Roundtable discussion: A snapshot of community practices’ health in a post-pandemic future
Staffing levels, budgets, revenue, incomes, physicians’ and staff mental well-being, patient referrals, and more all took a hit during the pandemic. Specialty physician practices are resilient, and work to successfully adapt to the changing healthcare environment. In our roundtable discussion, John Dodd, Director, Business and Clinical Consulting, AmerisourceBergen, Cass Schaedig, Vice President-InfoDive, IntrinsiQ Specialty Solutions, Brad Tallamy, Senior Director, Government Affairs, AmerisourceBergen, and Norman Gaylis, M.D., F.A.C.P., F.A.C.R, Medical Director of Infusion and Immunotherapy Center of South Florida, explain how practices coped and ask, as the percentage of vaccinated Americans increases, what will happen to the health of community physician practices?
Q: What has been the toll of the COVID-19 pandemic on community physician practices? Norman Gaylis: I think every practice was severely affected financially, emotionally, and physically, and the degree that they were affected depended upon how they got their arms around what was happening initially.
It was lumpy, bumpy process at beginning. Our practice really struggled to keep the normal routine in effect. A big plus was that that Medicare for the first time ever, and all the other payers followed suit, allowed us to bill for a visit with the patient through telemedicine. Especially in a rheumatology practice, that was extremely valuable because we could still talk to our patients, they could see us, and we could at least maintain continuity of care.
It certainly didn't compensate for what we could only do in the office. We couldn't inject people, we couldn't take an x-ray, we couldn’t measure bone density, we couldn't do an ultrasound.
Once the vaccinations started, I think, within a three-month period, things really started to change in terms of patients feeling safer about coming into the office.
Q: How have staffing shortages impacted the profession?
John Dodd: We’ve seen a tremendous number of clinical staff who decided to step away from the profession. Nearly 30 percent of frontline healthcare workers are considering leaving the profession, according to a Kaiser Family Foundation/Washington Post poll.
It’s primarily due to overwork, concern about their own and their families’ physical wellbeing, and overall burnout. One survey found 30 percent of physicians felt hopeless due to COVID-19’s impacts on their practice.
Safety precautions—while indispensable—took a toll on staff. I was in a practice Georgia in April. One of the things they brought up are the mitigation efforts, such as temperature checks, that changed how they check in patients. These alterations to the workflow effect the burnout of admin and clinical staff. That goes for the physicians as well.
NG: We were put into a very stressful financial situation. Suddenly provider income stops, but your outlay continues. You have a staff, in my case 35 people, for whom I needed to still find pay. I'm very proud I kept every person on full salary with the help of the Payroll Protection Plan
Q: What adjustments have practices made to compensate for staffing changes?
NG: In my particular case, we shut down completely very early in the pandemic, for approximately two weeks, then partially opened once we managed to get our hands on rapid tests so we could test both patients and staff every time they came in, personal protective equipment that we use, especially in our infusion centers.
JD: Non-clinical staff, such as human resources, administrators, etc., had to pick up the slack to fill in for some roles, like front desk positions. They switched their hats and stepped into the role, when needed. Additionally, a lot of the non-clinical staff were working from home which created additional workload because you don't have that smooth, easy, in-person communication.
Administrative staff increased their recruiting and hiring efforts to try to find replacements for the people who left. Every time I turned around, I’d see a sign saying, “We have positions open, please apply.” Practices are in that boat because, depending on the role, some potential employees actually made more money collecting unemployment.
As a way to combat that turnover, some health systems even begun to offer heavy bonuses to entice nursing staff to come on board.
NG: One issue that has the potential to affect turnover is COVID vaccinations. To this day, it’s a challenge for community practices to have all staff vaccinated. In some states, there are no laws to enforce vaccination, even for employees in healthcare settings. It’s an issue that many of us have been faced with, where you can't tell someone what to do in terms of their own personal health choices. You would like your staff to be 100 percent protected, and that may not be the case. Practices may face the dilemma of staff quitting rather than submit to a vaccine mandate
Q: What solutions can help practices better address day-to-day operations?
JD: We’re doing more telephone consulting since we’re limited as far as on-site work with practices. We’re trying to support staff in every way we possibly can. I had a physician group in California call me looking for OSHA COVID guidelines, for example. We're answering a lot more emails and taking a lot more phone calls, talking through aspects of what's going on in the practice and what we hear from other practices, so we can pass on information.
Our goal is to help practices effectively manage their operations because spending too much time on workflows takes time away from patients, who are the number one priority. Through our systems, we examine benchmarks to improve scheduling efficiencies. Another priority is connecting patients to financial assistance. We’ve developed a partnership that facilitates search for grants and monies across manufacturer patient support programs, foundation assistance programs, and charitable foundations. Tools to calculate total cost of care help specialty practices better educate patients.
Q: What financial adjustments should practices make to adapt?
JD: From a financial perspective, some practices took the money from earlier government relief packages and gave bonuses to their staff to reward long hours and hard work.
Other practices, though, banked those relief funds. A lot of them told me, “I'm not touching it because I don't know what going to happen. I've put away a nest egg just to be on the safe side.”
NG: If you were a community practitioner, you really didn't have any security blanket to hold on to. Truthfully, that's why most community practices desperately needed and ultimately benefited from the paycheck protection plan programs.
Cass Schaedig: Related to hiring, there is the cost of training new employees. If a practice uses an employment agency, they're paying additional fees to find workers. It gets more expensive the higher the turnover rate.
Practices also need to consider the costs of tangibles, like PPE, which is expensive and at times unavailable. Sometimes the costs of those items—which are necessary to run their business— are not included when budgeting.
