By Sally McMahon
Dean Dorton, a CPA firm in Louisville, Ky., recently hosted a roundtable discussion with leaders from the Kentucky Medical Group Management Association (KMGMA) about the impact of the COVID-19 pandemic.
Started in 1976, Kentucky MGMA includes members from across the commonwealth and provides advocacy, educational and networking opportunities for members by hosting webinars and conferences.
Participants included KMGMA president Martina Denny with Pediatric & Adolescent Associates; KMGMA president-elect Craig Gillispie with Family Practice Associates of Lexington; and KMGMA immediate past president Mollie Schnettler with Kentucky Diabetes Endocrinology Center. Adam Shewmaker, director of Healthcare Consulting at Dean Dorton, moderated. Below are the highlights.
Adam Shewmaker: Your teams are on the front lines, fighting this pandemic. How are your teams holding up?
Martina Denny, Pediatric & Adolescent Associates: I am extremely impressed with how well our team is holding up. The first two weeks were the most stressful and now we are getting acclimated to what is going on. Our staff have adapted and come together as a team and are volunteering to go home early so that another team member can stay and work.
Craig Gillispie, Family Practice Associates of Lexington: Overall, they have been doing well—some of them have been worried about COVID-19. There are a lot of unknowns with family members, and that unknown was stressful. We had two weeks where we were pausing on furloughs and not doing anything yet to try and do the right thing. Our employees wanted to know if they were going to be furloughed or not.
Mollie Schnettler, Kentucky Diabetes Endocrinology Center: We also had a lot of anxiety about furloughs. Employees wanted to know, one way or another, but they seemed to handle it well once we made the decisions. But the in-between time was rough.
Shewmaker: Describe the immediate impact COVID-19 has had on your practice (revenue, patient volume, morale).
Denny: Our patient volume has dropped significantly, probably 55 percent at this point, and that came on quickly. We were quick to pull the trigger on furloughing staff and physicians. Our staff did not have time to be overly concerned about what was going to happen because we were quick to tell them what was happening. We had to furlough four physician positions. We furloughed all part-time staff and we reduced all full-time staff to 30 hours per week. We are also taking volunteers to go home early. We are trying to get everybody in at that 30-hour mark. We also closed one of our locations temporarily. We typically have nine physicians in the office daily at multiple locations. We are keeping five right now; however, we only have enough work for about two-and-a-half to three.
Gillispie: We are down probably 60 percent. We have tried to bridge the gap some with the telehealth, telephone visits and that brought on its own set of circumstances and stress. We basically had a little bit of telehealth going on, but not really video visits, so we rolled that out with two different methodologies in one day. That was a problem. We also laid off staff and laid off six providers completely, extending our nurse practitioners and PAs and then reduced many others. The impact has been felt, and it was quick. We had a two-week period where knew we had to do something, and we just delayed if we could. We finally had to pull the trigger and make hard decisions.
Schnettler: We are down close to 70 to 75 percent currently. We did not do telehealth in the past. We talked about it, but we were so busy with the volume coming in, there was not time to schedule a provider to do telehealth. Almost immediately, we laid off our part-time staff and we started offering telehealth. It was challenging trying to implement telehealth immediately because everybody was hitting these telehealth companies at the same time. They were like, “I’ll get back to you in 30 days.” We did not have 30 days. We got it running in one and it seems to be going okay.
Shewmaker: What short-term measures has the practice made to help offset the operational and financial stresses of this pandemic? Any use of the Paycheck Protection Program (PPP) loan from the Small Business Association or accelerated Medicare payment?
Denny: We applied for the Economic Injury Disaster (EIDL) loan immediately but have not heard back. I know some folks are starting to get funds, so we are hopeful. We did that early. We applied for the $10,000 advance through the EIDL loan, but we have not received that either. We did apply for the PPP loan; that one is the most promising and would be the most helpful for us. We are waiting for these funds to come through. We have already done the leg work. Our owners are opting to go without a paycheck for the month of April, and possibly May, hoping that some of these funds will come through for us. Our main goal is to try and keep our full-time employees working at least 30 hours per week. We know they are struggling to pay mortgages and buy groceries.
