Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.


AMA Chief Experience Officer Todd Unger speaks with AMA President-elect Susan R. Bailey, MD, President of the Jasser Center for Comprehensive Health, M. Zuhdi Jasser, MD, and family medicine physician at Three Oaks Health Jim Milford, MD, on updates regarding COVID-19 including the steps physicians can take as they look to safely open their practices during the COVID-19 pandemic.

Learn more at the AMA COVID-19 resource center.

Transcript

Unger: Hello. This is the American Medical Association's COVID-19 update. Today we're discussing steps physicians can take as they look to safely reopen their practices.

I'm joined today by Dr. Susan Bailey, AMA's president-elect, and an allergist and immunologist in Fort Worth, Texas, Dr. James Milford, a physician and practice owner at Three Oaks Health in Johnson Creek, Wisconsin, and Dr. M. Zhudi Jasser, president of the Jasser Center for Comprehensive Care in Phoenix, Arizona.

We're hearing a lot of grim projection still in rising death tolls, but many states have loosened COVID-19 restrictions. In the midst of this, physicians, like the rest of us, are wondering when and how they can safely reopen. Dr. Bailey, what does a practice need to determine if it's safe to resume normal patient care?

Dr. Bailey: Todd, everything that needs to be done in a practice has to be based on science, on reliable evidence and dependable data. The AMA is recommending that four basic needs be met before opening a practice. Number one, there has to be a sustainable decrease in the number of new cases in the community. There needs to be a reliable testing network, so that those tests are well supplied and easily accessible. We need to have a public health infrastructure in each area that can do the appropriate surveillance, and then contact tracing if necessary. And finally, physicians, hospitals, all health care workers, have to be appropriately supplied, and have the workforce that they made to meet potential surges in demand.

Unger: Dr. Milford, Dr. Jasser, what advice do you have for physicians who are now looking to reopen?

Dr. Milford: Go ahead, Dr. Jasser.

Dr. Jasser: Sure. As somebody who's been in private practice now for 23 years, small practice, three providers, I have to tell you, this is probably one of the toughest times, and I know a lot of our colleagues have been stressed. Just like any small business, when you see a throughput decrease of 20-30% that can be almost everything for us. But thanks to AMA advocacy and a lot of the federal work, hopefully, many have been able to take advantage of the SBA loans. I was blessed to have gotten one now in the second round, but there may be more coming. Who knows? And I do think that make sure you've looked.

A couple things. Number one, financial sustainability, thanks to a grant. Now you'll see many Medicare providers would have seen the first round of that, from a total of $50 billion. Initially, a few weeks ago there was $20 billion distributed to all Medicare providers, based on a calculation from 2019. There's another $30 billion coming out in the next few weeks, but that needs application.

You can go to hhs.gov\providerrelief to provide some of the parameters to see if you qualify. Most of us small practices would qualify for that, and I'm in the process, and I've applied for that.

On the ground level. Remember, most small practices are turnkey. Yes, we might've had to have some of our employees take some time off, and other things, but now you can bring them back. And remember this is a medical crisis—so patients—there's a lot of new ways you can turn your operation into contacting patients more frequently by email, by phone, doing televisits. Now they're paying for televisits at the same way, at the same level they would pay for office visits, and you can look at the AMA's resources to find out how that's done. Turn some of the things.

And the other thing is to brand your practice. I tell my patients it's safer than going to the grocery store or any place else. We screen patients before they get to the waiting room. We screen them on the phone. Don't let your other chronic illnesses go to the wayside and have a pandemic come after the pandemic. We need to be on the front lines, and that'll allow your small business to survive.

Dr. Milford: Yeah, and I echo everything you said. I think that's great advice. We really have gotten back to the basics of what we went to medical school for. We focused on helping people and wanting to stay open as an attitude from the beginning. Right away we asked our whole team, are you on board with this? Do you want to move forward with this? How can we make you feel safe, so that our patients feel safe? And then we just started to innovate, and we started to do the research. There isn't a roadmap to any of this, so you had to go back to the basic studies, and really look at what you needed to do to keep your practice going, and you had to innovate as you go along, and we've done some of that.

