Hard-Earned Lessons

Amidst the pandemic’s challenges, physicians gain insights.

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May 2022 – The Journal of Healthcare Contracting

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Throughout the pandemic, healthcare providers, like everyone else, have faced interpersonal, emotional and financial challenges. In the process they have gained insights and growth.

Ron Holder, Chief Operating Officer of the Medical Group Management Association, says that even as late as this February, some patients still were avoiding as much physical contact with others – including doctors – as possible. Meanwhile, others were eager to get back to see their doctor in the office, a fact that has presented its own set of challenges.

“It’s a little bit like what happened when the healthcare exchanges first started,” says Holder, who served as vice president of operations and Central Texas cardiovascular service line administrator for Baylor Scott & White Health prior to joining MGMA. “When that happened, significant patient populations who had lacked healthcare coverage for years suddenly wanted to address everything they had been unable to have addressed previously. The patients in those initial ‘suddenly covered’ visits were more complex on average than the average primary care patient.

“With some patients, that is what is happening now,” he says. Due to COVID-19, they were deferring care, some by their own choice, others by necessity (e.g., discontinuation of elective procedures by medical practices or hospitals).

Many practices find themselves in a situation where they can only do so much during one visit, Holder says. “They are triaging for the most important issues and asking patients to schedule appointments for the additional ones.

“That means that the schedule can’t just be eight or nine one-hour appointments per day, because that would drive the appointment backlog way out into the future,” Lack of access could lead to increased urgent care or emergency room visits and present financial challenges for practices in risk-based or capitated contracts. “These impacts won’t necessarily be lasting in perpetuity. Once the backlog of care starts getting worked through, we will begin to approach pre-COVID levels of care and expectations.”

The emotional toll

Lingering challenges have exacted an emotional toll on practices. But many of these pressures didn’t start with COVID-19.

“Learning how to do documentation in electronic health records that weren’t necessarily built for managing a patient in an outpatient setting, managing patient message/work queues, and responding to requests from insurance companies for information to approve denied or delayed claims all represent additional work,” says Holder. “Add in value-based contracts with their inherent assumption of risk to the physician’s practices, learning telehealth, and staff shortages. On top of that, pile on COVID with its anxiety and depression, rollercoaster of uncertainty, risk of infection, fluctuating patient volumes, and the political battles around the science of medicine.”

Clinical and non-clinical support staff may be working longer or more unpredictable hours. In practices in which some people lost their jobs early in the pandemic, others fear they may be next. “That in and of itself is a stressor,” says Holder. Another challenge facing practices is a rise in disruptive patients. A recent MGMA poll showed that 71% of practices saw their levels of disruptive patients increase in 2021, he says.

And if one member of the care team is feeling stress, everyone on the team feels it. “A burned-out physician will spread anxiety and stress to the staff and vice versa. The irony is that having a team that is supportive of each other is one of the best ways to combat burnout.”

Increased stress, tension

Internist E. Linda Villarreal opened her adult medicine practice in 1989 in Edinburg, Texas, in the southern part of the state. Dr. Villarreal, who is president of the Texas Medical Association, became employed by WellMed Medical Management in 2018.

She has “definitely” seen increased levels of stress and tension among colleagues – not just doctors, but midlevel practitioners and ancillary personnel. Being covered from head to foot in PPE was itself a source of depression and anxiety, she says. “I didn’t realize the impact it had on me until one year later, when we were able to remove gowns and shields.”

Trained to take care of patients no matter what, physicians have traditionally put their emotions on the back burner, she says. But during the pandemic, it was difficult if not impossible to relax, reflect and recharge.

Dr. Villarreal says she saw depression among colleagues who had exhausted their savings and cashed in their 401(k)s as patient volumes dropped at the height of the pandemic. This on top of growing federal requirements in modern medicine. “Medical assistants are feeling the pressure too, because they are doing twice what they did 20 years ago,” she says.

