How to resume medical practice operations in today’s ‘new normal’

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5/26/2020

Nearly all respondents to a recent MGMA Stat poll indicated that they’ve reopened their practice to in-person visits. Doing so in the current COVID-19 landscape, however, has hardly been as easy as the flip of a switch.

Brian Ramos, MBA, CMPE, chief operating officer, Capital Anesthesia Partners, and president, Maryland MGMA, recently covered the topic on the MGMA Insights podcast, offering strategies for practices to consider as they resume operations in today’s “new normal.”

“The hardest part about this is that everything that we’ve done for the past two months has been new,” Ramos said. “We’ve had to collect and analyze and then act on new information. As we start thinking about reopening, we really need to consider our practices as startups, because that’s what we are.”

Be sure to access the COVID-19 Medical Practice Reopening Checklist, compiled by Ramos and MGMA industry advisors, for various financial, operations, staffing and procedural considerations for resuming operations and ramping up work in the coming weeks and months.

The following is a transcript of our interview with Ramos, which was recorded on May 15, 2020. The questions and answers have been edited for length and clarity.

Daniel Williams: What are some of the first steps that a practice administrator can take?

Brian Ramos: A few ideas about how to think about restarting your practice would be to first gather any information that you might need and organize that data. This could be financial information, your prior staff schedules, your prior provider templates. Secondly, start thinking about what your anticipated volume might be, including a ramp-up schedule. That is going to be the hardest part of it, because we don’t yet know what that new volume is going to look like in our practices. It will vary by specialty. It will vary by geographic location based on the impact of the virus. Finally, you’ll want to use all of that information to develop a pro forma so that you can right-size your staffing ratios and other variable expenses. And since we don’t yet know what that new volume’s going to look like, you may want to create several iterations of that document.

Williams: States are starting to reopen to non-emergency and elective medical visits. Patients haven’t been able to get some of those types of procedures done, so we think that there’s pent-up demand or the volume is going to be maybe even astronomical. But what are you seeing in reality? What really is going on when you’re looking at practices across the country?

Ramos: I think there is some pent-up demand just because all elective cases have been shut down for two months. So, at least initially, there will be an influx of volume in medical practices. But I think that may be short-lived, maybe two to four weeks. After that, I think we’re going to see another reduction in volume to what I’ll call "new normal volume." Since we don’t have point-of-care testing, we don’t yet have contact tracing capabilities and we obviously don’t have a vaccine, I think many patients will continue to either delay or defer any non-urgent care out of an abundance of caution.

It’s also important to remember that 20 million Americans have lost their jobs so far. There is an estimate by the Kaiser Family Foundation that 27 million people have lost their employer-sponsored health insurance. So, patients may either not want to enter medical practices unless they have something urgent going on. They may not have health insurance coverage. We may be operating at limited capacities. These issues really make me pessimistic about any real pent-up demand and accelerated volume ramp-up assumptions others are making in the field.

Williams: When we look at potential staffing solutions, something that you’ve mentioned in some of your other papers and your presentations is using rotating teams. Tell us a little bit more about that and how it could be beneficial to an organization in this environment.

Ramos: The issue with bringing patients and staff into your office is that there’s still very limited testing capabilities out there, so you have to assume that every person, every patient that comes into the practice is potentially COVID-19 positive. You need to protect your workforce so that if one of those employees becomes ill, your entire practice isn’t affected and forced to shut down yet again. My recommendation has been to think about placing your in-office staff on multidisciplinary teams that work together as a pod. Team one is going to be comprised of doctor A, nurse B, medical assistant C, tech D, receptionist E. And team two is comprised of an entirely different set of people, but in those same roles. And you’ll do that for as many teams as you can create based on your available staff. These pairs of teams never work in the office at the same time. This way, if any member of a team falls ill with COVID-19-like symptoms, the entire team can self-quarantine for 14 days, effectively falling out of the rotation where another team takes that spot. It works well and protects the workforce from everybody needing to self-quarantine for some period of time if there’s an exposure.

Additional resources:

Williams: Maintaining physical distance as employees is really important, but do practice administrators need to be considering it when it comes to keeping that distance for patients? We’ve all been in waiting rooms and know how crowded and susceptible to close encounters they can be. How do we get around that? How does that work? What does it look like?

