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Physician practices modify operations to cope with COVID-19

March 17, 2020

Maria Castellucci and Harris Meyer

 

Beginning Tuesday, staff at Indiana University Health Physicians are calling patients with scheduled appointments for routine care to come in at a later date, many being scheduled six weeks out.

The decision is one of many IU Health Physicians has made over the last 10 days to mitigate the spread of the novel coronavirus and protect its workforce, which consists of 200 primary-care and 1,700 specialty physicians spread across over 150 ambulatory locations in Indiana.

“The key message to our patients is we are not closing down, we are here for you, but if you don’t have to be here, we want to protect you and your families and our workforce by not having unnecessary exposure,” said Brian Kremer, chief operating officer of IU Health Physicians.

IU Health Physicians is one of many physician practices taking preventive steps to limit the exposure of the coronavirus in their communities and workforce while at the same time taking care of patients who continue to need routine care.

“We are not turning anyone away who has a need or desire to be seen at this time,” said Dr. Mia Taormina, infectious disease department chair at Illinois-based DuPage Medical Group, which has about 120 locations.

Similar to IU Health Physicians, DuPage is also limiting patient visits, specifically for patients who are elderly and have chronic conditions, because they are most at-risk for dangerous coronavirus symptoms. Every morning, DuPage practices are going over their schedules to see who is coming in and if the appointment can be rescheduled if the patient is open to it.

“If they are afraid of leaving the house for a routine appointment, they aren’t going to get dinged for canceling the appointment,” Taormina added.

Calming fears

Educating the community is another service practices are providing as they continue to field calls from worried and confused patients.

RWJBarnabas Health Medical Group, which has about 2,000 providers across 300 practice sites in New Jersey, has experienced a spike in calls mostly from patients concerned they have the virus.

“The public, our patients and our communities are very concerned, and the questions of course are ‘Do I have this or not? And how sick am I going to get from this?’ ” said Dr. Andy Anderson, CEO of the medical group.

RWJBarnabas Health has initiated robocalls to educate patients about the virus and how to protect themselves.

Low-risk patients are being told to stay home and practice social distancing. For those at high risk, some RWJBarnabas sites have access to testing for the virus. So far, one patient has tested positive for the coronavirus in a RWJBarnabas clinical setting, and all necessary guidelines were taken, including informing the New Jersey Department of Health and the Centers for Disease Control and Prevention.

Although shortages of protective equipment aren’t an issue yet, Anderson said if it becomes one, RWJBarnabas can redistribute supplies from some sites to others. RWJBarnabas is closely tracking its supplies.

In addition to a short supply of protective supplies like masks and gowns, limited coronavirus tests have been a source of confusion for practices.

Aledade, a consultancy that partners with physician practices across the country on value-based payment contracts, is getting questions from clinicians about how to test for the virus in their community, said Dr. Farzad Mostashari, CEO of the company.

Practices in rural areas are often the only source of healthcare for their community, but they don’t have personal protective equipment required to do tests safely, especially the masks, he said.

“We are working very hard on behalf of our practices,” Mostashari said. “We are out there trying to find a source of masks for them so they can continue to run their business.”

DuPage Medical Group is referring patients who screen high-risk for the coronavirus to local community resources that do the testing such as local health systems. The medical group is in the midst of planning to test patients at some of its clinics, but it would be the drive-thru style hospitals have been adopting to limit exposure, Taormina said.

Virtual visits

Telehealth is also becoming a vital tactic at this time for physician practices to deal with testing and supply concerns.

Similar to other healthcare providers across the country, IU Health Physicians has a limited supply of personal protective equipment so patients with coronavirus symptoms are being screened through telehealth as often as possible.

“The limitations of personal protective equipment for our staff and patients is by far our biggest concern,” Kremer said. “Much of the driver as to why we rescheduled all elective surgeries and limited our outpatient visits to those who have urgent needs is to preserve the personal protective equipment.”

IU Health Physicians is currently bringing on more than 100 physicians this week to its telehealth platform to mitigate in-person visits across its sites.

“We have had telehealth capabilities for a couple of years but uptake (by the physicians) has been slow,” said Dr. Greg Kiray, chief health officer of IU Health Physicians. In response to the COVID-19 outbreak “it’s now completely obvious the importance of virtual capabilities.”

Over the past few weeks, primary-care provider ChenMed has shifted care for most its Medicare Advantage patients from clinic visits to either telehealth or home visits in order to protect both patients and staff from exposure to the coronavirus.

“We’re 90% center-based patient care, and now we’ll pivot to 90% virtual appointments,” said Dr. Christopher Chen, CEO of the family-owned company, which operates 59 centers in 39 cities around the country. “Our patients are the highest-risk population for the coronavirus, and I want to keep them healthy, happy and at home.”

By Monday, Chen said his centers were serving nearly two-thirds of patients through virtual care or home care and should hit the 90% target by the end of this week.

It plans to keep its clinics open to serve the small percentage of patients who need to come in to deal with urgent medical conditions.

ChenMed staff have called and texted patients to notify them of the change. Chen said the reaction has been “extremely positive” because seniors are terrified of going to the doctor’s office or hospital and risking exposure to COVID-19.

ChenMed previously encouraged its patients—whose average age is 72 and who typically have five or more chronic conditions—to come into its centers frequently, as often as several times a month, to keep them as healthy as possible and avoid expensive emergency room visits and hospital stays. Each center has 2,000 to 3,000 patients at full capacity.

ChenMed has a financial incentive to do that because it serves most of its patients under a fixed per-member, per-month payment from Medicare Advantage plans.

It will continue that emphasis on heavy contact with patients but with far fewer clinic visits.

ChenMed’s staff drivers are dropping off iPad computers at the homes of patients who lack Internet access so they can make virtual medical visits. If tests are needed, clinical staff will visit patients’ homes, using safety protocols, to administer those tests, including EKGs.

Serving non-medical needs
Beyond that, ChenMed drivers will help patients with non-medical needs, such as dropping off groceries and supplies so that they aren’t out risking exposure to the coronavirus.

Aledade is helping its practice partners right now implement telemedicine. Only some currently do.

The CMS announced Tuesday Medicare will reimburse for telehealth services at the same rate as regular in-person visits.

Mostashari said late last week practices were in need of more clarity from the CMS on this issue.

The consultancy is also exploring using a risk scoring tool to help the practices identify patients who are most at-risk of dangerous coronavirus symptoms.

“People are scared and seniors are scared,” Mostashari said. “It’s a good time to hear from your primary care practices but the practices can’t call everyone, so we had this idea.”

Aledade has heard from other groups also working on a similar risk-scoring tool, so they are exploring potentially partnering with another organization, Mostashari said.

Chen said his company’s shift to virtual and home-based care during this crisis will position it well for the future, enabling ChenMed to make its services available to patients in a larger geographic area, including underserved rural communities.

“Some provider organizations are saying they’re going to hunker down and weather the storm of the coronavirus,” Chen said. “We’re not going to weather the storm. We’re changing the entire model.”

Staffing concerns

RWJ Barnabas has yet to experience staffing shortages due to illness or childcare concerns as schools close but they plan to consolidate practices should that occur.

“I’m anticipating that (staffing) is going to become an issue in the next few weeks” as the virus spreads, Anderson said.

He added that they can’t rely too much on staffing agencies to replenish low staff because they are also being strained.

ChenMed is requiring its physicians and other employees who are 60 or older or who have serious chronic conditions like diabetes to only provide care remotely. So far, only one ChenMed employee, who was exposed to a child who had come from Italy, has tested positive for COVID-19 and been quarantined, Chen said.

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