Early lessons learned from COVID-19 may mitigate economic impact in winter
Improved infrastructure, stockpiled personal protective equipment and a better understanding of how to provide care should have ophthalmic practices in a healthier economic position during the next wave of COVID-19.
The unknowns of COVID-19 made practicing medicine difficult when it first affected the United States in March. Practices were closed as national and state departments of health struggled to adapt to the unprecedented effects of the virus.
Source: P. Dee G. Stephenson, MD, FACS
Some practices were closed, and owners did not know how long the new conditions would keep them from practicing medicine or serving their patients.
“I have six employees who are crucial to my success. We were shut down from the second week in March through the second week of May, and during that time, I prepared my office and office staff for the worst. I continued to employ all of my employees and continued their regular pay even as we only saw emergency and telehealth cases,” P. Dee G. Stephenson, MD, FACS, of Stephenson Eye Associates in Florida, said.
Through employee and patient education, most practices reopened their doors later in the spring to provide care, albeit in a different manner from pre-COVID-19 measures. The lessons learned during those early months should help clinics better understand how to provide services during the next wave of COVID-19 this winter, Healio/OSN Cataract Surgery Board Member Cynthia A. Matossian, MD, FACS, of Matossian Eye Associates in New Jersey and Pennsylvania, said.
Early in the pandemic, strategies to continue care were made on the fly, using telehealth to see patients was new to many practices, personal protective equipment (PPE) was hoarded, and an infrastructure to deal with the challenges was nonexistent.
“Everything was new to us. We didn’t know what questions to ask patients, how to space patients out for social distancing, how to stagger patient appointments. ... We had to figure it all out,” she said.
Evolving circumstances
Strategies were formed to limit social contact, extra precautions were taken to keep patients safe, and additional time was added into each appointment to thoroughly sanitize testing and examination rooms. Practices evolved through the first volley of the pandemic, and the remaining infrastructure should make the next wave more palatable, Matossian said.
Ophthalmologists have identified emergent and vision-threatening situations that can be cared for during a lockdown, and practices know how to sterilize, sanitize and clean to increase safety for patients and employees, she said.
But even with new measures in place, it has been a challenge to continuously evolve with state- and national-mandated restrictions. The adaptability of her staff and the flexibility of her practice enabled Stephenson to retain all of her employees throughout the changes, even with the severe decrease in surgical revenue she experienced.
The infrastructure Stephenson Eye Associates now has in place has her confident she will be able to survive the next wave of COVID-19.
“I was unable to perform surgery for 2 months, but we cleaned and purged my office immediately and became totally paperless. We stocked up on personal protective gear, put partitions between staff and patients, and added shields to all of our equipment. ... We’ve implemented all new protocols and have adapted them as COVID-19 numbers rise,” she said.
Take action now
Finding new ways to continue care and increase safety is imperative to avoid the same level of job loss health care professionals experienced earlier in the year. According to the U.S. Bureau of Labor Statistics, employment in health care declined by 43,000 jobs in March, including 12,000 jobs in health care clinics.
This loss came after health care had grown by 374,000 jobs in the previous 12 months.
Proactive strategies are needed now to tamp down continued staff and economic losses, according to Patricia M. Morris, MBA, COE, a private consultant to national eye care practices.
Morris said the practices she represents have reported between a 50% and 60% decrease in revenue for 2020.
Practices must review their budgets, manage their expenses and “know your numbers cold” as they move into the winter, she said.
“What you don’t measure, you can’t manage. If you don’t have a budget, now is the time to build one. You’ve got to know exactly what the first wave did to your volume. You’ve got to watch your overhead and suspend all nonessential capital expenditures,” Morris said.
Going into the winter, practices should stock up on PPE because as numbers spike, practices could experience shortages as supplies are prioritized for hospitals because they have the most need and serve the most patients, Morris said.
Practice owners now need to extend their PPE stockpiles to plan for shortages so they can continue to serve patients for several months without having to scramble to find supplies, she said.
In addition, telehealth should be firmly embraced as an additional source of revenue. As practices began to see patients again in the spring and summer, telehealth numbers began to dwindle.