Gillispie: We applied for the PPP loan. We did get the accelerated Medicare payments and the HHS CARES (Coronavirus Aid, Relief, and Economic Security Act) stimulus. I am concerned about the accelerated Medicare payments. It is nice to have them upfront, but that means we must plan for fourth quarter. You will not have anything, Medicare-wise, in the fourth quarter. The PPP will be helpful as soon as that comes through.
Schnettler: We have applied for everything, too. I have not received any money yet. I have the exact same concerns about paying back the Medicare advances, 210 days after your 120-day period and then they will begin recoupment. I am not sure if there will be enough time for Medicare to recoup since everything is not just going to go back to normal all at once. We will have to write a check to Medicare—and that is a concern. We have a decent volume of Medicare—maybe 30 percent of our practice. That is a big thing to take a hit on in the fourth quarter. I hope we are back to full volume quickly, so we do not have a deficit.
Denny: I do not know that there was a lot we could have done to prepare financially. Obviously, if we could have seen this a year ago, we could have saved money—had a much larger savings account for 2020. I wish we had a larger inventory of PPE. None of us have ever lived through something like this before so it would not have been on the radar. We are pediatricians, so a lot of what we see are fevers and coughs, so it is hard to tell if this population has been affected as significantly as the adult population. We could be seeing kids that have it and not realize it. Then you send your staff out there without PPE. I wish we had N95 masks and I plan to have those in the future.
Gillispie: I echo the same thing. We are doing testing. In the first couple of weeks, they were not available. With the PPE, the issue has been a real one, along with some cleaning supplies. We are now even starting to run out of wipes. The gloves—we are okay. We do not have a lot of the disposable lab-jacket gowns for our staff who are swabbing, so we have assigned people to various tasks. One person parks in a designated exam room and one person swabs, minimizing the exposure to the staff and minimizing our use of the PPE.
Schnettler: We do not really have patients in the office now—they would have to be in bad shape to warrant a face-to-face encounter. The PPE has not been as big a struggle with us. We had some and that was enough so we could get by. Acclimating to patient need was just a challenge for us in trying to meet patient expectations because no one knew what was going on. We could not tell them what to expect with the virus and the length of quarantine. I also do not think there was anything any of us could have done because no one saw it coming. The information we all got, and continued to get, is confusing and constantly changing. People are asking a lot of questions and we do not have the answers for them.
Shewmaker: Have there been certain blind spots or operational weaknesses exposed due to COVID-19 that you can now address as a potential improvement opportunity?
Denny: For sure. We did not have a contingency plan for a pandemic. We had contingency plans for power outages, EHR outages, and we have dealt with ice storms in the past and knew how to function. It pointed out our lack of preparedness for a pandemic. Maybe others out there agree with me, but that was our weakness—we weren’t prepared for it so we are having to make a lot of decisions very quickly, where if you had time to think these things through you would obviously be more prepared.
Gillispie: I would agree, and everything changed so quickly—not just daily changes, but hourly changes for a couple of weeks— things about testing, when it was going to be available, who could be tested, and what the CDC was saying about healthcare workers. That was changing hour-to-hour, so we struggled operationally, trying to communicate those changes back to staff. They got frustrated, and still are, because things are a moving target. Our management team met daily, for at least an hour, to get ahead of as much as we could and brainstorm staffing and operational changes. It exposed to us the free care we have been giving to patients. Now we are trying to capture a lot via telehealth and telephone and are realizing we have been doing a lot for our patients for free—telephone advice, calling in prescriptions, etc.
Schnettler: I would say the same thing. The amount of free care we are giving is astronomical. When we told patients we were going to bill for phone calls, some were unhappy. Once they found out their insurance was going to cover it, they were fine. It is something we will look at, because there is a lot going out the door that we did not charge for. We should have had plans in place for a pandemic, but honestly it never crossed my mind. You have got to have contingency plans in place for almost everything—but pandemic just slipped through the cracks and we were not at all prepared. It took the doctors, the patients, and staff, everyone by surprise. The worst thing about all of this is the lack of information that we can provide to the patients. On a personal note, not knowing when this is going to end is difficult. It is even worse for people with a lot of health problems who feel so helpless. We have many patients who struggle with depression, so this magnified everything.