Grey Tsunami

“Absolutely there’s burnout among staff, because more is being asked of fewer people,” says Edward Fry, M.D., FACC, chair of the Ascension Health Cardiovascular Service Line in Indianapolis and vice president of the American College of Cardiology.

At the height of the pandemic, following a day’s work, many had to catch up with children at home who had been remote learning, or tend to elderly parents, he points out. Meanwhile, nursing ratios in the hospital were stretched. Supply chain snags and the complexity of today’s patients in the outpatient and inpatient settings added to the tension.

Among physicians, the rate of retirement had been accelerating prior to COVID-19, simply because of aging of the workforce, says Dr. Fry. “We’re still seeing some effects from the Great Recession of 2008, as many people who had been planning to retire were unable or unwilling to do so, but are ready now. It’s the Grey Tsunami, and it’s occurring along with the challenges of medical practice today, including the pandemic.”

Telemedicine is here to stay

One pandemic lesson learned by providers and patients has been the value of telemedicine, according to those with whom Repertoire spoke.

“Telemedicine is here to stay,” says Dr. Villarreal. “It’s the best thing to happen to patients, and it’s an additional tool for physicians to use.

“In the early months of the pandemic, when we were all isolated, we would call patients on the phone, and the grandkids would help grandma get on a Zoom call. We were able to find out what was going on with them, make sure they were taking their medicine. We stayed in touch with our patients. And we continue to offer that option today.” Telemedicine can be especially helpful for those who are bedridden or for whom transportation is difficult, she adds.

Donald Hoscheit, M.D., chief medical officer of Duly Health and Care, a Chicago-area multispecialty medical group with more than 900 primary care and specialty care physicians in over 150 locations, believes the pandemic has definitely influenced how patients access care.

“Our demand for telehealth visits exploded with the onset of COVID,” he says. “Last year [i.e., 2021], Duly physicians completed more than 250,000 telehealth visits – dramatically up from about 2,500 in the 18-month period prior to the pandemic. [The rapid increase] opened our eyes to the benefits of digital health. Payer reimbursement of digital visits will allow us to expand further.

“Patients’ perspectives of telehealth have changed too,” he says. “Senior patients have adapted quite well on a number of levels. It has brought them great and easy access, especially those elderly patients who don’t drive. No question these impacts will be lasting.

Says Dr. Fry, “We have been surprised that many patients whom you would expect to be resistant or not tech-savvy have really engaged with telemedicine. Now it’s a resource to complement traditional care.”

That said, as the pandemic wanes, Fry and colleagues have found that many of their patients are eager to return to face-to-face visits. That may reflect the age of many cardiology patients, as well as the fact that many come from rural Indiana, with poor or non-existent access to broadband.

MGMA’s Holder believes that patients’ interest in telehealth won’t go away. On the upside, telehealth reduces the need for bricks and mortar in expensive areas to serve patients, he says. “But when – likely not ‘if’ – payment for telehealth services is reduced to levels lower than in-person care, practices will have to … alter their cost structure for those visits or end up deciding not to do it. [But] if the practice does not offer it, they will lose some business to someone who has figured out how to do telehealth more cost-effectively.”

Poorly managed, telehealth can rub patients the wrong way, he adds. Even those who love telehealth bristle when, after waiting weeks for a telehealth appointment, the provider says this is an ‘in-person visit issue’ only. “Practices have to have methods in place to make sure that the practice is treating the patients in the best method possible, and not just best clinically. A practice that uses two appointment slots – one virtual and one in-person – to address a single problem is creating its own patient access problems as well as damaging patient satisfaction and engagement.”

Infection control

Another sure thing that will last beyond the pandemic is a heightened sense of infection prevention on the part of practices and patients, says Dr. Villarreal. “Patients will feel safe going to a practice that promotes infection prevention,” she says. But maintaining protocols will demand time and money. Curbside screening and check-in take time, and they may call for rearranging job descriptions, adding staff or lowering the number of patients seen per day, she says. Solo practices or those with two or three doctors may simply be unable to afford the changes.