“Practices need to invest in a permanent telehealth solution. We can’t expect the temporary removal of the HIPAA restrictions to last forever. Practices should build up their telehealth and market the services because this could be a new permanent source of providing care for our patients,” Morris said.
National programs
Morris said practice owners should take advantage of state and national programs to mitigate economic losses from reduced patient and surgical volumes.
One example is the AMA’s approval of code 99072, she said. The new CPT code was approved in response to additional measures adopted by practices and health care organizations to limit the spread of COVID-19.
The code, according to the AMA, can be used for additional supplies, materials and clinical staff time above what is usually required for an in-office visit or other non-facility service when performed during a public health emergency.
In addition, apply for government forgiveness programs and stay connected with national ophthalmology societies to receive real-time notifications on upcoming funding opportunities, she said.
“Really prioritize your revenue cycle activities right now. Collect copays, coinsurance and noncovered services at the time of service, and don’t forget deductibles at the beginning of the year. Work your denials and review managed care contracts. Now is the perfect time to do this,” Morris said.
The Economic Injury Disaster Loan (EIDL) and Paycheck Protection Program (PPP) are two federal loan options practices can look into to reduce the economic burden of the next wave. The EIDL is a Small Business Administration loan that can be used for payroll, accounts payable and fixed debts that otherwise cannot be paid due to a disaster. The PPP is part of a federal program for small businesses with fewer than 500 employees and can be applied for through any approved bank or lender.
“We received PPP and have followed all rules for and received EIDL. We have saved every possible dime” for the next wave, Stephenson said.
Focus on safety
Continuing to focus on patient and staff safety can help keep doors open during the next wave, according to Sumitra S. Khandelwal, MD, associate professor of ophthalmology, cornea, cataract and refractive surgery at Baylor College of Medicine, Cullen Eye Institute, Houston.
The channels of communication in a practice must be clear. Reiteration that all members of the practice should follow CDC guidelines during work hours, and even after work hours, is key, she said.
“Our staff that developed COVID-19 were from the community spread. However, following guidelines at work allowed the disease to be contained without spread even when they came to work with mild symptoms prior to realizing it could be COVID-19. Continued efforts to mask, clean rooms and test anyone symptomatic is important,” Khandelwal said.
Changes in patient screening, break room safety and contact tracing throughout institutions and practices keep everyone safe, she said.
Flexibility is necessary during this time. There have been more patient no-shows during the pandemic because of safety or personal concerns, but this has been balanced out by a higher number of urgent patient referrals.
“We have seen attrition of staff who need to focus on their family life during these times. We also have had several develop COVID-19 or COVID-19 symptoms from community spread. This can result in staff shortage, and we need to create ways to optimize staffing,” Khandelwal said.
Care for staff
Staffing has become an even bigger concern in the current climate. Matossian said her practice is still not up to pre-COVID-19 staffing levels, and her employee pool is stretched thin while working more hours.
Matossian Eye Associates wanted to extend practice hours to nights and weekends to accommodate the backlog of patients who needed care once it reopened after the lockdown but was unable to due to staff shortage.
“We’re performing temperature checks, asking COVID-19 screening questions before every appointment, donning personal protective equipment and increasing sanitation. This is all adding time to our already stretched staff,” Matossian said.
Before the pandemic, cash-pay procedures to treat dry eye, such as intense pulsed light therapy, LipiFlow (Johnson & Johnson Vision), iLux (Alcon), TearCare (Sight Sciences) and BlephEx (BlephEx LLC), could be offered as same-day add-on services. With increased appointment times and stringent social distancing requirements, these services cannot be offered right now as add-ons, Matossian said.
“We’re handcuffed because we don’t have the technicians nor the time to train new staff to do these in-office dry eye procedures and therapies. It is our goal to offer these procedures to patients as same-day services again in the near future when we bring on more staff,” she said.
Staffing shortages
Even before the pandemic, a shortage of ophthalmic technicians and assistants was a challenge in ophthalmology. Filling positions in this climate, interviewing candidates and training them are even more challenging, Matossian said.
