STRUGGLED THROUGH COVID

and how we are recovering: Local scenarios By Malissa Wade

While small businesses and individuals have been affected by COVID-19, many private physician practices have also been challenged to stay afloat. Nationally and even here locally, physicians have had to quickly pivot their entire business models to provide telemedicine care over the phone or via the internet, while at the same time manage worried staff members and struggle with an extreme shortage in Personal Protective Equipment (PPE).

Although many local physician offices faced challenges, a silver lining was revealed. Here are two different local perspectives and scenarios.>>

Impact According to the California Medical Association’s COVID-19 Physician Financial Health Survey, 95 percent of physician practices statewide are worried about their financial health due to the COVID-19 public health emergency. Practice revenue statewide has declined by 64 percent since March 1, 2020, and 75 percent of practices are experiencing a revenue decline of 50 percent or greater. Specifically to the Central Valley and in the waiting room, the office closed and we switched back to telehealth. We then fully opened again on May 10.” Conversely, some practices actually benefitted from the rapid change, particularly California Pain Consultants in Fresno, Calif., owned and operated by Amitabh U. Goswami, DO, MPH. “We weren’t tremendously impacted,” Dr. Goswami says. “I thought that things became a bit easier without the stress of seeing so many patients on a given day. We were quickly able coastal areas, the survey found that physicians ranked financial assistance “We weren’t tremendously impacted. I thought that things (64 percent), temporary housing (58 became a bit easier without the stress of seeing so many percent), and PPE (55 percent) as the most important resources they need. patients on a given day. We were quickly able to transition

Additionally, virtually all practices (95 to a telemedicine-based practice where I can still interact percent) reported a substantial decrease with my patients.” - DR. GOSWAMI in patient volume while practice revenue has declined by an average of 58 percent. Practices have had to implement multiple, drastic measures to stay viable: • 41 percent of practices have had to lay off or furlough physicians/staff. • 59 percent of practices have reduced physician/staff hours. • 27 percent have had to cut physician and staff salaries. • 9 percent have had to close their practice temporarily. to transition to a telemedicine-based practice where I can still interact with my patients.” Dr. Goswami says his practice never closed and was considered essential because the objective and goal was to help offload the local hospital ERs, ORs and urgent cares from a possible influx of patients with chronic pain problems. “For me, patient volume increased because I was able treat Due to an increased uncertainty and worry among his office staff once the statewide order to close was mandated, Praveen Buddiga, MD, FAAAAI, of Family Allergy Asthma Clinic in Fresno, Calif., closed his practice on March 15, 2020. “I have a small one-physician practice with seven employees,” he says. “I could see worry on most of their faces, so we shut down for 10 days and I had to switch to telehealth to maintain continuity of care for our patients.” Dr. Buddiga says performing consults over the phone was initially a big change, although manageable. The transition was most challenging for the MediCare and MediCal patient population due to lack of access to computers, so telephone consults were more successful in these cases. “There was a decrease in patient calls over a period of time because most patients did not want to do telehealth,” he says. more people via telemedicine,” Dr. Goswami says. “I don’t have physician assistants or nurse practitioners in my practice so I was able to personally video chat with more people in one day rather than taking time to go from room to room in my office.” Thankfully, Dr. Goswami says the Centers for MediCare & Medicaid Services (CMS) bills telemedicine the same as an inperson visit. However, the amount of procedures he performed at hospitals and surgery centers decreased. “The biggest thing that slowed down was the procedures I performed,” he says. “Most patients were interested in procedures during COVID; however their family members were more cautious. I carefully continued with elective pain procedures. It was essential to keep an increase of patients out of the hospitals in order to allow them to focus on potential COVID-19 patients.”

After 10 days of closure, Dr. Buddiga’s practice opened again for two weeks – until Coronavirus cases started aggressively rising. “That was around the time when the daily mortality rate in New York City was almost in the thousands,” he says. “For the protection of my staff as well as patient-to-patient interactions Challenges With change, there are always challenges to overcome. While many physician practices, institutions and hospitals across the country faced difficulties securing PPE and masks, it was no different for our health care entities in the Central Valley.

For Dr. Buddiga, lack of securing PPE was another significant factor as to why his business had to close.

“A big challenge and frustration is lack of PPE because it went so fast and it wasn’t available to immediately deliver, which is a major reason why I closed initially,” he says. “Still today, when I go online to order PPE, it’s very hard to find N95 masks and I have to be very careful where I order from, secondary to artificial price elevation and long delays in delivery.”

Luckily, the Fresno Madera Medical Society stepped in to help many physician practices like Dr. Buddiga and Dr. Goswami’s by delivering masks at no cost.

“When patients came in we took the appropriate precautions and care for them and staff – this is where the Fresno Madera Medical Society was very instrumental in helping us continue,” Dr. Goswami says.

Dr. Buddiga says another issue was creating and regulating a social distancing plan so that very few people are in the waiting room at once. Patients are instructed to call upon arrival and to sit in their car until their appointment time rather than in the waiting room.

Dr. Goswami says there were several challenges mandated from the City of Fresno. His practice changed the way people entered the building by placing signs on the floor and on chairs to designate the appropriate six-feet social distance. Still today, his staff also performs patient temperature checks before they enter, as well as conduct a Centers for Disease Control and Prevention (CDC)-provided COVID questionnaire in person and over the phone before scheduled appointment times. Masks are provided to patients who don’t have them and family members and visitors are instructed to wait for patients in their cars rather than in the waiting room.

In addition to these physical changes, physicians are also facing problems with the revenue cycle due to confusion in billing and coding for telemedicine.