Says Dr. Hoscheit, “We have always been steadfast in adhering to infection control protocols. With COVID, however, more direct attention has been paid to managing non-essential visitors, that is, those care companions who are integral to the patient’s care.

“Before the pandemic, care companions often accompanied patients on their visit to the doctor. In pediatrics, it was not at all unusual for parents to have children … along for the visit of a sibling. To stop the spread of COVID, providers everywhere implemented strict policies, including mask wearing and physical distancing, and, when peaks were at their worst, restricting visitors entirely. For example, in our ambulatory surgery centers, we have asked patients’ drivers to wait outside the facility and be reachable by phone instead of spending time in the waiting room while procedures are performed.

“We have worked tirelessly to lessen exposure for patients, family and staff by providing PPE, greater environmental spacing and symptom screening. Most challenging is not so much pivoting on new protocols as it is fostering compliance.”

Ron Holder believes the most challenging infection-prevention-related changes for small practices are those that require facility changes, such as finding new space or renovating existing space. That said, practices can “find space” without renovation or bricks and mortar by:

• Conducting telehealth from outside the clinic, either in new but inexpensive space, remotely, or in space owned by the practice that wasn’t in clinical use.
• Borrowing the “We will text you when your table is ready” concept from restaurants.
• (For larger practices with multiple locations), setting up a “COVID-positive” or “COVID-suspected” clinic and a separate “non-COVID” clinic.
• Offering separate entrances and staging areas to keep the COVID and non-COVID populations separate.

And when this is over?

Some physicians and practice owners have found that the pandemic has given them a chance to isolate and eliminate non-productive activities and attitudes, and replace them with patient-centric and staff-centric ones.

“We have learned a lot of good things,” says Dr. Villarreal. “The underlying issue is maintaining, protecting and preserving the patient-physician relationship. We have learned that we can do that in more than one way, including telemedicine.”

The experience has indeed had a transformative effect,” says Dr. Hoscheit. “Duly has implemented a Nurse Call Center where patients can reach us 24 hours a day, seven days a week with questions, concerns, requests for refills or certain test results. This helps patients address basic needs easily and efficiently and takes some of the workload off physicians. Additionally, we are developing a Care Ally program in which trained staff assist those who come for care and help navigate the visit, scheduling and testing. This makes for a more efficient visit for both the patient and our team.

“Enduring a pandemic has strengthened the concept of a healthcare team, working together, selflessly and heroically in every twist and turn thrown at us, caring for our communities under every circumstance.”

A focus on high-value care

Says Dr. Fry, the many months of pandemic-induced isolation, in which patients sought and received less care than they would have under normal circumstances, has reinvigorated the value discussion among providers, payers and patients. “We are asking ourselves, ‘What is high-value care?’” he says. “It’s a healthy process, because it brings us back to the importance of joint decision-making about care,” involving patients and providers.

Will these lessons last? “Early in the pandemic, there was a lot of energy around the idea of care transformation. In some ways, that was an antidote to the burnout and stress that people were feeling.” But as providers face the economic reality of surviving quarter to quarter, it’s difficult to maintain that long-term view, he says. “Still, a return to normal would be a failure. We need to take a little time to breathe, then come back and execute on the lessons we’ve learned.”

“Some practices have, can, and will use their experiences with COVID-19 to drive care transformation,” says Holder. “Practices should use COVID as a springboard to look for easier ways to accomplish tasks, to create a team culture that drives beyond employee engagement to employee loyalty, to right-size physical space needs, to move appropriate functions out of expensive real estate to more economical options, and engage with patients between in-person or virtual visits.”

Practices must also work on combating burnout, perhaps through formal training programs. “Some are investing in different staffing strategies or tech solutions to minimize … work that doesn’t necessarily require clinical judgment. Some are looking for ways to use artificial intelligence to aid in decision-making and/or automate functions that don’t necessarily require staff time to allow all levels of staff to spend a greater percentage of the day working at the maximum of their licensure.”