Nationally, patient volume has dropped 60% since the start of the pandemic and is now rebounding, either gradually or rapidly depending on local circumstances. However, practices are unlikely to return to normal volumes for some time as patients continue to avoid the office and as offices continue to keep high-risk patients at home and treat them via telehealth. These changes in patient volume have had drastic effects on practice finances, with one report noting that practice revenues have declined 55%.
As the lead family doctor in a small group practice in northern California and as a local medical director for Aledade (an organization that supports independent practices in building physician-led ACOs), I’ve seen a variety of responses from practices trying to recover their patient volume and their finances in the wake of COVID-19. Based on what we have learned in our area, I have gathered some tips that may be useful to other practices as well.
1. Continue to evaluate your mix of visits — in-office vs. virtual — as you seek to increase patient volume to normal levels while being responsive to the conditions in your area and the needs of your patient population. Infectivity and surges appear to have surprised each community in the news, so be prepared for local changes and patient ebbs and flows.
2. Make sure you have a clear process for deciding which visits should take place via telehealth and which can take place in the office. Practices have different philosophies on this. We are converting all visits to telehealth unless they involve a procedure, under 5's and middle school children for well-child checks and for immunizations, some teens, women whose pap smears are overdue or who have had an abnormal pap smear, and those whose diagnosis we were unable to make without a more detailed exam. My day currently averages 12 telehealth visits, three or four office visits, and two or three visits out of people's cars (usually patients who lack devices or just want to be seen in person without needing a detailed exam). We feel this is the safest approach until we have better insight into how to avoid asymptomatic and presymptomatic transmission. Additionally, it's tough to get an exam room turned over safely without letting it air out for some time, cleaning after each patient. We are aiming for a maximum of two patients per hour in our two small offices with five to six exam rooms, until we have a better understanding or approach to safety. For patients who do come to the office, we have trained our staff to assume all patients are positive and to use appropriate masking and personal protective equipment (PPE). In this way, we hope to avoid constant changes to policy if there are local surges, and to avoid inconsistency and confusion for our patients.
3. Reach out to patients. Demand can be influenced by patient engagement and improved with a strong front-office operation. Contact patients by risk category, starting with those who are high risk (e.g., those with chronic conditions leading to immune suppression), and let them know about the availability of telehealth or other visit options so they can have a plan of care during this crisis. You should also reach out to patients who have had cancellations over the past three months to let them know about their visit options. Even for preventive care, you can partner with patients on decisions to postpone or proceed with routine physicals or other preventive services.
4. Develop new messages for your web site, phone system, social media, or office signage to communicate your intention to continue providing care and explain the available visit options.
5. Consider adjusting your staffing levels. These are difficult decisions, but some options include furloughing nonessential staff, encouraging staff to take rotating vacation days or perhaps unpaid days off, and not replacing staff who chose to stay home in the early stages of the pandemic due to health or other concerns such as childcare needs. Interestingly, we have experienced staff loss and are finding replacement difficult, perhaps because staff who were furloughed are receiving enhanced unemployment payments in the short term.
6. Closely monitor financial benchmarks, from accounts receivables to payer mix. Your practice should have a spreadsheet that allows you to quickly see key parameters such as payments and charges by clinician. You need to be monitoring whether revenue is down and by how much so you can take action.
7. Educate yourself on new billing codes and rules, and ensure billers are using and following them. Make sure your staff are looking at insurers’ Explanation of Benefits forms for denials and are rebilling, particularly for early telehealth codes that were denied. For example, Medicare changed its recommendations for the telehealth modifier and place of service codes, allowing telehealth video visits to be billed as in office and providing parity in payments. But this was a few weeks after the onset of sheltering orders in many states, and in some cases practices needed to rebill. The same is true for telephone care codes.
8. Have your front-desk staff pay closer attention than usual to insurance changes since patients may have lost jobs. Additionally, some insurance companies have agreed to waive co-pays or coinsurance in the short-term for telehealth visits. Communicating this to patients may give them an incentive to schedule an appointment. Just make sure your staff understands which insurance companies are offering this and which aren’t so that co-pays don’t have to be collected after the fact — always an inefficient and time-consuming task. Also note that any viral infection in the current environment should be documented as possible COVID-19 because, while there is not a way to code for this besides by symptoms, many insurers have stated they will cover all or part of the cost of COVID-19. For example, Medicare has waived cost-sharing for visits that result in the order or administration of the COVID-19 test or involve the evaluation of an individual to determine the need for such a test; physicians should use modifier -CS to identify these services.
9. Review current obligations and fixed expenses. Are there any expenses you can cut? If you are unable to downsize in any way, at least create a monthly budget and try to stay within it for new expenses. Don’t hesitate to negotiate forgiveness for a month or two from landlords, vendors, etc.
10. Pay attention to inventory, and keep it lean where possible. You don’t want to have too much cash tied up in supplies right now. For example, we used to keep a month’s supply of vaccines but now keep just a week’s supply while prioritizing vaccinations and doing outreach to keep the children in our practice up to date. We are keeping other supplies lower because of fewer procedures and in-office visits. An exception is PPE. PPE costs are unpredictable right now but tend to be high even if there is availability, so we have to account for this.
11. Consider unforeseen expenses, such as devices for telehealth. Because most offices had to embrace telehealth quickly, they don’t have an ideal setup in place. For example, our office is making do with a few donated (repurposed from personal use) old tablets or iPads, and some physicians are using personal smartphones to see patients for the visual component of the telehealth visit. We have also converted old smartphones with new prepaid three-month SIM cards to give us a throwaway number to use for FaceTime and Skype for patients who cannot manage the HIPAA-compliant televisit technology. Since the relaxed HIPAA requirements for telehealth have an unclear sunset date, prepaying a few months at a time ($15 a month) has been a cost-effective solution. While $200 million in federal FCC funding has been made available to community clinics for device upgrades, no similar support is available for independent practices.
12. Consider all available options for financial assistance. Physicians who see Medicare patients should have received two stimulus payments (those who do not see Medicare patients were eligible to receive only the second stimulus amount), but many have found the combined total to be inadequate — in the range of one payroll cycle or less. The federal Payment Protection Program is another vehicle for payroll support for medical practices, although some businesses have had difficulty obtaining these loans. Medicare and some other payers have offered cash advances, which provide short-term relief but reduce future cash flow during the repayment period. For many practices this period will begin in August, leading to financial difficulties if they do not adhere to a tight budget. Practices that do not already have a relationship with their banker and a credit line in place should be looking at doing so now.
What practices need going forward
Family medicine and other primary care specialties have been undervalued and under reimbursed for years in this country, and our current visit-based, fee-for-service payment system does not provide steady financial support to care for a patient population. The current strain will require both skilled navigation by practice owners and managers, and strong advocacy from the organizations that represent us. In the process of struggling to pay expenses and do the work, many practices may fold unless payers make rapid shifts toward value-based care.
— Sumana Reddy, MD, FAAFP, Acacia Family Medical Group, Salinas, Calif.
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