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03.18.2020

What Worries Primary Care Practices Most About COVID-19

by Farzad Mostashari

UPDATE (March 18, 2020):

At Aledade, we partner with independent practices on the frontlines of this epidemic, caring for more than 500,000 seniors most at risk from COVID-19. We asked doctors in more than 100 primary care practices, "What worries you most about COVID-19 today?"

Their answers should worry us, and here's how Aledade is trying to help.

Shortage of PPE Resources

Their number one concern right now: they can't get masks, gowns, or eye shields to protect themselves, their staff, or their patients. The supply chain has completely broken down for them. I've reached out to health plan CEOs, innumerable GPOs, and state health officials to no avail.

This is a big problem, and no one knows what's going on

  • Are countries not allowing PPE to be shipped?
  • Are speculators holding out?
  • Citizen hoarding?
  • Are manufacturers really unable to keep up with increased demand?

We can't get hand sanitizer. Who's going to help? When?

***
What practices are saying:
"I am most worried that I will be infected and, therefore, be unable to care for my patients appropriately. I have a large number of patients over 65. I do not have appropriate PPE to protect myself or my staff."

"We have a critical shortage (<20 at present) facemasks, and are obviously unable to order."

"We are struggling with getting gowns in stock. We have a few but order keeps getting cancelled."

"Lack of masks for our patients and staff. Currently can only receive 1 box (50 masks) every 30 days from our Medical Supply vendor."

"Down to the last 2 boxes of N95 masks and orders for more have been cancelled."

"Being out of PPE and potentially exposing our staff and them being quarantined."

***
How Aledade is helping:

  • We are coordinating with large purchasers to try to acquire PPE equipment, specifically N95 facemasks. We are also pursuing conversations with suppliers for other items including regular facemasks and hand sanitizer.
     
  • We have streamlined communications between Aledade partner practices and private testing companies, like Labcorp, so practices can discuss their testing kit supply.
Staff Shortages

There are some masks in the strategic national stockpile, but not enough. Hospitals are running short. We need to get at the root of the problem, because this is going to be a long fight. We can't win if our front-line staff are getting exposed, quarantined, infected, killed.

***
What practices are saying:
"I worry that one of my staff members will get sick, which would put all other staff members at risk and our patients."

"I'm worried when the first employee gets sick, how do I remain open when I know that employee was in close quarters with lots of my other employees?""We have staff that are not going to be able to work because schools are being let out and they don't have alternate/sustainable child care."

***

How Aledade is helping:

  • Protecting staff by working to acquire more PPE resources, make the transition to televisits and telehealth simple and seamless for practices, and providing a wealth of information for practice staff to understand COVID-19 and prepare for it.
High Risk Patients

As befits these amazing doctors who I am proud to serve, they are desperately worried about their patients. 

They have seen the statistics, and they know too well the anguish of losing a patient they have sometimes known for 30 years.

"It only kills old people" is not acceptable.

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What practices are saying:
"That our system is completely unprepared for the tidal wave of patients that is coming in the next couple weeks and our offices and hospitals are going to be overwhelmed."

"Exposure of our high risk patients to an illness that is more deadly to them than to others. We have 150 patients over age 80!"

"I am worried that 75% of my patients are the most vulnerable patients out there."

"The high mortality on elderly and immunocompromised. Lack of resources and knowledge to battle the virus. No known cure or treatment."

"Spread in Long Term Care / Assisted living Facilities."
 

***
How Aledade is helping:

  • We're exploring how we can add high risk tags to the Aledade app to relieve some of the pressure on practices.
Impact on Chronic Diseases

We're telling elderly patients, those with chronic conditions, to stay home. "Don't go to your doctor's office," we're saying. "Avoid COVID-19." But these patients need primary care more than anyone.

As this stretches out to months (and it will), what will happen to deaths from chronic conditions?

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What practices are saying:
"Patients canceling appointments and not seeking the care they need for fear that they will either catch 'it' or if they do have it don't want to be the first in the community and won't tell others."