Unger: I'm sorry, go ahead.

Dr. Jasser: I was just going to add, one of the hashtags I like, as much as we want to crush the curve, we also want to crush the fear. I think patients especially, we don't want them to get the other chronic illnesses, so begin to reach out to them, so that they know how safe your office is, your practice is, your clinics are and how much screening you're doing, that it's really the safest place they can be outside of their home, so that you can continue to survive and take care of them.

Dr. Milford: You have to have that attitude about things, so that people really believe that. Your staff has to believe that, too.

Unger: Can you talk a bit more about that, because that's obviously a big concern, is that people be afraid to go back and see their physician. Are there any specific tactics you're using in your communication to your patients to get that message across?

Dr. Jasser: That's a great question, which should be not only what we say, but what we do. We reassure patients, that they see us washing our hands before and after every visit, wearing a mask when we're examining them. We tell them, if we're not going to touch you or do a test, we can do it from home. We recognize that we don't have to have them coming into the office all the time, and their insurance companies are allowing us to do that. Telling them we're screening people even before they come through our front door. I have one of my MAs sitting outside the office, in the front, screening people for temperatures, history, et cetera. And then if they don't pass, we do a televisit from their car or from home. A lot of these things, we reassure them through our newsletter, through communications. And then the other thing is to reassure your employees. We've done something in this crisis where we're having a team huddle every morning with my employees, so that they exude confidence when they talk to our patients.

Dr. Milford: Yeah. And we actually sit pretty close to our front office staff, so it's listening to them on the phone. And do they have a sense of assuredness when they talk to somebody on the phone, that they're safe coming in? And if they don't, why not? What can we do to make that different? But it is the visual cues. It's also asking your patients, what is it that makes you feel safe? I asked a patient that, and they said, well, when I go to the gas station across from your clinic there, I don't feel safe, because I have to open the door. We installed automatic doors, so that they don't have to touch the door. Different touch points and direct rooming we instituted, so that they can come directly in without going into the waiting room, and we're very verbal about that. They have that expectation ahead of time.

Dr. Bailey: I love all those ideas. One of the many wonderful things about being in a small independent practice is how flexible and nimble that you can be to make these adjustments immediately, if you need to. We tell our patients on the phone, listen, when you come in, you'll see everything's going to look completely different. We ask that you wear a mask before you come in. That's one thing our governor has required for practices to be open, but they'll see, we will tell them we've completely redesigned the waiting room. It's almost impossible to sit or be within six feet of another person. We're blessed to have a nice big waiting room, and things like that, so that they know that we are thinking of them, that we are concerned about their health and safety, as well as the health and safety of our employees.

Unger: Can you talk a little about the balance of telemedicine, which is new to many practices, and in-person care. How are you managing that?

Dr. Jasser: Well, if I can take that, I think that what's happened is first of all, I would lean on technology that patients already know. If you introduce a technology they haven't used—60% of my practice is Medicare, so it can be difficult for them. If they're doing FaceTime with the grandkids or other things, it's easier to use that. And now, thanks to the AMA advocacy, we've now had rules loosened a little, so that we don't have to use only proprietary technology. I'm using FaceTime, Google Duo, Google Meet, Zoom and other technologies that patients are used to.

Second is because of the distancing, what we've done is, we've done one physical meeting in the office, and then two televisits, and then alternating that, so that you have a throughput that's the same total number of visits in the day, so that I can keep my lights on, but then the physical presence in the office is down by 40-50%, while we intersperse the televisits through the day, so that the volume in the office is less, and you keep moving your providers through.