Shewmaker: How has technology served as solution to assist the practice with any challenges associated with COVID-19 and specifically, what have been the successes/challenges of promoting or implementing telehealth solution?
Denny: I have not touched on telemedicine yet, but we have been working on that for about nine months. We had everything in place, and we were ready to pull the trigger, but we were still a bit uncomfortable with it. I am grateful—if you can find a silver lining in this whole situation, that we had to implement it quickly. We could have waited months or years to start. Any time you must add things regarding technology, it can be great, or it can be burdensome. Many of us have been doing automatic appointment reminders and messages. But what a great thing to have during this time because you can send a message out very quickly saying, “This is what we changed, this is what we’re doing.” Even five years ago, we would have been calling everyone on the phone. We did not have anything set up for people to work from home–even our billing office. We can now have our RNs work from home answering phone calls.
Gillispie: Telehealth was a quick rollout for us. We started it a few weeks ago but had not really progressed. Our goal was to have it go through our EMR because it could support us, in that solution. We started with a few doctors that first week. There were all kinds of issues—it was not interfacing, so we went to a free service. We were doing them both at the same time, then we scrapped our EMR telehealth and used the free service as much as possible. Part of that is because it required our patients to be on the patient portal. We have a large population—probably 40-45 percent of our patients—on our portal. We used a free service called Doxy.Me that was challenging to roll out to doctors, staff and patients quickly. The other piece is whether patients are ready for telehealth. The amount of time my staff spent prepping them to use the telehealth visit, to talk them through an Android or an iPhone, whether mute is turned on, the camera turned off, etc. We had enough issues in our office trying to find enough computers with the cameras functioning—we had previously disabled a lot of those, from a privacy perspective.
Schnettler: We had the same thing and we are also using Doxy.Me in the office. We ended up using this service that you could implement yourself quickly. My physicians like it. They have the patient’s medical record pulled up and they are typing in it, just like the patient was in the office. I have a little different practice than the other two, so that makes it easier. For some patients, it has been a struggle, while others just love it. The patients have provided us with better information regarding their blood sugars, etc. We are using our portal where appropriate, but we probably have 40 percent on the portal. I wish the telehealth option would totally integrate with our EMR but there is nothing that could be implemented as quickly as we needed. For some patients, it has been a struggle; some of them we just do a telephone visit. We have a lot of patients from eastern Kentucky, in areas without great internet access. We also have a population who do not use or even want to use electronic methods. Our skeleton staff have adjusted well and the patients who use it like it. As far as working remotely, originally only my research manager and I were set up to work remotely. I have since set up a few additional employees. I offered the capability to some staff to work remotely, but they opted to come in instead.
Shewmaker: How has this pandemic forced you and your practice to re-think your normal business operations (increased remote technology, potential co-sourcing or outsourcing, etc.)?
Denny: I do not think we will see the “old normal” that we had in our practices ever again. Even small things—cleaning practices, sanitizing everything. As soon as we started doing that, I thought, “Why don’t we do that every flu season for the germs?” That is a good practice to keep as we move forward. Even things like the germ shields. Our windows were open and not shielding the employees. Putting things like germ shields up, shielding the employees, may be something silly and small, but it is something we can use year-round or during flu season. Something that is going to be the new normal is e-visits, and I hope that insurance companies are on board with it. We are not getting paid correctly by every insurance company. To my knowledge, we are billing it correctly. Things like mental health or medication rechecks, we would love to be able to offer that for convenience for the patient.