"If the COVID-19 virus continues to spread, access to quality care may also become a larger problem as the virus could impact staff/staffing, medical supplies, testing, and treatment."

"Elderly patients are encouraged to stay at home to decrease their risk of contracting the virus and they may not be getting appropriate care because they are canceling doctor's appointments and are not following up to get care for their chronic conditions."

"The strain on the healthcare system acutely and the aftermath of neglected chronic care due to the acute outbreak."

"How to care for my patients with chronic disease without exposing them."

***
How Aledade is helping:

  • With a high risk tag, we can help practices identify which patients have the highest risk and focus much of their energy and outreach on those patients.
     
  • We are providing practice facing materials in both English and Spanish to educate patients on the risks of the virus and proper procedures to follow in case they believe that they are sick. Materials include posters, postcards, and scripting for direct physician to patient outreach. 
Telehealth

We are working really hard to help our practices switch to tele- primary care visits. Tech. Workflow. And a morass of regulations.

It is great that Congress allowed tele-health billing for visits that are normally face-to-face, but CMS has yet to clarify rules, or allow billing.

Does the doctor have to document that they verified the identity of the patient? How?

Does the patient have to waive HIPAA if their doctor is using a consumer platform (like encrypted iPhone Facetime)? Does it have to be written consent? Can the copay be waived? And each state's different.

We will work our way through this, and this may well be the push that doctors and patients needed to make tele-health go mainstream, but it sure would be nice if every regulatory agency (including HHS's Office of Civil Rights) was on point to solve problems.

How Aledade is helping:

  • Providing the latest, cutting-edge policy updates around telehealth and televisits, like CMS's new guidance around telehealth, Congressional legislation waiving nearly all Medicare telehealth requirements, and working to understand if Rural Health Centers and Federally Qualified Health Centers will be able to bill for telehealth services. (Services that can be provided via video include AWVs and TCMs and E&M visits).
  • Meeting with and vetting telehealth vendors and EHR integrated platforms for our practices to use.
  • For practices without telehealth capabilities tied to their EHRs, we are working to develop alternative methods to streamline patient visits.
Devastating Practice Finances

Finally, these independent practices are small businesses. They've resisted selling to hospitals. They've weathered unjust payor fee schedules and Medicare facility fees that put them at a disadvantage. They've coped with rising costs and fixed reimbursement.

But this could be fatal

***
What practices are saying:
"Today I worry about having to lay off part of my staff who are dependent on their jobs to live because my well patients are scared to come to our office."

"I worry about how much extra sick time I will need to give employees and how I will be able to pay everyone's salary if we need to close the office if we are all infected (or were near someone infected…)."

"Other than my loved ones and employees getting sick, losing my practice financially."

"Mass quarantines resulting in decreased appointment slots = revenue."

"Closing the clinic or not being able to operate at full speed."

***

How Aledade is helping:

  • We're looking into options to provide loans to some practices.
Overwhelmed

At Aledade, we will do our best to help these 550 frontline practices. We're...

  • Sorting out confusing, evolving guidance on testing
  • Advocating for better policies (please, dedicated testing sites)
  • Looking for PPE
  • Advising on tele-health
  • We may even give some loans

The question is: Who cares for the rest?

***

What practices are saying:

"I worry that I can’t reassure and address all of the staff's needs and concerns all by myself and do everything else I am having to do. Pretty overwhelmed at the moment and stretched super thin! Any support is more than welcome and appreciated."

"Confirmed cases in surrounding county, no test kits, and patients canceling appointments."

"Confirmed that the state only has 350 [COVID-19 test] kits."

***
How Aledade is helping:

  • We are providing practice facing materials in both English and Spanish to educate patients on the risks of the virus and proper procedures to follow in case they believe that they are sick. Materials include posters, postcards, and scripting for direct physician to patient outreach.
     
  • Most of all, we want our partner practices to know that they are not alone. When they joined with Aledade, they found a true partner in the journey to value-based care, no matter how many obstacles we will face - and overcome - in the rest of that journey to come.