“We still don’t know yet if insurance companies cover telemedicine, so it’s a double edge sword,” Dr. Buddiga says. “Initially, some patients’ insurances were OK and some were not prepared. The computer system basically was not ready to understand our billers who were inputting codes for telemedicine so it was rejected initially, but after eight weeks it improved once the computers were updated. This also led to an enhanced administrative burden of billing most of the telehealth visits over again. Generally, every practice saw an increase in no-shows and a decrease of patient volume. Some practices’ patient volume dropped 60 percent. Hopefully in the next few months we will see it improve because change in volume directly correlates to the revenue cycle.”

“Small group practices have only one source of income and that’s inflow of patients – and when your patients don’t come to you, it’s basically shut down mode,” Dr. Buddiga says. “As doctors or health professionals, there should be some sort of leniency and accommodation to both public and private loans to continue to maintain payroll during a time like this.”

Luckily, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) provided a $377 billion stimulus package for small businesses that also included private physician practices. The package provided relief under a number of various Small Business Administration (SBA) programs.

According to the CMA, the fallout from this crisis has threatened to fundamentally alter California’s health care delivery system, not just during the 2020 COVID-19 outbreak, but for years to come. CMA’s COVID-19 Physician Financial Health Survey highlights the immediate need for financial assistance for physician practices. Specifically for the Central Valley and coastal areas, the survey found that more than half of practices (60 percent) applied for a loan created by the CARES Act.

“My practice was blessed with the Department of Health and Human Services (HHS) stimulus relief funds given to providers who see MediCare patients, and on top of that, we qualified for the Paycheck Protection Program (Triple P Loan) from the SBA to keep my staff on board so we could keep operations going,” Dr. Goswami says.

Dr. Buddiga was also granted the HHS loan for small businesses, which kept his business afloat.

says will continue to be followed throughout the rest of the year. “The good that has come out of this is we are now prepared for sudden changes to patient flow,” Dr. Buddiga adds. “We have adapted and learned. Telehealth has improved in terms of access to care – just because you can’t come in, you can still get access to care.” Dr. Goswami agrees in that there is a silver lining “I was able to pay rent and pay my staff salary during this time,” Dr. Buddiga says. “It helped significantly because I didn’t have to furlough staff.” What it looks like today As of early June 2020, Dr. Buddiga says his practice volume is still slowly picking up as patients feel more comfortable amidst the pandemic craze. “I reassure my patients that this is actually a very safe time to have procedures done because hospitals have implemented the same policies as my office, but at an even more stringent level,” he says. “They perform temperature checks, surveys and cleanings two-to-three times over between each case in the ORs, so I tell my patients it’s actually one of the best times to get procedures done.” “My practice was blessed with the Department of Health Dr. Goswami is planning and Human Services (HHS) stimulus relief funds given to to adhere to social distancing providers who see MediCare patients, and on top of that, measures until August, but that they are taking it month-by-we qualified for the Paycheck Protection Program (Triple P month. Only new patients are Loan) from the SBA to keep my staff on board so we could seen in person while all followkeep operations going.” - DR. GOSWAMI up visits are conducted via telemedicine. “I think that telemedicine is visiting doctor offices. “Patient volume is currently down 40 percent because of no-shows, uncertainty of the pandemic and whether or not patients think they should come to their appointments,” he says. “But if particular patients are really not well in terms of breathing I ask them to come in to the office to be seen while wearing a mask. All of my staff members also wear complete PPE throughout the entire patient interaction.” Dr. Buddiga anticipates his practice will continue social distancing precautions throughout the summer and until the end of the year. Patients are asked to call the office to alert the staff they are have arrived for their appointment once they park in the parking lot, a protocol that Dr. Buddiga a blessing in disguise,” he says. “There’s a paradigm shift in the way we think about treating patients today. We are able to treat them within telemedicine just as well as in person – but the question is whether insurances will pay to further expand the role it plays in health care today.” What can be done in the future? “Amid confusion and panic, there is a light at the end of the tunnel that is hard to see,” Dr. Goswami says. “We need a beacon of light for our families, patients and community, and if no one knows who to turn to, we have to become our own beacon of light for others.” Within the beginning stages of the Coronavirus pandemic unfolding in the Central Valley and beyond, there was much

confusion from all levels of the government and health care should be more help available. experts. Additionally, Dr. Goswami feels there should be town

“The outcome of this pandemic lifted the veil on our hall meetings or gatherings to provide an overview of the unpreparedness,” Dr. Buddiga says. “It showed how different types of physician practices in the Central Valley so unprepared we were as a country. It was hard initially getting a public health and government officials can better understand solid, consistent message out due to a level of unpreparedness different practice needs. and uncertainty among Coronavirus taskforce leadership, the “We are all collectively moving towards the same goal, but FDA and the CDC. In terms of messaging, everybody was on as individuals, we all have different needs,” Dr. Goswami their own. If we can learn anything from this, we should have a says. “We are on individual islands trying to stay afloat as the national emergency management allocation of PPE and other water is rising. With the help of the Fresno Madera Medical necessities for small health care facilities and private health Society, along with our local government and public health care practices that care for over 80-90 percent of patients in department, we can collectively be better prepared for the next America.” event that occurs.”

Dr. Buddiga says he received guidance from the Fresno “Hopefully there is a re-awakening of the value of health Madera Medical Society, California Medical Association and care providers in our community,” he continues. “We tend to American Medical Association, as well as from the California overlook health care systems when things are running well. Public Health Department, however the messaging is still The real need is for good doctors, nurses, medical assistants, changing every day. The local Medical Society was open to office staff, and administrators to work together. The recent physicians as an access point, but he feels next time there clash between the pandemic and the public over issues directly related to concepts of social distancing and wearing masks

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