Another adjustment practices may need to make is a potential change in payer mix. People who were previously employed have either been laid off or decided not to work. They may not have insurance coverage anymore and may be eligible for Medicaid. Data from the Kaiser Family Foundation showed Medicaid and CHIP enrollment increased almost 11 percent in 2020. A lot of community practices either don’t accept Medicaid or limit the number of patients they’ll accept. They’ll be more patients who can’t afford treatments and who look for hardship exceptions. Community practices will need more access to and information about patient assistance programs, which is something we can help them with.
"Our goal is to help practices effectively manage their operations because spending too much time on workflows takes time away from patients, who are the number one priority."
Q: How can practices prepare for the likelihood of sequestration relief cuts?
CS: Practices are getting paid additional money with the sequestration relief that applies to traditional Medicare patients. Doctors may think, finances are great because I'm getting more money. They shouldn’t grow too comfortable with this additional revenue. At the end of the year, Congress is likely to bring back those two percent cuts on Medicare reimbursements.
I predict practices will come to us in January as ask, “Why am I not doing so well? Why am I losing money on my drugs?” We must make sure they don’t lose sight of the very real possibility of the loss of sequestration relief. They should manage their operational budgets as if they were already two percent lighter. Take the extra money coming in from sequestration relief and use it to build up savings.
Q: What issues should practices’ advocate for legislatively in preparation for future pandemics?
Brad Tallamy: We have argued since 2013 that the Medicare sequester cuts should not be applied to our practices, and we’ll still advocate to get rid of sequestration completely. That fight won’t end. It’s just going to be more difficult as federal deficits keep increasing. If COVID-19 is hopefully in check this fall and winter, the sequestration moratorium will not be extended. But our community practices’ voices are still needed.
Practices can mobilize through Community Counts to reach out to their elected officials to educate them on the impacts of sequestration. Community physicians can’t revert to the old policies that had them teetering on the edge before the pandemic. They stepped up when hospitals were over-run. Practices need to tell Congress, “Let's finally address sequestration so that all of us who you saved by pausing these cuts are still in a position to treat during the next pandemic.”
Q: What is happening at the state level with PBM reform and how will that impact care delivery for community practices?
BT: The states have led pharmacy benefit manager reform initiatives. For example, in Texas, Governor Greg Abbott (R) recently signed HB 1763 and HB 1919 which improves patient access to prescription drugs and limits PBM overreach. Enhanced patient access will allow our practices to continue to deliver high quality, efficient care.
We’re hopeful that as more states tackle PBM reform, the federal government will be encouraged to adopt more nationwide solutions. Through Community Counts, we encourage our physicians to send letters urging their state legislators to pass laws that curb the power of the PBMs. The good news is that hundreds of state bills have been introduced in 2021 considering this approach.
Q: What trends have practices seen in their revenue and referrals, now versus at the height of the pandemic?
NG: We have another problem now—we have too many patients for our current staffing capabilities. What we've seen post-vaccination is a significant surge of patients. I’ve been in this business for forty years and I’m spending more time in the office than I’ve ever had.
We developed a whole new line of business with COVID long haulers. As a rheumatology practice we deal with the inflammatory cytokine pathway, we became the go-to practice when nobody knew how to take care of these patients. There’s been an increase in my patient volume due to normal rheumatological circumstances, but there's no doubt that we've been overwhelmed with people who are still suffering from the after-effects of COVID.
CS: The oncology practices have fared okay with revenue at this point versus a year ago. The financial impact was somewhat less because current patients were still coming in for treatments.
The real struggle was with new patients. If someone has a suspicious lump, they get it tested to see if it’s cancerous. Those initial tests and appointments with the surgeon were delayed during the height of the pandemic. JAMA research found a 46.4 percent decrease in new cancer diagnoses at the height of the pandemic lockdown (March 1-April 18, 2020). So, people saw the doctor later, when the stage of their disease was further along. This delay might have devastating consequences, some researchers predict an excess of 10,000 deaths from colon and breast cancers over the next decade.
Our surgical practices across specialties suffered more significantly. They couldn’t bring patients in unless it was a trauma case. They were essentially out of business for two months or more last year and saw a 35 percent decline in revenue. But, now they’re back.
JD: A few practices told me that relief funds from the government allowed them to be able to pay for their drug bills. With referrals down and patients scared to come out of the house, they saw a downturn in numbers and relied on those funds for short-term stability.
CS: Practices will need to account for how they used those monies from the federal government. If they received more than $10,000, they’ll need to report. Tied to getting the money was the expectation they’d tell the government how they used it. The deadline for reporting varies based on the payment period. September 30, 2021 will be an important date for our practices, since most received over $10,000 between April and June of 2020.
Q: What do physician practices need to do address burnout among staff?
JD: Practices need to take the pulse of their organization. Even though we’ve been dealing with COVID for over a year, it still hasn’t let up. A survey conducted by the Physicians Foundation found 58 percent of physicians often experience feelings of burnout.
Talk to employees, see how they and their families are coping. Make employee assistance programs and other services available to staff, so people have a confidential place to unload some of what they may be carrying around.
Clinical staff need to take a step back and ask, “What do I need?” They may say, “I love taking care of my patients, but I can't give them one hundred percent if I’m not at one hundred percent? What can I do to help me to be able to take care of them?”
NG: Community practices are the most stressed-out segment of the health care industry, in my opinion. I think the only thing that we can do is to try and be understanding, and to try and make sure that people have enough time out to do what they need to do.
It would be nice to tell everybody, take a long weekend, take off Fridays. Those would be great things if your practice can sustain itself with its daily needs and deal with the surge in patients. Without a doubt, the staff definitely grew closer by sharing the whole experience together. I make sure I tell them on a regular basis how much we appreciate what they're doing and how much their work is valued.