Ramos: Some practice administrators that I’ve spoken to are actually closing their waiting room entirely. They’re not using it and are pretending like it doesn’t actually exist in the footprint of their office. I would add that you can have the parking lot effectively become your waiting room. I would consider doing both check-in and checkout virtually to limit the amount of time that patients are actually in your office setting. And I would also consider having patients room themselves.

One point that I think is equally important is maintaining physical separation of your staff. One touchpoint that I think is going to be important is to consider is your breakroom. If you haven’t started thinking about how lunch breaks are going to occur and where they’re going to occur for your staff, that’s another area that I think you’re going to have to consider.

Williams: One of the other ways we’ve heard some experts in the field talk about maintaining some level of patient volume is to extend service hours to evenings and weekends. Have you heard about this or seen it in practice? What would this look like?

Ramos: I think everything is really on the table. My practice is considering extending the day, effectively running about 13 hour days in our endoscopy centers and opening on the weekends. Alternatively, you may even have to hire additional staff in order to be able to deal with that demand and have your staff work in shifts, a morning shift and an afternoon shift. That would be a great problem to have since we were closed for two months, having to hire more staff than you thought you needed to, so long as the volume's there.

Williams: We’ve seen telehealth adopted over these last couple of months. Patients are getting familiar with it. They’re getting used to it. But now we’re also hearing about, well, things could get rolled back, will they still be able to do telehealth? How important is it for practices to come up with a plan for integrating telehealth into their normal operations in order to be able to keep providing it?

Ramos: I think it's critical. Patients have gotten used to being provided telehealth services over the last few months, and medical practices really weren't prepared for it. Some were providing telehealth, but that was really through the use of mobile apps for concierge medicine practices. But the average medical practice just hadn't yet adopted the technology. It's been available for a while, we've just been very slow to do it, much like we were slow to adopt EHRs. Patients have gotten used to it, so if you don't offer that service moving forward and don't find a way to integrate telehealth services into your flow when you reopen, I think you run the risk of those patients leaving your practice and going to someone else that's offering that service.

CMS has relaxed a lot of regulations about practices being able to use sort of unsecured methods of communication during the pandemic, like FaceTime, but we all think that those regulations will tighten up pretty quickly. So, I think a couple things are important for practices: One is to make sure that you have a technology solution that complies with the prior security requirements, not the current relaxed rules.

Williams: You’ve closed some of your recent presentations with a poignant quote from a lovable TV character. It’s pretty timely considering all that’s going on in the world today. I was hoping you could share that quote with our audience and tell us why it resonates so strongly with you.

Ramos: I grew up watching PBS, and more specifically, "Mister Rogers." And so, as a kid, I loved when Trolley left his home to go to the land of make believe. But Fred Rogers had a famous quote that reads, “When I was a boy, and I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You'll always find people who are helping.'” If there was ever a time where we needed help, it’s right now, and I’ve been incredibly impressed with the volunteerism, the thoughtfulness of strangers, the access to information, not just within MGMA and the member community and my practice administrator colleagues, but just sort of globally. If you think about sort of when hot spot cities sounded the alarm asking for healthcare providers nationally to come in and help be reinforcements, physicians, nurses and others just jumped on a plane and flew to where they were needed. In fact, there's a registered nurse from Columbus, Ohio, who traveled to Washington, D.C., a few weeks ago to care for COVID-19 patients, and he unfortunately contracted the virus and is currently in an ICU fighting for his life. His name is Michael Rhodes. The helpers are there, and the helpers are putting themselves at great risk for us. And helping doesn’t necessarily mean running into a hospital to care for patients. Helping could also mean sharing resources like we’re doing today.

Notes

To keep up with the latest regarding the pandemic, be sure to visit MGMA.com/COVID. You can also connect with fellow members and healthcare peers at community.mgma.com.

If you like the show, please rate and review it wherever you get your podcasts. Subscribe on Apple Podcasts, Google Play, Spotify, Stitcher or countless other platforms to make sure you never miss an episode.

MGMA Insights is presented by Decklan McGee, Rob Ketcham and Daniel Williams.

Thanks to CareCredit for sponsoring this episode.

To learn how CareCredit is providing patients with payment flexibility and helping providers deliver a better patient financial experience, visit CareCredit.com/MGMAPodcast.