One possibility to consider is the tactic used by Spectrum, a large integrated healthcare system. The company mobilized its existing telemedicine program to offer free virtual screenings for anybody in Michigan showing possible symptoms of COVID-19. “We wanted to keep people out of our clinics, emergency rooms, and urgent care centers if they didn’t need to be there, and help allay fears,” he said.

Elmouchi said his company faced the problems that other physicians would also have to deal with. “It was a ton of work with a dedicated team that focused on this. The hardest part was probably trying to determine how we can staff it,” he said.

With their dedicated virtual team still seeing regularly scheduled virtual patients, the system had to reassign its traditional teams, such as urgent care, and primary care clinicians, to the virtual screening effort. “Then we had to figure out how we could operationalize it. It was a lot of work,” Elmouchi said.

Telemedicine capabilities are not just limited to screening patients, but can also be used to stay in touch with patients who may be quarantined and provide follow-up care, he noted.

Luckily in my practice we have used forms of telemedicine for many years either email or texts are the patient’s favorite mode of communication and virtual video chat only if necessary due the fact that my practice is a surgical practice. However, in these critical times I only want to see those needing urgent attention. If they report suspicious symptoms then we need to consider where to refer them. 

Therefore-

  • Identify COVID-19 Testing sites

Access to tests remains a problem in the U.S., but is improving by the week. Just consider the most recent announcement that they now have a test that can give results in 15 minutes. For practices that can attain the tests themselves, not in my practice, it will still require some creativity to administer them with as little risk as possible. In South Korea, for example, and increasingly in the U.S, healthcare organizations are instructing patients waiting to be tested to stay in their cars and have a practitioner wearing the proper PPE go out to patients to test them there. Alternatively, some practices may opt to have PPE-wearing staff members bring PPE to patients in their cars and then escort them to a designated testing area in the building-through the back door if noninfected patients are still being seen. I don’t recommend this last option because of the shortage of PPE equipment unless the patient is such a high risk and has multiple co-morbidities and needs a in depth exam. Here I suggest an in car rapid culture/test and if the need warrants to refer to the medical center better setup to manage the patient.

“Once in the office, you still need to isolate virus patients in any way you can,” Dahl said. “In fact, you may want a negative-pressure environment if possible, with the air being sucked out rather than circulating,” he said, adding that a large restroom with a ventilation system could be repurposed as a makeshift exam room. Here I am adamant! If you are going to see sick viral patients your practice should have negative pressure rooms. This protects the staff, other patients and you the practitioners.

Community testing sites are another possibility, my favorite option, given proper coordination with other healthcare organizations and community officials. Siddiqui has been working with several communities in which individual clinics and hospitals are unable to handle testing on their own, and have instead collaborated to create community-testing sites in tents on local athletic fields.

“One of our communities is looking at using the local college parking lot to do drive-through testing there,” he said. “We really need to embrace collaboration much more than we’ve ever done.”

 This is in fact what we have set up in our small town, using the local community college parking lots, etc.

Collaboration also requires sharing supplies and PPE, noted Dahl. “Don’t hoard them because of the shortage. Look at your inventory and make sure you can help whomever you may be sending patients to. “And if your office is falling short, Dahl advises checking with offices in your community that may be closing, such as dentists or plastic surgeons, for supplies you can purchase or simply have. I did this in my office, donating an SUV full of surgical gowns, facemasks and boxes of gloves to the hospital to deliver to whom needs them most.

The U.S. Food and Drug Administration has issued some guidance to healthcare providers about shortages of surgical masks and gowns, including advice about reusable cloth alternatives to gowns.

In addition, some hospitals have asked clinicians to keep their masks and provide guidance on how to conserve supplies. Our medical facility set up a Task Force to analyze, assess and allocate supplies calling on physicians and dentists, etc.

  • Preparing to Potentially Shut Down

A temporary closure may be inevitable for some practices. “Maybe the physician owners will not feel like they have a choice,” said Morgan. “They feel like they want to stay open for as long as they can; but if it’s not safe for patients or not safe for employees, maybe they’ll feel it’s better if they check out for a bit.” And remember if you are sick or one of your partners is sick or a member of your staff the stress becomes multiplied and, potential errors occur and everyone suffers!

Handling the financial ramifications of closure is a top priority as well, and will require a full understanding of what is and isn’t covered by the practice’s business interruption insurance. Practices that don’t have a line of credit should reach out to banks and the Small Business Administration immediately, according to Dahl and of course me. Practices that have lines of credit already may want to ask for an increase. Although the 2 trillion-dollar COVID-19 rescue bill may assist healthcare facilities. Meet and work with your account to review your financial liabilities, losses and needs for the future!

My other suggestion and that of many experts is to Apply for an SBA loan (CARES Act loan) to acquire working capital.

  • See: U.S. Small Business Administration, Disaster Loan Assistance
    Due to current traffic, non-peak hours are optimal 7pm – 7am EST.

Loan Application Checklist

Forecasting Cash Inflows for 13 Weeks

  • You may not have all of the information; however, don’t let that keep you from conducting this exercise. Use your best estimates, evaluate your forecast real-time (daily), and adjust the forecast as you go.
  • It may be easiest to start with the prior year’s weekly revenue and adjust accordingly. 
  • When determining cash inflows, consider any ongoing operations, accounts receivable, retained earnings, owner loans, and/or financial support from lenders (such as lines of credit or SBA above).
  • Decide how you will manage late fees/ waivers from your patients, customers and clients.