Gillispie: Telehealth is going to be here to stay although it will be tough to balance— some things we could do via telehealth, but it gets back to free care. The impact on lab has been huge. The lab is one of the last things we had that really made money, and we had to shut it down because even patients physically here in the office do not want to expose themselves by being around patients we swabbed. The sanitizing thing, I totally agree with. One other thing, we were already ramping up self-scheduling significantly, but that will be another area, along with telehealth, that will be enhanced. The volume of calls we have had has been huge and anything I can do to take some of that volume off will be important to our staff. Mental health—we just hired a psychiatric nurse practitioner on March 15, to go along with our counselor and they are both doing a lot of telehealth mental health. Our psychiatric nurse practitioner is slammed. People are so anxious during this time—we have had no problem keeping her busy.
Schnettler: Telehealth—patients and doctors really like it. I do not know what it will look like in the future, though. We do not know what the payers are going to continue to allow. We are also not being paid accurately. We struggle getting accurate payment for some of these services anyway and telehealth just adds another level of challenge. I like that the patients have been more prepared with the calls than when they come into the office. They have their list of questions, rather than being vague, like, “I’m here for a checkup.” It is a more productive session for both the patients and the doctors. We also need better in-house cleaning processes, like wiping areas multiple times during the day. Operationally, I always heard you should have three months of cash in reserve; well, that is probably not enough. At least not for us. I think we must re-think our operational priorities, administrative and clinical. Some of our vendors have been good to work with. But others are saying, “Your annual contract is up, and we need your payment now.” Going forward, I will clarify in my vendor agreements that in a situation where the state and country are in a disaster, the expectations would not be that business goes on as normal. Some companies have been good, but others have not. I also took a huge hit in my lab. It was one of the first things we had to close. We could not get the supplies to run the tests. It was not like A1Cs were in shortage, but getting deliveries was tough. We understand that delivery of medical supplies to the hospitals is the priority.
Shewmaker: Any predictions on the ramp-up phase and how/if practices will be able to support the volume once it returns? How do you anticipate bringing back staff to coincide with the “new” business?
Denny: I hope this ramp-up period comes sooner rather than later. For those of us who are going to get PPP loans, it will have you more prepared for the volume that hits. It will allow you to get your staff back to normal capacity—I totally anticipate having staff here, twiddling their thumbs, waiting for this ramp-up period starts. As for all those who have been pushed off until the summer for checkups, we have talked about being more flexible. Currently we only do checkups until 3:30 pm, but we will likely do checkups Monday through Friday until six pm and do checkups on Saturday and Sunday. We will bring additional physicians and staff into the office to work during the week and on weekends. We are still seeing the sick visits via telemedicine or in the office. It will be the checkups—we will handle by being more flexible. I doubt any staff will complain because they have seen what it is like on the other side—not being busy. I anticipate their cooperation and flexibility.
Gillispie: I echo all of that—expecting a flood gate at some point. Some patients will be reluctant to come into this office. My biggest apprehension is getting staff off unemployment. The extra $600 they are giving will make it hard to get someone to come back by the end of July, when it ends. We have already talked internally about how to address that because I anticipate calling a staff member to come back and being told to call someone else. We will strategize how to roll that out so that it is fair to staff and fair to us. If I offer you a chance to come back and you say you do not want to come back, then I am not sure it is my responsibility to let you hang on unemployment just because it is better for you at the time.
Schnettler: I agree. When we do get money from various loans, our priority is bringing back the staff. I will have some who will want to stay out, but they will be a minority. As of right now, there probably will not be an option of whether to come back if we ask them to return. They will have to come back or find something else to do. Because of the backlog of care our practice normally provides, we will need to be more flexible on appointments because we are so far booked out. We will have to work flexible hours to bring people in who need to be seen. We will need to talk about what schedules will accommodate our patient needs and access. We want to bring employees back at the first opportunity but they will have to be back on the terms we can give them—staying a little later at night, working a Saturday morning once a month for a while, etc. If they cannot be flexible, we may have to re-evaluate. We must put the patients first. I do not see it as everyone can come back at once, but I want to be sure that we bring back as many as possible as quickly as possible. And then making sure we are providing excellent quality patient care on a reduced staff. Most staff are grateful for how we have tried to work with them through this situation. We are paying their health insurance and trying to do anything else we can. But there will always be some employees who do not believe you have done enough.