Dr. Milford: It really is having to innovate. Luckily, we dabbled with it a bit before it was certainly mainstream here, and that's allowed us to have those platforms, and we hope, of course, we all hope, that this continues forward and the payment for it continues forward too, along with the HIPAA relaxing, and being able to use different platforms to communicate with patients. That's so helpful, because everybody has a different way of doing it, and we purchased an iPad, a couple of iPads, and different experiments with different techniques to be able to communicate. Luckily, we have a young staff that's allowed us to do that. We're small, so the IT part, we can just figure it out. We did the social distancing amongst ourselves within our office, too. Unfortunately, I now do telehealth in a closet. We converted a closet into my telehealth room, so that part's the only downside about the telehealth for me. But we really just switched out a visit for our telehealth visit, so it just flowed right into the mainstream. I think about 40% of our visits right now, 40-50%, are telehealth.

Dr. Bailey: All of my patient visits now are telehealth, but there is a part that you can't do virtually, and that's giving allergy shots and administering biologic injections for our patients with severe asthma. Patients can't afford to stop those during this time, because if their allergies or their asthma go completely out of control, because they're not on their maintenance therapies, then obviously that's going to put them at greater risk for severe disease. I'm personally doing all my visits online, and my patients, so far, have been pretty accepting of that.

Unger: As you think about what you've learned through the past several months, and then project into the future, what advice would you give small practices, so that they're able to stay open in the event of a second surge down the road?

Dr. Bailey: I'll jump on that one first. I think practices need to look back and say, okay, what was it that made us slow down or close in the first place? Was it because we didn't have enough PPE? Was it because our patients were afraid? Was it because we didn't have enough of a financial reserve to sustain a downturn? And then make sure that you've got a plan to meet all of those things. I know in our practice, we had zero PPE, virtually. We had a little financial reserve, and now we're going to have a plan going forward, so we will never get caught in a situation that bad again.

Dr. Milford: Yeah, I think the personal protective equipment has definitely been the biggest barrier. It seems like it should be the easiest thing, compared to telehealth and everything else, but it's been the most difficult and cumbersome roadblock that we've faced. Having access to that and thinking ahead about stocking some of those things, especially when you come off of a lean system and Kaban, and you're trying to have a minimal inventory. Gosh, I wish I would have had more masks.

Dr. Jasser: And I think, if I can add, we're going to find, and I'm going to state the obvious for most people in private practice, which is we're going to have a lag to the pandemic, which is because billings are usually two to three months behind. You're going to find in the next two to three months a huge dip, while our volume will probably start to get back up. How do you staff the clinic while you're trying to get back to financial sustainability? As the Washington Post had on its front page, primary care was already on its a weak legs, and thanks to the AMA, now we're trying to put things in place, where possibly insurance companies and others who see the value of our gatekeeper status. Not only primary care, but every practice can't live with 20-30% fluctuations and throughput.

Try to continue to be as efficient as possible through the tough time in June and July. And then slowly, as it ramps back up, organizations and networks like the AMA, we have a private practice caucus within our House of Delegates that has been an unbelievable network for me to know the things that are available, and I think through many of your specialty and national organizations, you can continue to keep up to date on financial opportunities, grants through your states and federal grants, in addition to possibly incentives through your insurance companies.

Unger: Dr. Bailey, the AMA has produced a guide which outlines some of the specific practices in getting back to reopening. Can you talk a little about that, and any other advice that you might have for practices?

Dr. Bailey: Yes. The AMA has recently come out with its own checklist, if you will. Its guide to opening or reopening your practice, and it's full of checklists of things that you need to think about, links to important sources, such as CDC, that can help you with that, and also helping physicians, being aware of new regulations that may be in place, help them be aware of specific liability concerns, help them with scheduling issues, continuing on with telemedicine, and I think it can be a very helpful resource to help get physicians' practices back online.

Unger: Well, thank you. That's it for today's COVID-19 update. Dr. Bailey, thanks for being here, Dr. Milford and Dr. Jasser, and sharing your perspectives. We'll be back tomorrow with another COVID-19 update.

In the meantime, to take a look at the guidelines and checklist that Dr. Bailey just mentioned. Go to the VID-19 resource center on the AMA site at ama-assn.org/COVID-19, and thanks for being with us here today.

Dr. Milford: Thank you.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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