Private Practice in a Time of Pandemic

Add to that a worldwide pandemic and a toilet paper shortage, and you just have struck the disaster jackpot.

On March 1, noticing a rise in the incidence of COVID-19 in the United States, I made several logistical changes at my office. I have only one waiting room, one entry and exit, and nine exam rooms shared by three medical professionals and two behavioral health professionals, so the chance of cross-contamination is significant.

We are fastidious about contact precautions in our office. Given an R₀ of 2.5, which denotes an illness with a high risk of human-to-human transmission, we had to be significantly more vigilant to reduce the risk of our own exposure, as well as our patients' risk. We moved well patients to morning appointments (physicals, follow-ups, injuries, acute noninfectious visits, etc.) and sick patients to the afternoons. We also separated, as best we could, patients in the afternoons by 15-minute gaps. Any respiratory illness patients would be masked on arrival, and staff would gear up when rooming those patients. The doors from waiting room to exam area were wedged open (no touching doorknobs), and patients with respiratory symptoms were directed right to their rooms on arrival (no sitting). We ran polymerase chain reaction flu tests on patients with fever, cough and body aches, and, if negative, we would then send the test for COVID-19 to an outside lab.

When the number of confirmed COVID-19 cases started rising in Arizona, where I practice, we shifted gears. We had been providing telehealth visits, primarily for patients with behavioral issues, and we started doing a lot more through this platform for medical patients. Our behaviorists' schedules were changed from 7 a.m. to 1 p.m., and then they offered telehealth visits from home in the afternoons to eliminate the risks that their healthy patients would come into contact with our sick patients. We use texting more and more frequently to communicate with our patients securely, and we employ many of the tools patients have been using with just about every other type of business that are now available in health care. Ideally, with the AAFP's advocacy, we hope telehealth will be recognized by payers as not just a nicety but a necessity to provide and be paid for.

Patients with fevers higher than 100.4, cough and flu were evaluated by telehealth and then asked to drive up and text us on arrival; we came out to their cars geared up to take samples for PCR flu and then reflex to COVID-19 if negative. We have canceled all wellness exams and moved some of our routine follow-ups online.

We have a UV-C sanitizer to clean our shields, stethoscopes, laptops, iPads and pens between patients. Due to hoarding and shortages, we are having to reuse our filter masks every day, praying that the rubber straps don't break. This is probably the most frustrating part of running a private practice during this crisis. Although we recognize the necessity of stocking our hospitals with personal protective equipment, we cannot forget our other frontline soldiers -- family physicians -- in this fight.

Obviously, health care is forever changed. All of the hassle you and I go through with quality programs, prior authorizations, the Merit-based Incentive Payment System, payment gates, tiers and step therapy needs to be reexamined -- and reexamined now. Because none of those things benefits patients. None of them. And at this time, our patients need doctors, not database entry clerks. MIPS does not pay for ventilators. Making sure my patient is taking a statin 292 days a year will not save a large number of seniors in one single nursing home from dying. And making me complete a prior authorization for extended-release generic metformin does not put enough personal protective equipment in my office to keep my staff and my patients safe.

We are all on the frontline now. Payers need to take down the barbed wire so we can charge into battle.

Andrew Carroll, M.D., is a member of the AAFP Board of Directors.