It did not see a surge of COVID-19 patients, but Twelve Oaks Pediatrics faced financial and supply-chain pressures it had not experienced before. But it never shut down, thanks to a timely loan, helpful county officials, and a resilient staff that quickly adapted to telemedicine and took advantage of new regulations that facilitated its use.

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The Novi, Michigan, practice scaled back its hours, implemented a screening process for everyone who walks in the door, instituted a mandatory mask policy, and is beginning to open its doors a little wider to see more patients.

“We never shut down completely,” said Sheryl Hirsch, MD, though the practice scaled back to only seven or eight patients a day with about 50% of visits being done via telehealth technology. Meanwhile, payment was coming due on a refrigerator full of expensive vaccines that sat there unused and other financial pressure mounted.

Dr. Hirsch recently appeared on a Perspectives with the AMA podcast series to discuss how her practice continued caring for patients and kept financially afloat amid the COVID-19 pandemic. The podcast reviewed the AMA’s guidance for reopening practices during the pandemic and how some practices have begun to reopen. Other expert panelists are Carol Vargo from the AMA and Virginia family physician Thomas Eppes, MD.

Before the COVID-19 pandemic hit, the practice was open from 8 a.m.–7 p.m., Monday–Friday, and 9 a.m.–12:30 p.m. on Saturdays, with a 10-person staff to support three pediatricians and a nurse practitioner—with two or more of these providers present at all times. Physicians’ schedules were filled two to three months in advance with space reserved for same day appointments and urgent needs.

Dr. Hirsch said the 8 a.m.–9:30 a.m. time slot was popular and was used for walk-in patients. This helped parents keep their kids out of hospital emergency departments or urgent care.

Sheryl Hirsch, MD
To maintain physical distancing, the waiting area in Dr. Sheryl Hirsch’s practice has been unused during the COVID-19 pandemic.

When COVID hit, walk-ins were eliminated, as were Saturday hours, and only one clinician worked at a time in order to keep safe physical distancing among staff and to allow the waiting room to be closed off. Families called from their cars, were screened at the door, all given masks, and brought directly into the exam room.

Plans to add a fourth pediatrician this September have been deferred.

In addition to the measures taken to protect staff, patients and visitors from COVID-19, there was a general lack of demand for sick visits as children stayed home from daycare, nursery school and kindergarten and did not pass the usual cold viruses back and forth among each other.

“Interestingly, when people went into quarantine, pediatric illness almost disappeared—people were not getting colds, earaches, sore throats—anything,” Dr. Hirsch said. “It was absolutely unbelievable. It was dramatic.”

Most appointments during this time were well child visits and immunizations for newborns and children between 2 and 4 years old. The few sick children who were seen (mostly through telemedicine) were those who still attended daycare because their parents provided daycare for essential workers.

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“Otherwise, nobody was getting sick,” Dr. Hirsch said, adding that parents worried about catching COVID-19 were also cancelling scheduled visits. “Early on, we had families booked, and then they’d say: ‘We’re not ready to come in yet.’”

While parents are getting more comfortable with wearing masks and taking other precautions to go out in public, Dr. Hirsch said that she still has parents who tell her “we haven’t left the house until this visit.”

State, medical practice slowly reopening

Business is beginning to pick up as Michigan manufacturing plants are gearing up to reopen and parents want to take care of their children’s well visits and immunizations before going back to work.

Except for newborns, Twelve Oaks set a limit of only allowing one parent to accompany a child with no siblings allowed to tag along. Appointments for children who are sick or possibly contagious are reserved for the end of the day or seen by telemedicine.

“A few haven’t been happy about it, but I think they understand that we’re just trying to protect everybody,” Dr. Hirsch said.

This is more manageable if two parents are at home, she added. But, in single parent households or if one goes back to work, the limits may cause some families more stress.

“Our flow is very good for now,” Dr. Hirsch said. “It will become more challenging with more providers in the office at the same time.”

A strong January and February to start the year helped carry the practice through some initial rough spots. Then their landlord helped by deferring rent, but more help was needed so the practice looked to get a loan through the federal Paycheck Protection Program (PPP).

“Our regular bank was an absolute disaster and we ended up switching banks,” Dr. Hirsch said. “After getting the PPP loan, we all took a breath and said: ‘We’ll be fine now.’”

County health department was PPE lifesaver

Access to personal protection equipment (PPE) has been an issue and friends of staff were sewing cloth masks until surgical masks and face shields were made available through the Oakland County, Michigan, Health Division.

“We’d order masks—and they’d never come. We were getting pretty desperate,” she said. “The health department kind of saved our lives.”

Hand sanitizer is still difficult to find, but PPE has become easier to obtain. Also, more families now have their own masks, so the practice doesn’t have to provide as many as before.

Changes are positive, negative and lasting

The use of telemedicine will probably be the most lasting change and new payment policies geared to facilitate adoption were probably the most helpful government actions during the crisis, according to Dr. Hirsch.

Adopting telemedicine—especially for medication management of patients with attention-deficit/hyperactivity disorder—was often discussed at the practice, but never taken up before COVID.

When implementation became necessary, it was found to be remarkably simple.

“It was very easy to set up with minimal cost—and the patients liked it and we liked it,” Dr. Hirsch said.

Payment reforms also eased adoption.

“We didn’t have to worry that telemedicine visits would not be covered,” she said. “In terms of making life easier for us, that was the biggest help.”

Payment for telemedicine services has been pretty smooth from both private and public payers, though there was some confusion and delays early on with Medicaid managed care plans, which has since been straightened out.

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The practice is in a suburban area north of Detroit, and about 20% of its patients are enrolled with Medicaid managed care. If unemployment continues to climb, Dr. Hirsch expects the practice’s percentage of Medicaid patients to grow with it.

She has also seen two changes that affect her personally with one positive and one negative.

“Because we’re spacing out our appointments much more, we don’t get behind and we don’t have patients waiting, I’m able to spend more time with a family and I’m just enjoying not having that pressure,” Dr. Hirsch said. “We’ve discussed how to preserve that extra time with patients.”

The negative change is that the PPE interferes with patient interaction.

“I enjoyed seeing the babies and kids seeing me smile and seeing their reactions,” she said. “Now, I’m all masked up and they just stare at me.”

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