Additional staffing losses should be expected as COVID-19 cases rise, schools close, family issues keep employees home and lockdowns are initiated. All of this, coupled with cold and flu season, will equate to more employee absences and leaves, Morris said.
She said she has opened agreements with local temporary agencies for several of her practices in anticipation of employee losses.
“This is all in case we have a mass exodus of employees, which is really what happened during the first wave. Hopefully I can bring in additional people if need be. They probably won’t be able to hit the ground running, but at least we’ll have some backup to support our doctors as we continue to provide care,” she said.
Now is not the time to be careless with staffing or finances, Morris said. By now, many of the pandemic policies that were put into place should be formalized and introduced into employee handbooks or official guidelines. Employees should be on script so they can quickly and thoroughly answer any questions patients have about safety or appointment procedures.
Practices should use their websites to communicate changes in procedures and cleaning programs. This new way of thinking needs to be embraced by everyone in a practice, she said.
“We need to embrace the new normal and what’s becoming the new normal. I still have staff that are fearful to come to work. You need to help them, let them work from home or introduce them to another way of making a living for your practice. Fear can’t be a reason to not come to work forever,” Morris said.
Formalize plans
Proactively planning for COVID-19 exposure is a must. Plans must be implemented for providers, staff and patients who contract COVID-19 or come in contact with the virus. If a patient, provider or staff member exposes the clinic to COVID-19, then concrete mechanisms to notify patients of possible exposure need to be in place to limit virus spread.
All of these scenarios and guidelines should be formally published in an employee handbook and communicated with practice members to ensure there is no confusion. Training is imperative, and everyone in the practice needs to be on the same page with state health department and CDC guidelines, Morris said.
Do not relax measures
Everything needs to be accounted for in this climate, even with promising news about possible vaccines, Khandelwal said.
“I think in March through May, we thought COVID-19 would be a few waves then go away. I think considering the strange way this disease works, the way we interact and travel in this day and age, and the questionable effectiveness of a vaccine mean we are going to be living with this for some time. Each clinician, staff and patient is going to need balance their own health, including mental health, with safety,” she said.
It is a strange time for practices and providers, but even more so for patients. Letting patients know that isolation and depression are real problems can help put them at ease when they come in for care, Stephenson said.
“Now is the time to show what you are made of. Show your kindness. Caring doctors, technicians and office staff will make us, not break us. We are a work family, and through respect and love, we will get through these terrible times,” she said.
- References:
- AMA announces new CPT codes as COVID-19 advancements expand. www.ama-assn.org/press-center/press-releases/ama-announces-new-cpt-codes-covid-19-advancements-expand. Published Sept. 8, 2020. Accessed Nov. 11, 2020.
- Nonfarm payroll employment down 701,000 in March 2020. www.bls.gov/opub/ted/2020/nonfarm-payroll-employment-down-701000-in-march-2020.htm. Published April 7, 2020. Accessed Nov. 5, 2020.
- Occupational employment and wages, May 2019. www.bls.gov/oes/current/oes292057.htm#nat. Accessed Nov. 6, 2020.
- The employment situation — October 2020. www.bls.gov/news.release/pdf/empsit.pdf. Published Nov. 6, 2020. Accessed Nov. 12, 2020.
- Steinert A. Shortage of skilled technicians can lead to inefficient clinics. www.healio.com/news/ophthalmology/20181226/shortage-of-skilled-technicians-can-lead-to-inefficient-clinics. Published Jan. 3, 2019. Accessed Nov. 5, 2020.
- For more information:
- Sumitra S. Khandelwal, MD, can be reached at Baylor College of Medicine, 1977 Butler Blvd., 2nd Floor, Houston, TX, 77030; email: sumitra.khandelwal@bcm.edu.
- Cynthia A. Matossian, MD, FACS, can be reached at Matossian Eye Associates; email: cmatossian@cmassociatesllc.net.
- Patricia M. Morris, MBA, COE, can be reached at 935 Great Plain Ave., Suite 277, Needham, MA 02492; email: visionpro1@hotmail.com.
- P. Dee G. Stephenson, MD, FACS, can be reached at Stephenson Eye Associates, 200 Palermo Place, Venice, FL 34285; email: eyedrdee@aol.com.
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