Independent Primary Care in COVIDTimes: Handling Decreases in Patient Volume

Post by Kim Yu, MD, FAAFP

Read the introduction Independent Primary Care in COVIDTimes – Navigating change through a pandemic. 

Read more about Financial Concerns.

In addition to PPE and testing difficulties, family physicians are seeing declines in patient volumes and record patient cancellations that are completely unprecedented. Practices are seeing declines in patient volume ranging from 30-70%, with many practices dropping by an average of 40-50%. To facilitate telehealth adoption, Aledade supplied practices with a telehealth platform at no cost. All have adopted telehealth rapidly, with 100% of our California practices providing telehealth within 2 weeks, and now seeing increases in volume of telehealth visits to an average of 35-40% of visits (range 20-85%).

Leveraging telehealth is especially important during COVID-19, as patients who require ongoing care are able to access their physicians via telehealth without risking contracting COVID-19. There have been limitations, however, as physicians have reported that many patients are not able to access telehealth because they lack a computer, access to the internet, or smart phones. Some patients lack the ability to navigate the telehealth software. Other platforms, including Facetime, Skype and other services, have helped when difficulties arise with current telehealth platforms, but it is not known how long payers will permit those services.

Parity payments for phone visits that occurred at the end of April were especially helpful to allow for care for the elderly, and those that lacked the technology for true video telehealth visits. Best practice use of telehealth, including scripting for both front office staff, medical assistants and clinicians, patient communication, workflow and implementation, is essential and there are resources available here:

• AAFP Telehealth Resources
• Aledade - https://www.aledade.com/sustaining-telehealth-family-medicine-today-and-tomorrow?utm_source=twitter&utm_medium=organic&utm_campaign=webinar_aafp_telehealth&utm_content=post,
• Physical exam TH link - https://cme.jefferson.edu/content/telemedicine-providers-conducting-effective-telehealth-physical-exam
• AAFP telehealth member interest group

Primary care is not the only place seeing decreased volume. All specialties are seeing declines, with some far more than in primary care (see table) and it is interesting to see how some are trying to address this.

Source: Ateev Mehrotra et al., “What Impact Has COVID-19 Had on Outpatient Visits?,” To the Point (blog), Commonwealth Fund, Apr. 23, 2020. https://doi.org/10.26099/ds9e-jm36 (3)

For those in Emergency Medicine facing declines of 50% or more in volume, one can look at the study done by Adventist Lodi, CA, (4) who found certain interventions helped address patient fears of infection at their ED. In addition to messaging via emails and social media about their cleaning protocols and detailing their pulmonary vs. non pulmonary sectioning pods of their ED, they found that informing patients about risks was important as was providing each patient entering the hospital with a mask, hand sanitizer and wipes. They also provided information on what to expect when arriving at their hospital and alerted patients to what symptoms constitute an emergency.

To ensure patients feel comfortable returning for their visits at their family physician practice, it would be wise to take steps to ensure that all patients are aware of the procedures and steps that your practice has taken for your staff and their safety during this pandemic. This can include car park triage, waiting in cars instead of the waiting room, being escorted directly to patient rooms, converting visits to telehealth visits, especially for those in high risk groups, and informing patients of cleaning procedures, mask usage etc. This information might help alleviate your patients’ concerns of contracting COVID-19 at your practice. Likewise, informing patients of types of visits that may be done via telehealth may help increase patient understanding of what care can be delivered by practices, decreasing the chance that patients will seek out urgent care or emergency department care.

It's important that practices carefully consider ways to increase not only revenue but preventive care as well. If left unchecked, decreased immunization rates may bring severe increases in communicable diseases. Chronic diseases could be left unmanaged to the detriment to patients’ health. On a webinar I spoke at last week, a family doctor from the UK said 2,300 cancer referrals were being deferred in the United Kingdom – each week (5).

To be proactive, consider the following:

1. Preventive care:

• Continue well child vaccinations on schedule using parking lot vaccination clinics and separating well child visits from sick visits to decrease chance of spread with pre-triage for all patients.
• As for Annual Wellness Visits – up until this past week, it was not clear that AWVs could be performed by telehealth as previous information from CMS stated that practices had to obtain vitals and body mass index in person. CMS clarified this information on May 15th, 2020, and practices can now conduct AWVs via video telehealth visits if patients self-report their vitals and their height and weight. They may also be obtained via phone; however, it is not clear that risk codes obtained on phone visits will count, so it is advisable to conduct AWVs via video telehealth visits only or in ones’ practice (preferably at the beginning of the day, followed by steps to protect elderly patients coming to the practice in person.)

2. Chronic care:

• Maximizing care for patients who are at high risk – for patients at high risk of morbidity or mortality if sick with COVID-19 (e.g. those with multiple comorbidities, obesity, HTN, or diabetes) consider telehealth visits. We have implemented a Stay Well at Home program (6) that enables physicians to identify patients most at risk, and care for those patients, if necessary, via telehealth to maximize their wellbeing, identify risky behaviors, address advance care planning, ensure medications are refilled and keep them healthy.
• Chronic care management – some clinics have implemented hypertension mobile clinics, deploying BP machines to patients that require frequent blood pressure monitoring or, if patients are self-monitoring already, to have monthly telehealth visits until at goal. Ensuring hypertensive patients are as well controlled as possible decreases the likelihood of stroke and heart attack.
• Psychiatric care – it is clear that the toll of COVID-19 will include not only those who have perished, but those who are left behind, who may be suffering from acute grief reactions, stress, PTSD, depression, anxiety and other mental health diagnoses. It is vital that family physicians reach out to these patients to ensure they have the resources, medications and information they may require for improving their mental health. (https://www.aafp.org/dam/AAFP/documents/practice_management/COVID-19/stress-reduction.pdf and https://psychiatry.ucsf.edu/coronavirus)

3. Business Processes:

• Become billing and coding experts – it may seem the past few weeks that we have been asked to become experts in COVID19 clinically, and also experts in telehealth, billing and coding, PPE procurement officers and perhaps even loan application experts. It is especially important at this time to talk to your biller and ensure that you are using the right codes for your patient visits, to track whether you are being paid for visits or whether you are having many denials in claims. Track these carefully and ensure that if it is necessary to resubmit, that correct codes are utilized. (see AAFP resources here - https://www.aafp.org/fpm/topicModules/viewTopicModule.htm?topicModuleId=113 including information on all the modifiers: https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/coronavirus_modifier_coding.html, and how to get paid for treating uninsured patients: https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/uninsured_covid.html.)
• Importance of data integration for optimal transitions of care, ED follow up and continuity of care for patients. Now, more than ever, it is imperative to have timely information exchange to and from hospitals, especially on those patients who might be positive for COVID19 to allow for adequate care and follow up. Unfortunately, gaps still exist in HIE data integration, and these gaps must be addressed to ensure quick and complete transfer of information from hospitals to primary care practices and vice versa.

References:

3. The Commonwealth Fund - The Impact of the COVID-19 Pandemic on Outpatient Visits: A Rebound Emerges (May 19, 2020)
4. Where Are All the Patients? Addressing Covid-19 Fear to Encourage Sick Patients to Seek Emergency Care, Laura E. Wong, MD, PhD, Jessica E. Hawkins, MSEd, Simone Langness, MD, Karen L. Murrell, MD, Patricia Iris, MD & Amanda Sammann, MD, MPH.
NEJM May 14, 2020 https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0193
5. Cancer Research UK - How coronavirus is impacting cancer services in the UK
6. Telehealth Toolkit Resource link - https://www.aledade.com/covid-19/telehealth