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.