Forecasting Cash Obligations for 13 Weeks- Leverage your Networks. 

  • Watch and prepare for outside influences including landlords, local, state, and   federal actions
  • Determine where obligations may need to be reduced
  • Negotiate with Vendors and seek extensions* 
    – If this seems daunting, start with those you spend the most money. 
  • Negotiate with Credit Card Companies
    – Can you reduce your minimum payment or increase your line of credit?
  • Negotiate rent with Landlords 
    – Consider evaluating any lease agreements that include Force Majeure clauses (freeing both parties from liability or obligation when an extraordinary event or circumstance beyond the control of the parties) and work with your legal counsel to evaluate options and/or circumstances that may invoke this provision.
    – If you own the building, contact your lender to evaluate term extensions, etc.
  • Develop Staffing Plan with the Assistance of Legal Counsel
    – What can you afford based on your forecast? 
    – Do you need to reduce hours, reduce staff through lay-offs or furloughs? 
    – Consider job sharing options (1 staff member M, W, 2nd staff member works T, Th)

Protecting employees’ income is challenging as well. For employees who are furloughed, consider allowing them to use their sick leave and vacation time during the shutdown-and possibly let staff “borrow” not yet accrued paid time off. I went through this discussion with my staff and ended the discussion with the assurance that if we cut back hours or let people go their jobs were secure when this was all over and that I guaranteed them financial support for rent and food, etc. for however long the shutdown lasts. Our practice sets aside a savings account for emergencies.

        Considerations for Furlough/Layoff
– If you are to keep staff, identify specific job responsibilities. 
– If your staffing plan includes remote employment, which I will discuss in the next section, you may need to determine how to utilize your staff in a remote capacity. For example, can they work on updating your practice’s website and/or before & after galleries, build out social media marketing calendars, mine your practice management system, etc. More discussion will be found in the next section where I discuss working from home.

Marketing
– Determine ROI on current efforts. What’s working/what’s not/what’s the plan moving forward?

However, there’s a risk with certain jobs in a medical practice that tend to have extremely high turnover, so physicians and administrators may be reluctant to pay people too much because they don’t know for sure those employees will come back to those jobs,” Morgan said. “On the other hand, if you have had a stable team for a very long time and feel confident that those employees are going to stay, then you may make a different decision.” Therefore, if you need to cut back staff temporarily, when things stabilize you will have able and willing staff and not need to find new employees who will need to be trained, etc.

  1. Seize Work-From- Home Opportunities

“Even if the practice isn’t seeing patients, there may be opportunities for some employees, such as billers, coders and schedulers, to continue to work from home.” Morgan noted. Particularly if a practice is behind on it’s billing, a closure or slowdown is an ideal time to catch up. This measure will keep at least some people working-perhaps including some individuals who can be cross-trained to do other tasks-and maintain some cashflow when the practice needs it most.

Other remote-friendly jobs that often fall by the wayside when practices are busy include marketing tasks such as setting up or updating Google business pages, Healthgrades’s profiles, and so on, noted Morgan.  And make sure your staff has the software and hardware to support Work-from Home strategies.

“Another thing that can be even more important, and is often overlooked, is making sure health plan directories have correct information about your practice,” she added. “These are pesky, often tedious tasks that may require repeated contact with health plans to fix things-perfect to do when the office is not busy or closed.”

For administrators and billers, if the practice is able to keep paying these employees while partially or fully closed, it can also be an excellent time to do the sort of analysis that takes a lot of focused attention and is hard to do when busy. Some examples: a detailed comparison of payer performance, analysis of referral patterns, or a review of coding accuracy. Morgan suggested. 

We had an excellent opportunity to have our staff analyze our practice and plan our future move to a new facility and start packing, etc. Make use of your employees and the opportunities that you have been putting off due to your busy practice!

As with many, HIPAA is a leading concern, though it needn’t be, according to Morgan and the notification of the relaxation of some HIPAA regulations to allow various forms of communication with our patients.

Finally, as the crisis begins to abate, practices and businesses must keep working in teams to evaluate and structure an orderly return to business as usual, gleaning best practices from colleagues whenever possible. Strategize how to re-boot your practice or any of the other businesses. Consider what the world will look like when the crisis is over and plan how to rebuild and reschedule, etc.

“I would tell practices this is not a time when anyone is competing with anyone.” Said Elmouchi. The more collaboration between practices and health systems that have larger resources the better.”

I would add that the physicians and other practitioners as well as the other businesses who were forced to close need to support your staff though these difficult times and acknowledge their importance and your gratitude for their hard work and sacrifices during this crisis. Save some time AFTER the pandemic is over and there is no possibility of health risk to have lunch or dinner or just time to celebrate surviving.

As I mentioned any small or medium business can use this set of tips to survive in this tempestuous time. As the restaurants are doing, create a pickup system, or use your employees to create a delivery system to keep as many of your employees on the job. You can also evaluate your marketing and do some strategic planning. It is the time to use your staff to plan the future together and

Engage in Team building so that when the pandemic is over you will create a more effective, efficient system to deliver what ever you goal or goals are to your patients, clients or customer want and need. Be creative and this is the time to consider process improvement. 

Use the time wisely. Over communicate with your patients, clients and customers and more important your staff including document your plans and use a decision tree for staff and referral businesses including possible Web site announcements.

Also, realizing the there are many that may need federal aid/loans, if you decide that you may need assistance apply now!! And don’t let all this stress you or your staff out! Work together with your staff and your patients and network through this pandemic crisis and for the future.