The coronavirus pandemic has left many physician practices struggling to stay afloat.
They’ve lost revenue as the number of patient visits have dropped dramatically as people stay home to avoid exposure to the highly contagious virus. Specialty practices have also put off revenue-producing elective surgeries and procedures.
“The big takeaway for us is that every primary care practice in the country is at significant risk right now because of the way we have paid primary care,” said Dan Bowles, senior vice president at Aledade, a company that partners with independent primary care practices across the country.
Bowles, who has been leading the company’s efforts to help doctors navigate the coronavirus crisis financially, said some cash-strapped practices are wondering if they will have to close their doors.
Some practices have only two to three weeks of cash on hand. Some are exploring layoffs or have already laid off staff. Some are talking about closing or at least shuttering their doors until the economic crisis resulting from coronavirus passes with the hopes of reopening.
But there are things practices can do to shore up their finances and keep their doors open, said Bowles.
There are three components practices need to look at, according to Bowles. Aledade, which works with 550 practices across the country in the transition to value-based care, has also been advising these practices on navigating the coronavirus crisis.
“By and large, this is the playbook: Bolster your revenues, manage your expenses and let’s help you find ways to get access to new capital,” he said.
So where to begin?
Find ways to bolster revenue.
For many practices, this begins with telehealth services. “If you are not on telehealth, get on telehealth immediately and bill for those visits,” he said.
At least temporarily for the duration of the coronavirus emergency, the Centers for Medicare and Medicaid Services (CMS) and some states have eased many of the restrictions that made it difficult for practices to conduct telehealth visits.
CMS has also increased the reimbursement for these services to create a closer payment parity between virtual visits and traditional office visits. And on Monday, it moved to cover patient visits conducted over the telephone (PDF).
Most of Aledade’s partners did not have telehealth services in place, because it was so hard to bill for those services, Bowles said. Since the reimbursement changes, the company has helped 200 to 250 practices get set up on telehealth visits in about a week.
That was also the case for the practices that Elation Health works with, said Kyna Fong, CEO and co-founder of the company that works with practices and offers an electronic health records system. At the beginning of the outbreak, most of the practices were not set up for telehealth visits. “We’ve been working around the clock to get them on there,” she said. “Bandwidth and time is a challenge.”
Because of the COVID-19 outbreak, the government has made it possible for practices to use non-HIPAA compliant connections such as Facetime and Skype.
“If they can get themselves set up for telehealth and virtual visits, they can recover some of their lost revenue,” said Fong.
For many, it’s not so much the technology, but the challenge of letting patients know they now have telehealth appointments, she said.
“How do you communicate with patients you are open for business? There are all these complexities," Fong said.
Practices are putting information about how to use telehealth visits on their web sites, using their patient portal to get the word out as well as mailing letters to patients and making phone calls.
Fong said one doctor she talked to was glad he tried it. “He loved it,” she said because it allowed him to have efficient, focused conservations with his patients and to keep more on time.
Consider the services where there are high-paying codes, particularly under Medicare, for telehealth services, said Bowles. These include transitions of care visits, which typically pay two to four times more under the Medicare physician fee schedule than for traditional evaluation and management (E/M) visits, he said.
Physicians also can patient visits for advanced care planning meetings via telehealth. These are end-of-life conversations and while it may sound harsh to talk about those issues in light of the mounting coronavirus deaths, now is the time for patients to make their wishes clear about what kind of care they want to receive.
For instance, some elderly or seriously ill patients may choose not to be put on a ventilator. There are other visits that pay reasonably well and can be delivered via telehealth, Bowles added.
File all claims for outstanding services. While it may sound obvious, if practices have any outstanding claims, file them now, Bowles said. “Bill for everything you’re already done immediately.”
Take on new patients. It’s also a time when practices that are accepting new patients can market themselves, said Fong. Many people, especially younger people, may not have a primary care doctor and have relied on urgent care. They may now be re-thinking whether they need a primary care doctor that they can call, she said.
Manage the expense side of the ledger.
Look at your fixed monthly expenses. What can you defer, delay or not pay this month?
You may find relief is available for your rent or mortgage payments. “That’s a big expense for a lot of practices,” he said.
On the personal side, physicians can consider the salary they are taking and whether they can defer student debt they accumulated as part of their medical education.
Consider how to reduce payroll. “The biggest expense for a lot of practices is payroll,” he said. While it may be painful, now may be the time practice leaders need to think about ways to structure their practices so they can keep their doors open. That may mean layoffs that ensure staff are eligible for unemployment assistance. Other practices are reducing staff hours, said Fong.
Find access to new capital.
Consider a Small Business Administration loan. The Trump administration is making loans available for small businesses, which may be eligible for up to $2 million at relatively low-interest rates.
“The difficult thing is the process is really onerous,” Bowles said. “We found essentially it takes upwards of 20 hours to fill out the paperwork. Most of our practices don’t have 20 hours.” Other restrictions may include the need for a personal guarantee from the practice owner before becoming eligible for a loan. “It’s not as simple as it sounds on its face.”
Community health centers are in luck. Those federally-funded centers, which serve some of the country’s most vulnerable populations, will receive $100 million in federal funding to boost their role in responding to the coronavirus pandemic.
Check into assistance that may available from your state. Some state-based payers may have funding as well, Bowles said. States may have small business assistance or be able to advance shared savings payments.
While it’s important that the nation’s hospitals receive assistance, “we can’t forget about primary care because if we do, it not only hurts the hospitals, it hurts us over the long-term from a system perspective,” said Bowles.
He fears some practices won’t survive the financial crunch.
“Frontline primary care practices are absolutely critical to the healthcare structure right now,” said Fong, noting these practices triage patients with coronavirus symptoms and care for those with chronic illness.
“That is the last thing we need at a time where we need more healthcare capacity is for these critical frontline practices to be shuttering their doors,” she said.